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Suspected Long COVID-19 (case definitions, risk factors)
CDC case definition:1 - Umbrella term for wide range of health consequences that are present ≥4wk after SARS-CoV-2 infxn
- The ≥4-wk time frame provides a rough approximation of effects that occur beyond the acute period, but timeframe might change as more learned about condition
- Post-COVID conditions can occur in pts who’ve had varying degrees of illness during acute infxn, incl those w/ mild or asymptomatic infxns
WHO definition:2 - Post-COVID-19 conditions occur in individuals w/ hx of probable or confirmed SARS-CoV-2 infxn, usually occurring 3mo from onset of COVID-19 sx and lasting ≥2mo; can’t be explained by an alternative dx
- Common sx incl fatigue, SOB, cognitive dysfxn, plus others; generally have an impact on everyday functioning
- Sx may be new onset following initial recovery from acute COVID-19 episode or persist from initial illness
- Sx may also fluctuate or relapse over time
Potential risk factors for long COVID in children:3 - older age
- female gender
- Hx allergic dz
Nonetheless, recent observational studies suggest that COVID-19 vaccination may protect against development of long COVID4-7 Synonyms: Long COVID is referred to by a wide range of terms, including:1 - Post-acute sequelae of SARS-CoV-2 infection (PASC)
- Post-COVID conditions
- Post-acute COVID
- Long-term effects of COVID
- Post-acute COVID syndrome
- Chronic COVID
- Long-haul COVID
- Late sequelae
Footnotes 1 CDC 2021. Evaluating and Caring for Patients with Post-COVID Conditions: Interim Guidance. Updated 6/14/21. Accessed 3/10/22
2 WHO 2021. World Health Organization. Soriano JB, et al. A Clinical Case Definition of Post COVID-19 Condition by a Delphi Consensus. Lancet Infect Dis. 2022. Apr(22(4):e102-e107. Accessed 3/10/22
3 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
4 Cabrera Martimbianco AL, et al. Frequency, signs and symptoms, and criteria adopted for long COVID: a systematic review. Int J Clin Pract. 2021. Oct;75(10):e14357. Free full-text article
5 Zisis SN, et al. The Protective Effect of Covid-19 Vaccination on Post-acute Sequelae of Covid-19 (pasc): A Multicenter Study From a Large Health Research Network. Open Forum Infect Dis. 2022. May 7;ofac228. Free full-text article
6 Ayoubkhani D, et al. Trajectory of Long Covid Symptoms After Covid-19 Vaccination: Community-Based Cohort Study. BMJ. 2022. May 18;377:e069676. Free full-text article
7 Ayoubkhani D, et al. Risk of Long Covid in people infected with SARS-CoV-2 after two doses of a COVID-19 vaccine: community-based, matched cohort study. Open Forum Infect Dis. 2022. Sep 12. ofac464. Free full-text article
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Initial assessment (general) Dx is clinical. Neg SARS-CoV-2 Ag or Ab test may not r/o PASC1 - Consider antinucleocapsid Ab test in vaxxed pts. A strong epidemiological link (2 positive close contacts) or distinctive clinic features (anosmia/ageusia) w/o alt dx may be considered evidence of prior infxn
- Use initial eval to guide need for additional considerations and specific tx options based on findings1
- Per AAP, if sx persist >12wk and/or are impacting pt’s ability to perform normal activities, then perform additional dx testing & consider referral to a multidisciplinary pediatric post-COVID-19 clinic or subspecialist based on most problematic s/sx2
Exclude other dx: - Screen all youth w/ PASC for mental health sx2
- AAP recommends also screening parents for well-being, perinatal depression, & intimate partner violence2
- Consider that psychosomatic sx (pain, appetite changes, irritability, sleep disturbances) may be linked to anxiety2
- Don’t assume sx are all related to a somatic d/o and perform thorough investigation into any newly emerging physical sx
