The treatment for pediatric patients with cancer who develop COVID-19 is very poorly defined. The risk of severe disease is unknown because although adults with cancer appear to have worse outcomes than those without, non-immunocompromised children seem to have few severe outcomes from the disease and few cases in immunocompromised children have been reported.

Below is our current plan for treatment, but please keep in mind that this practice will likely change as new information becomes available.

All patients should be treated according to standard febrile neutropenia and non-neutropenic fever best practices in addition to any COVID-19 directed interventions. We emphasize trying to manage patients without admission when it is safe/feasible to do so and also to try to minimize clinic visits.

We suspect that most COVID-19 patients will not require antiviral therapy but we might consider antiviral therapy in patients who have lower respiratory tract findings (especially those with moderate or severe T-cell deficiency or requiring higher levels of respiratory support). In general, we might consider antiviral therapy in a patient with only upper respiratory tract findings if the patient had severe T-cell deficiency.  

We will try to avoid giving steroids for treatment of COVID-19 unless there is another indication for steroids such as ARDS, adrenal insufficiency, sepsis etc., as steroids might prolong viral shedding or worsen disease as with MERS or SARS.

If possible, we will try to hold further immunosuppressive treatment, especially those directed at lymphocytes until the clinical illness has resolved, and possibly until the patient has 2 negative COVID-19 tests at least 24 hours apart.

We will also keep in mind that myocarditis can occur with COVID19 and consider collecting troponin and creatine kinase if the patient worsens and try to be judicious with giving IV fluids (Ruan Q et al., Intensive Care Med 2020 , Huang C et al., Lancet 2020).

There are no anti-viral agents currently indicated for treatment of COVID19 or any other coronaviruses.  The agents below could be considered based on in vitro data for COVID19 or limited observational data for MERS and SARS:

 
Remdesivir

- Lai CC et al., Int J Antimicrob Agents 2020
- Wang M et al., Cell Res 2020
- Lu H BioSci Trends 2020

LPV/r (Lopinavir/Ritonavir)

- Li G et al., Nat Rev Drug Discov 2020
- Beck et al., bioRxiv 2020
- Sheahan et al., Nat Commun 2020
- Chan et al., J Infect Dis 2015
- Chan KS et al., HK Med J 2003
- Chu CM et al., Thorax 2004
- Yao et al., J Med Virol 2020
- Cao et al., NEJM 2020

Hydroxychloroquine
Chloroquine

- Li G et al., Nat Reve Drug Discov 2020
- Wang M et al., Cell Res 2020
- Gao et al., BioSci Trends 2020

Nitazoxanide

- Wang M et al., Cell Res 2020