AAP issues interim guidance for MIS-C

In the early days of COVID-19, it seemed like the disease rarely infected children and when it did the disease course was mild. Then in late April, pediatricians in the United Kingdom and New York were discovering children who seemed to have something similar to Kawasaki disease (KD) and testing positive for COVID-19. The complication, multisystem inflammatory syndrome in children (MIS-C), remains the biggest wrinkle in pediatric cases of COVID-19. The American Academy of Pediatrics has released interim guidance for identifying and treating MIS-C.¹

The guidance covered the symptoms that are common for the presentation of MIS-C:

• Symptoms reminiscent of KD, such as rash, red cracked pips, and coronary artery enlargement
• Symptoms similar to toxic shock syndrome as well as hemodynamic instability
• Hyperinflammatory features or cytokine storm/macrophage activation
• Gastrointestinal symptoms, poor heart function, acute kidney injury, or abnormal clotting
• Breathing patterns that are suggestive of congestive heart failure

If a clinician believes that a child has MIS-C, the testing may include an echocardiogram, an electrocardiogram, or a chest radiograph. Expanded testing such as troponin, pro-BNP, triglycerides, creatine kinase, amylase, blood and urine culture, D-dimer, prothrombin time/partial thromboplastin time, international normalized ratio, c-reactive protein, ferritin, lactic acid dehydrogenase, comprehensive metabolic panel, and fibrinogen should be ordered, if they haven’t been performed. The patient should also be tested for COVID-19.

The interim guidance included information for treating MIS-C:

• A hematology consult is recommended to assess clotting risks
• Steroid therapy (ranging from 2 to 30 mg/kg/day of methylprednisolone) and biologics (eg, anakinra, 2 to 10 mg/kg/day, subcutaneously or intravenously, divided every 6 to 12 hours) have been used
• Intravenous immunoglobulin, 1 to 2 grams/kg, the patient’s fluid status and cardiac function will help determine when it’s administered

The guidance highlighted the fact that many of the children diagnosed with MIS-C may have been prescribed antibiotics due to the need to start treatment in multiple avenues as soon as possible. It also mentions that children who are given steroids and biologics are often give a 3-week supply to taper off the steroid and/or biologic treatment.

Reference

1. American Academy of Pediatrics. Multisystem Inflammatory Syndrome in Children (MIS-C) Interim Guidance. Services.aap.org. Updated July 13, 2020. Accessed July 20, 2020. https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/multisystem-inflammatory-syndrome-in-children-mis-c-interim-guidance/.