Long COVID in Children

Long COVID in Children

By: Eric S. Mull, DO, MA, and Endy A. Dominguez Silveyra, MD
Pediatric Chest Medicine Network
Published: October 1, 2021

At the onset of the SARS-CoV-2 pandemic, there was a concern regarding the impact that this infection may have in children. To date, approximately 4.8 million children have tested positive for the SARS-CoV-2 virus.¹ Although the SARS-CoV-2 infection course in children seems to be more benign than in adults on average, pediatric intensive care management was necessary for 2% to 6% of those infected children.²

Despite initial reports that children were largely spared from severe manifestations of COVID-19, there are increasing reports of the long-term complications in some patients as the pandemic continues. Some of these persistent symptoms in children include palpitations, fatigue, respiratory problems, headaches, and insomnia.³

This phenomenon is well-described in adults and has been formally dubbed “post-acute sequelae of COVID-19 (PASC),” or more colloquially as “long COVID.” However, there are limited published reports describing PASC in children.⁴

In adults, long COVID is defined by signs and symptoms that develop during or after an infection consistent with COVID-19 that continue for more than 12 weeks and cannot be explained by an alternative diagnosis.⁴ Although less common in children than in adults, long COVID is also appearing in children.³ The incidence of long COVID in children is unknown and has been described as being in anywhere from 0% to 27% of children following SARS-CoV-2 infection.⁵

Post-acute sequelae of COVID-19

In adults, symptoms such as cough and dyspnea, and findings such as decreased diffusion capacity and persistent radiological abnormalities, have been noted as chronic features following acute COVID-19.^6,7 Similar presentations have been reported after SARS-CoV-2 infection in younger children and adolescents.^3,4,9

An Italian study including 129 children with COVID-19 showed that at least 14.7% reported chest pain and/or chest tightness and 12.4% reported nasal congestion up to 60 days after the initial diagnosis.³ Other studies reported symptoms such as cough and exertional dyspnea.^4,9 Another prospective study in children with symptoms consistent with long COVID revealed that 45% of the cases with pulmonary function testing had abnormal results—mostly a mild obstructive pattern, with half of those cases demonstrating reversibility with bronchodilators.⁸ This suggests that pulmonary function testing in children with chronic symptoms following a SARS-CoV-2 infection may be essential.⁹

The most serious consequence of SARS-CoV-2 infection in children is multisystem inflammatory syndrome (MIS-C), an inflammatory syndrome that presents similarly to Kawasaki disease. A number of long-term sequelae can develop following MIS-C, including life-threatening coronary dilatation or aneurysms, left ventricular dysfunction, and dysrhythmias.²

Other commonly reported long-term symptoms in children include fatigue, dyspnea, and palpitations.¹⁰ Neurologic symptoms such as recurrent headaches, sleep disturbances, and difficulties concentrating have also been reported.¹¹ There may also be possible links related to hyperinflammation, contributing to the development of acute appendicitis¹² and even new onset of type 1 diabetes.¹³ However, this remains conjectural and requires further evaluation.

While the literature focused on the pediatric outcomes of COVID-19 remains limited, previously infected patients with persistent symptoms require close medical follow-up. More research is needed on these serious post-COVID-19 medical conditions in children.

References

1. Cull B, Harris M. Children and COVID-19 State-Level Data Report. The American Academy of Pediatrics and the Children’s Hospital Association; 2021. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/children-and-covid-19-state-level-data-report/
2. Sperotto F, Friedman KG, Son MBF, et al. Cardiac manifestations in SARS-CoV-2-associated multisystem inflammatory syndrome in children: a comprehensive review and proposed clinical approach. Eur J Pediatr. 2021;180(2):307-322. Preprint. Posted online August 15, 2020. PMID: 32803422; PMCID: PMC7429125. doi: 10.1007/s00431-020-03766-6
3. Buonsenso D, Munblit D, De Rose C, et al. Preliminary evidence on long COVID in children. Acta Paediatr. 2021;110(7):2208-2211. https://doi.org/10.1111/apa.15870
4. Ludvigsson JF. Case report and systematic review suggest that children may experience similar long-term effects to adults after clinical COVID-19. Acta Paediatr. 2021;110(3):914-921. Preprint. Posted online December 3, 2020. PMID: 33205450; PMCID: PMC7753397. doi: 10.1111/apa.15673
5. Radtke T, Ulyte A, Puhan MA, et al. Long-term symptoms after SARS-CoV-2 infection in children and adolescents. JAMA. Preprint. Posted online July 15, 2021. doi:10.1001/jama.2021.11880
6. Logue JK, Franko NM, McCulloch DJ, et al. Sequelae in adults at 6 months after COVID-19 infection. JAMA Netw Open. 2021;4(2):e210830. doi:10.1001/jamanetworkopen.2021.0830
7. Zhao Y-M, Shang Y-M, Song W-B, et al. Follow-up study of the pulmonary function and related physiological characteristics of COVID-19 survivors three months after recovery. EClinicalMedicine. 2020;25:100463. Preprint. Posted online July 15, 2020. https://doi.org/10.1016/j.eclinm.2020.100463
8. Ashkenazi-Hoffnung L, Shmueli E, Ehrlich S, et al. Long COVID in children: observations from a designated pediatric clinic. Pediatr Infect Dis J. 2021. doi: 10.1097/INF.0000000000003285
9. American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. American Academy of Pediatrics; 2021. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/post-covid-19-conditions-in-children-and-adolescents/
10. Yasuhara J, Kuno T, Takagi H, et al. Clinical characteristics of COVID-19 in children: a systematic review. Pediatr Pulmonol. 2020;55(10):2565-2575. Preprint. Posted online August 4, 2020. PMID: 32725955. doi: 10.1002/ppul.24991
11. Lin JE, Asfour A, Sewell TB, et al. Neurological issues in children with COVID-19. Neurosci Lett. 2021;743:135567. Preprint. Posted online December 19, 2020. PMID: 33352286; PMCID: PMC7831718. doi: 10.1016/j.neulet.2020.135567
12. Lishman J, Kohler C, de Vos C, et al. Acute appendicitis in multisystem inflammatory syndrome in children with COVID-19. Pediatr Infect Dis J. 2020;39(12):e472-e473. PMID: 32925543. doi: 10.1097/INF.0000000000002900
13. Rubino F, Amiel SA, Zimmet P, et al. New-onset diabetes in Covid-19. N Engl J Med. 2020;383(8):789-790. Preprint. Posted online June 12, 2020. PMID: 32530585; PMCID: PMC7304415. doi: 10.1056/NEJMc2018688
14. Brackel CLH, Lap CR, Buddingh EP, et al. Pediatric long-COVID: an overlooked phenomenon? Pediatr Pulmonol. 2021;56(8):2495-2502. doi: 10.1002/ppul.25521

Eric S. Mull, DO, MA

Dr. Mull is a third-year pediatric pulmonary fellow at Nationwide Children’s Hospital in Columbus, Ohio. He currently serves as a fellow-in-training on the Pediatric Chest Medicine Network Steering Committee. His specialty areas of research focus are the architectural changes in the lungs following post-infectious SARS-CoV-2 and e-cigarette or vaping use-associated lung injury.

Endy A. Dominguez Silveyra, MD

Dr. Dominguez Silveyra is a pediatric pulmonologist and Associate Professor of Pediatrics at Texas Tech University Health Sciences Center El Paso, as well as Medical Director of the Respiratory Department and Pediatric Pulmonary Function Laboratory at El Paso Children’s Hospital in Texas. His area of interest is the impact of pulmonary pathologies on the pediatric population of the borderland.

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