Nursing care recommendation for pediatric COVID-19 patients in the hospital setting: A brief scoping review

Background The hospitalization of children during the COVID-19 pandemic has affected their physical and mental health. Pediatric nurses have faced challenges in providing high-quality nursing care for children and their families. However, the pediatric nursing care recommendations for COVID-19 patients in the hospital setting remain unclear. The current scoping review provides recommendations for nursing interventions for pediatric COVID-19 patients in the hospital setting. Methods and findings The selected articles containing management and nursing recommendations for COVID-19 that have occurred in pediatric patients ages 0–19 years old. A search strategy was developed and implemented in seven databases. We included peer-reviewed articles that reported observational or interventional studies, as well as policy papers, guides or guidelines, letters and editorials, and web articles. A total of 134 articles and other documents relevant to this review were included. We categorized the results based on The Nursing Intervention Classification (NIC) taxonomy which consists of six domains (e.g., Physiological: Basic); eleven classes (e.g., Nutrition Support); and eighteen intervention themes (e.g., Positioning, Family Presence Facilitation, Family Support, and Discharge Planning). Conclusion Apart from the intervention of physical problems, there is a need to promote patient- and family-centered care, play therapy, and discharge planning to help children and families cope with their new situation.

Introduction strategies; 2) identifying relevant research articles; 3) selecting research articles; 4) extracting and charting data; and 5) summarizing, discussing, analyzing, and reporting the results [45]. In this current scoping review, the Joanna Briggs Institute (JBI) guidelines, which is a leading source of scoping review guidance, was used as the primary protocol for conducting this research [46]. JBI guidelines was an extended and refined work from Arksey and O'Malley's framework.

Literature search strategy
A systematic search of the CINAHL, Science Direct, ProQuest, Embase, SpringerLink, PubMed, and Taylor and Francis databases was performed, including references from inception of databases to 10 February 2021, using the terms 'children' AND 'COVID-19' with a combination of keywords. A detailed example of the search strategy is provided in S1 Table.

Identification and selection of relevant studies
Studies were eligible for a full-text analysis when all patients were under 18 years and the publication related to in an outpatient or in-hospital environment. Randomized controlled trials, controlled and non-controlled before-and-after studies, controlled and non-controlled interrupted time series, and cohort studies were included. The overall criteria of this study are provided in S2 Table. Systematic reviews, scoping reviews, and meta-analyses were excluded. Studies on both adults and children from which the extraction of pediatric data was not possible were also excluded. We excluded studies published before December 2020 because the concept of COVID-19 was formally introduced in that year. We did not include articles about types of disease other than COVID-19 and its' related medical condition similarly MIS-C. Fig 1 shows the process used to search and select the research articles. Four investigators independently performed reviews of the titles, abstracts, and full texts (A.R.U., R.N., T.A.A., and R.Y.). Any disagreement regarding the collection of studies was resolved by discussion with a fifth reviewer (D.E.).

Data synthesis and analysis
A structured data collection was conducted and a table (S3 Table) was created to document extracted data that summarized information about authors, year of publication, country, study time, type of article, and purpose of the study. Five authors (A.R.U., R.N., T.A.A., R.Y., and D. S.) conducted the data extraction from the included studies. They read every full text thoroughly to identify any statement that could be transformed into a clinical nursing intervention in the hospital setting. A.R.U., and R.N. adopted the Nursing Intervention Classification (NIC, 7th ed.) to rearrange the extracted data into suitable domains, classes, and interventions [47]. Each included study has chance to be generated in more than one domain, class, and intervention. Because it is a specialty among other pediatric patients, we divided nursing interventions for neonates into separate parts in each table. The recommendations were categorized according to the appropriate class and intervention. D.E. then performed an in-depth review for a new set of nursing recommendations that was derived from the previous authors who extracted the data (A.R.U., R.N., T.A.A., R.Y., and D.S.). Any changes made by D.E. were discussed with all authors involved in the data analysis process. We used our expertise and experience in delivering nursing care in the pediatric and neonatal wards, as well as in intensive care, to ensure the fine-tuning and applicability of these recommendations. We reported this scoping review following the PRISMA-ScR Checklist (S1 Checklist) [48].
Planning, Case Management). The distribution of eligible studies in the taxonomy describes in Fig 2. Among the six domains, the Physiological: Basic domain was widely discussed among the variety of interventions for Nutrition Support, Immobility Management, and Physical Comfort Promotion. Table 1 provides 16 interventions for Nutrition Management, Transfer, Positioning, and Pain Management: Acute. In addition, the Physiological: Complex domain showed various intervention recommendations for classes of Respiratory Management, Thermoregulation, and Tissue Perfusion (as described in Table 1). Thirteen interventions were identified: Mechanical Ventilation, Airway Suctioning, Oxygen Therapy, Hyperthermia Treatment, Hypothermia Treatment, and Fluid Management.
As shown in Table 2, the domain with the highest number of intervention recommendations was the Safety domain in the Risk Management class, which described the intervention recommendations for Infection Control (61 interventions) and Vital Sign Monitoring (six interventions). The domain with the lowest number of intervention recommendations was the Peripheral Capillary Oxygen Saturation.
The number in the point of intervention column corresponds to the order of the articles in S3 Table. https://doi.org/10.1371/journal.pone.0263267.t001  Behavioral domain, which consisted of the Behavioral Therapy and Coping Assistance classes. A total of seven recommendations for Therapeutic Play and Counseling interventions were drawn from those two classes (see Table 2). Table 3 shows the Family domain, which consisted of two intervention themes: Family Presence Facilitation and Family Support. Twenty-seven recommendations were identified in the intervention themes. Furthermore, the Health System Mediation class in the Health System domain provided 33 recommendations for Discharge Planning interventions.

