The purpose of this guideline (NG174) is to maximise the safety of children and young people (those aged 17 years or less) who are immunocompromised during the COVID-19 pandemic.
However, it is also suggested that the guideline may be relevant to newborn babies less than 72 hours old and 18-24-year-olds accessing healthcare services.
NG174 defines children and young people who are immunocompromised as those with:
- Primary immunodeficiencies
- Secondary or acquired immunodeficiencies due to their condition
- Secondary or acquired immunodeficiencies due to immunosuppressive therapy
- Chronic diseases associated with immune dysfunction (for example, organ dysfunction or failure or severe inflammatory disease.
NG174 focuses on what can be stopped or started during the pandemic and should be used alongside any other relevant professional guidance.
Patient communication and minimising infection risk
NG174 discusses the importance of communicating with patients, their families and carers to support their mental wellbeing during the COVID-19 pandemic to alleviate any anxieties or concerns they might have about the virus. The guideline suggests signposting patients to relevant charities and support groups including the NHS guidance on mental health and wellbeing aspects of COVID-19, NHS volunteer responders and the Royal College of Paediatrics and child health resources for parents and carers.
NG174 suggests that staff disseminate the fact that COVID-19 infections are usually mild and self-limiting in children even those who are immunocompromised. Patients are advised to continue to attend any scheduled appointments unless informed otherwise. Where a patient suspects COVID-19 infected, they are advised to contact their specialist teams to enable an appropriate assessment. Alternatively or if they are unable to contact the team, they must contact the NHS111 online coronavirus service but if seriously ill to contact emergency services.
NG174 advises on the need to minimise face-to-face consultations and make use of either via telephone or video instead or to contact patients via email or text messaging. Use of electronic rather than paper prescriptions is also suggested as is the need for alternative delivery routes for prescriptions and medicines such as pharmacy delivery services, via the post, using NHS volunteers or drive through medicine pick-up points. Patients are advised to maintain a current list of all treatments and a copy of their latest clinic letter to help healthcare staff should they require any treatment for COVID-19.
NG174 advises patients and their parents to seek individual advice from their teams if they are in a designated shielded group and directs staff to further guidance from the Royal College of Paediatrics and Child Health shielding guidance and the UK government advice on shielding and social distancing.
NG174 advises clinical staff to be familiar with any safeguarding concerns for patients, especially those deemed vulnerable and to use clinical discretion when advising on shielding and school attendance. The guideline signposts staff to the UK government guidance on supporting children and young people during the COVID-19 outbreak.
Where parents or carers have COVID-19
NG174 suggests that clinical staff work with parents or carers to develop appropriate plans for a child with complex needs should they parent/carer become infected with COVID-19. Such plans should include details of who might provide treatments and any training or support that they might be required.
Managing an underlying condition when the patient is not known to have COVID-19
When face-to-face appointments are required, patients should attend with a single family member and to avoid public transport if possible. NG174 recommends that staff inform parents of the need to inform the department prior to appointments if they or the patient has any COVID-19 symptoms. Staff are advised to triage the patient’s care and either rearrange or cancel appointments or ask them to attend as a suspected COVID-19 patient (see below). Home visits are a suggested alternative if possible, provided staff follow UK government guidance on infection prevention and control.
NG174 advises that where face-to-face appointments are required, staff aim to minimise the time patients spend in the waiting area through careful scheduling of appointments, discouraging early attendance and that patients remain in their transport vehicle until they receive a text message informing them that they are ready to be seen.
Once at the department, NG174 strongly recommends a “clean route” through the hospital and that treatments and prescriptions are delivered and dispensed rapidly.
Starting treatments affecting the immune system
NG174 suggests that staff take account of the following when considering to start drugs which affect the immune system:
- Can treatment be safely delayed?
- If treatment is not immediately required, undertake watchful waiting
- If a treatment is required, are there alternatives with a lower risk to the patient?
- Are monitoring and treatment reviews currently feasible or can this be performed remotely or at a reduced frequency that minimises the risk to patient wellbeing?
- Are there alternative routes of drug administration that would reduce hospital attendance or admission?
In cases where treatments affecting the immune system are currently used, NG174 advises continuation to minimise the risk of graft rejection, a relapse or flare. In such cases, NG174 suggests that staff explore changes to the dosage, mode of delivery/route of administration, frequency of monitoring frequency (if possible) and whether the monitoring can be done remotely.
Managing the underlying condition in patients known or suspected of having COVID-19
From a clinical perspective, NG174 reminds staff that children and young people often show either no or mild COVID-19 symptoms although immunocompromised individuals may be more vulnerable to the virus. COVID-19 can also be difficult to diagnose as symptoms can overlap with other disease and in patients prescribed drugs affecting the immune system, the infection can present with atypical symptoms.
A relevant point made in NG174 is that since COVID-19 affects children differently to adults, there may be less risk in starting or continuing with treatments affecting the immune response.
NG174 states that if patients develop any red flags e.g. sepsis, meningitis or febrile neutropenia, assess and treat them in line with usual care guidelines.
In the absence of red flags, NG174 advises following the government guidance on investigation and initial clinical management of possible cases which provides information on testing and isolating patients.
If COVID-19 has been identified, NG174 advises following the UK government guidance on infection prevention and control.
If COVID-19 is later diagnosed in a patient not previously isolated from admission, NG174 advises following the UK government guidance on management of exposed healthcare workers and patients in hospital setting.
Stopping usual treatment in those with symptoms of COVID-19
When considering stopping a patient’s usual care, NG174 suggests that staff contact specialist teams for urgent advice and that staff consider:
- The severity of the patient’s condition
- The risks and benefits of stopping treatment on both the current and any other conditions
- Whether COVID-19 has been confirmed and the severity of infection
- Any other relevant factors including age and comorbidities.
Modification to usual care
NG174 recommends that specialist centres modify usual care to reduce patient exposure to COVID-19 and to make best use of available resources. Where modification of a patient’s treatment is deemed necessary, this should be undertaken by a multi-disciplinary team and in light of their clinical circumstances and any relevant preferences and the reasoning behind the changes fully documented.
Supply of medicines
The guideline advises that teams plan how best to manage any potential disruptions to normal supply routes e.g. home care delivery services and to only supply sufficient amounts to meet patient’s clinical need. Repeat prescriptions for oral medicines or other at-home treatments should also be prescribed to avoid the need to visit the hospital.
NG174 suggests that all NHS staff involved in all aspects of patient care (including receiving, assessing and caring) who have known or suspected COVID-19 infection, follow the UK government guidance for infection prevention and control. In addition, any healthcare staff with known or suspected COVID-19 infection should self-isolate and not return to directly working with patients who are immunocompromised until:
- They show no symptoms for at least a week
- Test negative for COVID-19
NG174 does state that healthcare workers can return to work in other clinical areas after self-isolation provided they follow the UK government guidance for households with possible COVID-19 infection. If self-isolating staff are still able to work, suggested roles include undertaking telephone or video consultations and participation in virtual multidisciplinary meetings. These staff can also help identify patients who can be monitored remotely and those who might require more support as well as performing any routine tasks which can be done remotely.
NG174 is available online and interested readers should check this version for further updates.