COVID-19 - guidance for paediatric services

This page provides advice, guidance and signposts to further resources, to support members working in paediatric services during the current remobilisation phase of the COVID-19 pandemic in the UK.

We will update this guidance on a regular basis as new data becomes available. We'll work with others to bring together the best available information. Advice and guidance should be used alongside local operational policies developed by your organisation.
Last modified
21 April 2021

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If you have any questions relating to this guidance, please contact us on health.policy@rcpch.ac.uk

Infection prevention and control

National Guidance

UK-wide guidance on infection prevention and control for remobilisation of services has been issued jointly by the Department of Health and Social Care (DHSC), Public Health Wales (PHW), Public Health Agency (PHA) Northern Ireland, Health Protection Scotland (HPS)/National Services Scotland, Public Health England (PHE) and NHS England as official guidance.

In England, a further toolkit and resources have been published to support compliance with IPC measures in healthcare settings.

Tonsillar examination - infection control implications

This guidance is produced by RCPCH and the British Paediatric Allergy Immunity & Infection Group.

BPAIIG - British Paediatric Allergy Immunology & Infection Group

Context

At the onset of the COVID-19 pandemic, our priority was to keep ourselves and our colleagues safe while maintaining a pragmatic approach, and being mindful that PPE was potentially in limited supply.

We now believe that the guidance we previously offered which was full PPE can be adjusted whilst maintaining staff safety. 

Guidance is available from PHE on the safe approach to taking a combined nose and throat swab for COVID-19 and we would recommend that this is followed for throat examination for all years, whilst allowing for an individual risk based assessment.

Clinical recommendations

  • We recommend that the oropharynx of children should only be examined if essential.
  • Following the NHS evidence base review, we now believe effective precautions can be taken by using droplet PPE (apron / gloves / surgical mask) with eye protection. This can be visor, goggles or safety spectacles.
  • Visors must be available in primary care, children's assessment units and EDs and if reusable cleaned between patients.

Note: it is inappropriate to refer a child to secondary care solely for the purpose of a tonsillar examination.

Suspected tonsillitis in primary care or emergency departments

  • Where a diagnosis of tonsillitis is suspected on clinical history but it is decided by an individual risk assessment (for example, in an older but non-compliant child) the default remains not to examine the throat unless absolutely necessary.
  • If using the feverpain scoring system to decide if antibiotics are indicated (validated in children 3 years and older),3 we suggest that a pragmatic approach is adopted, and automatically starting with a score of 2 in lieu of an examination seems reasonable.  
  • Antibiotics should be considered in children with a total feverpain score of 4 or 5  (we suggest children with a score of 3 or less receive safety netting advice alone).  
  • Although this may lead to a small increase in antibiotic prescribing in specific circumstances, we feel that this is preferable to healthcare staff being unnecessary exposed to COVID-19. Antibiotics rarely confer a benefit in children under 3 years with tonsillitis and should only be prescribed in exceptional circumstances or if a diagnosis of scarlet fever is strongly considered.

 

Child friendly resources

 

Safeguarding, looked after children and vulnerable children processes in England, Wales and Northern Ireland

Key Considerations

  • Throughout these exceptional times, all professionals who look after children and young people, must continue to base their judgments on the best interests of the child or children that they are caring for. This fundamental of good paediatric practice is the constant that must not alter however much the circumstances change around us.
  • Paediatricians and other colleagues involved in safeguarding children, looked after children (LAC), adoption, child death and children with special education needs (SEN) work may be intermittently redeployed into providing acute lifesaving medical services or support of those services.
  • The result of this may be an intermittent reduction in paediatricians and other colleagues’ ability to contribute fully to the multi- agency processes and these problems will be mirrored by workforce and safety issues within partner agencies.  
  • Paediatricians and other colleagues should ensure safeguarding arrangements are considered in the context of any future influx of young adults into children’s hospitals and wards. Every reasonable effort should be made to separate different age groups.
  • We always discourage admission of well children and young people to hospital because this is deemed to be a place of safety until suitable accommodation can be found, unless no other alternative arrangements can be made. 
  • Key vulnerable children professionals should contribute to the discussions for contingency planning with regard to what will happen when parents, foster carers, connected carers and residential home workers become unwell and can’t look after children in their care. 
  • Key vulnerable children professionals should contribute to discussions for contingency planning with regards to how food and medicines will be supplied to vulnerable children and families in households in self-isolation.      

