Clinical Features and Burden of Postacute Sequelae of SARS-CoV-2 Infection in Children and Adolescents

To characterize the postacute sequalae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection (PASC) in children.

659 286 patients younger than 21 years of age who underwent testing for SARS-CoV-2 antigen or PCR between March 1, 2020 and October 31, 2021. All patients were part of the National Institutes of Health Researching COVID to Enhance Recovery (RECOVER) Initiative.

Syndromic, systemic, and medication PASC characteristics were obtained from retrospective chart review using International Classification of Diseases, 10th Edition codes of electronic health data data. Outcomes were assessed in patients 28 to 179 days after cohort entrance or December 31, 2021, whichever came first. Adjusted hazard ratios (aHRs) were obtained for PASC features of patients who tested positive compared with those who tested negative for SARS-CoV-2.

The cohort consisted of 348 091 (52.8%) males, with a mean (SD) age of 8.1 (5.7) years. Of participants, 59 893 (9.1%) tested positive for SARS-CoV-2, whereas 599 393 (90.9%) tested negative, and PASC data were obtained between four to five months following initial test date. Those with test positivity were more likely to be non-Hispanic Black (20.2% vs 15.4%), Hispanic (18.8% vs 15.3%), and older (16 to younger than 21 years, 17.4% vs 12.1%). Most common syndrome and systemic PASC features included loss of smell (aHR 1.96, 95% confidence interval [CI], 1.16–3.32), and myocarditis (aHR, 3.10; 95% CI, 1.94–4.96), respectively. The most commonly used medication included cough or cold preparations. Compared with those with negative tests, participants with positive tests had an incidence proportion difference of 3.7% (95% CI, 3.2–4.2) for having at least one syndromic, systemic, or medication PASC feature. Proportional hazards models showed the highest rate of any PASC feature in children younger than 5 years of age, those with complex chronic medical history, and those who received ICU level of care during acute SARS-CoV-2 infection.

Compared with adult studies, the burden of PASC in children may be low. The incidence proportion difference of PASC features between those who tested positive versus negative was 3.7%. Factors associated with an increased risk of PASC included young age, comorbid medical complexity, and acute illness severity.

This exploratory study suggests the overall burden of post-SARS-COV-2 infection in children may be low. According to a systemic review by Groff et al, more than 50% of adults with SARS-COV-2 infection had at least one PASC feature 6 months after recovery.¹ In addition to identifying the most common PASC features in children, this study also highlights the lack of neurologic and respiratory PASC manifestations in children compared with adults. Some limitations include potential underestimation of positive cases and PASC burden as this was a retrospective chart review relying on International Classification of Diseases, 10th Edition codes of follow-up visits.