Discussion
This scoping review was conducted to provide nursing intervention recommendations for nursing staff caring for pediatric patients with COVID-19 in the hospital setting. To the best of our knowledge, this study is the first to review the scope of the literature on the comprehensive nursing care of pediatric patients with COVID-19. Previous systematic and scoping reviews concerned epidemiological studies [23,173], nursing approach in diagnosing COVID-19 in children [174], and patients' clinical manifestations [13,20]. Other previous studies discussed nurses' efforts in preventing and controlling the spread of COVID-19 infection in neonates [175], improving clinical service in the maternity field [176], newborn care during the COVID-19 pandemic [177], and palliative care for people with dementia [178]. However, comprehensive reviews of nursing care in pediatric patients with COVID-19 are limited. Our research was conducted using a systematic method with a rigorous approach, which should be considered credible.
The three biggest domains revealed in this study are Safety, Health System, and Physiological: Basic which are comprised 79, 44, and 37 point of nursing interventions, respectively. Thus, Infection Control, Positioning, and Discharge Planning will be discussed as representative from those domains. Furthermore, we also highlight Ventilation Management: Invasive, Hyperthermia Treatment, Discharge Planning, Family Presence Facilitation, and Therapeutic Play because of their potency to fulfill practice gap in pediatric nursing alongside COVID-19 context.

Infection control
Infection control strategies are the main points highlighted in preventing the transmission of COVID-19 or SARS-CoV-2 infection. Nurses play an important role in infection prevention and control through some measures in daily practices [174]. Various changes in interventions The number in the point of intervention column corresponds to the order of the articles in S3 Table. https://doi.org/10.1371/journal.pone.0263267.t002 • Involve other family members to increase family cohesion and support [151].
• Facilitate parents to contact health service through audio visual services [68].

NEONATES:
• Only parents or primary supporters are allowed to visit the NICU indefinitely [144].
• Promote skin-to-skin contact without time limit and safe breastfeeding for babies who are not isolated [144,152]. If the mother is quarantined, discuss family members who will do skin-to-skin contact [144]. • Maximize interaction with babies whether using / not wearing masks or using transparent masks as an alternative to connecting and communicating with babies [99, 125-127].
• Observe for excessive stress in infants who are separated from the mother and make sure the baby gets a touch of caregivers [152].
• Observe the symptoms of stress, anxiety and depression in the parents due to separation and restrictions with the baby [60].
• Provide support and facilitate communication when the mother-baby condition is separated [138].
Family Support Family-Centered Approach [153,154] [153,154]. Give a touch to the baby experiencing stress due to separation from the mother [152].  occurred in the care of pediatric patients during the pandemic, but the emphasis of the recommendations that have been made still on the use of Personal Protective Equipment (PPE). Health workers must use PPE properly to protect themselves and prevent cross-infection, so training on the use of PPE needs to be provided for health workers [121]. In addition, nurses also need to follow the general principles of managing patients undergoing aerosol-generating procedures (AGP) [114,115] when performing AGP such as chest compressions, airway management, ventilation, and suction [74] who are at high risk of transmitting infection. The use of PPE must be rational according to the setting, personnel, and type of activity [179].
Neonatal care settings are undergoing substantial changes. Before COVID-19, the WHO recommendation on the timing of the newborn's first bath should be postponed until 24 hours after birth [180] considering the incidence of hypothermia in newborns. The results of a recent study even suggested delaying the first bath up to 48 hours after delivery to effectively maintain the baby's body temperature and effectively maintain skin moisture which can have a positive impact on the development of the baby's skin [181]. Unlike during COVID-19, babies are bathed immediately after birth to clean viral particles obtained from environmental exposure [145].
The direct contact of the baby with the mother, which was previously the main intervention carried out after birth, has turned into something that is not done or postponed until it meets the safety criteria from the transmission of COVID-19 infection. This context is the highlight of this scoping review. A total of 21 papers describe the regulation of contact between infants and mothers who are infected with COVID-19 or at risk of COVID-19. The types of interventions recommended by previous authors include avoiding skin-to-skin contact [56, [138][139][140][141][142], isolation of infants in negative pressure incubators [60, 67, 111, 143,144] or isolation separately  [170]. Actively communicate the surgical plan and reasons for postponing surgery to parents regarding COVID-19 [170].
• Carry out family tracing and activities on children infected with COVID-19 [172].