Good practice for paediatricians

  • Designated and named professionals, or their equivalents, should meet with colleagues in social care and the police to discuss what the different levels of support may be, which are likely to vary in a step wise manner as local health resources change.
  • Safeguarding assessments of children should take place face to face following appropriate risk assessment. Telephone or video conferencing facilities may still be utilised when face to face meetings are judged not to be necessary, and in some circumstances may be a preferable method of consultation, or may form part of the consultation.  
  • Paediatricians should wear correct PPE as per PHE guidance for examining children and in particular for examining the oropharynx. It is recommended that the oropharynx should only be examined if essential and this should be done following risk assessment using the appropriate precautions. You can read our full guidance on tonsillar examination and infection control implications.
  • NHSE has requirements on how providers of community services can release capacity to support the COVID-19 preparedness and response. This document advises which services should currently be prioritised with guidance for LAC teams, safeguarding and sexual assault services (PDF). In addition, in a more recent communication from the LGA, NHSE and PHE, it advises that vulnerable children professionals in the community should not be redeployed.      
  • CoramBAAF has guidance for the LAC sector on how to respond to the pandemic, including information on the provision of health aspects of fostering and adoption work. Lead agencies are working together to support operational aspects of LAC work and as guidance is developed this will be added to the Looked After Children webpage.
  • Public Health England has updated the NHS entitlements: migrant health guide to state that no charge can be made to an overseas visitor for the diagnosis or treatment of COVID-19.
  • Consent issues for vulnerable children can be complex. A guide to this by Nottingham Children’s Hospital is available to download at the bottom of the page.
  • Children who are shielded, and those that are not, should still attend hospital for essential treatment as recommended by their clinical teams, following risk assessment. The need for this should be discussed with families and young people in a sensitive and reassuring manner. On occasion, non-compliance with treatment recommendations may amount to significant neglect of medical needs and will require discussion with the local safeguarding team, particularly the Named Doctor for Safeguarding Children, and may meet threshold for referral to children’s social care. More information about children who should shield is available here.
Paediatricians and other colleagues must:
  • Treat injured children where there is no option but to admit to hospital. This group of children are likely to have already presented to emergency departments with fractures, burns and head injuries, etc. 
  • Face to face child protection medical assessments for all referrals as appropriate should go ahead, following risk assessment, in settings with appropriate PPE.
  • Redeployment of staff within vulnerable children teams should be resisted during any future waves of infection.
  • Attend to the essential health needs of sexually assaulted children in line with the Faculty of Forensic and Legal Medicine guidance on Sexual Assault Referral Centres (SARC) requests for Forensic Medical Examination.
  • Continue to provide health based telephone advice to social care and the police about urgent child protection, LAC, adoption, and child death matters. This advice service may be arranged on a rota basis within existing health networks.
  • Remain mindful of contextual safeguarding issues. This advice will be based on their best clinical judgement and on resources available at the time. 

Recovery

Paediatricians and other colleagues should: 

  • Be aware of potential future waves of COVID-19 infections, which will affect parts of the UK at different times and they must therefore operate flexibly.  
  • Include a strategy under recovery planning for how to catch up with routine health appointments and the increased demand for mental health services. This strategy should include encouraging parents to bring children and young people to all health appointments whether in the hospital or in the community. 
  • Identify resources needed and prioritisation to catch up with the increased work that will be required following lockdown.  
  • Risk rating for how LAC initial and review health assessments should be performed will be influenced by local community infection rates and other factors including the needs of individual children. Such assessments may be carried out as normal, or by collection of health data remotely with face to face consultations taking place at a later date. Similar processes are in place for adoption medical assessments and SEND health assessments. 
  • Advocate for additional resources to preserve the quality of services.  
  • Be mindful of the wellbeing of colleagues, develop a local strategy to identify and signpost to local pathways for access to support and wellbeing resources. 
  • RCPCH have published Reset, Restore and Recover, its principles to approach recovery planning for children’s health services in the wake of the pandemic.

The Royal College of Nursing, NHS England and the National Network of Designated Healthcare Professionals (NNDHP) are supportive of the above guidance for professionals working in safeguarding and looked after children's areas of practice. We remind all concerned to ensure they also follow local operational policies developed by their organisation.

