Myocarditis After COVID‐19 Vaccination in Pediatrics: A Proposed Pathway for Triage and Treatment

December 11, 2020, the US Food and Drug Administration granted emergency use authorization for the Pfizer-BioNTech mRNA based COVID-19 vaccine for individuals aged 16 years, followed by extension of this authorization to children ages 12 to 15 years on May 10, 2021 1 and to ages 5 to 11 years on November 2, 2021. As vaccination numbers accelerated in these age groups, pediatric vaccine recipients began presenting with features meeting the Centers for Disease Control and Prevention (CDC) definition of myocarditis, 2 including chest pain, laboratory evidence of myocardial inflammation, and, in some cases, characteristic findings suggestive of myocardial edema and fibrosis on cardiac magnetic resonance imaging (MRI). The CDC and Food and Drug Administration have determined a causal link is likely between the mRNA vaccines (ie, Pfizer-BioNTech, Moderna) and myocarditis. 2 Though this is a rare complication (70.7 and 105.9 cases in adolescent males per million doses of Pfizer-BioNTech vaccine in ages 12-15 and ages 16-17, respectively) 3 more cases of post-vaccine myocarditis/myopericarditis are anticipated as more adolescents and younger children become vaccinated. With the goal of standardizing care and reducing variability, while still ensuring safety, we propose this pathway to guide decision-making about triaging, testing, and treatment for all providers involved in the care of these patients, beginning in the emergency department, where most (if not all) patients will be triaged (Figure). We believe our pathway can be applied at all centers including those without immediate access to certain cardiology testing modalities (eg, continuous telemetry, pediatric echocardiography services, cardiac MRI). ] Most patients were admitted for observation while some were followed as outpatients. Some received NSAIDs only, and others received additional immune-therapies including intravenous immunoglobulin (IVIG) and systemic corticosteroids. In addition to routine cardiac testing with ECGs and echocardiograms, many, but not all, patients underwent cardiac MRI with contrast. Despite the wide variation in management, which remains provider and center-specific, to date, the overwhelming majority of these patients have recovered clinically and have been discharged home within 10 days or less with