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When it comes to long COVID in children, physicians should focus on mitigating symptoms and encouraging multidisciplinary rehabilitation designed to improve age-appropriate development, according to new clinical guidance from the American Academy of Physical Medicine and Rehabilitation (AAPM&R).

Long COVID can present differently in children, so standard practices for managing the condition in adults should not be automatically applied to pediatric cases, according to Sarah Sampsel, MPH, a healthcare quality consultant in Albuquerque, New Mexico, and colleagues, who published the guidance in .

For instance, children with long COVID may have fatigue or attention problems at school or in extracurricular activities, or they may experience ongoing fever, headaches, or sleep issues, the guidance states. It also includes an extensive list of possible pediatric symptoms of long COVID:

• Fatigue, including exercise intolerance or post-exertional malaise

• Sleep disturbances

• Fever or cough

• Anxiety, depression, or "low mood"

• Regression in academic or social milestones

• Dizziness, lightheadedness, or vertigo

• Headache or nausea

• Paresthesias or numbness

• Difficulties with attention, concentration, or memory

• Cognitive fatigue or "brain fog"

• Shortness of breath or dyspnea

• Chest/thoracic pain or tightness

• Palpitations or tachycardia

• Abnormal or lack of smell or taste

• Muscle, bone, or joint pain

• Gastrointestinal problems such as constipation or diarrhea

• Weight loss

• Lack of appetite

"We know pediatricians and family care doctors are most likely going to be seeing, diagnosing, and treating children and adolescents with long COVID symptoms," ​co-author Amanda Morrow, MD, of the Kennedy Krieger Institute and Johns Hopkins Medicine in Baltimore, said during a Zoom press conference.

"They are vital to diagnosing and treating long COVID in children," Morrow continued. "This guidance is intended to provide diagnosis and treatment recommendations from the multidisciplinary PASC [post-acute sequelae of SARS-CoV-2] Collaborative Pediatric Workgroup."

The pediatric guidance is the latest in about long COVID from the PASC Collaborative, the of which focused on fatigue and was published in August 2021. Others have focused on cardiac issues and breathing discomfort, and all of the statements have attempted to develop clear clinical outlines for possible symptoms and treatment options, AAPM&R president-elect Steven Flanagan, MD, of NYU Langone Health in New York City, said during the press conference.

"This is a problem that we know is right here, right now, and we need to address it," Flanagan said.

The pediatric guidance outlines several accommodations that physicians and other caretakers should consider for children struggling with long COVID symptoms, especially those related to physical fatigue, post-exertional malaise, or cognitive symptoms.

For example, schools should develop plans that will help alleviate symptoms such as allowing kids extra time to walk between classes, letting them use an elevator instead of stairs, arranging for extra time when taking a test, or even limiting homework.

Morrow acknowledged that these might be difficult to coordinate, but the most challenging element of providing care might be successfully incorporating the multidisciplinary approach in communities that don't have access to long COVID clinics.

"In more resource-limited areas it may be a bit more challenging to do what we do in our clinic -- where we have our physicians, our physical therapists, and psychologists all working together -- so we know that not [everyone] has that luxury, unfortunately," Morrow said.

Still, she believes it could be possible to create patchwork networks of specialists in these communities -- ones that are able to collaborate and coordinate care across specialties and caretakers.

"They are hopefully still able to provide some referrals to perhaps something like physical therapy or a psychologist, [a] social worker, or other type of mental health therapist," Morrow continued. "That is asking a lot of primary care doctors, who are burdened with a lot of patient demands and responsibilities."

The goal, she said, is to provide tools and concepts to help providers identify solutions to these challenges. Indeed, Morrow and her co-authors developed the guidance statement to address the increasing concerns and struggles of patients, caretakers, and pediatric providers around the country.

The estimates that anywhere from 9 million to 28 million Americans either are currently experiencing or have experienced symptoms of long COVID, and the new guidance suggests that the number of children affected by long COVID has also increased.

While most pediatric cases of COVID-19 are mild or asymptomatic, the prevalence of long COVID symptoms in children has been estimated to be anywhere in the range of 4% to 66%, according to Sampsel and co-authors. They also highlighted the need for caution when diagnosing long COVID because most of the symptoms identified in the statement can also be attributed to other conditions.

Correction: An earlier version of this article incorrectly stated that the Kennedy Krieger Institute was part of Johns Hopkins Medicine. It is a separate nonprofit healthcare provider.

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