It’s hard to tell these days, but COVID-19 disease is still a health threat. Despite the maskless triumph we might feel as we walk into an event or crowded public space with our families during times of lower infection rates, the SARS-CoV-2 virus that causes COVID is still lurking and morphing.
In times of higher case rates, however, communities need to pull down that fist of triumph and use precautions to prevent a disease that may not only cause short-term flu-plus symptoms of COVID but— 7% of adults and 2% of kids who test positive or a doctor’s diagnosis of COVID-19—continued, sometimes more debilitating, symptoms for three or more months. The latter medical scenario—Long COVID—can seriously impact a child’s health and ability to keep up in school. While not all children will experience Long COVID for months on end, according to Seattle Children’s Hospital experts, the average recovery for a child seen in outpatient Long COVID treatment is two years.
“Kids and teens can get Long COVID too, and the risk appears to increase with age,” says Dr. Eric Chow, chief of Communicable Disease Epidemiology and Immunization within the Prevention Division for Public Health – Seattle & King. “Early research findings suggest that long COVID is less commonly reported in children than adults, but there’s still a lot we don’t know.”
How to protect kids hasn't changed
Public Health—Seattle & King County has not changed its tune on how to protect kids from COVID-19 infection and potentially debilitating Long-term COVID. Here are the tools the health department hopes all families will use:
- Stay up-to-date on COVID-19 vaccinations, especially if you or your child have a health condition. The next vaccine booster is expected to be available in September.
- Wear a mask in high-risk settings (such as crowded places) to protect yourself and others, especially people with medical conditions who are less able to fight the virus.
- Test for COVID-19 if you have symptoms or have been in close contact with someone who tests positive.
- If you or your child test positive for COVID-19 or are at higher risk from the disease, talk to your provider about COVID-19 treatment early to help protect you from severe illness and hospitalization.
- Keep activities small and outdoors if people who are unvaccinated will participate.
- Reduce the virus in the air by having good air flow indoors and using air filters.
Some statistics: According to the U.S. Centers for Disease Control and Prevention (CDC), about 90% of kids in the U.S. have had COVID. CDC data shows that children aged 12–17 were twice as likely as those aged 0–5 years to get Long COVID, 2% compared to 1%. Kids ages 6–11 have the lowest prevalence at .8%.
According to the Washington Department of Health, there are 1.8 million children in Washington. At 90%, that means more than 1.6 million have had COVID-19. While not all of them went on to develop Long-Term COVID-19, the CDC statistic’s 2% means that more than 32,000 Washington kids have experienced symptoms of COVID-19 for 12 weeks or more.
“It’s a small percentage, but when you take into account how many kids got COVID, it’s actually a pretty high number,” says Dr. Payal Patel, who directed the NeuroCOVID clinic program at Seattle Children’s Hospital from 2021 until 2023 and is now a researcher in the National Institutes of Health RECOVER program. Dr. Patel is a collaborator in the recently funded UW Long Covid Clinical Care Grant.
As COVID cases in King County—like the rest of Washington and the nation—surged between May and mid-July, we had a discussion with Dr. Patel about long-term COVID in kids, its prevalence, treatment, and policy implications. Here’s part of that discussion:
Seattle’s Child (SC): What is Long COVID?
Dr. Payal Patel: The definition is very similar in adults and kids. Long COVID is a constellation of symptoms. They’re not just one symptom, but usually multiple symptoms that affect multiple systems in the body, usually starting within the first four weeks after a COVID infection and persisting for at least 12 weeks.
SC: I’ve read conflicting numbers ranging from 1.3% to 20% regarding how many kids contract Long COVID-19. What is the percentage researchers at UW and Seattle Children’s are using?
Dr. Patel: Using our strict criteria, the prevalence is about 2% of all kids who acquire COVID will go on to develop Long COVID.
SC: Why is it so hard to pinpoint how prevalent Long COVID is in kids?
Dr. Patel: The most important thing, and probably the reason why there’s so much variability in the documented prevalence, is that for us [at Seattle Children’s], Long COVID is a diagnosis of exclusion, meaning that if you have a sign of anything else going on, we would put that diagnosis rather than assigning a [Long COVID] diagnosis. But, other groups do it differently, roping different types of medical conditions within the umbrella of Long COVID and that’ll dilute the prevalence numbers.
SC: Do we know why some kids get Long COVID and others don’t? Is there one commonality?
Dr. Patel: That’s a really good question. As Dr. Janna Friedly, who runs the UW Long COVID Center and is chair of Rehabilitation Medicine, describes it, COVID is like lighter fluid. Individuals with underlying conditions, like immunologic conditions, even allergies, are at increased risk of going on to develop Long COVID, although that increased risk is still pretty small. [Not] every kid with allergies will get long COVID; it’s more likely that they won’t go on to develop it. But we do see that that is a particular risk factor.
SC: If a child only gets a mild case of COVID, can it develop into Long COVID?
Dr. Patel: Yes. If you have any symptoms at all, you can go on to develop Long COVID.
SC: Who is most at risk for complications from COVID and the Long COVID?
Dr. Patel: [Children] with chronic medical conditions are at increased risk of worsening their underlying medical conditions, but there are a lot of nuances in there. To be clear, this isn’t unique to COVID. Infections have a tendency to worsen underlying medical conditions across the board. The worsening [of medical conditions] can persist well beyond what would be expected after an infection has gone away.
