More than 4 million children have tested positive for SARS-CoV-2 in the United States. Although children and adolescents may have less severe acute illness than adult populations, COVID-19 can lead to many secondary conditions, which can range from subacute to severe. Long-term effects from SARS-CoV-2 infection may be significant, regardless of the initial disease severity.

Pediatricians play an important role in caring for children and adolescents following a SARS-CoV-2 infection. Pediatric visits are critical to monitor resolution of COVID-19 symptoms, administer COVID-19 vaccine and other routine vaccines, screen for and address mental health concerns, document physical and psychosocial development, coordinate care with specialists as appropriate, and emphasize anticipatory guidance for optimal health. Telehealth will play an increasingly important role in follow-up for these patients with potentially long-term symptoms that require ongoing monitoring.

This interim guidance provides pediatricians with direction to navigate the follow-up care of infants, children, and adolescents following a SARS-CoV-2 infection.

Suggested Guidance

Do all children who have experienced a SARS-CoV-2 infection, whether symptomatic or not, require a follow-up visit?

All patients who test positive for a SARS-CoV-2 infection should have at least one follow-up conversation or visit with their primary care medical home. The medical home is a trusted source of information for patients and families, including information about asymptomatic infection or COVID-19 disease and its sequelae. Because of the wide range of post-COVID-19 manifestations, a coordinated dialogue is necessary to monitor residual symptoms, explore the development of new symptoms, and help guide return-to-activity (eg, sports, school, camp, employment, volunteer activities).

Acute COVID-19 severity does not necessarily predict subsequent or ongoing symptoms. However, a pediatric patient with moderate disease (>4 days of fever >100.4°F; >1 week of myalgia, chills, or lethargy; non-ICU hospital stay) or severe disease (ICU stay and/or intubation) may be at greater risk for subsequent cardiovascular disease; therefore, an in-person visit is recommended. For asymptomatic or mild disease severity (<4 days of fever >100.4°F, <1 week of myalgia, chills, and lethargy), a follow-up visit by phone or a video visit may be sufficient if all residual symptoms are resolved. Follow-up visits should take place after the recommended quarantine period and prior to return to physical activity. Telehealth has become invaluable in providing health care to individuals during the COVID-19 pandemic and can also be a useful tool in providing care to individuals with post-COVID-19 conditions. Patients with continued symptoms should receive coordinated follow-up depending on the specific symptoms (see below) and their duration.

What should the pediatrician discuss in the evaluation of a child or adolescent after a SARS-CoV-2 infection, regardless of residual symptoms?

COVID-19 vaccination

Vaccination with age-eligible COVID-19 vaccine products is recommended for all children who do not have contraindications. Vaccination can occur immediately following the recommended quarantine period unless the patient received monoclonal antibody therapy, which requires a delay of at least 90 days (see Centers for Disease Control and Prevention (CDC) Interim Clinical Consideration for Use of COVID-19 Vaccines Currently Authorized in the US).

Return to Daily Living

Pediatricians should identify all necessary supports to facilitate return to activities of daily living (including return to learning, play, and employment). Patients with ongoing symptoms may require additional support in their efforts on return to learning. This might include gradual return to school and cognitive activities based on tolerance; addition of cognitive “rest periods” throughout the school day; interval academic accommodations; close monitoring and communication by the family, school, and pediatrician to assess progress; and other academic adjustments or accommodations as needed. It is essential that children and adolescents are supported in make-up work accrued during the acute illness and that schools avoid penalizing students for ongoing or residual symptoms that affect learning and completion of assignments. Children and adolescents need to reestablish connections with their friends, peers, and nonparental adults in an environment that supports their development and overall well-being.

Return to sports or physical activity

All children and adolescents should connect with their pediatrician prior to returning to physical activity, as outlined in the AAP Return to Sports and Physical Activity interim guidance. Children and adolescents who had moderate or severe symptoms within 6 months require an extensive preparticipation examination, including an American Heart Association (AHA) screening and electrocardiogram or cardiology evaluation to guide return to sports.

