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AAP COVID-19 guidance: What to know about monoclonal antibody therapies, surge episodes, providing acute care

September 27, 2021

Editor’s note: The guidance in this article has been updated. Please visit the guidance documents on monoclonal antibody treatment/post-exposure prophylaxis, managing care of patients in inpatient/outpatient settings during episodes of surge and providing acute care in ambulatory settings.For the latest news on COVID-19, visit

To help pediatricians manage COVID-19 surges while also meeting the needs of non-COVID-19 patients, the AAP has released interim guidance on monoclonal antibody treatment/post-exposure prophylaxis, managing care of patients in inpatient/outpatient settings during episodes of surge and providing acute care in ambulatory settings.

Treatment, prevention

Three monoclonal antibody (mAb) therapies have received emergency use authorization (EUA) from the Food and Drug Administration (FDA) for treatment of mild to moderate COVID-19 and post-exposure prophylaxis (PEP) in children 12 years and older who weigh at least 40 kilograms and are high risk, according to outlined criteria.

A table in the guidance summarizes the three mAb therapies, their indications, route of administration, dosing information and links to fact sheets for health care professionals and patients (also in Spanish). Sotrovimab has received EUA for treatment, casirivimab/imdevimab for treatment and PEP and bamlanivimab/etesevimab for treatment and PEP . According to the guidance, pediatricians should consider the local circulating variant when choosing the most appropriate mAb therapy. (See

The guidance also includes a table on subcutaneous dosing and administration of casirivimab/imdevimab, including initial and subsequent dosing, vials and dose packs, instructions on administering the mAb, materials needed, dispensing details and storage instructions.

The guidance does not offer any additional adjunctive therapies or interventions to treat or prevent the progression of COVID-19 in children and adolescents. Azithromycin, ivermectin and hydroxychloroquine/chloroquine are not recommended.

“It is strongly recommended that these unproven interventions be avoided, not be prescribed, and parents counseled against their use,” according to the guidance.

Episodes of surge

The pandemic has brought a prolonged surge that requires a continued response. New interim guidance addresses strategies to manage surge capacity in inpatient and outpatient settings and care for patients in episodes of surge. Other considerations should factor in prolonged or recurrent episodes of surge during fall and winter months.

The guidance defines surge capacity as “the ability to evaluate and care for a markedly increased volume of patients — one that challenges or exceeds normal operating capacity.” It includes planning for continued response and prevention and additional preparedness strategies.

Pediatricians in ambulatory care settings may be among the first impacted by a patient surge, which is why it is crucial to remain aware of local/community disease prevalence, incidence and severity. The guidance describes challenges practices could face related to limited space, supplies and materials; disruptions in routine referral practices; increased acuity of patients; and a higher volume of non-COVID infectious diseases.

It also outlines considerations specific to the ambulatory care setting such as planning for personal protective equipment (PPE), ensuring all staff are vaccinated, and establishing scheduling processes to ensure continued routine well-child care and vaccinations. To ease the burden on the ambulatory care setting during episodes of surge, the guidance suggests triaging conditions suited for telehealth visits, developing mechanisms for referrals, testing outside the clinic and increasing methods of communication with families.

Considerations specific to inpatient and outpatient settings (ambulatory care settings, hospitals, tertiary care and critical care facilities) include:

  • unique challenges (e.g., limitations, disruptions, changes in patient volume),
  • materials and equipment (e.g., PPE, technical supports for telehealth),
  • staff (e.g., mental health and wellness needs, training, scheduling),
  • space (e.g., alternate care sites like parking lots), and

Finally, the guidance emphasizes the need to support mental health and wellness during “unprecedented stresses on health care workers and support structures.”

Acute care

Updated acute care guidance also addresses the surge in pediatric SARS-CoV-2 infections as well as COVID-19 cases related to variants and other circulating viruses like respiratory syncytial virus. It answers common questions on providing sick care, adapting patient scheduling and triage, offering telehealth, and protecting and supporting the practice team during a surge.

The guidance is centered on ensuring access to care and supporting pediatricians so they are capable of providing “the right care for the right patient in the right place at the right time.”

“In summary, providing access to high quality, safe, timely and cost-effective care to all pediatric patients is challenging during the COVID-19 pandemic but is achievable if communities work together to provide a coordinated medical home neighborhood/regional network,” according to the guidance. “Child health professionals should also work together to create a culture of caring and support for their practice teams.”

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