Long-COVID is a well-documented multisystem disease in adults. Far less is known about long-term sequelae of COVID in children. Here, we report on the occurrence of long-COVID in Dutch children.
Patients and Methods
We conducted a national survey asking Dutch pediatricians to share their experiences on long-COVID in children. We furthermore describe a case series of six children with long-COVID to explore the clinical features in greater detail.
With a response rate of 78% of Dutch pediatric departments, we identified 89 children, aged 2–18 years, suspected of long-COVID with various complaints. Of these children, 36% experienced severe limitations in daily function. The most common complaints were fatigue, dyspnea, and concentration difficulties with 87%, 55%, and 45% respectively. Our case series emphasizes the nonspecific and broad clinical manifestations seen in post-COVID complaints.
Our study shows that long-COVID is also present in the pediatric population. The main symptoms resemble those previously described in adults. This novel condition demands a multidisciplinary approach with international awareness and consensus to aid early detection and effective management.
Our study shows that long-COVID is also present in children and that the main symptoms resemble those previously described in adults.2–4 It is one of the first studies to provide nationwide data on the extent of long-COVID as a new disease entity in children and highlights that long-COVID can seriously affect children of all ages. Long-COVID leads to limitations in daily functioning in the majority of children reported here.
In a single-center study from Italy by Buonsenso et al.,8 persistent symptoms in children previously diagnosed with COVID-19 were also reported in 42.6% of children that had been presented with COVID-19 to that hospital. The reported long-COVID symptoms in this Italian study showed resemblance to the symptoms reported in our study, although the prevalence differed. A possible explanation could be that the children described in our study were all identified by Dutch pediatricians. Consequently, these children had severe enough complaints to get referred to the pediatrician by the general practitioner, which may also explain the higher percentage of children with limitations in daily functioning in our study compared to the Italian group.
Ludvigsson et al., reported in November 2020 a five-patient case series on long-COVID in children, where none of the children were able to attend school 6–8 months after the acute-COVID.10 These cases resemble the findings in our study.
The varying presentation of pediatric long-COVID, will, without a standardized diagnostic plan, result in a varying diagnostic approach, as shown by our patient case series.
Our study has several strengths. First, the survey response rate was high, including 78% of all hospitals, providing a national, pediatric, representative sample. Second, we were able to assess the most common symptoms directly from the treating physicians. Third, our cases highlight the challenges faced by health care professionals taking care of these children. This study clearly identifies the need for an international consensus and guideline on long-COVID in children.
Our study also has some limitations. We only collected data from pediatricians working in general and university hospitals, and not from family doctors. We expect that the more severe cases of long-COVID will be referred to the pediatrician and that milder cases may be underrepresented in our study. The type of symptom may also prompt referral, which could be a reason for the high percentage of patients suffering from fatigue and breathlessness. Second, due to privacy considerations, limited clinical data was collected in the questionnaire.
Therefore, data on comorbidities, pre-existing disease, height, weight, psychological status, and diagnostic workup are missing. Third, only retrospective data were obtained from pediatricians. While they were able to consult their records, this may still have led to a recall bias, and thus an underestimation of total cases, and potentially an overrepresentation of severe cases.
What are the clinical implications of our study? In the Netherlands 139,221 children have tested positive for SARS-CoV-2, since the beginning of the outbreak in the Netherlands on February 27, 2020 (as published February 9, 2021).12 In relation to the total number of children tested positive for SARS-CoV-2 in the Netherlands, the number of 89 patients reported in our survey seems small. However, we suspect that these children represent the tip of the iceberg since some children with long-COVID may only be treated by the general practitioner. Furthermore, long-COVID is still an unknown phenomenon to many pediatricians, likely resulting in underdiagnosing. Nevertheless, we can conclude that long-COVID is a disease entity in children. This study does not yet inform us about the incidence and risk factors of long-COVID in children, but it seems to be relatively rare. Severe acute COVID-19 in children leading to hospital presentation and/or admission is also infrequent, as demonstrated in our national cohort study, the COPP study.13 Children in general experience additional impact on mental and social health due to governmental restrictions, and this might also influence occurrence and course of long-COVID in children.14
Long-term sequelae of COVID-19 in children have been less well described than in adults and data on possible long-term sequelae of COVID-19 in children needs to be collected and shared on a national and international level. Not only severe acute COVID cases but also mild acute COVID cases with long-COVID need our attention. Long-COVID in children exists and leads to high morbidity and limitations in daily functioning. Increased awareness is needed to perform prospective follow-up studies and multidisciplinary, evidence-based guidelines for diagnosis and treatment.
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