There is a lack of data supporting efficacy of antiviral agents for the treatment of Covid-19 in children, though there are recommendations available from multicenter initial guidance on the use of antiviral agents in children (45, 46). Given the typically mild course of paediatric Covid-19, supportive care alone is suggested for the overwhelming majority of cases. Antiviral therapy generally should be reserved only for symptomatic children or those with underlying conditions with a high risk of disease progression.
Remdesivir inhibits Ribonucleic acid dependent Ribonucleic acid polymerase and has activity against coronaviruses. According to a multicenter panel Remdesivir is preferred to other antiviral agents due to its better tolerance and beneficial effects in adults with Covid-19. Hence the same assumption is being made for children, even though data regarding the benefits of Remdesivir for children with Covid-19 are lacking. On October 22nd, 2020 U.S. Food and Drug administration has approved Remdesivir to treat COVID-19 for use in adults and paediatric patients 12 years of age and older and weighing at least 40 kg requiring hospitalization.
Lopinavir / Ritonavir are not recommended for children due to the absence of efficacy and unfavorable pharmacodynamics and negative clinical trial data (47).
Immune modulators for adjunctive therapy:
The benefits and risks of immune modulators (eg, glucocorticoids, Interleukin 6-inhibitors, interferon-beta 1b) and of convalescent plasma from recovered Covid-19 patients in the treatment of children with Covid-19 are uncertain. The use of these medications is referred only on a case-by-case basis according to disease severity. The routine use for Covid-19 patients is not recommended. The cytokine profiles of serum from some patients with moderate to severe Covid-19 overlap with those seen in macrophage activation syndrome and secondary hemophagocytic lymphohistiocytosis. Thus Interleukin 6 and Interleukin 1 blockades and Janus kinase inhibition, has been proposed as an approach to treat the systemic inflammation associated with severe Covid-19 illness (48). Corticosteroids are reserved only for critically ill patients with Covid-19. There is insufficient evidence for or against systemic corticosteroids for mechanically ventilated patients with acute respiratory distress syndrome (CI)*, and for adults with Covid-19 and refractory shock. The National Institutes of Health recommends using low-dose corticosteroid therapy (BII)* (49).
The safety and effectiveness of dexamethasone for paediatric Covid-19 treatment have not been sufficiently evaluated as the RECOVERY trial did not include a significant number of paediatric patients. According to the recent National Institutes of Health statement Dexamethasone is not generally recommended for paediatric patients who require only low levels of oxygen support. On the other hand Dexamethasone may be beneficial in difficult cases where mechanical ventilation is required. Additional studies are needed to evaluate the use of steroids for the treatment of COVID-19 in paediatric patients, including for multisystem inflammatory syndrome in children (50, 51).
There is no available data on the use of vitamin A for Covid-19, however it is recommended to be used as adjunctive agent for Covid-19 patients due to its effect on decreased morbidity and mortality from measles-associated pneumonia (52).
* Rating of Recommendations: A = Strong; B = Moderate; C = Optional
Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies; III = Expert opinion.