COVID-19 - guidance for paediatric services

This guidance has been prepared to provide health professionals working in paediatrics and child health with advice around the ongoing outbreak of COVID-19. Guidance on this page is applicable to all paediatricians, with advice signposted information for settings specific guidance (community, neonatal and acute). It also links to further information developed by national bodies.

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
7 July 2020

We are reviewing this content each weekday, and will publish any updated guidance.

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

    Preparing for COVID-19

    Wellbeing and self-care

    As a healthcare professional, the COVID-19 outbreak is likely to add to your workload and heighten stress levels. Our Wellbeing Hub features key tips from clinicians, peer support networks and free resources that we hope will help you to look after yourself during this uncertain and busy time.

    Occupational health

    'Shielding' advice for children and young people

    This guidance provides information on which paediatric patient groups should be advised to 'shield' during the COVID-19 outbreak, to protect those at very high risk of severe illness from coming into contact with the virus. The guidance identifies the most at risk children and young people.

    The page also provides advice on how to communicate with children and families, including a set of frequently asked questions (FAQs) for parents and carers.

    This advice has been developed in partnership with a wide range of paediatric specialty groups: British Association of Paediatric Nephrology, British Association of Perinatal Medicine, British Congenital Cardiac Association, British Inherited Metabolic Disease Group, British Paediatric Allergy, Immunity & Infection Group (working with the UK Primary Immunodeficiency Network), British Paediatric Neurology Association, British Paediatric Respiratory Society, British Society for Paediatric Endocrinology and Diabetes, British Society of Paediatric Gastroenterology, Hepatology and Nutrition, British Society for Rheumatology, Children’s Cancer and Leukaemia Group, Paediatric Special Interest Group of British Haematology Society. Many specialties also worked with parents and patient groups as they developed their advice.

    Tonsillar examination - infection control implications

    For asymptomatically infected children

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

    BPAIIG - British Paediatric Allergy Immunology & Infection Group

    Context

    Our priority is to keep ourselves and our colleagues safe while maintaining a pragmatic approach, and being mindful that PPE is potentially in limited supply.

    While the COVID-19 narrative has focused predominantly on adults, there is growing concern about the role played by asymptomatic children in the spread of infection.1 Transmission from the upper airway has been raised as a particular concern by ear, nose and throat (ENT) specialists,2 with viral replication shown to take place in the upper airway as well as the lower airway. This may explain why a number of paediatric and ENT healthcare professionals have developed disease in the absence of exposure to children with currently defined risk factors.

    Clinical recommendations

    • We recommend that the oropharynx of children should only be examined if essential.
    • If the throat needs to be examined, full personal protective equipment (eye protection / visor, FFP3 mask, thumb loop gown and gloves) should be worn, irrespective of whether the child has symptoms consistent with COVID-19 or not.  

    Suspected tonsillitis in primary care or emergency departments

    • During the COVID-19 pandemic, if a diagnosis of tonsillitis is suspected based on clinical history, the default becomes not examining 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 is likely to result in a temporary increase in antibiotic prescribing in children, 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.

    Pregnancy

    Information for the vulnerable workforce, including pregnant staff members, is available from the RCPCH COVID-19 guidance for planning paediatric staffing and rotas

    Guidance from the Royal College of Obstetricians, Royal College of Midwives, RCPCH, Public Health England and Health Protection Scotland covers COVID-19 infection and pregnancy, information for pregnant women and their families, and occupational health advice for employers and pregnant women. 

    Public Health England has guidance on PPE that should be worn on the labour ward (section 8.7). This is adopted by all UK countries.

    PHE guidance for households with possible coronavirus infection would indicate that if a mother and baby leave hospital and return to share a home with someone with symptoms of COVID-19 infection they should self-isolate. 

    The Scottish Government has infant feeding guidance for us by all NHS staff working in maternity, community and Health and Social Care Partnerships during the COVID-19 outbreak. For guidance regarding COVID-19 suspected and positive mothers, see 'Breastfeeding by COVID-19 suspected or confirmed mothers' in the 'Working in neonatal settings' section, below.

    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. Statutory processes related to LAC and adoption have been amended until 25 September 2020.  
    • 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.
    • Public Health England has guidance on the provisions being made for vulnerable children and young people.       

    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. You can read guidance for LAC teams, safeguarding and sexual assault services (PDF). This document advises which services should currently be prioritised. However, given the current reducing rates of COVID-19 the vulnerable children’s workforce should be being redeployed back into their normal roles.
    • 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.
    During any future localised lockdowns 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.
    • Paediatricians and other colleagues should remain mindful of contextual safeguarding issues. This advice will be based on their best clinical judgement and on resources available at the time. 

    Recovery

    Following the peak of the pandemic, paediatricians and other colleagues should: 

    • Be aware of a potential ‘second wave’ of COVID-19 infections, which could affect parts of the UK at different times and they must therefore operate flexibly.  
    • Begin recovery planning, which should include a strategy for how to catch up with routine health appointments and the likely increased demand for mental health services. 
    • Identify resources needed and prioritisation to catch up with the increased work that will be required following lockdown.  
    • Prepare for a surge in child protection referrals whenever pupils begin returning to school and ensure a suitable out-reach plan is made for those that do not return, such as those shielding. 
    • 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.

