Editor’s note: For the latest news on COVID-19, visit http://bit.ly/AAPNewsCOVID19.
When her hospital opened a COVID recovery clinic in spring 2021, Amy M. Edwards, M.D., FAAP, saw firsthand how the SARS-CoV-2 virus could have long-lasting effects on pediatric patients. Two years later, she still is seeing a large volume of patients presenting with an array of post-COVID symptoms at the University Hospitals (UH) clinic in Cleveland.
“A lot more kids are getting repeated COVID infections,” said Dr. Edwards, a physician in the Division of Pediatric Infectious Diseases and associate medical director for infection control at UH Rainbow Babies & Children’s Hospital. “It’s not unusual to see somebody get COVID in January, then in April and again in September. What we often see is by that second or third infection, they develop long COVID. That, for me, is very concerning.”
Post-COVID condition (PCC), or long COVID, is an umbrella term for a wide range of physical and mental health consequences present for four or more weeks after an initial SARS-CoV-2 infection, including for patients who had initial mild or asymptomatic acute infection, according to the Centers for Disease Control and Prevention (CDC). Children with PCC are more likely to have fatigue, altered smell and anxiety than healthy children.
The World Health Organization recently issued a clinical case definition for PCC in children and adolescents (http://bit.ly/3Y65A52), which is based on the latest scientific data and was developed through an expert consensus process.
Wide range of symptoms reported
Even with tools available to fight the COVID-19 virus, many pediatricians across the country still are seeing a large number of infections and lingering symptoms in their patients.
Among her long COVID patients, Dr. Edwards is seeing children with fatigue, gastrointestinal symptoms, constipation, diarrhea and loss of appetite, which is leading to even more severe health issues.
“One of the things that we’re seeing that’s kind of scary is anorexia,” Dr. Edwards said. “A lot of kids are having tremendous struggle with complete loss of appetite where they could go days and days without eating because they don’t feel hungry. It’s different from loss of smell and taste. Food still tastes the same, but it is no longer appealing to them.”
Alexandra Brugler Yonts, M.D., FAAP, director of a post-COVID program at Children’s National Hospital in Washington, D.C., also sees a large number of children with long COVID symptoms.
“After omicron, we had a big influx of patients, but we’re still getting many new referrals, and they’re booked out until June,” Dr. Yonts said. “It’s not a problem that seems to be going away even though (COVID) cases have largely dropped.”
Both doctors are seeing post-exertional malaise, a worsening of symptoms following even minor physical or mental exertion, in addition to headaches, joint pain, stomach issues and sleep disturbances among long COVID patients.
“Far and away, it’s fatigue that interferes with activities of daily living is kind of the biggest thing that I think parents should watch out for,” Dr. Yonts said.
Studies on long COVID in children
The CDC recently held a webinar for clinicians on how to evaluate and manage children and adolescents who present with PCC (http://bit.ly/3ZtnAr2).
Results from a European study were presented showing that long COVID appears to be more common in older children, especially those with a history of allergic disease (http://bit.ly/3YaKmCT). Among children previously hospitalized with COVID-19 infection, the study showed the most common PCC symptoms include fatigue, sleep problems, disturbed/loss of smell and/or taste, and headaches.
“Compared to the youngest children, those ages 6 to 11 years and 12 to 18 years have a higher risk of PCC,” Tarayn Fairlie, M.D., M.P.H., FAAP, a medical officer in the CDC’s Corona and Other Respiratory Viruses Division, said during the webinar. “Children with a history of allergic diseases, or ATP, such as asthma, allergic rhinitis, eczema or food allergy, are also more likely to report post-COVID conditions compared to those without such a history.”
Nonhospitalized children who experienced milder acute infection also report post-COVID conditions, according to a survey in the United Kingdom, with occurrence being more common among adolescents (http://bit.ly/3YcDx3K).
“Among the 16- to 18-year-olds, 7% had ongoing symptoms at 12 weeks, and symptoms were increased in this older age group with up to 4% having symptoms that impact activities of daily living for 12 weeks or longer,” Dr. Fairlie said.
Treatment options vary
The American Academy of Physical Medicine and Rehabilitation developed guidance on diagnosis and treatment of PCC in children and adolescents (https://bit.ly/3SDqXJU), which was discussed during the CDC webinar.
When assessing a child for possible PCC, clinicians should consider a patient’s history and physical, study evidence of past COVID-19 infection and target labs/diagnostics based on symptoms to exclude other diagnoses. Children with PCC, however, may have normal labs, imaging and physical examination.
Treatment generally is supportive to alleviate symptoms.
For patients with fatigue, the guidance recommends treating known medical causes of fatigue based on screening results (e.g., iron supplementation for anemia); discussing lifestyle modifications to optimize nutrition, hydration and sleep; and advancing physical activity/exercise as tolerated. Patients with chest pain, palpitations or dizziness should be sent to the emergency department and/or referred to a cardiologist if there are concerns for acute ischemia.
Dr. Edwards said she often prescribes medications to address orthostatic intolerance, pain, anxiety and depression. Stimulants have been helpful to alleviate brain fog and fatigue, she added.
“What we have found is that kids have an easier time functioning, like going to school and living their life, if you can control as many symptoms as possible,” Dr. Edwards said. “… There’s a balance there,” she added. “You don’t want to start with a bunch of different medications.”
Dr. Edwards also stresses the importance of eating healthy foods as well as cutting down on screen time to help children recover.
“In a good percentage of kids, we do eventually start to wean off of some of those medications because their bodies do seem to heal with time,” she said. “But having said that, there is a significant portion of the population that does require chronic ongoing management because they do not get better as easily.”
Advice for fellow pediatricians
Drs. Edwards and Yonts acknowledged that most pediatricians do not have access to clinics dedicated to long COVID patients, and caring for these patients can be challenging.
“The first step I would say is listen to your patients and to believe them,” said Dr. Edwards, who also suggested tapping resources that are available such as a nutrition specialist or cardiologist.
Dr. Yonts recommended arranging follow-up visits, including phone calls or telehealth visits, four weeks after patients are diagnosed with COVID-19 to see if they still are having symptoms or if they have developed new symptoms.
“At that point, if symptoms are present, you can do some basic lab work to screen for other causes or other known treatable causes of those symptoms,” she said.
Preventing COVID infection is the best way to prevent long COVID, Dr. Yonts said.
“… Even if you’ve already had COVID, getting vaccinated to prevent reinfection is important,” she said.
CDC webinar “Evaluating and Supporting Children and Adolescents Presenting with Post-COVID Conditions,” http://bit.ly/3ZtnAr2