Active COVID-19, Clinical Pathway — All Settings

Therapies by Severity of Illness: Hospitalized Children

This guidance reflects the limited available evidence and the expert opinion of a multidisciplinary team from CHOP Infectious Diseases, Critical Care, Antimicrobial Stewardship, Oncology, the Dysregulated Immune Response Team (DIRT), Immunology, Emergency Medicine, Primary Care, Laboratory Medicine and Pharmacy. The guidance here is subject to change as new evidence becomes available. Clinicians should continue to tailor clinical decision making to the unique aspects of individual children while weighing the risks/benefit ratio of administering experimental therapies or therapies with limited pediatric data.

Treatment Recommendations for Hospitalized Children
Illness Severity Category	Antiviral Medications	Immunomodulator Medications	Anticoagulation
All children should receive supportive care, regardless of illness severity.
Hospitalized, not for COVID-19 Mild disease attributable to COVID-19 with no new/increased O₂ required	Moderate-severe immunocompromise or high-risk condition AND not fully vaccinated: consider remdesivir on a case-by-case basis All others: Supportive care	Steroids are not recommended unless indicated for another condition	Anticoagulation per usual recommendations for hospitalized children, VTE pathway
Hospitalized for COVID-19 Mild disease attributable to COVID-19 with no new/increased O₂ require	Moderate-severe immunocompromise or high-risk condition AND not fully vaccinated: consider remdesivir on a case-by-case basis All others: Supportive care	Steroids are not recommended unless indicated for another condition	Anticoagulation per recommendations for children with COVID-19
New or increased supplemental oxygen requirement attributable to COVID-19 lower respiratory tract disease On low-flow O₂ Severe disease	Suggest remdesivir	Steroids not routinely recommended, can be considered on a case-by-case basis, particularly in older adolescents, children with symptoms ≥ 7-10 days, and/or children with escalating oxygen requirements, weighing individual risk/benefit Tocilizumab/baricitinib not recommended	Anticoagulation per recommendations for children with COVID-19
Requires non-invasive mechanical ventilation or HFNC attributable to COVID-19 lower respiratory tract disease Critical disease	Consider remdesivir	Recommend steroids Age ≥ 9, consider baricitinib or Age < 9, consider tocilizumab	Anticoagulation per recommendations for children with COVID-19
Requires invasive mechanical ventilation or ECMO attributable to COVID-19 lower respiratory tract disease Critical disease	Remdesivir not recommended	Recommend steroids Age ≥ 9, consider baricitinib or Age < 9 or contraindication to baricitinib, consider tocilizumab	Anticoagulation per recommendations for children with COVID-19
Bronchiolitis, asthma, or croup due to COVID-19	Remdesivir is not routinely recommended, given that oxygen requirements are likely multifactorial in these disease processes and given the self-limited nature of these disease processes.	Steroids are not routinely recommended for infants with bronchiolitis, and there is no evidence that bronchiolitis due to COVID-19 should be managed differently than other causes of bronchiolitis Steroids should be administered per usual care standards for children with viral ARDS, croup and asthma	Anticoagulation per recommendations for children with COVID-19

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.