Evaluating and Treating Children With Long COVID

Experts shared advice on diagnosis and treatment of children and adolescents showing signs of post-COVID conditions — also known as long COVID — during a CDC Clinician Outreach and Communication Activity (COCA) webinar.

“Post-COVID conditions” is the preferred term of the CDC and is defined as “the wide range of physical and mental health consequences present 4 or more weeks after SARS-CoV-2 infection,” Tarayn Fairlie, MD, MPH, a medical officer at the CDC, said during the webinar last week.

Signs, Symptoms, and Risk Factors

Common symptoms of post-COVID conditions are fatigue, pain, orthostatic intolerance and dizziness, abdominal pain, prolonged altered smell and taste, palpitations, shortness of breath, cognitive fatigue or “brain fog,” and mental health problems such as depression and anxiety, Fairlie said.

Risk factors for post-COVID conditions in children and adolescents include being older than 12 years; a history of allergic diseases, such as asthma, allergic rhinitis, eczema, or food allergies; and unvaccinated status, she noted. Post-COVID conditions seem to occur at higher frequency among children who were hospitalized or experienced more severe illness, Fairlie said; however, they can also occur in children with mild or asymptomatic infections.

Assessing Post-COVID Conditions

To characterize children’s symptoms and “functional activity limitations,” Louise Vaz, MD, MPH, an associate professor in the Division of Pediatric Infectious Diseases at the Oregon Health & Science University in Portland, recommended starting with a thorough history and physical.

The webinar presentations amplified points in the “Multi-disciplinary collaborative consensus guidance statement for the assessment and treatment of post-acute sequelae of SARS-COVID-19 in children and adolescents.” The American Academy of Physical Medicine and Rehabilitation launched the collaborative in March 2021.

To start, clinicians should seek evidence of a past SARS-CoV-2 infection which coincides with post-COVID condition symptoms, such as a prior positive test; “distinctive clinical features” of COVID-19, such as the loss of sense of smell or taste; or a “strong epidemiological link,” such as a person in the child’s household testing positive for COVID-19, she said. Targeted labs and imaging may be necessary to exclude other diagnoses; however, physical exams and lab tests for pediatric patients often come back normal, Vaz noted.

Assessments by Symptom Category

Amanda Morrow, MD, co-director of the Pediatric Post-COVID-19 Rehabilitation Clinic at the Kennedy Krieger Institute at the Johns Hopkins University School of Medicine and Mt. Washington Pediatric Hospital in Baltimore, a co-author of the consensus statement, broke down the guidance into symptom categories. Among those she discussed were:

Systemic or Constitutional Symptoms

Systemic or constitutional symptoms include fatigue and physical activity or exercise intolerance, and “post-exertional malaise,” defined as “worsened symptoms that can occur 12 to 48 hours after even mild, physical, cognitive, or emotional exertion,” Morrow said.

In addition to physical activity, screening for baseline nutrition, including fluid intake, medications or supplements, and substance use in age-appropriate individuals, can help flag other “possible contributors or known medical causes of fatigue,” she added.

Given the overlap between post-COVID condition symptoms and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), the collaborative has suggested screening for ME/CFS.

Often the “pattern of fatigue” in children may be similar in both conditions. Morrow noted some children may not meet the 6-month threshold or “full criteria” for ME/CFS. Evaluation should include a full physical exam including neuromuscular tests; possibly, tests of physical function or endurance (e.g., a 6-minute walk test, a 30-second sit-to-stand test); bloodwork (e.g., a compete blood count and iron panel); and a sleep study if there is a concern regarding sleep apnea.

Treatment for systemic or constitutional symptoms of post-COVID conditions should include the following:

• Addressing medical causes of fatigue — for example, treating anemia with iron supplements
• Implementing “lifestyle modifications” such as ensuring adequate nutrition, hydration, and sleep
• Gradually increasing physical activity or “pacing” as tolerated, while staying alert to possible post-exertional malaise

Patients often require a multidisciplinary approach that leverages a range of traditional therapies — such as pediatric rehabilitation, physical therapy, occupational therapy, and mental health therapy. Some complementary therapies — such as yoga, Tai Chi, acupuncture, massage, and meditation may also help with fatigue.