 

Child protection, looked after children and vulnerable children processes in Scotland

Key considerations

  • Throughout these exceptional times, all professionals who look after children and young people, must continue to base their judgements on the best interests of the child or children that they are caring for. This fundamental of good paediatric practice is the constant that must not alter, however much the circumstances change around us.
  • Paediatric child protection services should be seen as a critical service, that is adequately staffed and rotas maintained. 
  • Robust rotas of paediatricians with expertise in child protection need to be available to multi-agency colleagues to ensure medicals can still take place but IRD (initial referral discussion) and case conference is likely to be affected as workload increases and human resource depletes. Face to face medical assessments should proceed, if risk assessed as essential.
  • The clinical leadership of the lead paediatrician in child protection should be protected to ensure that clinical and multi-agency staff have appropriate clinical advice, but other strategic roles of this post will not be maintained during this period of crisis.
  • Paediatricians and other colleagues should ensure safeguarding arrangements are considered in the context of any future influx of young adults into children's hospitals and wards. Every reasonable effort should be made to separate different age groups. 
  • Paediatricians should always discourage admission of well children and young people to hospital because this is deemed to be ‘a place of safety’ until suitable accommodation can be found, unless no other alternative arrangements can be made. 
  • Key professionals involved in the care of vulnerable children should contribute to the discussions for contingency planning with regard to what will happen when parents, foster carers, connected carers and residential home workers become unwell and can’t look after children in their care.
  • Key vulnerable children professionals should contribute to discussions for contingency planning with regards to how food and medicines will be supplied to vulnerable children and families in self-isolation. Paediatricians must be aware of the impact of prolonged lockdown period on ‘Unseen Children’ and acknowledge that events that occur in this period are not disclosed, or have less detail when they eventually do disclose.
  • Scottish Government has supplementary national guidance for child protection during the COVID-19 outbreak.

Good practice for paediatricians

  • Lead paediatricians for child protection and Paediatricians with a Special Interest in Child Protection, should meet with colleagues in social care and the police to discuss what the different levels of support may be, which are likely to vary in a step wise manner as local health resources change.
  • Child protection assessments should take place face to face following appropriate risk assessment. Telephone or video conferencing facilities may still be utilised when face to face meetings are judged not to be necessary, and in some circumstances may be a preferable method of consultation, or may form part of the consultation.  
  • Paediatricians should wear correct PPE as per PHE guidance for examining children and in particular for examining the oropharynx. It is recommended that the oropharynx should only be examined if essential and this should be done following risk assessment using the appropriate precautions. You can read our full guidance on tonsillar examination and infection control implications.
  • CoramBAAF has guidance for the LAC sector on how to respond to the pandemic, including information on the provision of health aspects of fostering and adoption work. Lead agencies are working together to support operational aspects of LAC work and as guidance is developed this will be added to the Looked After Children webpage.
  • NHS Inform has changed its guidance to state that no charge can be made to an overseas visitor for the diagnosis or treatment of COVID-19.
  • All children including those that are shielding, should still attend hospital for essential treatment as recommended by their clinical teams, following risk assessment. The need for this should be discussed with families and young people in a sensitive and reassuring manner. On occasion, non-compliance with treatment recommendations may amount to significant neglect of medical needs and will require discussion with the local safeguarding team, particularly the lead paediatricians for child protection, and may meet threshold for referral to children’s social care.

Paediatricians and other colleagues must:

  • Treat injured children where there is no option but to admit to hospital. This group of children are likely to have already presented to emergency departments with fractures, burns and head injuries etc.
  • Undertake face to face child protection medical assessments for all referrals as appropriate, following risk assessment in settings with appropriate PPE.
  • Attend to the essential health needs of sexually assaulted children in line with Faculty of Forensic and Legal Medicine guidance on Sexual Assault Referral Centres (SARC) requests for Forensic Medical Examination.
  • Continue to provide health-based telephone advice to social care and the police about urgent child protection, LAC, adoption, and child death matters. This advice service may be arranged on a rota basis within existing networks.
  • Remain mindful of contextual safeguarding issues. This advice will be based on their best clinical judgement and on resources available at the time. 

