The long COVID in children still raises many questions

By American Heart Association News

TUESDAY, April 25, 2023 (American Heart Association News) — In the ever-evolving history of the pandemic, the long COVID — the lingering effects that can follow a SARS-CoV-2 infection — are among the toughest twists , the one that researchers are just beginning to capture in adults.

And in children, it could be a whole different story.

“It’s a very difficult set of symptoms, with no clear single treatment,” said Dr. Sarah de Ferranti, a pediatric cardiologist at Boston Children’s Hospital. “I think it’s especially difficult for parents to help their kids with this, because it’s hard to figure out which symptoms are related to COVID versus other illnesses, and because the long COVID in children is different from long COVID in adults.”

Questions abound about the causes of long COVID and how common it is, and parents need to be aware of the physical and psychological aspects. But clearly it’s “a real entity,” said Dr. Suchitra Rao, an infectious disease specialist at Colorado Children’s Hospital in Aurora, and something children “can be quite debilitated about.”

Long COVID goes by many names. Researchers may call it post-acute sequelae of SARS-CoV-2, or PASC. The Centers for Disease Control and Prevention uses “post-COVID conditions” for the wide range of health consequences that can be present four weeks or more after infection. A World Health Organization definition adopted in February states that “post-COVID-19 condition” in children involves symptoms that began within three months of COVID-19 and last for at least two months.

According to the CDC, children appear to be less commonly affected by post-COVID conditions than adults, but estimates vary widely depending on how common the problem is.

How many children are affected by the long COVID?

“I would say that on average we’re looking at somewhere between 4% and 25% of children who had SARS-CoV-2 infection who continue to have symptoms of long COVID,” said Rao, who is also Associate Professor. at the University of Colorado School of Medicine. However, “this is a very difficult question to answer, simply because different groups explore this in slightly different ways, with different definitions.”

Rao led a study published last August in JAMA Pediatrics that used data from 659,286 children across the United States. Comparing those who tested positive for COVID-19 with those who did not, the study estimated the rate of long COVID at just under 4%.

De Ferranti, who is also an associate professor of pediatrics at Harvard Medical School, said that was likely a reasonable number. Some studies may have overestimated the prevalence because many children develop long COVID without having had visible symptoms of COVID-19, she said.

Likewise, long COVID experiences vary from child to child, de Ferranti said. “Some might have more heart issues, and others are more neurological or gastrointestinal.”

The American Academy of Pediatrics says long COVID can include up to 60 symptoms. And the list might not be the same for children and adults, Rao said.

Both groups suffer from headaches, fatigue, “brain fog”, difficulty concentrating and loss of taste and smell, she said. “But we also see additional unique characteristics in children.”

In his team’s work, rashes, diarrhea, abdominal pain and vomiting “appear to be somewhat more common in children”, who also appear to recover more quickly than adults. Older children are more likely to develop postural orthostatic tachycardia syndrome, or POTS, which can cause heart palpitations and dizziness, she said.

A rare condition called Multisystem Inflammatory Syndrome in Children, or MIS-C, which affects multiple organs can follow COVID-19. Researchers would consider it a post-COVID condition, Rao said, although it is also a separate disease.

“I think it’s a different animal,” de Ferranti said.

De Ferranti, who helped develop treatment advice on the long-running pediatric COVID and co-authored a 2022 American Heart Association scientific statement on the cardiac effects of coronavirus in children and young adults, said that ‘a good number of patients with long COVID do not have previous problems that would seem to make them vulnerable.

“These are usually healthy children who catch a virus and then experience a lot of fatigue, exercise intolerance or neurological symptoms,” she said.

De Ferranti said his patients had the same symptoms, such as chest pain or shortness of breath, that would have led parents to see a cardiologist before the COVID-19 era. Some worry about myocarditis, a rare heart inflammation that can follow a COVID-19 infection. (It can also follow vaccination, but research has consistently shown that the risk of infection is higher.)

Such issues can be serious, de Ferranti said, but there isn’t always a clear link to COVID-19. “While children can certainly have heart symptoms like palpitations, I don’t see an onslaught of significant and frightening new coronary artery problems or COVID-related arrhythmias or myocardial issues.”

Deconditioning, or weakness from having been absent from the activity, may be a factor for some of the young people she sees, she says. “Certainly when we get people back into activity in an organized way, they seem to get better. But I don’t think that’s the only factor. I don’t think they show up as sick because they don’t have everything. just haven’t done There’s something going on here that we haven’t fully described yet.

Mental health after COVID-19

Post-COVID mental health issues are “very common,” according to the AAP. And again, many factors can be at play.

“There has definitely been an association between patients who get COVID and then have mental health issues, including anxiety and depression,” Rao said. But it can be difficult to disentangle the cause, “because everything is happening in the context of what happened during the pandemic”, including school closures and social isolation.

Anxiety, she says, shows up differently in children than it does in adults. “A lot of kids who were seen in long COVID clinics were complaining of chest pain, but a little higher up in their chest – almost like pain in their throat, lower neck, upper chest or oppression. And it could be manifestations of anxiety.” Some had vocal cord issues, which may also be related to anxiety.

Physical and mental issues can interact, which is why de Ferranti said treatment for post-COVID conditions should include an assessment of mental health symptoms.

She and Rao agreed that the first professional a parent should see is their child’s pediatrician.

“It’s something that can run very broadly, and it’s something we’re learning more about,” Rao said. Starting with a primary care physician is “always a good idea to determine next steps to rule out other things that may not be related to long COVID.”

A family pediatrician can also help navigate the suite of specialists who can review specific issues and ensure everyone is on the same page, de Ferranti said.

Many large health care centers have long COVID pediatric clinics. De Ferranti said the RECOVER research project, supported by the National Institutes of Health, can direct families to clinical trials studying long COVID.

For prevention, the two doctors agreed on the potency of the vaccines. “Vaccines are very effective in preventing COVID infections and severe COVID infections,” Rao said. “So that means directly they will also reduce the risk of having long COVID.”

For those already struggling with the disease, de Ferranti advises perseverance and patience as researchers search for answers.

“Right now we’re still kind of new to the game,” she said. “We are still learning.”

News from the American Heart Association covers heart and brain health. Any opinions expressed in this story do not reflect the official position of the American Heart Association. Copyright is owned or held by the American Heart Association, Inc., and all rights are reserved.

By Michael Merschel, American Heart Association News

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