Mental and physical health should be evaluated in children and adolescents with long COVID

Abbreviation

DSM‐V

diagnostic and statistical manual of mental disorders, fifth edition

Children and adolescents have been deeply affected by the COVID‐19 pandemic. Many have been ill, mostly with mild versions, but some have received care for multisystem inflammatory syndrome in children or been in intensive care. A relatively small number have died. Millions have lost parents, grandparents and other family members. Children have also been affected by the lockdowns and social restrictions put in place to stop the spread of the virus and many have lost 1 or 2 years of school and leisure activities.

It would be very surprising if the collective life experiences of the pandemic did not have an impact on the mental well‐being of children. For example, a global meta‐analysis of 29 studies, covering 80 879 subjects, reported that 1 in 4 children and adolescents had depressive symptoms and 1 in 5 experienced anxiety during the pandemic. These were double the pre‐pandemic levels. ¹

It is essential to highlight the need for heightened attention towards child and adolescent mental health and that is what Cozzi et al do in their paper in this issue of Acta Paediatrica. ² They state that clinicians should not confuse mental health issues with long COVID in children and adolescents. Cozzi et al suggest that care for children with long COVID symptoms should be multidisciplinary and based on a high suspicion of mental health disorders.

While mental health problems in children and adolescents should not be ignored, it is vital that new‐onset physical complaints in young people after a COVID‐19 infection are not treated primarily as psychiatric issues. Long COVID, which is the term that Cozzi et al chose to use in their paper, is a symptomatic state that affects patients but has no clear definition. There is a published definition of paediatric post‐COVID‐19, referring to children who have symptoms persisting at least 12 weeks after a COVID‐19 infection that cannot be explained by an alternative diagnosis. ³ This definition describes a symptomatic state and does not imply any pathophysiological explanation to the symptoms. In addition, it does not limit which symptoms could be included if they are not explained by an alternative diagnosis.

Paediatric long COVID research is still very scarce, as noted by Cozzi et al. ² Most studies describe the frequencies of self‐reported symptoms by participants, with or without control groups. Very few studies have described the results of investigations of patients or their diagnoses and no studies have focused on the pathophysiology or treatment of long COVID in children.

A meta‐analysis and systematic review published in November 2021 was based on 22 papers and 23 141 individuals. ⁴ The authors reported a number of symptoms that were more common in cohorts affected by COVID‐19 than controls and these were cognitive difficulties, headaches, loss of smell, sore throats and sore eyes. A review published in 2022 stated that fatigue was the most frequently reported symptom after COVID‐19, followed by headaches. Other common symptoms were insomnia, concentration difficulties, coughs, rhinorrhoea and anosmia. Less common symptoms were dizziness, palpitations, arrhythmias and chest tightness, delayed bladder emptying and dysphonia and dysphagia, which in some cases required nasogastric tube feeding or total parenteral nutrition. ⁵

One study reported that having had COVID‐19 more than doubled the risk of being diagnosed with type I diabetes diagnosis than controls who had not had the disease, with a hazard ratio of 2.66 (95% confidence interval 1.98–3.56). In contrast, the risk of developing diabetes did not change after an acute respiratory tract infection in the pre‐pandemic period (HR 0.99 95% confidence interval 0.84–1.15) ⁶ Another study reported that children with long COVID had been diagnosed with peripheral neuropathy, including Guillain Barré Syndrome and central neurological disorders, such as acute disseminated encephalomyelitis and encephalitis. ⁵

Given this vast knowledge gap regarding the pathology and diagnoses behind post‐COVID symptoms, the statements by Cozzi et al seem quite bold. ² They report that specific clinical features reported by adolescents with long COVID seem to mirror highly suggestive symptoms for somatic symptoms and mental health disorders in general. They further state that such patients are likely to benefit from a treatment approach that the authors have used for somatic symptom disorders.

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM‐V) criteria, a somatic symptom disorder diagnosis requires a person to exhibit one or more distressing somatic symptom and ‘excessive thoughts, feelings or behaviours’ related to these symptoms for more than 6 months. ⁷ When examining a patient for such a diagnosis, a health care provider should not consider whether the somatic symptoms have been medically investigated, treated or understood.

As paediatricians, we need to understand our patients' symptoms from a medical point of view, to avoid doing harm. Therefore, I would argue that the gold standard for working with symptoms that could be psychosomatic is still valid, even when a patient presents with symptoms that fulfil the DSM‐V somatic symptom disorder diagnosis criteria. This rule is that clinicians should always try to exclude common or possibly dangerous and medically treatable somatic diagnoses behind their patient's symptoms. Researchers who have studied adults with post‐COVID‐19 have reported brain structure abnormalities, declining renal function, myocarditis and autonomic nervous system dysfunction, including postural orthostatic tachycardia syndrome. ⁸ These have even been described in young adults who did not have a severe acute COVID‐19 infection and were previously healthy. Such findings underline the importance of not dismissing children and adolescents who complain of prolonged physical symptoms after a COVID‐19 infection.

For example, an adolescent girl presenting with fatigue, anxiety, headaches and concentration difficulties should still receive a full investigation of her mental and physical health if her symptoms began after COVID‐19 or she has struggled with the pandemic. Without accurate somatic diagnostic reasoning, we are doomed to fail to find treatable pathology or other important findings, such as unknown pregnancies.

Proper investigations, referral, treatment and follow‐ups for somatic organ system dysfunctions and mental health issues, psychiatric disease or neuropsychiatric disorders are of equal importance. Psychiatric and somatic disorders are not mutually exclusive. On the contrary, one American study of 48 000 participants aged 6–25 found that being diagnosed with a chronic physical condition increased the risk of developing a mental health condition by 51%. ⁹ Part of this increased risk resulted from the limited activity imposed by chronic physical conditions. Workups for somatic and mental health should preferably be executed in parallel. They should be carried out by one team with comprehensive competence or by close collaboration between paediatricians, child physiotherapists, occupational therapists, dieticians and registered nurses, and child and adolescent psychiatry or mental health teams. This is the best way to ensure that children and adolescents growing up during the pandemic, including those who have had COVID‐19, have the best chance of developing their optimum physical and mental health.

Multi‐professional teams should be prepared to follow their patients for as long as needed, as this is the best way of avoiding unnecessary retesting and investigations. It also helps us to build relationships between medical staff, patients and their families. Society needs to recognise the increased need for this approach to healthcare for children and adolescents affected by the pandemic. In the best interests of the child, optimal care should be provided, irrespective of whether the symptoms called long COVID in a patient is caused by stress due to lockdowns or social distancing or losing family members or organ damage or dysfunction due to long‐term infectious sequelae.

CONFLICT OF INTEREST

None.