Most commonly reported PASC sx: fatigue, HA, stomach/abdo pain, muscle aches, post exertional malaise, and rash2 Red flags on hx:1 prolonged T>100.4F for >10 days, wt loss, vomiting, or HA at night/early am, developmental regression, focal weakness, sensory changes, syncope, chronic cough Red flags on exam:1 focal neuro deficit, extracervical nodes >2 cm, hepatosplenomegaly, joint swelling/redness, cardiac murmurs Eval1 - Inciting event. Ask for description of acute SARS-C0V-2 infxn
- Characterize sx. Note presentation, duration, pattern, frequency, and interventions or behaviors that lead to improvement/worsening for each sx, incl past tx & responses
- Limitations. Note factors that limit activity, cause fatigue
- Functional limitations. Compare current level of fxn to baseline, incl mobility, ADLs, school, work, sports, hobbies, etc
- Obtain PMHx, fam Hx, & soc Hx
- Perform comprehensive PE: Findings may be NL
- Tests: Labs may be NL. If checked w/in 6mo may not need repeat. Target other testing based on sx as outlined in sx eval & mgmt
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
2 AAP 2022. AAP Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic. Last updated 9/10/22. Accessed online 11/29/22
Systemic/Constitutional (fatigue/exercise intolerance, sleep disturbance
Fatigue/exercise intolerance Fatigue and physical activity/EI are common1 - Mobilize pts w/ physical activity intolerance in a timely fashion to minimize lasting effects of decreased activity or poor exercise tolerance
- Some pts may meet criteria for myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS)1
- Individualize physical activity program w/ graduated exercise approach. Multidisciplinary approach may be helpful. Consider referral to rehab medicine2
Hx and sx assessment2 - Screen for baseline level of physical activity pre-COVID infxn
- Characterize pattern of fatigue & sleep habits
- Eval for post exertional malaise (worse sx 12-48h after mild cognitive/physical exertion)
- Assess degree of EI w/ modified pediatric Borg or OMNI rating of perceived exertion scales
- Assess nutritional status
- Review meds, incl vit/supplements that may contribute to fatigue
- Screen for substance abuse when age appropriate
- Screen for other causes of fatigue
Eval2 - Full exam w/ neuromuscular exam & provocative tests specific to any areas of pain
- If dizzy/lightheaded: Perform orthostatic vitals
- Consider formal physical fxn and endurance tests (eg, 6-min walk test, 30-sec sit-to-stand test)
- Labs: CBC, CMP, TSH/T4, iron panel, ferritin, vit D. Consider mag, vit B12, ESR/CRP, celiac screen based on sx. If assoc cardiopulmonary sx: Consider BNP, ECG, echo, cardiopulm exercise test, pre/post exercise PFTs, CXR
Interventions2
- Meds: Treat any known causes of fatigue/EI (eg, iron for anemia, pain meds/modalities for MSK pain)
- Optimize nutrition, hydration, sleep
- Physical activity: advance slowly as tolerated w/ focus on pacing and avoiding sx exacerbation or post-exertional malaise. AAP recommends consistent daily routine & gradual 𐰹activity spread throughout day.3 Consider PT referral +/or multidisciplinary post-COVID clinic consult, esp if significant exac of sx after activity (“push and crash” cycle)3
Referrals2 - Pediatric Rehabilitation Medicine for overall mgmt & rehab recommendations
- PT for oversight of individualized activity/exercise program w/ focus on pacing. Additional goals incl improving ROM, strengthening, endurance, mobility & safe ambulation. If tolerated, advance to higher levels of resistance training & aerobic exercise
- OT for those w/ EI w/ ADLs or minimal exertion to focus on an individualized plan for facilitating modified ADLs
- Complementary therapies (eg, acupuncture, yoga, Tai Chi, massage, meditation as adjunct to traditional tx)
- Mental health specialist for strategies to cope w/ physical sx and/or if any concerns for comorbid mood conditions
- Other subspecialists if concerns for cardiac, pulmonary, neuromuscular, or rheumatologic cause of fatigue or EI
Footnotes 1 ME/CFS is dx of exclusion characterized by profound fatigue occurring for >6mo w/ significant impairment in day-to-day fxn including physical, school performance, and extracurricular activities.