NEONATES:
• Follow the modified algorithm directions by the neonatology team in case of the emergency airway in neonates [154].

Positioning
The prone position is highly recommended for COVID-19 patients with acute respiratory distress syndrome (ARDS) [182]. Early prone positioning is recommended for pediatric patients with moderate to severe pediatric acute respiratory distress syndrome (PARDS) for 12-18 hours per day (avoid disconnection) to improve the oxygen state [79]. The average time of prone positioning in children and adults is similar. In adult COVID-19 patients with severe ARDS, prone position can increase PaO2:FiO2, primarily in patients with PaO2:FiO2 <120 mm Hg. It can be delivered five sessions per day was 14 hours [183]. Another study noted that after 16 hours of prone position per day in adult COVID-19 patients, moderate to severe ARDS reduced mortality and improved physiological parameters [184]. The respiratory system mechanics of patients with ARDS, with or without COVID-19, were broadly similar, and the management of ARDS patients with or without COVID-19 was similar [185]. Multifactorial factors plays a role in improving oxygenation during prone ventilation by reducing lung compression and improving lung perfusion and changes in the distribution of extravascular lung fluid and secretions [186].

Discharge planning
Discharge from hospital to home or to another level of care is a transition situation in pediatric care [47,187]. Nurses' activities in managing patient discharge include providing patient care knowledge and skills, patient teaching, and post-discharge evaluation [47]. Discharge planning intervention recommendations were found to differ in knowledge preparation, re-examination, and post-treatment care. Before discharging a pediatric patient with COVID- 19 [161][162][163][164][165][166][167][168] after discharge, seems to be the main issue in providing child services that can reduce physical contact and maintain distance during the period of social isolation or quarantine. Similar to the management of COVID-19 cases in children, the application of a safe distance in the clinical service setting [168] can limit direct contact with health workers. In this case, teleconsultation services and parental education through video media have a crucial role in maintaining the best possible service delivery to pediatric patients and their families [168].

Mechanical ventilation management
Intubation procedures occurred in 4.5% of pediatric patients admitted to intensive care units [188]. To prevent complications and air leaks in this study, nurses should check the endotracheal tube (ETT) cuff pressure at a safe limit of <20 cm H 2 O every 6-12 hours [79]. Our findings were similar to previous studies. Kumar et al. and Bulamba et al. [189,190] proposed a pressure target of an ETT cuff at 20-30 cm H 2 O. The correct endotracheal cuff pressure must be less than the capillary perfusion pressure or less than 30 cm H 2 O [191]. Talekar et al. [192] also suggested ETT cuff daily monitoring every 6-12 hours. Increased pressure has the potential to decrease mucosal blood flow, possibly increasing the risk of subsequent tracheal stenosis, rupture, ventilator-associated pneumonia (VAP), and other complications [193]. Poor cuff pressure management could increase the number of days in the Intensive Care Unit (ICU) and prolong the use of mechanical ventilation [194].

Hyperthermia treatment
Another substantial change found in our review is the attitude toward fever in pediatric patients with COVID-19. Increases in body temperature need to be closely monitored even when they are minimal [92]. A previous study found maximum body temperature among the admission factors that led to the progression of COVID-19 [195]. Moreover, severe hyperthermia was expected, and increasing temperatures were independently associated with increased mortality rates [196]. A significant increase in mortality was recorded for every 0.5˚C increase in maximum body temperature during COVID-19 [197].

Family presence facilitation
Patient and family-centered care (PFCC) has been an essential part of pediatric care during the pandemic [198]. Based on our findings, we recommend the presence of the families of pediatric patients in isolation. This recommendation is in line with former studies outside the COVID-19 context [199]. Additionally, our findings emphasized the challenges in involving families in child care with provisions for isolation and restrictions on admission to the care unit to stay safe and prevent the spread of the virus [25, 68]. Parents and caregivers must wear a mask, wash hands, and show average BT to reduce the risk of COVID-19 while accompanying the child [68,150]. Other modes of family presence, such as virtual presence (video conference), should be considered when physical attendance is not possible [200]. However, in this mode, there are issues related to patient privacy and the exacerbation of racial, socioeconomic, and geographic disparities in populations that lack reliable internet access, devices, or technological literacy [153]. Several measures have been developed to maintain the family's presence despite burden issues in pediatric isolation settings [153,201].

