Post-COVID-19 Conditions in Children and Adolescents
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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.
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?
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?
Because the lungs are the most commonly affected organ for patients with SARS-CoV-2 infection, persistent respiratory symptoms following acute COVID-19 are not uncommon. The symptoms include chest pain, cough, and exercise-induced dyspnea. The time to improvement depends on the premorbid condition and the severity of the illness. Some of these symptoms can last for 3 months or longer. Follow-up chest imaging is needed for persistent respiratory symptoms or patients who had pulmonary abnormality identified during the acute infection. Children 6 years or older who have persistent symptoms should receive pulmonary function testing. For any patient with persistent exercise-induced dyspnea after initial cardiopulmonary evaluation, including evaluation for thromboembolic disease and heart disease, cardiopulmonary exercise testing can be performed to assess for deconditioning or pulmonary/cardiac limitation under stress.
Perhaps one of the most concerning aspects of SARS-CoV-2 infection is the potential risk for cardiac involvement, which can be part of the initial disease presentation (including MIS-C), observed as a sequela of the disease or as a potential risk following one of the mRNA COVID-19 vaccines.
There is increasing evidence to suggest that myocarditis can develop after COVID-19 infection. Common presenting symptoms of myocarditis can include chest pain and shortness of breath, as well as arrhythmias and fatigue. In more severe cases, myocarditis can lead to heart failure, myocardial infarction, stroke, or sudden cardiac arrest. Although the etiology of myocardial involvement is unclear, it appears to be related to either the virus itself or potentially the host immune response to the virus.
The incidence of myocarditis following SARS-CoV-2 infection is not known. A recent study of patients recently recovered from COVID-19 suggested that after being screened via cardiac magnetic resonance imaging (MRI), 60% of COVID-19 survivors had developed myocarditis, regardless of the initial severity of illness.1 A study looking at athletes recovering from SARS-CoV-2 revealed that 12 of 26 athletes had indications of either current or past myocarditis.2 These data are concerning for pediatricians, patients, and families, because the majority of COVID-19 cases in the pediatric population are asymptomatic or mild but may still place children at risk of significant cardiac sequelae.
Since April 2021, there have been more than 1000 reports to the Vaccine Adverse Event Reporting System (VAERS) of cases of myocarditis and pericarditis occurring after receipt of one of the mRNA COVID-19 vaccines in the United States (Pfizer-BioNTech or Moderna). The majority of confirmed cases have occurred in male adolescents and young adults 16 years or older, usually after receiving the second dose of an mRNA COVID-19 vaccine. The timeframe of symptom onset, including chest pain, shortness of breath, and feelings of a fast-beating, fluttering, or pounding heart is typically within several days of COVID-19 vaccination. Individuals who have experienced this extremely rare side effect had, in most cases, mild symptoms and have recovered on their own or with minimal treatment. Myocarditis is much more common, and the risks to the heart are potentially much more severe with SARS-CoV-2 infection than with COVID-19 vaccination. The AAP recommends COVID-19 vaccine for all eligible individuals.
Anosmia and/or Ageusia
COVID-19 can result in changes to smell and taste, particularly in adolescents. As many as 1 out of 4 individuals 10 to 19 years of age develop anosmia. Beyond the ability to detect dangerous odors, reduction or loss of the sense of smell (anosmia) or taste (ageusia) can affect the nutritional status, mood, and quality of life in children and adolescents. Symptom report can be challenging in very young children, but reduced oral intake, changes in feeding behaviors, or gagging with/avoidance of previously well-tolerated food could indicate changes in smell or taste resulting from COVID-19. Whereas adults have demonstrated persistent anosmia and ageusia for many months, anosmia and ageusia in children typically resolves in several weeks. Persistent anosmia warrants further evaluation, nutrition optimization, olfactory testing, and potentially olfactory training.
An age-specific history and evaluation for neurodevelopmental impairment is recommended to assess for changes or delays in cognitive, language, academic, motor, or mood/behavioral domains.3 Acute COVID-19 can result in neuroinflammatory disorders (eg, stroke, encephalitis). Significant injury will result in readily apparent motor, cognitive, and/or language deficits (eg, right hemiplegia and aphasia following left middle carotid artery infarct). However, more subtle neurodevelopmental sequelae are also possible, especially in younger children. Persistent symptoms require referral to either a neurodevelopmental neurologist, developmental and behavioral pediatrician, neuropsychologist, speech language pathologist, psychologist, and/or physical or occupational therapists.
Cognitive Fogginess or Fatigue
“Brain fog” (a generic term that refers to unclear or “fuzzy” thinking, inattention, difficulty with concentration or memory) is a frequent neurologic complaint in adults following SARS-CoV-2 infection. School aged-children and adolescents may also complain about neurocognitive changes following SARS-CoV-2 infection as compared with baseline function. These changes can manifest as inattentiveness, seeming to be more forgetful to a parent, slower in reading or processing, requiring more repetition in learning, less endurance and/or requiring more breaks when reading or performing other cognitive tasks, etc. It is critical to treat any behaviors that may potentially impact cognitive functioning, including but not limited to getting adequate nighttime sleep, maintaining a consistent sleep/wake schedule with daily activities, avoiding alcohol and drugs, and addressing stressors. For cognitive complaints that persist and result in functional impairment, a targeted neuropsychological evaluation can identify the basis for these symptoms and guide the development of an appropriate, often multidisciplinary, treatment plan.
Physical fatigue/poor endurance
Following SARS-CoV-2 infection, children and adolescents may complain of easy fatigability and poor endurance even without known cardiac and respiratory involvement. Assuming both cardiac and respiratory function are clinically normal, postviral fatigue typically improves over time. Encouraging a consistent daily schedule and gradual increase in physical activity throughout the day is most effective. Depending on the response, the reconditioning program may need to be led by a physical therapist or multidisciplinary team.
Headache is a common symptom during and following SARS-CoV-2 infection. The history, evaluation, and management are the same as any child presenting with headache—evaluating for “red flag” characteristics, associated neurologic findings, and other possible causes of headache. Causes of post-COVID-19 headache may be most related to situational factors such as change in routine, medication overuse, social isolation, changes in sleep hygiene, poor hydration and/or nutrition, lack of aerobic exercise, and other stressors. Management of headaches during recovery from infection is similar to postviral or postconcussive headaches. Lifestyle factors are typically addressed first; however, if headache symptoms are severe enough to impede recovery, preventive medication may need to be initiated.
Mental health/behavioral health sequelae
Pediatricians should be aware of the impact of stress and adjustment disorders when diagnosing and managing new symptoms in children who have experienced COVID-19. Following SARS-CoV-2 infection, mental health sequelae are very common and likely multifactorial. The AAP has published interim guidance on integrating and supporting the emotional and behavioral health needs of families affected during the COVID-19 pandemic.
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.
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