2 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
3 AAP 2021. American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. Updated 12/17/21. Accessed 3/10/22
Common sx incl insomnia, difficulty w/ sleep maintenance, restless leg syndrome, sleep apnea, hypersomnia/excessive daytime sleepiness1 - Unclear if sleep difficulties are d/t COVID-19, related to other psych or medical conditions, a product of increased psychosocial distress, or combo of factors
- Insufficient sleep may be assoc w/ mood changes, impaired attention and concentration, and decreased immune response
- Start tx w/ behavioral interventions
Eval1 - Ask about meds or other substances that may interfere w/ sleep
- Ask parents to keep sleep diary for review
- Tests: TSH, ferritin, PSG to eval for sleep apnea if am HA, snoring, frequent awakenings or concern about sleep-related movement d/o. Actigraphy if concern about total sleep time and diary not done. Consider smart watch if formal test n/a
Interventions1
- Behavioral: sleep hygiene and consist sleep schedule. Limit screen time for 30-60min before bed
- Meds: Consider melatonin to reset circadian rhythm only if behavioral interventions fail. If treating comorbid conditions (HA, mood d/o): Consider agents that might help w/ sleep
- Referrals: Psych/therapy for CBT for insomnia if behavioral interventions insufficient and/or comorbid mental health concerns. Sleep med specialist if PSG abnl
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Psychiatric (anxiety, depression, suicidality, PTSD, school avoidance) Anxiety is common. If hx of social anxiety, sx may recur upon return to school after prolonged absence. Monitor school avoidance. Adolescents w/ disabilities may have differential impacts related to anxiety, esp if minoritized racial/ethnic group, warrant close screening, monitoring1 Eval: Use valid scales1 - Age 12+ yo: GAD-7 indicates severity
- Age 5-17 yo: PROMIS Pediatric Item Bank V2.0-Anxiety can be converted to T-score to indicate severity
- Age 8-18 yo: SCARED scale helps distinguish type of anxiety sx
Interventions1 - If significant dysfxn in daily life and mild-mod anxiety scale score: Consider referral to psychotherapy. AAP recommends mindfulness and reframing2
- If significant dysfxn in daily life supported by mod-severe score on anxiety scales: Consider trial of SSRI. Discuss w/ parent/guardian b/c few meds FDA approved in youth
- Consider referral to evidence-based tx (eg, CBT or exposure/response prevention)
- Refer to psych if no improvement after SSRI trial x2 or complicated w/ other psych dx
- Support children & adolescents who are sub-threshold for dx or are otherwise not being referred to mental health w/ common factors approaches3 & brief interventions provided in primary care4
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
2 AAP 2022. AAP Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic. Last updated 9/10/22. Accessed online 11/29/22
3 AAP 2021. HEL 2P 3 mnemonic (Hope, Empathy, Language, Loyalty, Permission, Partnership and Plan) to operationalize family-centered techniques to build a therapeutic alliance w/ parents & children & facilitate communication. Resources for these approaches & guidelines for managing conditions such as ADHD & depression in the primary care setting are available. Children who do not respond to these interventions or have a significant change in functioning should be referred for additional support.
American Academy of Pediatrics. Practice Tools. Mental Health. Common Factors Approach: HEL 2P 3 to Build a Better Alliance. Addressing Mental Health Concerns in Pediatrics: A Practical Resource Toolkit for Clinicians, 2nd Edition. 2021. Accessed online 11/29/22
https://downloads.aap.org/AAP/PDF/mhtk2e_commonfactorsapproach.pdf
4 Foy JM, et al. Committee on Psychosocial Aspects of Child and Family Health, Mental Health Leadership Work Group. Mental Health Competencies for Pediatric Practice. Pediatrics. 2019. Nov;144(5):e20192757. Free full-text article
ED visits for SI and attempts in adolescents in U.S. have increased since 2020, esp adolescent females - In addition to screening for depression, screening for suicide may improve the detection of this often-hidden risk
- Resources for families on suicide prevention should be shared widely, even in the absence of screening
- May be assoc w/ uncharacteristic behavior changes (eg social withdrawal, irritability)1
Eval: Use valid scale2 - PHQ-9 – has SI question. Be prepared w/ plan if positive score
- Ages 5–17 yo: PROMIS Pediatric Item Bank v2.0–Depressive Symptoms: brief screening scale that can be converted to T-scores to indicate severity
- CES-DC scale
- ASQ for SI
Interventions2 - If SI: urgent consult w/ mental health specialist
- If imminent risk of harm to self: Refer to ED/crisis intervention service/inpt psych unit