Return to camp

Decisions on camp attendance and participation should consider the facility, the expectations of participation, any residual symptoms, and the camp’s ability to identify and support the camper’s/camp counselor’s needs.

Return to child care, school (K-12) and higher education

Return to school and child care is a critical factor for education and social well-being in children. This guidance from the AAP, along with local health department information, can help to guide parents and children as they return to normal daily living. Return to higher education may require additional thought for students and families.

Multisystem Inflammatory Syndrome in Children (MIS-C)

Multisystem inflammatory syndrome in children (MIS-C) is a rare complication that typically occurs 2 to 4 weeks following SARS-CoV-2 infection. A persistent fever without a clear clinical source that is accompanied by new symptoms or coincident with recent exposure to a person with COVID-19 should raise suspicion of possible MIS-C. Some signs and symptoms of acute illness progress rapidly, and children and adolescents may develop hemodynamic compromise. These patients should be followed and cared for in a hospital with tertiary pediatric/cardiac intensive care units whenever possible, as outlined in the AAP MIS-C interim guidance.

Patients and families should be instructed about signs and symptoms that require further evaluation even if new concerns are likely unrelated to a recent COVID-19 illness.

Do children or adolescents who previously were SARS-CoV-2 positive need testing if they develop new COVID-19 symptoms?

It is highly unusual for reinfection to occur within 90 days of resolved SARS-CoV-2 infection. However, with variants circulating, and as data continue to accumulate regarding longevity of immunity from natural infection, the AAP has developed interim guidance on testing after previous SARS-CoV-2 infection.

Is there a role for serum antibody testing in children or adolescents after a documented SARS-CoV-2 infection?

Although qualitative and quantitative antibody testing are available, they are not recommended for routine use by the AAP or CDC. There is no current evidence to support antibody testing guiding clinical management, the decision to vaccinate, or relative protection from variant strains.

Outside of the acute illness, what are some of the ongoing or residual symptoms known to occur after a SARS-CoV-2 infection in children or adolescents?

How should the pediatrician approach children and adolescents with previously known significant underlying medical or behavioral conditions who have experienced COVID-19?

For individuals with existing mental/behavioral illness, events surrounding COVID-19 (hospitalization, isolation, absence from school activities) may exacerbate symptoms. A team-based approach is recommended for those with significant physical impairments or with multiple comorbidities. This team-based approach should be coordinated by the primary care pediatrician, incorporating medical, surgical, occupational, and behavioral specialists as needed.

Do children and adolescents experience long-haul COVID-19 similar to adults?

The post-COVID-19 condition called “long-haul COVID-19” is an umbrella term that encompasses physical and mental health consequences experienced by some patients that are present 4 or more weeks following a SARS-CoV-2 illness. Although the reported frequency of post-COVID-19 conditions varies widely in the medical literature, several studies show that long-term symptoms can occur in children and adolescents. One study showed that as many as 52% of young adults 16 to 30 years of age may experience residual symptoms at 6 months.4 A study of 129 children in Italy showed that 42.6% of children experienced at least one symptom >60 days after infection.5 Finally, the United Kingdom Office for National Statistics estimates that 12.9% of children 2 to 11 years of age and 14.5% of children 12 to 16 years of age still experienced symptoms 5 weeks after infection.6

No specific lab test can definitively distinguish “long-haul COVID-19” conditions from other etiologies. Although a conservative approach (ie, minimal diagnostic evaluation, optimizing function and working toward achievable healthy goals) can be considered for the 4 to 12 weeks following illness because potential harm may arise from excessive testing, pediatricians should also consider other differential diagnoses and pursue additional investigation as clinically appropriate. If concerns persist past 12 weeks (3 months), then additional diagnostic testing and/or referral to a multidisciplinary post-COVID-19 clinic for consultation may be appropriate.

The abuse may be brief, but the trauma lasts a lifetime.
Kids’ lives and futures are on the line!
Be the voice against neglect and contribute to end child maltreatment today.