Physiatrist Group Issues First Guidelines for Long COVID in Children

Alicia Ault

September 29, 2022

Editor's note: Find the latest long COVID news and guidance in Medscape's Long COVID Resource Center.

Working with physicians from multiple specialties, the American Academy of Physical Medicine and Rehabilitation (AAPM&R) has issued the first set of guidelines related to the diagnosis and treatment of pediatric patients with long COVID.

The physiatrist organization also issued separate guidance for individuals with long COVID who are experiencing autonomic dysfunction.

The pediatric guidance is, according to the group, the first official set of recommendations for children who have long-term effects after being infected with the SARS-CoV-2 virus.

Although much is still unknown about which children may be at higher risk for post-infection problems, it appears that they're usually older and often female, said Amanda Morrow, MD, a principal co-author of the pediatric guidance and a rehabilitation physician who treats children at the Pediatric Post-COVID-19 Rehabilitation Clinic at Kennedy Krieger Institute in Baltimore, Maryland.

Speaking at a media roundtable, she said 6%-60% of children who have been infected also have long COVID, citing the wide range of estimates for the condition. More than 14.7 million children have tested positive since the pandemic began, according to the American Academy of Pediatrics.

Children with long COVID most commonly experience extreme fatigue, attention or concentration problems, headache, light-headedness, sleep issues, persistently elevated temperatures, and anxiety and depression, Morrow said.

The 29-page guidance statement has detailed recommendations on how to assess whether children have long COVID. It also details a variety of treatments — many of them nonpharmacologic — for symptoms.

The main treatment goal is to get children back to school, extracurricular activities, and socializing, all of which are important to a child's development, Morrow said.

The hope is that the statement will "improve recognition and awareness," she said, noting that the earlier doctors can intervene in long COVID, the more likely they are to have success. "Some of these energy conservation strategies are very easy to implement and are really important early on."

Concerning fatigue, for instance, the guidance urges optimizing nutrition, hydration, and sleep, and slowly advancing physical activity with a focus on avoiding postexertional malaise.

Similar recommendations are made for autonomic dysfunction in children, with a focus on hydration (2-3 liters of noncaffeinated fluid per day), limiting salt intake to less than 6 grams per day, and pacing physical activity.

For sleep disturbances, the guidance recommends promoting good sleep hygiene and a consistent sleep schedule — and limiting screen time for 30-60 minutes before bedtime.

The statement was partially aimed at primary care physicians because they are often the first to see children with long COVID and may be the ones who end up treating them, especially if there are no multidisciplinary long COVID clinics in the area, said Morrow.

AAPM&R President-elect Steven R. Flanagan, MD, a physiatrist at NYU Langone Health in New York City, said during the briefing that the organization is considering "providing this information in a more easily accessible or more easily readable manner to primary care providers, who are on the front line dealing with folks that are coming to them with long COVID."

Almost 95 million Americans have survived a COVID-19 infection; an estimated 29 million have had some sort of postviral syndrome, according to the AAPM&R PASC dashboard.

Autonomic Dysfunction

The group also has published guidance on how to assess and treat people with long COVID who are having impairments of the autonomic nervous system. These people may have trouble remaining upright or standing without experiencing symptoms such as light-headedness or palpitations.

Usually the first presenting symptoms are cardiovascular, said Alba Azola, MD, co-director of the Johns Hopkins Post-Acute COVID-19 Team, and lead author of the 22-page guidance on autonomic dysfunction. A key part of the guidance is helping clinicians discriminate between underlying structural cardiovascular issues and postviral autonomic symptoms, she said at the briefing.

Treatment has to take into account patients' limited energy envelope, said Azola. If the rehabilitation work exceeds those limitations, it can exacerbate symptoms and lengthen the recovery process.

"Autonomic dysfunction is not something we're taught in medical school at length or with much detail," she said, noting that the cumulative experiences of patients and physicians are distilled into the guidance. One thing they've found is that "autonomic dysfunction symptoms can sometimes be eased with common medications and dietary changes."

Azola also said that it was important that "trusted sources" provide scientifically-vetted information to people with long COVID, whom she called a "vulnerable population." Some of her patients have been subject to "predatory tactics" by online purveyors of expensive treatments.

The AAPM&R has issued guidance on fatigue, breathing discomfort, cognitive symptoms, and cardiovascular complications and expects to issue statements on mental health and neurology in the future, said Flanagan.

PM R. Published online September 28, 2022. Abstract. Malone et al.
PM R. Published online September 28, 2022. Abstract. Blitshteyn et al

Alicia Ault is a Lutherville, Maryland-based freelance journalist whose work has appeared in publications including JAMA and You can find her on Twitter @aliciaault.

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