- If significant dysfxn in daily life and mild-mod anxiety scale score: Consider referral to psychotherapy
- Make safety plan
- Consider outpt program/partial hospital program based on acuity and risk level
- If significant dysfxn in daily life supported by mod-severe score on depression scales: Consider trial of SSRI. Discuss w/ parent/guardian b/c few meds FDA approved in youth
- Consider referral to evidence-based tx (eg, CBT, behavioral activation)
- Refer to psych if no improvement after SSRI trial x2 or complicated w/ other psych dx
Footnotes 1 AAP 2022. AAP Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic. Last updated 9/10/22. Accessed online 11/29/22
2 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
PTSD is common in adults w/ PASC, but rate unknown in children1 - May be increased in those w/ hx of hospitalization, PICU, multiple procedures1
- May also be assoc w/ maltreatment which increased during pandemic1
- Use open-ended surveillance questions to identify if children have experienced COVID-19 or other traumas; consider use of trauma sx screening tools to help assess presence and severity of sx1
Eval: Use valid scale2 - UCLA PTSD Assessment Tool
- CAPS-CA-5 PTSD Scale for DSM-5-Child/Adolescent Version
Interventions2 - Investigate for possible traumatic events, incl trauma sx following inpt admit or medical procedures
- Assess for child maltreatment (physical, emotional, sexual abuse and neglect)
- Refer to trauma-focused CBT
- Consider psych referral if pt meets criteria for PTSD
- Report any suspicion for abuse to CPS
Footnotes 1 AAP 2022. AAP Interim Guidance on Supporting the Emotional and Behavioral Health Needs of Children, Adolescents, and Families During the COVID-19 Pandemic. Last updated 9/10/22. Accessed online 11/29/22
2 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Eval: Use valid scale1 - If ADHD suspected: Consider Vanderbilt ADHD Diagnostic Rating Scale (VADRS)
- Assess level of support at school and presence of section 504/ individualized education program plan
- Assess for anxiety, depression, attention, or learning issues
- Obtain feedback from school (counselor, teachers, support staff, nurses)
Interventions1 - Communicate w/ school to establish support for child (may increase likelihood of successful reintegration)
- Support accommodations at school in favor of ongoing attendance, even if initially only partial attendance. May need to modify educational goals
- Consider inclusion of academic, social, and/or physical comfort measures as well as exec functioning and cognitive endurance measures in the plan
- Refer to therapy for additional assessment of school support measures and school avoidance behaviors
- Consider neuropsych testing to assess level of cognitive/exec functioning deficit
- If learning difficulties/poor academic performance leading to avoidance: Consider academic testing
- If comorbid anxiety, depression, ADHD, somatic sx d/o: Refer to child psych
- If fxn highly affected: Consider referral to a higher level of care (eg, partial hospitalization program or inpt admit)
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Autonomic dysfunction/POTS POTS is chronic d/o of autonomic nervous system characterized by orthostatic sx (fatigue, lightheadedness/dizziness in upright positions, brain fog, EI, post exertional malaise, HA, GI sx, heart racing, palpitations, heat intolerance, hyperhidrosis).1,2 May overlap w/ somatic sx of anxiety, depression2 Eval2 - Screen for mood concerns, hypermobility (EDS is common comorbidity). Perform echo if concern for EDS
- Check orthostatic vital signs, 10-min standing test or refer for tilt testing
- Labs: CBC, CMP, ferritin, vit D, vit B12, ESR, CRP, TSH
Interventions2 - Lifestyle mgmt: hydration (2-3L/day for 40-kg pt) w/ salt intake (4-6 g/day). Physical activity w/ pacing: Start w/ recumbent. Progress to more upright as tolerated. Progress slowly in time & intensity to avoid exacerbating sx or triggering post exertional malaise. Consider compression garments (20-30 mmHg). Elevate HOB 4-6 in. Physical counter measures (crossing legs, tensing muscles, etc). School accommodations
- Meds: Rx if physical measures fail. 1st-line: beta blocker to lower HR, fludrocortisone to expand blood vol, midodrine to increase vasoconstriction
- Refer to PT to supervise physical activity program. If life style and 1st-line meds not enough, refer to POTS specialist. Cards if palps/CP predominate sx
- Consider EDS if joint hypermobility plus abnl echo, strong fam hx, skin involvement; refer to genetics
Footnotes 1 NIH 2021. POTS definition, per 2019 NIH Expert Consensus Meeting, criteria include:
• A sustained HR increment of ≥30 bpm w/in 10min of standing; for age 12–19 yo, the required HR increment is ≥40 bpm.
