This site is intended for UK healthcare professionals
Medscape UK Univadis Logo
Medscape UK Univadis Logo
News

National consensus on managing COVID-19 paediatric inflammatory syndrome

The PIMS-TS National Consensus Management Study Group has developed guidance on the investigation and clinical management of children with suspected paediatric inflammatory multisystem syndrome temporally associated with COVID-19 (PIMS-TS). Key recommendations are summarised below.

Investigation

Initial investigation:

Children presenting to hospital with fever, abdominal pain, gastrointestinal, respiratory or neurological symptoms who are stable and have no other clear cause for their symptoms should have the following initial blood tests done:

  • full blood count;
  • C-reactive protein (CRP);
  • urea, creatinine and electrolytes; and
  • liver function.
Second-line investigations:
  • blood gas and lactate;
  • fibrinogen;
  • ferritin;
  • D-dimer;
  • troponin and NT-pro-B-type natriuretic peptide (proBNP);
  • lactate dehydrogenase;
  • SARS-CoV-2 reverse transcription-polymerase chain reaction (RT-PCR) test and serology;
  • septic and viral screen (lumbar puncture only if specifically indicated);
  • 12-lead electrocardiogram;
  • chest radiograph;
  • echocardiogram;
  • for children with abdominal pain, abdominal ultrasound should be the first-line investigation;
  • children who are physiologically unstable should have a daily echocardiogram; and
  • consult with paediatric cardiologist for children with coronary artery dilatation.
Features of severe disease
  • Extended capillary refill time.
  • Persistent hypotension.
  • Persistent tachycardia.
  • Requirement for 40 mL/kg fluid bolus.
  • O2 <92% in room air.
  • Increased CRP.
  • Increased/increasing troponin.
  • increasing NT-proBNP.
  • Increased/increasing lactate.
  • Increased/increasing ferritin.
  • Increased/increasing D-dimer.
  • Increased/increasing lactate dehydrogenase.
  • High or low fibrinogen.
  • Increased creatinine.
Management
  • Multidisciplinary team discussion within 24 hours of admission or identification of PIMS-TS.
  • First-line intravenous immunoglobulin 2 g/kg in single or divided dose.
  • A second dose may be considered.
  • Children who meet the criteria for the RECOVERY trial should be invited to participate.
  • High-risk children include those <12 months and those with coronary artery changes; these children should receive early intravenous methylprednisolone (10-30 mg/kg) alongside immunoglobulin.
  • Second-line therapy is intravenous methylprednisolone (10-30 mg/kg) for children who remain unwell 24 hours after intravenous immunoglobulin, particularly if they have ongoing pyrexia.
  • Gastric protection (e.g. omeprazole) should be given to children on high-dose steroids.
  • Biological therapy should be considered as a third-line option. Preferred biological therapy for Kawasaki disease-like phenotype is infliximab. Consensus was not reached on a preferred biological agent for non-specific presentation phenotype.
  • For the small number of children in this phenotype meet the criteria for haemophagocytic lymphohistiocytosis (HLH), discuss with a specialist team and consult HLH 2004 guidelines.
Antiviral and antibiotic therapy
  • Children who test positive on RT-PCR or antigen testing might be considered for antiviral therapy; remdesivir is the first-choice antiviral therapy.
  • Intravenous antibiotics should be commenced in all patients.
  • Children who meet the criteria for toxic shock syndrome should be given clindamycin with broad-spectrum antibiotics.
Antiplatelet and anticoagulation therapy
  • All children >12 years should wear compression stockings.
  • Follow local Kawasaki disease guidelines for aspirin dosing.
  • Low-dose aspirin should be continued for six or more weeks.
  • Follow local protocols for management of thrombotic event.
  • Children with abnormal coronary arteries should be discussed with a haematologist regarding long-term antiplatelet and anticoagulation therapy.
Discharge criteria
  • Children who are otherwise well should have stable cardiac function and no pyrexia for 24 hours.
  • Follow-up (including echocardiography) in the first one to two weeks after discharge and six weeks after discharge.
  • Multidisciplinary follow-up for children with coronary artery abnormalities or who required organ support.
  • Include paediatric cardiology and paediatric infectious disease experts in the follow-up.

References


YOU MAY ALSO LIKE