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Updated AAP COVID-19 Testing Guidance outlines who, when and how children should be tested for COVID-19, what to expect when testing after previous infection or COVID-19 vaccination, which patients should quarantine and how school screening programs fit into the picture.
Minor updates were made to the interim guidance on Obesity Management and Treatment During COVID-19.
Testing, screening, quarantine
Changes to the testing guidance factor in the surge of infections due to the delta variant and the increase in breakthrough infections in fully vaccinated individuals.
Previously, the AAP did not recommend testing asymptomatic fully vaccinated adolescents for COVID-19 infection after exposure to a person with confirmed or probable SARS-CoV-2 infection. “It is now recommended that all children, adolescents and young adults seek PCR (polymerase chain reaction) testing three to five days following a close contact exposure, regardless of their personal immunization status. Exposed patients who have symptoms should not delay testing,” according to the guidance.
The guidance describes how schools can screen groups of asymptomatic individuals without known exposure to identify SARS-CoV-2 cases early. This includes offering screening tests to students who are not fully vaccinated when community transmission is moderate, substantial or high. Ideally, PCR tests would be used at least weekly.
The guidance also offers information on use of non-PCR based tests such as antigen tests for screening every one to two days but notes the lower reliability for asymptomatic patients particularly when transmission levels are low. Schools also may use isothermal assays, but they generally are less sensitive than PCR tests and may require increased frequency of use, according to the guidance.
For asymptomatic patients with close contact exposure, timing was updated to delay testing until three to five days after exposure (previously, four days was recommended). A PCR test should be used for asymptomatic exposed patients.
“Testing for active SARS-CoV-2 infection using NAATs (nucleic acid amplification tests) or antigen-based tests is not generally recommended for asymptomatic patients who have previously tested positive within the past 3 months,” according to the guidance. However, “… in a child with known exposure and compatible symptoms, it may be reasonable to retest within the three-month window.”
Pediatricians are reminded that NAATs may yield positive results for weeks or months after initial infection, and a positive test result may reflect prior infection.
The guidance includes a table that outlines NAATs, antigen tests and antibody tests, and explains the pros and cons of their use.
The guidance also explains when to consider testing for other respiratory viruses such as influenza and respiratory syncytial virus.
Asymptomatic children who are not fully vaccinated should quarantine after exposure to a close contact with confirmed infection. The quarantine options should be based on local circumstances and resources. Other interventions (e.g., mask use, physical distancing) must be met through day 14.
Obesity during pandemic
Updates to Obesity Management and Treatment During COVID-19 highlight the need for pediatricians to be vigilant in managing obesity, a chronic disease that increases risk for severe COVID-19 disease. New data indicate an increased prevalence of obesity in children and adolescents from pre-pandemic levels, and emerging data indicate a worsening metabolic status among children and adolescents with obesity.
As the pandemic continues, pediatricians are reminded to continue assessing and treating children and adolescents for obesity and related comorbidities. “The consequences of obesity … are among proposed mechanisms for increased COVID-19 severity,” according to the guidance. “The combination of COVID-19 and obesity is likely to worsen health inequities during and after the pandemic."