Recovery

Paediatricians and other colleagues should: 

  • Be aware of potential future waves of COVID-19 infections, which could affect parts of the UK at different times and they must therefore operate flexibly.  
  • Include a strategy under recovery planning for how to catch up with routine health appointments and the increased demand for mental health services. This strategy should include encouraging parents to bring children and young people to all health appointments whether in the hospital or in the community.
  • Identify resources needed and prioritisation to catch up with the increased work that will be required following lockdown.  
  • Risk rating for whether LAC initial and review health assessments should be performed face to face at a later date, as currently almost all being performed by collation of health data remotely and should be categorised in terms of post lockdown priority. Similar processes are in place for adoption medical assessments and SEND health assessments. 
  • Advocate for additional resources to preserve the quality of services.  
  • Be mindful of the wellbeing of colleagues, develop a local strategy to identify and signpost to local pathways for access to support and wellbeing resources. 
  • RCPCH have published Reset, Restore and Recover, its principles to approach recovery planning for children’s health services in the wake of the pandemic.

We would like to remind all concerned to ensure they also follow local operational polices developed by their organisation. 

 

Clinical advice on COVID-19

Children and young people who are clinically extremely vulnerable to COVID-19 infection

The College has worked with specialty groups to develop guidance on those paediatric patient groups who are clinically extremely vulnerable and at very high risk of severe illness from coming into contact with COVID-19. The guidance identifies those children and young people most at risk.  

Pregnancy

Guidance on caring for pregnant women with suspected or confirmed COVID-19 and their babies is published and available from the Royal College of Obstetricians and Gynaecologists website.

RCPCH statement on anti-inflammatory medicines and COVID-19

Experts at the RCPCH have have produced a statement that recommends parents treat symptoms of fever or pain related to COVID-19 with either paracetamol or ibuprofen as there is currently insufficient evidence to establish a link between the use of ibuprofen and contracting or worsening of COVID-19.

 

Paediatric settings

Community settings

Alongside the British Association for Community Child Health (BACCH), we have developed operational and clinical guidance for community settings.  

The operational guidance includes minimising potential exposure to COVID-19 for patient and practitioner while keeping patients safe, and the role of community care in supporting the NHS response to COVID-19 (England only). The clinical guidance includes the isolation of children from household members and other health professionals, and how to manage suspected cases in the clinic, educational settings and residential settings and during home visits.

British Association for Community Child Health - logo

Neonatal settings

The British Association of Perinatal Medicine (BAPM) have developed COVID-19: FAQs for neonatal settings.

Guidance on caring for pregnant women with suspected or confirmed COVID-19 and their babies is published and available from the Royal College of Obstetricians and Gynaecologists website

British Association of Perinatal Medicine - logo

Acute settings

The COVID-19 guidance for acute settings developed in collaboration with the APEM, BPAIIG, BPRS and PCCS provides links to guidance and other resources to support members working in acute paediatric services during the current remobilisation phase of the COVID-19 pandemic in the UK.

Association of Paediatric Emergency Medicine
BPAIIG - British Paediatric Allergy Immunology & Infection Group

 

Virtual Consultations

We have gathered some Principles for conducting virtual consultations with children and young people. Virtual consultations has enabled the continuity of services, for those with long term conditions, and patients who are unable to travel (e.g. those in high risk groups), and has allowed shielded staff and those in quarantine to conduct outpatient work from home. However, virtual consulting presents challenges for young people aged 10 – 25 and carries potential risks, such as safeguarding, confidentiality and digital exclusion due to socio-economic status and access to technology.

Additionally, the Young People's Special Interest Group, RCPCH, Adolescent Health Group for RCGP, RCGP and the Association for Young People's Health have produced this joint statement  that also outlines some of the issues that need to be considered when undertaking virtual consultations with young people.

Occupational health

 

Further information

Clinical guidance

NICE guidance on COVID-19 

NHS and public health guidance 

Government COVID-19 information hubs

RCPCH COVID – 19 guidance

The full suite of RCPCH COVID-19 guidance is available here

Key guidance and principles not mentioned elsewhere in this document are:

Latest updates on this page

Updates in this version (21 April 2021)

  • Link added to toolkit and resources to support compliance with IPC measures in healthcare settings in England.

Updates in version 5 January 2021

  • Paediatric settings: added link to Principles for conducting virtual consultations with children and young people.

Updates in version 21 December 2020

  • Minor updates to the Safeguarding section for England, Wales and Northern Ireland and Child Protection Section for Scotland.

If you need to know what updates occurred on days prior to those specified above, contact us on health.policy@rcpch.ac.uk

To get an email notification of each update, you can log in and select the pink button in the grey box 'Notify me when updated'.

 

  • 3. Little P, Hobbs FDR, Moore M et al. Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management). 2013; 347: f5806