SC: Do we have any sense of how long kids might struggle with symptoms of Long COVID?
Dr. Patel: My clinical experience is all with kids and I should say kids are very resilient. The kids that have participated in our program have made tremendous progress. And most over the course of two years have recovered.
Do kids fully recover? Is there anything that improves the chances of full recovery?
Dr. Patel: I should say as a caveat that a lot of the initial group of kids we saw early on in the pandemic were athletes. They had really healthy baselines. Though the recovery took a long time, there were a lot of things in place that helped them recover, including their school coaches, physical therapists, really involved parents who followed our program. They’re kind of a unique group in that way. I think what happened initially was that the kids that were athletes were diagnosed earlier. People were able to pick up on the deviation from their baseline level of activity.
SC: What about kids who aren’t athletes?
Dr. Patel: Now we see kids that have a broad range of baseline levels of activity — they’re the kids we started seeing later on in the pandemic so they haven’t made that two-year mark yet. But the initial group that we saw early on in the pandemic have actually all gotten better.
SC: Does reinfection with the SARS-CoV-2 virus and getting COVID increase the risk of developing the Long COVID?
Dr. Patel: What we do know from our clinical experience is that reinfections, if you already have Long COVID and get infected with COVID again, have a tendency to worsen your Long COVID symptoms. In fact, a lot of people have gone back to the very first most debilitating part of their Long COVID condition after they got reinfected.
SC: Is there any good news when it comes to Long COVID, especially in kids?
Dr. Patel: There’s a recent study published in the New England Journal of Medicine that shows that with each subsequent strain, it looks like the risk of developing long COVID has decreased. Although, of course, not to zero.
SC: There was a spike in COVID cases among newborns to 3-year-olds earlier this year in Washington, according to the Washington State Department of Health. Are you seeing more incidences of developmental delay that might be connected to COVID?
Dr. Patel: This is a tough question to answer because we really rely on the reporting of symptoms in order to diagnose Long COVID. There isn’t a very clear test, like imaging or blood markers, that we can use to diagnose COVID. If you don’t have the ability to tell us what’s happening? We really don’t know.
But we are really diligent about [testing] for developmental delays and I think that if there was some serious increase in the number of kids diagnosed with developmental delays, we would have found that. We will never be able to tease out the effects of the pandemic as far as it relates to getting kids access to care, especially kids who are already diagnosed with developmental delays. The pandemic made all the in-person physical therapy programs shut down, for example, for many months. For that reason, I think you can’t really say that COVID didn’t impact young children developmentally. I also think you can’t blame it on COVID infection without taking into account the whole context.
SC: Let’s talk about treatment. What works to help kids recover from Long COVID?
Dr. Patel: What really works is something called pacing. It’s commonly used in post-concussion treatment. And it’s commonly used in different recovery programs that athletes use.
Pacing is a graded return to activity. We believe what is happening [with Long COVID] is that the body’s own autonomic nervous system, which controls heart rate spikes, blood pressure, and volume balance within the body automatically, takes a hit subconsciously. The body reacts to activity very differently than it did prior to the COVID infection.
We work in partnership with physical therapists, coaches, parents, and schools to do this graded return to activity, supplementing body volume with increased salt intake, increased hydration, sometimes the use of compression stacking, and a gradual return to physical activity, along with avoiding cognitive overload. That means not just jumping back straight into a full day of school, but gradually returning to a full if school over the course of a year and tending the amount of time that kids have in order to complete tasks and complete homework. We really try to avoid stressors. Avoiding even small stressors has been proven in our clinic to enhance recovery.
SC: What are the missing pieces of social/emotional recovery for kids with Long COVID?
Dr. Patel: I think it is important to address the COVID infection itself and the risk of infection universally in a way that allows kids who are at risk of developing serious consequences as a result of COVID infection to participate in society to be normal kids. I think we should all consider whatever is in our power to make public places and activities accessible. And this is not just for COVID. It would be helpful in flu season as well. For example, you could do a library day where masking is required so that people know that they can go to the library during this time. Sports teams could offer a certain hour of the week when masking is required. This way, the kids who have chronic conditions and who are at higher risk of getting sick with COVID infection can still participate in activities that are fun.
SC: We know vaccines are an effective way to protect against COVID and thus Long COVID. What else should parents be considering?
Dr. Patel: I think in the long term, we’re going to see seasonal spikes of COVID like we see seasonal spikes of influenza. The spike that we have now is very similar to a spike we saw this past winter.
Every family should independently assess the risks and benefits of doing things like traveling during flu season. There are a lot of factors that go into that assessment: How young are your kids? What groups are they going to be around? Will there be a lot of people on an airplane or in a car ride? What about grandparents? Many families already do this with the flu. Similarly, during a COVID spike, they should consider doing the same.
SC: I’ve heard people—many parents of young children—say they are just tired of masking. And during the May-July COVID surge, the majority of people going through SeaTac airport weren’t masked. Thoughts?
Dr. Patel:
We know there had to be an end to the mask mandate. That is a necessary part of our society and our economic infrastructure, as well as for the delivery of our academics and health systems. But I think that universally, we do need to take into account that there are individuals, including children, who are at increased risk and will remain an increase with each surge (of COVID infections). How do we as a community become more inclusive for them? I think that requires discussion at a community level.
Read more:
County’s communicable disease chief urges COVID precautions
King County whooping cough cases skyrocket
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