The Omicron variant brought to light how serious COVID-19 infections can be in children. The winter surge led to a 5-fold increase in COVID-19 hospitalization rates among children ages 4 and younger in the US compared with rates during the peak of the Delta variant. Many clinicians had to scramble for more information on COVID-19 treatments for hospitalized children and teens during this spike, according to Kerry Shields, MSN, MBE, CRNP, CPNP-AC, who outlined current updates on this topic at the National Association of Pediatric Nurse Practitioners (NAPNAP) virtual conference held April 26 to 29, 2022.

Between December 2021 and February 2022, the US saw an upswing in hospitalization rates in children caused by the Omicron variant, with rates being particularly high among those younger than 5 years (Figure). These hospitalizations most commonly affected children with underlying comorbidities, with asthma, cardiovascular disease, obesity, and neurologic disease being most frequently encountered conditions among NPs and PAs treating the pediatric population, said Shields who is a pediatric critical care NP at the Children’s Hospital of Philadelphia (CHOP) and associate program director at the University of Pennsylvania Pediatric Acute Care Program Critical Care Concentration.

Credit: Centers for Disease Control and Prevention

Guidelines for COVID-19 Treatment in Children and Teens

Guidelines for acute COVID-19 treatment in children are available from the Centers for Disease Control and Prevention (CDC), National Institutes of Health (NIH), Society of Critical Care Medicine (SCCM), and American College of Rheumatology (ACR). Shield’s session focused on the NIH guidelines.

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Shields also outlined the CHOP clinical pathway for evaluating and treating acute COVID-19 infection in children, which categorizes children by illness severity (mild/moderate, severe, or severe/critical) to aid in treatment decision-making. Treatment options in the outpatient setting include monoclonal antibodies and oral antivirals (Table).

Table. Acute COVID-19 Treatment Options for Children

Outpatient TherapiesIn-patient Therapies
Monoclonal antibodiesAnticoagulation
Oral antiviralsAntivirals: remdesivir
 Kinase inhibitors: baricitinib
 Interleukin-6 inhibitors: tocilizumab
 Steroids: dexamethasone

For hospitalized patients, the antiviral remdesivir is the only agent that is FDA approved for the treatment of COVID-19. The approval was recently expanded to include pediatric patients who are at least 28 days old weighing at least 3 kg with positive results of direct SARS-CoV-2 testing who are hospitalized or not hospitalized and have mild to moderate COVID-19 and are at high risk for progression to severe COVID-19, including hospitalization or death. Liver function tests should be performed at baseline and monitored during treatment as they may increase with remdesivir use, she said.

Dexamethasone 0.15 mg/kg/dose (maximum, 6 mg) once daily for up to 10 days is recommended for hospitalized children who require high flow oxygen, noninvasive or invasive ventilation, or extracorporeal membrane oxygenation (ECMO). Steroid treatment is not recommended for children with a low level of oxygen support or who are profoundly immunocompromised. Use of alternative glucocorticoids can be considered. For patients with asthma, dexamethasone should be used in conjunction with their asthma steroid therapy.

Baricitinib was granted emergency use authorization (EUA) for use in combination with remdesivir in hospitalized children 2 years and older who require supplemental oxygen, invasive mechanical ventilation, or ECMO. Patients should be monitored for complete blood cell count with differentiation (CBC/d), liver function, and renal function during treatment.

Tocilizumab was granted EUA in combination with corticosteroids for use in hospitalized adults and children 2 years and older with COVID-19 who require supplemental oxygen, noninvasive ventilation, mechanical ventilation, or ECMO. Clinicians should monitor children for liver function, CBC/d, infection, and bowel perforation.   

The anticoagulants heparin and enoxaparin are recommended for hospitalized children with COVID-19; the indications for venous thromboembolism should be the same as those for children without COVID-19. She encouraged the audience to seek out hospital pathways that drill down further on additional recommendations for moderately or critically ill children, such as the one available on the CHOP website

What Not to Use as COVID-19 Treatments in Children

The following treatments are currently not recommended for use in children with acute COVID-19 infection: convalescent plasma, extracorporeal cytokine adsorber (CytoSorb), hydroxychloroquine, azithromycin plus hydroxychloroquine, ribavirin, ivermectin, and lopinavir-ritonavir.


Shields K. Epidemiology and pharmacologic management of pediatric COVID-19. Presented at: NAPNAP National Conference on Pediatric Health Care; April 26-29, 2022.