Antivirals Are Unnecessary for Most Children with COVID-19

September 29, 2020

A panel of pediatric infectious diseases experts recommends supportive care only for children with mild or moderate COVID-19 and suggests remdesivir therapy for those with severe illness requiring supplemental oxygen.

Most children infected with SARS-CoV-2, the virus that causes the coronavirus disease 2019 (COVID-19), experience mild illness and don’t require antivirals, but for those with severe illness, remdesivir is suggested, according to new multicenter interim guidance published in the Journal of the Pediatric Infectious Diseases Society.

The guidance was developed by a panel of pediatric infectious diseases experts from 20 geographically diverse North American institutions through teleconferences and web-based surveys.

“The biggest takeaway is that the majority of children with SARS-CoV-2 infections recover with time and supportive care, without need for any antiviral medication,” lead author Kathleen Chiotos, MD, of Children’s Hospital of Philadelphia’s Roberts Center for Pediatric Research, told Contagion®.

The new interim guidance is an update to a guidance document originally published in April. Further updates are needed as more data evaluating treatment candidates for COVID-19 in children become available.

“A challenge in generating this guidance was that the data evaluating various antivirals is from adult studies,” Chiotos said. “While it is common for pediatricians to apply adult data to pediatric practice, this is especially challenging for COVID-19, given that children generally fare better than adults when infected—and therefore the benefits of antiviral therapy are less certain.”

Supportive care alone is recommended for most pediatric COVID-19 cases, since the disease is typically mild in children. For those with severe illness requiring supplemental oxygen, the panel suggests remdesivir therapy for up to 5 days. The panel said 5-10 days of remdesivir therapy should be considered for children with critical COVID-19, marked by the need for mechanical ventilation, hemodynamic instability requiring vasoactive agents, multisystem organ failure, or a rapidly worsening clinical trajectory.

“In addition to the statement above that most children recover with no specific therapy, remdesivir is thus far the only antiviral agent with evidence supporting its efficacy,” Chiotos said. “We therefore suggest use of remdesivir in hospitalized children with acute COVID-19 who require supplemental oxygen. Use of remdesivir in critically ill children requiring invasive or non-invasive mechanical ventilation or ECMO should be considered. Finally, lopinavir-ritonavir and hydroxychloroquine should not be used for children with COVID-19 of any illness severity.”

The US Food and Drug Administration has issued an Emergency Use Authorization (EUA) for remdesivir and revoked an EUA for hydroxychloroquine. The guidance also noted that studies have found lopinavir-ritonavir to be ineffective.

“We encourage pediatric clinicians to enroll children in clinical trials evaluating therapies for COVID-19 as these become available,” Chiotos said.

The report emphasized the importance of ongoing critical review of emerging data and referred to guidelines published by the Infectious Diseases Society of America and the National Institutes of Health.