DIAGNOSIS AND MANAGEMENT OF COVID-19 INFECTION
IN CHILDREN

Sri Lanka College of Paediatricians, Family Health Bureau and

World Health Organisation (WHO)- Sri Lanka

3. Clinical Features And Severity

3.1 Phenotypes of covid-19 in children
Pre-symptomatic period: The time between exposure to the virus and the development of symptoms. The child may be infectious during the pre-symptomatic period, especially two days before the onset of symptoms.
Asymptomatic children:  It includes children who are confirmed positive without any clinical features. These children are identified during contact tracing or as part of routine testing for hospitalization for other unrelated reasons. However, asymptomatic children also could be infectious.
Classic manifestations: Symptoms are mainly related to the respiratory system (cough, cold, sore throat, shortness of breath, rhinorrhea, loss of smell) with or without fever. In addition, they may have fatigue and myalgia. Loss of taste is less frequent.
Atypical manifestations: Gastrointestinal symptoms – diarrhea, nausea, vomiting, and abdominal pain are reported in a small proportion of cases. In 5-10% of children these manifestations would be the only presentation without respiratory symptoms. Cutaneous manifestations – maculopapular, urticarial or vesicular eruptions, transient livedo reticularis, COVID toes (reddish-purple inflammatory nodules on the feet and toes, sometimes in hands and fingers). These features are mostly related to Multisystem inflammatory syndrome in children (MIS-C).
3.2 Severity of covid-19 infection in children
Mild Disease:
Fever, sore throat, rhinorrhea, cough, or mild gastrointestinal symptoms such as vomiting and diarrhea WITHOUT tachypnoea, respiratory difficulty, or other features of pneumonia.

Moderate disease:
Presence of features of pneumonia (fever, cough, crepitations, etc.) with tachypnoea. (Tachypnoea is defined according to the age group: ≥ 60/min for <2months, ≥50/min for 2-12 months, ≥40/min for 1-5 years, ≥30/min for >5years).
  • BUT does not have features of severe pneumonia (see below)
  • While the diagnosis can be made on clinical grounds chest imaging (CXR, USS) may help to identify pulmonary involvement.

Severe disease:
Severe pneumonia is considered when any of the following features are present (without features of critical disease)
  • SpO2 <90% in room air (the trend of dropping SpO2 in an individual is important rather than this single cutoff value).
  • Grunting, severe chest retractions, or other evidence of increased respiratory efforts.
  • Lethargy, somnolence, Seizures
  • Cyanosis
While the diagnosis can be made on clinical grounds chest imaging (CXR, CTS, USS) may help to identify pulmonary involvement. In sever disease, generally, radiographic infiltrates are > 50% of the lung field with multi-lobar involvement

Critical disease:
Presence of any of the following complications in a child with severe disease
  • Acute respiratory distress syndrome (ARDS)
  • Circulatory shock
  • Multi-organ dysfunction syndrome (MODS)
  • Acute thrombosis
  • Multisystem inflammatory syndrome in children (MIS-C)