Long COVID in children

Symptom prevalence and persistence in children

Initial reports of the multisystem symptomatology in children appeared in case reports and small series, mostly among those who had severe COVID-19 illness.¹² The estimated prevalence among children varies considerably.¹³ The definition of the condition (especially if the need for a confirmed test of COVID-19 illness is included), the broad range of symptoms (as some may have started before COVID-19 illness), and the similarities to other conditions (eg, chronic fatigue syndrome) are some of the reasons for the diagnosis being challenging. Furthermore, studies to date have had small cohorts, suffered from the biased selection of populations or recall bias of reported symptoms, had no control groups, and had variable lengths of follow-up.¹⁴ A large Norwegian study reported a substantial increase in the number of individuals seeking post–COVID-19 primary care visits 2 or 3 months after positive tests, particularly in young children. The investigators described a noteworthy increase in respiratory and unspecified conditions.¹⁵

Over the course of the pandemic, more information has emerged about long COVID. Among 5 Swedish children with a median age of 12 years, symptoms persisted after 6 months and included fatigue, muscle and joint pain, headache, and insomnia. None were hospitalized at diagnosis, but 1 child was later admitted for pericarditis-myocarditis.¹²

In a study of 129 Italian children with COVID-19, almost half reported having at least 1 symptom 60 days or more after infection.¹⁶ Common symptoms included fatigue, muscle and joint pain, headache, insomnia, respiratory problems, and palpitations. The investigators found that even some children with asymptomatic COVID-19 infections developed chronic, persistent symptoms, although follow-up was brief.

Among 171 children seen at a dedicated COVID-19 follow-up clinic in Melbourne, Australia, with one-third asymptomatic and most with mild disease, 12 (8%) of the 151 children for whom follow-up data were available at 3 to 6 months had postacute COVID-19 symptoms. All of these children were symptomatic when they had acute COVID-19. Symptoms such as fatigue lasted up to 8 weeks, and almost all children in the clinic returned to their baseline levels of health.¹⁷

In a prospective cohort study from a designated pediatric clinic in Israel, long COVID symptoms were associated with functional impairment up to 7 months after the onset of infection (mostly fatigue and dyspnea).¹⁸

The neuropsychiatric symptoms that present in children with long COVID are of interest. Further research is needed to determine whether they are the consequence of COVID-19 infection or a result of stress, anxiety, or changes in behaviour related to restrictions associated with the pandemic. While the prognosis of children with long COVID is generally good, some children may develop long-term symptoms that have a profound impact on daily family life.

Support for patients and caregivers

Much more information is needed on this new condition, and a standardized definition of the syndrome will help characterize it and evaluate its prevalence in children. In the meantime, primary health care providers can support children and their caregivers based on presenting symptomatology. Treatment protocols for long COVID in children are still in development, and more research will ensure management is evidence based. Completing the initial evaluation, spending time eliciting a detailed history on symptomatology, and performing a comprehensive physical examination are essential. It is yet unclear which tests, if any, are helpful as part of the initial investigation or during follow-up. Primary health care providers’ follow-up is warranted, either when the symptom pattern changes or every 2 to 4 months. Providing patients and families with advice about how to cope with symptoms, especially fatigue, muscle and joint pain, headache, insomnia, and mood, is vital.