Paediatric-Specific Recommendations

Tertiary paediatric hospitals have the capability to take paediatric presentations away from other hospitals in order to increase capacity to treat unwell adults in those hospitals.

We recommend:

1.  Initial streaming of patients (based on infection risk) takes place as outlined earlier.
2. That, if resources are available, children should be assessed in a separate area to adults. If multiple members of a family present seeking care, they should all be triaged and assessed in the same part of the department.
3. That families and children requesting testing, but not requiring emergency care, should be redirected to an appropriate screening clinic. This direction should occur prior to hospital through self-assessment algorithms or telephone triage/advice.

We recommend:

1. That children receive usual routine care, such as adequate analgesia and sedation for procedures, including the use of nitrous oxide.
2. That close attention is paid to infection control. Potentially aerosolising procedures (such as nebuliser therapy, high flow nasal oxygen therapy, foreign body removal from nose/throat, throat examination or nasogastric tube insertion in uncooperative children) require appropriate airborne precautions to maintain staff safety.
3. That children streamed into the low-risk group should be seen in a physically separate space from those who are potentially infected, as deemed appropriate by local guidelines.

Some patient groups are more at risk than others. Although there is little supporting data, the following groups should be considered as having higher risk of morbidity and mortality:

1.  Immunocompromised patients including haematology/oncology patients.
2. Patients with chronic respiratory illness such as cystic fibrosis, bronchiectasis, prematurity or home ventilation.
3. Patients taking immunomodulating medication e.g. those with rheumatological disease. 

We recommend that patients at high risk of complications are rapidly assessed and, if they do not require immediate resuscitation, are admitted to the ward or other protective isolation area for work-up, to minimise exposure.
 
We advocate for age-appropriate negative pressure facilities, recognising that these may not always be available.
 
Some children may find respiratory precautions particularly challenging, such as those with autism spectrum disorder or other neurodevelopmental disorders. Although these children are not at higher risk in themselves, the process of isolation, swabbing and respiratory precautions may prove to be particularly challenging.
 
We recommend rapid assessment and disposition of children who may have difficulty tolerating respiratory precautions, especially those under school age or with special needs.

Typical features include fever, cough and sore throat. Knowledge is developing rapidly as more reports of the paediatric clinical picture are published.
 
Recent papers describe:

1. Fever, dry cough, and fatigue.
2. Upper respiratory symptoms including nasal congestion and/or runny nose.
3. Gastrointestinal symptoms (less common), including nausea, vomiting, abdominal pain, and diarrhea. 

There is no one pathognomonic feature in the initial assessment that will point to the diagnosis of COVID-19. As with the adult population, a history of recent foreign travel or exposure to a confirmed case must be specifically sought.
 
We recommend:

1.  That clinicians actively consider COVID-19 as a cause of fever in children (and ensure appropriate PPE), but also consider a broad differential diagnosis.
2. That well children with a viral syndrome and no specific risk factors should be rapidly discharged home with appropriate advice on:
   • Isolation until well.
   • When to seek further medical assistance.

We recommend:

1.  ​Specific swab tests for COVID-19 should follow recommendations from local health departments. 
2. Radiological investigations should be used selectively, and only if the results are anticipated to change management.
3. CT chests should not be used in children for assessment of COVID-19.

We recommend:

1. That children who are febrile AND distressed can be treated with paracetamol (15mg/kg) or ibuprofen (10 mg/kg). There is currently no evidence that ibuprofen can make COVID-19 worse.
2. That low-flow oxygen is appropriate for most cases of hypoxaemia.
3. That High Flow Nasal Cannula Oxygenation NOT be used for work of breathing in the absence of hypoxaemia.
4. That High Flow Nasal Cannula Oxygenation only be used for hypoxia and work of breathing which is not responding to low-flow oxygen.
5. High Flow Nasal Cannula Oxygenation is a potentially aerosol-generating procedure and should be carried out with aerosol PPE, and in an appropriate negative pressure space if possible.
6. The decision to give nebulised adrenaline in children with croup should be made by a senior doctor, and only if there is severe work of breathing. Weight based dosing of steroids is often sufficient.
7. Nebuliser therapy is a potentially aerosol-generating procedure and should be carried out with aerosol PPE, and in an appropriate negative pressure space if possible. 

We recommend that appropriate discharge advice is provided, including isolation at home, planned follow-up, and when to seek further medical care.
 
We advocate that follow-up should be provided in the community setting, either through traditional consultations and/or telehealth.

Hospitals are already a potentially frightening place for children and their carers. Being provided with a face mask, and being cared for by healthcare providers dressed in PPE is likely to make the child’s hospital experience even more distressing than usual.
 
We recommend:

1.  That children and their carers are fully informed regarding their journey through the department.
2. That families and children have access to psychological support wherever possible during their hospital stay in order to mitigate long-term psychological consequences. 

We advocate for child and family involvement in the decision-making process.
 
It is anticipated that the COVID-19 pandemic will cause marked disruption to day-to-day life, economic hardship, and significant household stress. In this context, domestic violence and child abuse is likely to increase.
 
We recommend that clinicians consider the risk of increased child abuse and domestic violence in all consultations.
 
We advocate that any alterations to staffing practices follow standard procedures to protect children from harm.

This section has been developed to assist clinicians with decisions about appropriate healthcare in Emergency Departments in Australia and Aotearoa New Zealand during the COVID-19 outbreak. It is a framework for planning and responding to this pandemic, including the assessment and management of patients.

This section is targeted at clinicians only. Patients, parents or other community members using it should do so in conjunction with a health professional and should not rely on the information in the guideline as professional medical advice.

The section has been developed by an expert team of practising emergency physicians, by consensus and based on the best evidence available. The recommendations contained do not indicate an exclusive course of action or standard of care. They do not replace the need for application of clinical judgment to each individual presentation, nor variations based on locality and facility type.

The section is a general document, to be considered having regard to the general circumstances to which it applies at the time of its endorsement.

It is the responsibility of the user to have express regard to the particular circumstances of each case, and the application of the section in each case.

The authors have made considerable efforts to ensure the information upon which it is based is accurate and up to date. However, the situation is rapidly evolving, and a certain amount of pragmatism needs to be employed in maintaining such a ‘living document’. Users of this section are strongly recommended where possible to confirm that the information contained within the document is correct by way of independent sources.

The authors accept no responsibility for any inaccuracies, information perceived as misleading, or the success or failure of any treatment regimen detailed. The inclusion of links to external websites does not constitute an endorsement of those websites nor the information or services offered.

The section has been prepared having regard to the information available at the time of preparation and the user should therefore have regard to any information, research or other material which may have been published or become available subsequently.

Whilst we have endeavoured to ensure that professional documents are as current as possible at the time of their creation, we take no responsibility for matters arising from changed circumstances or information or material which may have become available subsequently

Resources that are relevant to this section can be accessed through the Clinical Guidelines web-based material [Link]. COVID-19 related ACEM Resources [Link], COVID-19 related external resources [Link], and the latest Government advice on COVID-19 [Link] are also available.