Autonomic Dysfunction/Postural Orthostatic Tachycardia Syndrome (POTS)

The second category of symptoms include fatigue, orthostatic intolerance (light-headedness in upright positions), as well as “brain fog,” exercise intolerance, post-exertional malaise, headaches, “upset stomach,” palpitations, and hyperhidrosis (excessive sweating).

The diagnostic criteria for POTS, according to a 2019 NIH Expert Consensus Meeting, include:

• A sustained heart rate of no less than 30 beats per minute following 10 minutes of standing for adults or at least 40 beats per minute for children and adolescents ages 12-19
• A lack of orthostatic hypotension
• Frequent orthostatic symptoms

These symptoms should occur for at least 3 months in the absence of other conditions that might explain them, Morrow noted. Evaluating POTS often requires more than bedside orthostatic vital signs “since you are looking for a sustained change in heart rate,” she said. However, a 10-minute passive standing test can be done in a clinic setting or the patient can be referred for a “tilt table test” to confirm a diagnosis.

“And if POTS is suspected, it’s important to screen for joint hypermobility with the Beighton scale,” because Ehlers-Danlos syndrome frequently co-occurs with POTS, said Morrow.

Even in children who don’t meet the full criteria for POTS, if orthostatic symptoms or intolerance are observed, Morrow still recommended treatment, beginning with lifestyle interventions, including:

• Increasing fluid (2-3 l) and salt intake (4-6 g)
• Leveraging POTS-specific exercise protocols, with modifications for patients with post-exertional malaise
• Wearing compression garments
• Elevating the patient’s head at night
• “Physical countermeasures maneuvers” such as crossing legs and tensing muscles

“We have [seen] some patients with complete resolution of POTS symptoms purely with lifestyle interventions,” Morrow noted. Currently, there are no FDA-approved medications for patients with POTS. However, beta blockers can be used to lower heart rate; fludrocortisone can help to expand blood volume; and midodrine can be used to increase vasoconstriction.

Respiratory/Pulmonary Symptoms

Shortness of breath, coughing, and wheezing were the main respiratory symptoms highlighted in the webinar. Diagnostic evaluation are important to look for alternative etiologies, explained Laura Malone, MD, PhD, co-director for the Pediatric Post-COVID-19 Rehabilitation Clinic at the Kennedy Krieger Institute.

A “basic diagnostic work-up” can include pulse oximetry (both at rest and while walking), while chest x-rays and pre- and post-bronchodilator spirometry can also be helpful, Malone noted. Many children, Malone and her colleagues have seen, do not have severe, acute COVID infections but “additional testing” may be necessary for children that do.

With regard to treatment, she noted that most symptoms resolve in time, however some patients may be newly diagnosed with “reactive airway disease” or asthma, and they may “benefit from a trial of bronchodilators,” Malone said.

Patients may also benefit from a referral to an ENT specialist or physician speech language/pathologist if a “vocal cord dysfunction” is suspected. Breathing exercises also may be beneficial.

Gastrointestinal Symptoms

Abdominal pain, nausea and/or vomiting, chronic diarrhea, reflux, indigestion, and decreased appetite are among the most common gastrointestinal symptoms with COVID-19, and have been reported lasting for 2 to 3 months after an infection.

For treatment of dyspepsia, an acid blocker trial may be used. Also, given that many children’s symptoms appear to resemble irritable bowel syndrome, a trial of probiotics may be useful as well as identifying and avoiding triggers, such as certain foods or stress. An appetite stimulant may also be beneficial among these patients, Malone said.

Finally, children with post-COVID conditions may experience depression and anxiety, and Malone strongly recommended screening for suicidality.