During a CDC Clinician Outreach and Communication Activity (COCA) Webinar.

“Post-COVID Conditions” is the CDC’s preferred term 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, an official CDC physician, 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 disturbance of smell and taste, palpitations, shortness of breath, cognitive fatigue or “brain fog,” and mental health problems such as depression. and anxiety. Fairly said.

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

Assessment of post-COVID conditions

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

The webinar presentations expanded on points in the “Multidisciplinary Collaboration Consensus Guidance Statement for the evaluation and treatment of post-acute sequelae of SARS-COVID-19 in children and adolescents.” The American Academy of Physical Medicine and Rehabilitation launched the collaboration in March 2021.

To begin, clinicians should look for evidence of a prior SARS-CoV-2 infection that matches symptoms of the post-COVID condition, such as a prior positive test; “clinical hallmarks” of COVID-19, such as loss of sense of smell or taste; or a “strong epidemiological link,” such as a person in the child’s household who tested positive for COVID-19, she said. Specific laboratory and imaging tests may be needed to exclude other diagnoses; however, physical exams and laboratory tests in pediatric patients are often normal, Vaz noted.

Assessments by Symptom Category

Amanda Morrow, MD, co-director of the Post-COVID-19 Pediatric Rehabilitation Clinic at the Kennedy Krieger Institute at Johns Hopkins University School of Medicine and Mt. Washington Children’s Hospital in Baltimore, co-author of the consensus statement, broke break the guide down 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 “worsening symptoms that may occur 12 to 48 hours after even mild physical, cognitive, or emotional exertion,” he said. Morrow.

In addition to physical activity, baseline nutrition assessment, including fluid intake, medications or supplements, and substance use in age-appropriate individuals, can help pinpoint other “potential contributors to or known medical causes of fatigue,” he added.

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

Often the “pattern of fatigue” in children can be similar in both conditions. Morrow noted that some children may not meet the 6-month threshold or “full criteria” for ME/CFS. The evaluation should include a complete physical examination including neuromuscular testing; possibly tests of physical function or endurance (eg, a 6-minute walk test, a 30-second sit-stand test); blood tests (eg, a complete blood count and iron panel); and a sleep study if there are any concerns regarding sleep apnea.

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

• Addressing medical causes of fatigue, for example, treating anemia with iron supplements
• Implement “lifestyle modifications” such as ensuring adequate nutrition, hydration, and sleep.
• Gradually increase physical activity or “pace” as tolerated, while remaining alert for possible post-exertional discomfort.

Patients often require a multidisciplinary approach that takes advantage of a variety 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, can also help with fatigue.

Autonomic Dysfunction/Postural Orthostatic Tachycardia Syndrome (POTS)

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

he diagnostic criteria for POTS, according to a 2019 NIH expert consensus meeting, include:

• A sustained heart rate of not less than 30 beats per minute after 10 minutes of standing for adults or at least 40 beats per minute for children and adolescents 12-19 years of age.
• Lack of orthostatic hypotension.
• Common orthostatic symptoms

These symptoms must occur for at least 3 months in the absence of other conditions that might explain them, Morrow noted. Screening for POTS often requires more than bedside orthostatic vital signs “since you’re looking for a sustained change in heart rate,” she said. However, a 10-minute passive standing test can be performed in a clinical 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 detect joint hypermobility with the beighton scale,“Because Ehlers-Danlos syndrome often co-occurs with POTS,” Morrow said.

Even in children who do not meet full criteria for POTS, if orthostatic symptoms or intolerance are noted, Morrow still recommends treatment, beginning with lifestyle interventions, including:

• Increase fluid intake (2-3 l) and salt (4-6 g)
• leverage POTS-specific exercise protocols, with modifications for patients with post-exertional discomfort
• Wear compression garments
• Elevate the patient’s head at night.
• “Physical countermeasure maneuvers” such as crossing your legs and tensing your muscles

“Have [seen] some patients with complete resolution of POTS symptoms simply with lifestyle interventions,” Morrow noted. Currently, there are no FDA-approved drugs for patients with POTS. However, beta-blockers can be used to reduce the frequency heart failure; fludrocortisone can help expand blood volume and midodrine can be used to increase vasoconstriction.

Respiratory/lung symptoms

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

A “basic diagnosis” may include pulse oximetry (both at rest and while walking), while chest X-rays and spirometry before and after the bronchodilator may also be helpful, Malone noted. Malone and her colleagues have found that many children do not have severe, acute COVID infections, but “additional testing” may be needed for children who do.

Regarding treatment, he noted that most symptoms resolve over time, however, some patients may be newly diagnosed with “reactive airway disease” or asthma, and may “benefit from testing with bronchodilators,” Malone said.

Patients may also benefit from a referral to an ENT or SLP/Speech Pathologist if “vocal cord dysfunction” is suspected. Breathing exercises can also 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 to last 2-3 months. after an infection.

For the treatment of dyspepsia, a test with acid blockers can be used. Also, since many children’s symptoms seem to resemble irritable bowel syndrome, a probiotic trial can be helpful, in addition to identifying and avoiding triggers, such as certain foods or stress. An appetite stimulant could also be beneficial among these patients, Malone said.

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