    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. This may mean that fewer child protection doctors cover the rotas in order to allow paediatricians with a range of skills to be deployed to other areas.
    • 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. 
    • 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 self-isolation.
    • Scottish Government has guidance on critical childcare for key workers and 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.
    • NHSE has new requirements on how providers of community services can release capacity to support COVID-19 preparedness and response. You can read guidance for LAC teams, safeguarding and sexual assault services (PDF). This document advises which services should currently be prioritised. However, given the current reducing rates of COVID-19, the vulnerable children’s workforce should be redeployed back into their normal roles. 
    • 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.
    • 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 lead paediatricians for child protection, and may meet threshold for referral to children’s social care.

    During any future localised lockdowns 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.
    • 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.
    • Paediatricians and other colleagues should remain mindful of contextual safeguarding issues. This advice will be based on their best clinical judgement and on resources available at the time. 

    Recovery

    Following the peak of the pandemic, paediatricians and other colleagues should: 

    • Be aware of a potential ‘second wave’ of COVID-19 infections, which could affect parts of the UK at different times and they must therefore operate flexibly.  
    • Begin recovery planning, which should include a strategy for how to catch up with routine health appointments and the likely increased demand for mental health services. 
    • Identify resources needed and prioritisation to catch up with the increased work that will be required following lockdown.  
    • Prepare for a surge in child protection referrals whenever pupils begin returning to school and ensure a suitable out-reach plan is made for those that do not return, such as those shielding. 
    • 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. 

    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

    Alongside the British Association of Perinatal Medicine (BAPM), we have developed guidance for neonatal settings.

    It covers: maternal admissions, neonatal management in labour suite; baby born in good condition; baby requiring additional care; transfer to NNU; management on NNU; transport; PPE required for suspected or confirmed cases being cared for within neonatal services; testing and isolation of infants, and NICU admissions; moving out of isolation; breastfeeding; newborn screening; managing NNU capacity; parents and visitors; discharge and follow up; and staff wellbeing.

    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 and emergency settings

    Alongside the Association of Paediatric Emergency Medicine (APEM) and the British Paediatric Allergy, Immunity and Infection Group (BPAIIG), we have developed guidance for paediatric emergency and acute settings.

    The guidance includes preparations, good practice tips, infection control, management of suspected cases in ED and as inpatients, plus advice and guidance on critical care scenarios. 

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

    Intensive care settings

    The Paediatric Intensive Care Society (PICS) is working with the RCPCH, NHS England, the HCID network and other agencies to ensure that members are provided up to date and relevant guidance to support management of critically ill children with COVID-19 infection. The PICS guidance includes: 

    • Referral and transport of critically ill children with suspected and confirmed COVID-19 infection.
    • Flow diagram for the management of critically ill children with suspected and confirmed COVID-19 infection. 
    • PICS and ICS joint position statement on planning for the pandemic.
    • Management of high risk aerosol-generating procedures.
    • Checklist for intubation.
    • Transport of children with suspected and confirmed COVID-19 

    NHS England has guidance on management of paediatric patients during the pandemic. This includes actions for team leadership, emergency paediatric surgery and service reconfiguration. The guidance notes that there may be a role for PICU in admitting young adults under 25 years of age. 

    The Faculty of Intensive Care Medicine, Intensive Care Society, Association of Anaesthetists and Royal College of Anaesthetists have developed a website to provide information, guidance and resources on understanding of and management of COVID-19 for the UK intensive care and anaesthetic community.

    Paediatric Intensive Care Society

    Paediatric scenarios

    We have developed guidance scenarios for children needing resuscitation.

    Isolation plans

    We have developed guidance on isolation plans for parent-child combinations, including a single parent and child meeting COVID-19 case definition and isolation plan while waiting for virology results.

    Latest updates on this page

    Updates in this version (published 7 July):

    • Child protection, looked after children and vulnerable children processes in Scotland: guidance updated in line with the continuing movement towards the recovery phase of the pandemic. Section on recovery added.

    Updates in version published 6 July:

    • Safeguarding, looked after children and vulnerable children processes in England, Wales and Northern Ireland: guidance updated in line with the continuing movement towards the recovery phase of the pandemic. Section on recovery added.

    Updates in version published 12 June:

    • Full list of paediatric specialty groups involved in updating 'shielding' guidance updated

    Updates in version published 20 May:

    • Tonsillar examination: clinical recommendations on use of PPE updated.

    .

    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'.

      • 1. Kam KQ, Yung CF, Cui L et al. A Well Infant with Coronavirus Disease 2019 (COVID-19) with High Viral Load. Clin Infect Dis 2020
      • 2. Lu D, Wang H, Yu R et al. Integrated infection control strategy to minimize nosocomial infection of corona virus disease 2019 among ENT healthcare workers. J Hosp Infect 2020
      • 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