More About the Science

Clinical Manifestations in Children and Adolescents 

Long COVID is heterogenous with more than 80 associated symptoms across all body systems. Most affected children have multiple persistent symptoms, on average more than four. There are some commonalities across many affected children: fatigue, headaches, sleep difficulties, exercise intolerance and cognitive dysfunction are the most common symptoms across all age groups and populations.   

However, children of different ages present differently and differently than adults, as detailed in the articles below from the RECOVER Pediatrics cohort, which is important for pediatricians to consider during evaluation.  

The impact of these symptoms on activities of daily living, education, development and quality of life is significant. Over 50% of children with Long COVID are unable to participate fully in school without accommodation, and 75% cannot participate in their previous extra-curricular activities, hobbies or social and cultural activities. Children with long COVID report lower quality of life than those with other chronic health conditions.  

JAMA: Characterizing Long COVID in Children and Adolescents 

Compared with uninfected controls, school age children (5-11 years) who have had a SARS-CoV-2 infection are more likely to present with trouble with memory/focus, back and neck pain, headache, lightheadedness, stomach pain, nausea/vomiting, trouble sleeping, specific phobias, school refusal, and rashes. Adolescents present with additional symptoms of loss of smell or taste, myalgias/arthralgias, daytime tiredness/sleepiness and exercise intolerance/post-exertional malaise but not with trouble sleeping, stomach pain, nausea/vomiting, phobias, school refusal, and rashes. There are also some important phenotypes. In both school age children and adolescents, there are a group of children with high symptom burden affecting almost every organ system (multisystem) and another predominated by fatigue and pain (including headaches). School-age children uniquely have a symptom cluster predominately characterized by trouble with memory/focusing and sleeping, and another predominately characterized by gastrointestinal (GI) symptoms. Adolescents have a cluster predominated by loss of taste and smell. 

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JAMA Pediatrics: Characterizing Long COVID Symptoms During Early Childhood 

Compared with uninfected controls, infants and toddlers who have had a SARS-CoV-2 infection are more likely to present with persistent poor appetite, trouble sleeping, cough and stuffy nose. Infected pre-school age children are more likely to present with daytime tiredness/sleepiness/low energy and dry cough.  

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JAMA Pediatrics Long COVID Handout  

The lead authors of the RECOVER-Pediatrics reports and the President and Founder of Long COVID Families created this concise educational handout for providers and families describing the most common symptoms in children of different ages.  

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Diagnosis and Management Considerations 

Long COVID should be considered early in the post infectious course. Pediatricians and other primary care providers can screen for persistent symptoms, particularly fatigue, orthostatic intolerance and post-exertional malaise, after COVID-19 infection in the early post-infectious stage (4-12 weeks after infection).  If present, other metabolic, endocrinologic or hematologic causes of symptoms, such as iron deficiency should be screened for and treated appropriately. The impact of these symptoms on daily activities and school attendance should also be assessed and early discussion regarding school accommodations should be considered.  

If symptoms persist beyond 3 months, multidisciplinary evaluation should be pursued. Specialties that may be beneficial to include in a multidisciplinary team include, but not limited to, Infectious Diseases, Psychology, Physical Medicine & Rehabilitation, Cardiology, Neurology, Gastroenterology and Allergy/Immunology. There are a very limited number of pediatric multidisciplinary clinics focusing on Long COVID in the United States; these clinics may be an option for patients with resources but cannot be the sole option for management of this patient group.  

There are no specific diagnostic tests for Long COVID. In fact, most of the time standard laboratory assessments will be normal.  As such the clinical case definition, with specific consideration of timing of symptom onset in relation to acute COVID illness, are the means to make a formal diagnosis. Formal guideline development is ongoing and iterative.  

A few trials for Long COVID in pediatric patients are ongoing or starting. However, at this time, given the lack of evidence-based or FDA approved specific therapies for Long COVID, symptom management is still critical and should be individualized, symptom based and focused on specific goals for patient function and priorities. It is also important for families to have a diagnosis, even if there is not yet a disease-modifying therapy.  Treatment for previously described co-presenting syndromes (POTS and dysautonomia, ME/CFS, MCAS) should be provided as appropriate and additional symptomatic management for fatigue, cognitive dysfunction, pain, headaches, gastrointestinal symptoms and other symptoms should be used until Long COVID specific or disease modifying treatments are identified. 

The CMSS Long COVID Education, Engagement, and Care Management program was supported by Cooperative Agreement Number CDC-RFA-IP21-2111, funded by the U.S. Centers for Disease Control and Prevention.