• An absence of orthostatic hypotension
• Frequent orthostatic sx
• Duration of sx for ≥3mo
• Absence of other conditions explaining sx
Vernino S, et al. Postural orthostatic tachycardia syndrome (POTS): State of the science and clinical care from a 2019 National Institutes of Health Expert Consensus Meeting – Part 1. Auton Neurosci. 2021. Nov;235:102828. Free full-text article
2 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Neurological (cognitive sx, headache) Includes attention difficulties, memory problems, word-finding difficulties, trouble concentrating, “brain fog,”1 declining school performance2 - Use neuropsych eval to determine level & types of school supports & to inform therapeutic approaches1
- A brief, targeted neuropsych eval (eg, concussion model) is appropriate for most pts (except those w/ preexisting developmental disability or neuro dz)
- Don’t delay cognitive assessment until sx severely impair fxn d/t increased risk for additional comorbidities and prolonged recovery2
Eval2 - Use validated tools & objective measures. For changes to cognition: PROMIS Parent Proxy Short forms. Increased academic difficulties/declining school grades. Observable changes in the home and community settings or functional decline (World Health Organization Case Report Functional subsection). ADHD sx (Vanderbilt ADHD Diagnostic Rating Scale). Anxiety and mood sx (eg, Patient Health Questionnaire-9, Generalized Anxiety Disorder Scale-7, and pediatric sx checklist)
- Perform full neuro exam. Eval for exacerbating conditions (sleep, fatigue, endocrine, autoimmune, mental health, psychosocial stressors)
- If developmental regression or focal deficits: Order brain MRI & refer to pediatric neuro specialist
Interventions2 - Treat comorbid conditions. Wean off contributing meds
- Lifestyle modifications (regular sleep & meals, consistent sleep/wake schedule w/ daily activities,1 good hydration, stress mgmt, regular exercise. Assess impact of return to daily activities & exercise. Avoid EtOH/drugs1
- School accommodations w/ goal of reducing as sx improve. Tailor based on neuropsych tests
- Refer for brief/targeted neuropsych eval: if significant change in cognitive status, persistent fxn impairment,1 accommodations still needed after 1-2mo, or hx of ICU admit or MISC
- Refer for comprehensive neuropsych eval: if premorbid med/developmental concerns, accommodations still needed after 6 -12mo and brief eval
Footnotes 1 AAP 2021. Sx may include “fuzzy thinking,” inattention, forgetfulness, slow processing/reading; may need repetition to learn or have lower endurance or higher need for breaks during cognitive tasks.
American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. Updated 12/17/21. Accessed 4/13/22
2 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Common sx in children w/ PASC1 - If abnl neuro exam or hx concerning for CNS dz: Perform prompt neuroimaging1
- Consider HA multifactorial. No primary HA type identified1
- Post-COVID-19 HA may be related to situational factors (eg, change in routine, med overuse, changes in sleep hygiene, poor hydration and/or nutrition, lack of aerobic exercise, and other stressors)2
If red-flag sx present, refer for urgent neuroimaging & to pediatric neuro:1 - positional HA (worse when lying flat)
- HA wakes child from sleep
- focal neuro sx
- worsens w/ strain (coughing, sneezing)
- recurrent vomiting w/o nausea
- worsening visual sx
Eval1 - Screen for red-flag sx
- Review med list for contributing meds
- Full neuro exam w/ fundoscopic exam if visual changes. Consider vision exam for eye strain that might be contributing
- Consider sleep study if am HA, frequent night awakenings, snoring, pauses while breathing
Interventions1
- Lifestyle modifications (eg, regular sleep, regular meals, good hydration, regular exercise, and stress mgmt)
- Targeted intervention for contributing comorbidities: sleep disturbances (eg insomnia, sleep apnea), anxiety, depression, POTS