Therapeutic play
The COVID-19 disease causes physical and psychological problems similar to those in the Ebola epidemic [202]. Signs and symptoms of changes in the psychological health status, coping mechanism, and causes or risk factors of pandemic stress in children and their families must be identified by pediatric nurses in treating pediatric COVID-19 patients [102, 104]. Pediatric COVID-19 patients in quarantine could experience mental health problems due to the loss or separation from parents or families who suffer from chronic illnesses [32, 34]. They could also suffer stigmatization, social exclusion [35], uncertainty about disease status, boredom, and restrictions on movements and daily activity [36]. The manifestations of psychological stress are anxiety, social interaction disorders, and negative changes in children's behavior, such as aggression and affect [151], decreased appetite, depression, lethargy, irritability, and fear [31, 32]. Psychological interventions must be provided by child health services [34, 100] to reduce stress and increase the adaptability of children and families to life during the pandemic.
The results of this review showed that various kinds of therapeutic play interventions were recommended by previous authors to address the psychological problems of children of all ages due to the pandemic, such as playing collaborative games and painting [31, 69, 100]. In pediatric patients, playing can act as a medium to reduce loneliness, provide distractions [31], and improve health status and wellbeing [203]. However, strategies for fulfilling children's play needs during isolation or quarantine different from those before the pandemic [203]. One guideline recommended the application of safe physical distancing in children's physical activities and playtime [204].
The findings of this scoping review indicated that the amount of literature on physical, psychological, and social care is increasing. However, studies are lacking on the spiritual care of children and preparation for the death or loss of a child, parent, or family member, which could occur suddenly. Furthermore, cultural aspects have not been considered by many previous authors. The COVID-19 pandemic has led to many cultural changes. For example, the culture of maintaining health during COVID-19 requires wearing masks, frequent handwashing, and the increased consumption of fruits and vegetables, which may present special challenges in the pediatric population. Atout et al. [151] showed that many children refused to use masks and other personal protective equipment for non-essential reasons, such as feeling uncomfortable and feeling different from their peers. Therefore, further studies should be conducted to determine cultural influences on providing holistic care in children.

Limitations
This brief scoping review has several limitations. First, we included only articles that were published in the English language. Second, because of the heterogeneity of the design of this scoping review study, we did not perform a structured quality assessment. However, this is in line with accepted methodology of scoping review proposed by Arksey and O'Malley [43]. We accept low levels of evidence in order to understand the whole landscape of published literature.

Implications for practice
Besides physical complaint, the COVID-19 situation has led to psychological problems in children who suffer parental separation, social isolation, and stigmatization. Pediatric nurses are expected to be able to propose various creative ways to meet the needs of children and families despite the various limitations in isolation rooms. Pediatric should promote family presence where it is possible [200]. Using technology might become a good alternative to connect children with their families where physical contact is unaffordable. Some gadgets have developed specific software that enables the child, family, and health care team to stay connected all day. Pediatric nurses should manage the daily schedule where family can connect to health care team among the other routine tasks along the shift period [198].
Furthermore, the pandemic has caused a new situation that affects the readiness of both children and families in undergoing the transition from hospitalization to isolation at home. On this occasion, discharge planning can play an essential role in preparing child and family knowledge, and skill. Parents and child should be educated about the post-treatment isolation period including routine care, nutritional and emotional support, home isolation procedures, and sign of emergency. Pediatric nurses should also help family to decide on child-caregiver at home which may lead to family dilemma. The pandemic situation has prompted pediatric nurses to show leadership in managing resources to ensure that good nursing care has been delivered to consider all needs of pediatric patients and their families.

Conclusion
We found Safety, Health System, and Physiological: Basic as the three most domain revealed in this brief summarizing study. Accordingly, our guideline in Infection Control, Positioning, and Discharge Planning should be considered to be delivered to in-hospital pediatric nursing practice. Ventilation Management: Invasive, Hyperthermia Treatment intervention was formulated to address one of the major physical conditions in pediatric with COVID-19. Nursing intervention should pay attention to pediatric patients with psychological problem by providing Family Presence Facilitation, and Therapeutic Play. Using technology to promote proper discharge planning in pandemic context found to be essential to delivered nursing practice comprehensively. Pediatric nurses should collaborate with their interprofessional team members and use the resources available to ensure the best care despite various restrictions during the COVID-19 pandemic.

Acknowledgments
We would like to thank all pediatric nurses for their outstanding dedication to delivering nursing care during the COVID-19 pandemic around the world. We also thank our colleagues in the Indonesian Pediatric Nurses Association for their strong support while we conducted this study. Our special thanks to pediatric patients and families struggling during the COVID 19 pandemic. Finally, we gratefully acknowledge Ns. Bejo Utomo, MSc for proofreading and technical support.