When a school-age child comes into clinic with fatigue, brain fog, or vague chest discomfort that just won’t quit, you might hear that little voice in your head: Could this be long COVID?
Estimates suggest that anywhere from 1% to 45% of children with acute COVID-19 go on to develop symptoms consistent with long COVID—potentially affecting millions of kids in the U.S. alone. The wide range speaks to the uncertainty and variability in data, study design, and symptom presentation. But what’s increasingly clear is this: pediatric long COVID is real, and it has a measurable impact on quality of life.
Dr. Lael Yonker, a pediatric pulmonologist and long COVID researcher at Mass General Hospital, explains long COVID as a post-viral condition where new or worsened symptoms arise after a SARS-CoV-2 infection and persist for weeks to months, significantly impacting a child's daily function.
Long COVID symptoms can:
▪️Start immediately post-infection and never resolve
▪️Appear weeks later, seemingly out of nowhere
▪️Be exacerbations of pre-existing conditions
Early in the pandemic, we saw severe post-COVID cases like MIS-C (multisystem inflammatory syndrome in children). Though rarer now, MIS-C helped us understand that SARS-CoV-2 could cause post-acute inflammatory syndromes. Long COVID is on that same spectrum—typically less dramatic, but often more persistent.
There’s evidence that SARS-CoV-2 may linger in gut tissue after respiratory symptoms resolve. This could fuel ongoing immune responses and explain the broad range of long COVID symptoms we’re seeing in kids.
While we’re still learning, some trends have emerged:
▪️Children who had more severe acute infections
▪️Those with family histories of long COVID or MIS-C
▪️Kids with pre-existing conditions like Ehlers-Danlos or chronic fatigue syndrome
Interestingly, GI diseases like IBD or celiac don’t seem to confer increased risk, despite the gut's role in viral persistence.
Long COVID symptoms in kids can vary, but the most common are:
▪️Fatigue
▪️Brain fog/difficulty concentrating
▪️Orthostatic intolerance (POTS)
Younger children may instead show increased abdominal pain or behavioral changes. The key is to look for changes in baseline function, like school absences or trouble keeping up with peers.
There’s no diagnostic lab test for long COVID. It remains a diagnosis of exclusion. Workups may include:
▪️CBC, thyroid panel, B12, and inflammatory markers
▪️Pulmonary function testing, if respiratory symptoms dominate
▪️Orthostatic vitals if POTS is suspected
Testing for COVID antibodies rarely clarifies the picture. Most kids have had exposure, and antibody levels aren’t reliably diagnostic.
While we wait for definitive treatments, pediatricians can still help immensely by:
▪️Validating the experience: Families often feel dismissed. Listening goes a long way.
▪️Joining the research: Connect families to local or national long COVID studies.
▪️Targeting Long COVID symptoms: For example:
▪️POTS: hydration, salt intake, compression garments, beta blockers or fludrocortisone
▪️Mast cell activation or chronic pain: antihistamines, NSAIDs, or other symptom-based treatments
▪️This is a case report, but it walks through treatment options that can be tailored to an individual presentation.
Some experimental adult treatments (like IVIG) are being studied, but are not yet approved for kids.
The trajectory varies. Some children improve within months, while others experience COVID symptoms for years. COVID vaccination appears to reduce the risk of long COVID, though data in kids remains limited. Importantly, as new infants are born without immunity, vigilance and vaccination remain key public health strategies.
Dr. Yonker leaves us with this guidance:
▪️Long COVID in children exists and impacts lives.
▪️Keep an open mind. If a child’s function changes post-illness, consider long COVID.
▪️Empathetic listening and basic vitals can reveal a lot.
▪️Symptom management and research enrollment offer hope.
Pediatricians don’t need to wait for a specialty clinic to start helping. Your clinic can be the first place where long COVID is seen, validated, and addressed—one patient at a time.
Want to learn more about pediatric long COVID? Tune in to Peds Reviews and Perspectives podcast segments “Pediatric Long Covid” and “Long Covid: One Teen’s Experience”.