- Counsel on the neg effects of med overuse (incl APAP or ibuprofen) (>3x/wk) and rebound HA
- Consider an abortive regimen for more severe HAs (eg, APAP or ibuprofen w/ antinausea med and water or sports drink). Avoid use of abortive regimens >3x/wk regularly)
- Consider a daily preventative med if HA are predominant sx and interfering w/ daily activities. Consider comorbid sx in med choice. Topiramate might worsen brain fog, amitriptyline might worsen orthostatic intolerance but could tx other nerve-pain related sx. Propranolol for POTS. Cyproheptadine for sleep disruption/abdo pain/appetite stimulation. Duloxetine for anxiety
- Consider vitamin supplementation (eg, magnesium, melatonin, coenzyme Q10, riboflavin). Melatonin can be beneficial for sleep and HA
- Consider nonpharmacologic tx (eg yoga, acupuncture, relaxation therapies w/ deep breathing exercises) esp for those w/ sensitivity, resistance, or inability to tolerate meds
- Refer to a pediatric neurologist or HA specialist if the 1st or 2nd trial of daily preventative meds is ineffective
- Refer to pediatric ophthalmologist if visual changes
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
2 American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. Updated 12/17/21. Accessed 4/13/22
Respiratory (SOB, cough, wheezing, chest pain) Have low threshold for referral to pulmonologist1 - Preexisting asthma is risk factor for PASC
- Immunosuppressed children may have higher risk for developing postacute lung damage
- Consider functional resp d/o (eg, hyperventilation, sighing dyspnea) esp in setting of anxiety
- Inducible laryngeal obstruction (ILO)/paradoxical vocal fold movement (PVFM), if tightness in the throat and inability to get air in that’s unresponsive to bronchodilators
- Less common manifestations incl bronchiectasis/postinfectious scarring, pulmonary fibrosis (more common if severe initial illness), or rarely postinfectious bronchiolitis obliterans (PIBO)
Eval1 - Assess sx frequency, activity limitations, hx of prior resp illness, exposures
- Tests: pulse ox (at rest and w/walking), CXR (per AAP, if persistent pulm sx or hx of abnl imaging),2 spirometry/PFTs if >6 yo w/ persist sx.2 If dyspnea, 6-min walk test or 1-min sit-to-stand test. If hx of abln CXR or use of supplemental O2 during acute COVID illness: Consider diffusing capacity for CO. If findings on lung exam: Consider body plethysmography
- Per AAP, 1st do CV/pulm eval (heart dz, PE, etc), then ✓ CPET for persistent exercise-induced dyspnea.1 If cough >12wk: Pursue additional tests +/or multidisciplinary post-COVID clinic consult2
Interventions1 - If hx of asthma: Optimize tx per asthma guidelines
- If no hx of asthma, but bronchodilator responsiveness: Consider bronchodilators and steroids, per asthma guidelines. Don’t use cough/cold meds in children <4 yo3
- If flattened inspiratory loop, hx of throat tightness, inspiratory stridor: Refer to ENT/speech for eval of PVFM/ILO and treat w/ breathing exercises
- If consolidation on CXR after acute COVID infxn: Consider chest CT, short course PO steroids, bronchoscopy
- If no hx of asthma w/ NL exam and tests: Reassure that most sx improve over time. Consider breathing exercises for breathlessness. Assess for mental health concerns
- If ongoing/persist sx or abnl tests: Refer to pulmonology. If pt w/ significant dyspnea or EI w/ documented SpO2<93% at rest or decrease of 3% w/ exercise: Consider trial of supplemental O2
- Refer to cardiology if concerns for cardiac cause
- Refer to PT for deconditioning
- Refer to pain mgmt if cardioresp causes ruled out & pain still impedes fxn
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
2 AAP 2021. American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. Updated 12/17/21. Accessed 3/10/22
3 AAP 2018. American Academy of Pediatrics. Choosing Wisely. Cough and Cold Medicines Should Not Be Prescribed, Recommended or Used for Respiratory Illness in Young Children. Released 2/21/13. Updated 6/12/18.
