parent holds child in doctor’s office

Why kids struggle with long COVID

When children contract COVID-19, they aren’t as likely to get severely ill as adults. But long COVID can have a severe impact on kids, according to a new study in the journal Pediatrics. Dr. Ziyad al-Aly, chief of research and development at the V.A. St. Louis Health Care System, talks with The World’s Carolyn Beeler about how and why kids’ immune systems struggle with the condition.

The World

The COVID-19 pandemic is entering its fifth year, and recommendations for how to handle it might be changing. 

The Washington Post reported that the Centers for Disease Control and Prevention (CDC) is planning to get rid of a key recommendation for people who contract the virus to stay isolated for five days. 

The report said that, instead, they’ll recommend that people use clinical guidelines — like being fever-free for 24 hours.

A spokesperson from the CDC told WCNC’s Verify that there are “no updates to COVID guidelines to announce at this time” after the report caused a frenzy online. However, critics are concerned that more-relaxed guidelines may still come into effect while the coronavirus — and long COVID — continue to derail lives around the world. 

A new study in the journal Pediatrics details just how disruptive long COVID is for children and teens. 

Dr. Ziyad al-Aly, chief of research and development at the V.A. St. Louis Health Care System in St. Louis, spoke with The World’s Carolyn Beeler when the news first broke about the CDC’s future plans. He shares how and why kids’ immune systems struggle with long COVID and why it should be taken seriously. 

Carolyn Beeler: What is the rationale behind the shift in CDC guidelines?
Dr. Ziyad al-Aly: So, this is really premised or predicated on the idea that most people in the US now have some immunity, some from vaccination and infection or both. And they are realizing also that most people in the US are not following these guidelines, anyway. They want it to sort of shift or transition to a more practical approach that would align with guidelines [we’ve been following] for the flu and RSV for the past several decades.
I understand that you’re not entirely convinced that this is the right approach.
These guidelines actually ignore the reality that immunity wanes with time. Yes, maybe some people were vaccinated a year or two years ago [or] had been infected a year or two years ago … but immunity wanes over time. Immunity from natural infection has a significant cost: hospitalizations, deaths and long COVID. So, relaxing these guidelines, what that really means for the average person now [going] home, it really elevates that probably somebody sitting next to you could have had COVID-19 two, three, four or five days ago, but now is not isolating at home, and is actually sitting right next to you in the subway with the potential of transmitting to you. It’s really uncalled for. It’s not totally aligned with the reality of things. I was hoping that, like we learned from this pandemic, that they would learn that infections hurt people. So, instead of aligning COVID-19 policies with the decades-old policies of flu and RSV — which are outdated — maybe we’d have learned from this pandemic and try to protect people and align decades-old policies of flu or RSV with the more beneficial policies of COVID-19; like staying at home when you’re sick, isolating for five days to make sure that when you come back to work, you’re not transmitting that infection to the people around you.
Let’s talk about this new study in the journal Pediatrics about long COVID. You weren’t involved in this study, but you’ve spent a long time looking at why and how children struggle with long COVID. What is new and valuable in this recent study?
So, this study suggests that cumulatively, over the span of this pandemic, about 6 million kids in the United States have contracted long COVID. It means that some of them may have had long COVID that has resolved, and some of them may still have long COVID at this point. It’s also important to caveat that 6 million number, by the fact that some of those were from an earlier era of the pandemic when we didn’t have vaccines, where the virus was very different. We didn’t have vaccines or antivirals. The picture now has dramatically evolved over time. Clearly, the virus has changed from the original ancestral strain to the most recent variant. We now have vaccines that reduce the risk of long COVID. We also have antivirals that reduce the risk of long COVID. So, all of those variables suggest that the risk of long COVID now is much less than it was at the beginning of the pandemic, in both adults and kids. But it’s still a significant problem that we definitely need to tackle, especially since we have no treatment for it. They also say that long COVID in kids can affect nearly every organ system. It can affect the kidneys, the heart, the brain. It can affect the metabolic system and can lead to new-onset diabetes in kids. So, it’s not a mild disease in kids and, in some instances, could lead to a significant chronic condition that may last for a long time in these kids. 
At this point in the pandemic, how prevalent is long COVID among children and teenagers who become infected with the virus?
Luckily, long COVID among kids is less prevalent than it is in adults, but it’s still out there. There needs to be a more concerted effort to better characterize the epidemiology of long COVID and come to conclusive and more definitive answers about the prevalence both in adults and kids.
Are there any new treatments for kids and young people?
Unfortunately, there are zero FDA-approved medications for long COVID at this point. Most of the treatment strategies or approaches are managing symptoms for people who develop tachycardia or fast heart rates and managing that fast heart rate for people who have dizziness or other components of long COVID. Managing these symptoms literally symptomatically, there’s no curative, FDA-approved treatment for long COVID. And that again should stimulate more research in this area, because for the people who are suffering from long COVID, for the kids who are suffering from long COVID, for the parents who are watching their kids suffer from long COVID, and also adults who are suffering from long COVID … they want treatment yesterday. They really needed treatment yesterday. 
Viruses other than COVID-19 can also cause serious, long-lasting impacts like fatigue and pain. Do doctors think there’s something unique about the COVID-19 virus and its ability to cause long-term damage, or are we talking about it and hearing about it a lot more just because COVID is so high profile and so many people have contracted it?
Thinking about it more deeply now and also reviewing the literature from historical accounts after the flu pandemic of 1918 — the Spanish flu —it’s very clear that that flu pandemic also left in its wake a lot of people with disability and chronic disease, Parkinson’s disease, fatigue, etc., so profound that, in some areas of the world, it precipitated famine. In those days, farmers in New Zealand could not shear wool from sheep, so there are very clear historical accounts from the 1918 pandemic that suggests that this is not unique. What is perhaps unique about COVID-19 is the scale of it. We are living in a pandemic now with billions of people who got infected in a short span of time, and the novelty of it, you know, rewind to 2018, 2019: SARS-CoV-2 did not exist on Earth. So, novelty and scale are two unique characteristics of SARS-CoV-2. However, the idea that viruses can lead to chronic illnesses or viruses that produce acute infections that can lead to chronic illnesses is really not new. We sort of swept it under the rug for the past 100 years, ignored and marginalized this idea, and then got hit with a pandemic. Now, we have had to literally rediscover it. And I think if we get one lesson from this pandemic, I think we really should take the lessons to not trivialize infections because infections can have long-term consequences that destroy the lives of people. It can [also] impact economies and have serious long-term ramifications for the whole world. 

This interview has been lightly edited and condensed for clarity.

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