**3.6 MIS-C treatment**

Currently, studies comparing clinical efficacy of various treatment options are lacking. According to the United States Center for Disease Control, Colombian Association of Infectious Disease and American College of Rheumatology treatments have consisted primarily of supportive care and directed care against the underlying inflammatory process. Supportive care may include that may include fluid resuscitation, inotropic support; respiratory support and in rare cases, ECMO [58, 59].

**Figure 1.**

*Preliminary case definition according to the World Health Organization.*

*COVID-19 Transmission in Children: Implications for Schools DOI: http://dx.doi.org/10.5772/intechopen.99418*


#### **Table 1.**

*Case definition according to National Institute of health of Colombia.*

**Figure 2.** *Probable MIS-C COVID-19 case.*

Anti-inflammatory measures may include the use of intravenous IgG (IVIG) and steroids. Aspirin may be used due to concerns for coronary artery involvement and antibiotics are sometimes used to treat potential sepsis while awaiting bacterial cultures. Thrombotic prophylaxis is often used to treat the hypercoagulable state typically associated with MIS-C.

The Colombian Association of Infectious Diseases (CAID) [60] and the American College of Rheumatology (ACR) (cite website shown above) have provided consensus statements for the management of MIS-C related to the immunomodulatory, antiplatelet and anticoagulation that are summarized below:

Immunomodulatory management of MISC:

• A stepwise progression of immunomodulatory therapies should be used to treat MIS-C with IVIG and/or glucocorticoids considered as first tier treatments (ACR)

The use of human polyclonal IVIG at a dose of 2 g / kg is suggested for all patients who meet MIS-C diagnostic criteria (CAID) with stable cardiac function and fluid status (ACR).

	- Low to moderate doses of glucocorticoids may also be considered (ACR) noting that in endemic countries antiparasitic management with albendazole or ivermectin is needed to avoid hyperinfestation syndromes of strongyloides (CAID).
	- The use of a second dose of IVIG at a dose of 2 g / kg in case of no response within 36 hours of the first dose, with or without steroid at a low dose (prednisolone orally at a maximum of 1 mg / kg / day or its intravenous equivalent if there is intolerance to the oral route, according to response) may be applied (CAID).
	- High dose intravenous pulse glucocorticoids may be considered in shock (ACR) such as the administration of pulses of methylprednisolone at 30 mg / kg / day for 3 days (CAID).
	- Children with severe respiratory symptoms due to COVID-19 should be considered for immunomodulatory therapy if any of the following are present: ARDS, shock/cardiac dysfunction, substantially elevated LDH, d-dimer, IL-6, IL-2R, CRP, and/or ferritin levels, and depressed lymphocyte count, albumin levels, and/or platelet count (ACR). Risks and benefits suggest that anakinra (intravenously or subcutaneously) be used as first-line immunomodulatory treatment of children with COVID-19 and hyperinflammation (ACR).

Antiplatelet and Anticoagulation management of MISC:

The use of aspirin at anti-inflammatory doses (3–5 mg / kg / day maximum 81 mg/day) is recommended in MIS-C (CAID and ACR) in the event of thrombocytosis (≥450,000 / L) or dilatation of the coronary arteries until resolution and if there is no thrombocytopenia (≤80,000/μl), gastrointestinal bleeding, abnormal liver function tests (up to 5 times normal values of transaminases), uncontrolled asthma, oral intolerance, or influenza A or B virus infection (CAID). In cases of thrombocytosis (platelet count ≥450,000/μl), aspirin should be continued until the platelet count normalizes (ACR). Furthermore, patients with MIS-C and documented thrombosis or an ejection fraction <35% should receive therapeutic anticoagulation with enoxaparin until at least 2 weeks after discharge from the hospital (ACR).