Cardiac (chest pain, palpitations, dizziness) Exclude myocarditis, pericarditis, heart failure, & arrhythmias (all rare)1 - Signs/sx concerning for cardiac etiology include: CP w/ exercise, radiation of pain to neck, jaw, or down arms, and/or CP accompanied by dizziness and/or LOC
- Refer to cardiology for these sx. Resp CP often accompanied/preceded by cough/wheezing/dyspnea
Eval1 - Check for chest wall tenderness. Perform orthostatic vitals. If dizziness: Screen for gait/balance disequilibrium (ie, vestibular dizziness)
- If palpitations: Check fam hx of SCD or deafness (genetic prolonged QT syndrome)
- Tests: ECG, troponin, CXR, echo. If palpitations: TSH. Consider Holter/event monitor. Distinguish sinus tachy assoc w/ autonomic dysfxn/acute illness from abnl cardiac rhythm w/ EKG or other monitoring technology
Interventions1 - If cardiac etiology suspected: Restrict activity. Refer to cardiology
- In others: Increase fluids, gradual return to activity
- If vertigo: Refer for vestibular tests and consider vestibular PT. If concern for vestibular migraines: Refer to neuro
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
ENT (anosmia/hyposmia, ageusia/dysgeusia) COVID-19 infxn can cause a range of smell and taste disturbances that last beyond the acute infxn1 - As many as 1 in 4 children 10 -19 yo develop anosmia2
- In very young children, may manifest as reduced oral intake, change in feeding behaviors, gagging/avoidance of previously tolerated food2
- Loss of smell is generally not assoc w/ concurrent nasal sx (eg, congestion, obstruction, rhinorrhea, d/c). If concurrent sinonasal sx, then perform further eval for other causes of smell disturbance1
- Observation is 1st-line strategy since most peds COVID-related loss of smell resolves w/in 3-6mo. Imaging not recommended for isolated loss of smell/taste1
Eval1 - Perform anterior rhinoscopy. Refer to ENT for smell testing. Objective (age dependent: Sniffin’ sticks, ped smell whell, UPSIT) more reliable than subjective (SNOT-22, Questionnaire of Olfactory Disorders)
- Indications for nasal endoscopy: assoc nasal sx to r/o masses, polyps, mucopurulence, inflammation. Isolated loss of smell/taste >4wk w/o assoc nasal sx
Interventions1 - If loss of smell/taste >2wk after resolution of other covid sx: Consider olfactory training.1 Oral steroids optional
- If loss of smell/taste >2wk w/ assoc nasal sx: Consider intranasal steroids
- No evidence for vit A drops, omega-3 supps, alpha-lipoic acid
- Refer to ENT if isolated loss of smell/taste >3mo or >4-6wk w/ assoc nasal sx. Refer to neuro if assoc neuro sx
- Ensure nutrition, which may suffer d/t dysgeusia3
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
2 AAP 2021. American Academy of Pediatrics. Post-COVID-19 Conditions in Children and Adolescents. Updated 12/17/21. Accessed 3/10/22
3 Examples of training programs or websites: Abscent, Fifth Sense
Musculoskeletal (muscular, joint, generalized weakness) Perform motor and sensory exam w/ consideration of specialized joint testing if needed1 - Evidence of joint inflammation w/o inciting injury should prompt further rheumatologic w/u
- Mechanisms for pain in PASC are unclear, but some data suggest similarities to fibromyalgia
- Juvenile fibromyalgia characterized by chronic widespread pain & assoc sx of fatigue, nonrestorative sleep, cognitive sx, HA, abdo pain, and depressed mood & share overlapping characteristics w/ ME/CFS
Eval1 - Assess for comorbid sleep and mood disturbances, fatigue, orthostatic sx, & joint hypermobility seen w/ fibromyalgia. Assess for fam hx, incl pain d/o (eg fibromyalgia, rheumatologic conditions)
- Review meds for causes of medication-induced myopathy (eg, rheumatologic agents, antifungal agents, statins, etc)
- Perform complete neuro and MSK exam w/ specialized joint tests prn. Eval for hypermobility w/ Beighton score. If concern for fibromyalgia: manual painful point survey
- If concern for septic/reactive arthritis: Perform joint aspiration. If warmth/swelling/redness of joint: Consider imaging. ESR/CRP, CBC, Chem if pattern concerning for autoimmune/rheum cause
- If muscle weakness: CL and UA to eval for rhabdo
Interventions1 - Lifestyle modifications: Optimize nutrition and sleep. Address mental health concerns. Establish good social support system
- Physical activity/exercise: tailored individual approach w/ PT/OT. Gradual increases and pacing strategies to avoid post exertional malaise. Treat w/ ice/heat, myofascial release, transcutaneous elect stim, desensitization, etc
- Meds: topical NSAIDs, lidocaine. Use APAP/Ibuprofen sparingly to avoid side effects/overuse. If concern for costochondritis: Consider short course of NSAID. Rarely for fibromyalgia that failed other measures: Consider antiepileptics, SSRI, SSNRI, TCAs, esp if comorbid sx (mood, sleep, HA)
- Refer to psych for CBT & pain-coping strategies. Refer to neuro if concerns for myositis or neuropathic pain. Refer to rheum for autoimmune conditions, incl arthritis. Refer to physiatry/ortho if concern for comorbid injuries, joint integrity, or alignment
- Consider complementary tx for pain (acupuncture, yoga, massage, meditation, biofeedback, chiropractic, etc in age-appropriate groups)
- If conservative measures & outpt tx fail: Consider acute inpt rehab for multidisciplinary approach w/ focus on improving fxn and independence
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
Weakness may present as fatigue, refusal to move, motor impairment, irritability, and lethargy, esp in young children1 - Determine true weakness vs exercise intolerance (EI) or fatigue/malaise by careful PE
- If focal weakness or proximal vs distal weakness: Refer to neuro
- Weakness w/ diminished/absent reflexes in the setting of recent viral infxn is concerning for Guillain-Barré syndrome, acute flaccid myelitis, or other peripheral neuropathies & urgent tx may be needed
- Otherwise, manage as EI, deconditioning, fatigue/malaise (see section on Fatigue/EI)
Eval1 - Review meds (eg prolonged steroid use can cause painless steroid myopathy)
- Perform full MSK and neuro exam w/ complete manual muscle testing for strength if able to follow directions and >5 yo developmentally. Otherwise observe for asymmetries in use of arms/legs, ability to change position, stand, move, and the need for assistance
- If weakness w/ myalgias/urine color change: Check CK and UA for rhabdo. If CNS cause suspected/focal weakness:Order MRI of brain/spine
Interventions1 - If true neuro weakness/sensory deficits: urgent referral for imaging & neurology
- All others, tailored individual approach w/ graduated physical activity w/ PT/OT supervision. Goal: improve mobility and strength
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
GI (abdominal pain, N/V, chronic diarrhea, anorexia, reflux/indigestion) Common sx in PASC incl abdo pain, diarrhea, N/V, & loss of appetite1 - Sx such as chronic diarrhea & nausea have been reported to last for 2–3mo after recovering from initial illness
- Presence of abdo pain, N/V don’t seem to be assoc w/ dz severity
- Mgmt is sx-based
Red flags1 - wt loss
- hematemesis
- bilious emesis
- growth deceleration
- focal abdo pain vs periumbilical or nonspecific pain
- hematochezia
- fam hx of IBD/celiac
- significant diarrhea
Eval1 - Tests: CBC, celiac serology (total IgA, tissue transglutaminase IgA) ESR, CRP, LFTs, amylase, lipase, UA, fecal calprotectin. TSH if poor appetite
- If chronic diarrhea: occult blood, infectious stool studies; if bloody: Send cx for salmonella, shigella, campylobacter, Yersinia, E coli and C diff; if non-bloody: Giardia antigen
- If RUQ pain or abnl LFTs: abdo US. If vomiting/significant regurgitation: upper GI
- Consider GI consult for endoscopy
- If diarrhea w/ elevated fecal calprotectin: Consider colonoscopy
- If poor appetite: Screen for depression, eating d/o
Interventions1 - If red flag sx, abnl labs, bloody stool or persistent sx: Refer to pediatric GI specialist
- If concern about psychosocial stressors or poor fxn (eg missing school): Refer to psych/social work. Consider dietician if related to food
- For abdo pain: Consider tx of constipation w/ PEG; if dyspepsia/reflux: Trial of H2 blocker/PPI; if IBS/functional abdo pain: Consider trial of probiotics and identify triggers
- For N/V: Consider trial of H2-blocker/PPI
- For chronic diarrhea: Consider probiotics, lactose-free diet or increasing fiber intake
- If concern for gastroparesis: Consider trial w/ prokinetic or cyproheptadine
- For poor appetite: Consider appetite stimulant (eg cyproheptadine) or trial of H2-blocker/PPI
Footnotes 1 AAPM&R 2022. Malone, LA, et al. Multi-disciplinary collaborative consensus guidance statement on the assessment and treatment of postacute sequelae of SARS-CoV-2 infection (PASC) in children and adolescents. PM&R. 2022. Oct;14(10):1241-1269. Free full-text article PDF
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