Long-Term Pulmonary Symptoms Following COVID-19 Infection in Children

Long-Term Pulmonary Symptoms Following COVID-19 Infection in Children 1024 683 Mary Bates, PhD

Fatigue and shortness of breath may persist, even in the absence of abnormal test results.

Researchers at Nationwide Children’s recently published the largest U.S. study to date of pediatric patients with long-term pulmonary sequelae following COVID-19 infection. The authors note the persistence of symptoms such as shortness of breath and fatigue and highlight at least three clinical phenotypes to help guide further diagnosis and treatment of these patients. The study is published in Pediatric Pulmonology.

So-called “long COVID” can result in lasting pulmonary sequelae in adults but little is known about long-term outcomes in children and adolescents post-COVID-19. In February 2021, Nationwide Children’s initiated a multidisciplinary Pediatric Pulmonary Post-COVID clinic for children experiencing prolonged pulmonary symptoms after COVID-19 infection.

For the new study, researchers conducted a retrospective analysis of all patients seen in the clinic between February 2021 and December 2021. They evaluated measures of lung function, including lung volumes, diffusion capacity, pre- and post-bronchodilator spirometry, and performance on a 6-minute walk test, and analyzed changes in pulmonary findings over time.

Despite a mostly mild, outpatient acute infection, virtually all patients presenting to the clinic experienced notable fatigue and shortness of breath, says Katelyn Krivchenia, MD, a member of the Section of Pediatric Pulmonary Medicine at Nationwide Children’s and one of the study’s authors.

“Regardless of their prior physical function, most of them felt tired and short of breath,” she says. “We saw kids that used to run a 6-minute mile getting short of breath after walking up the stairs.”

Dr. Krivchenia and colleagues found that the majority of these patients had no significant abnormalities on chest imaging, lung function testing, or physical exam. However, most patients consistently demonstrated tachycardia and heart rate variability during the 6-minute walk test, potentially suggesting autonomic dysfunction, as well as completing a lower-than-expected distance in the allotted time. At follow-up visits, 6-minute walking distance and tachycardia tended to improve, while heart rate variability, fatigue, and shortness of breath persisted in many patients.

The researchers identified at least three clinical phenotypes in their cohort of patients. About one-third of patients responded positively to bronchodilator therapy, even if their initial spirometry testing was negative. Children in this group generally had a family or personal history of asthma. Another group of patients, about 12% of the cohort, had paroxysmal vocal cord movement disorder. And a final group exhibited symptoms even though no abnormalities could be found.

Dr. Krivchenia, who is also an assistant professor of pediatrics at The Ohio State University College of Medicine, says the findings demonstrate that the full panel of lung tests may not be necessary for pediatric patients.

“We show that in this population, virtually everybody has normal testing results, in contrast to what we see in adults with long COVID,” she says.

The researchers also conclude that bronchodilator therapy may be worth starting sooner with pediatric patients, given that about a third of them respond positively. In addition, the results suggest that clinicians should be aware of vocal cord dysfunction as a potential contributor to shortness of breath and fatigue in children with long COVID.

Dr. Krivchenia also notes that over three-quarters of the children seen in the clinic were not vaccinated against COVID-19, and some of them suffered re-infections with the virus.

“We found that long COVID is debilitating for some of these kids,” she says. “People think this disease is mild in pediatric populations but we see kids that can’t go back to school, don’t graduate on time and can’t play their sport anymore.”

Overall, Dr. Krivchenia and colleagues emphasize that better definitions of long COVID in children are needed, as well as more studies to understand what treatments help with symptoms.

“Our current knowledge of long COVID in kids is just the tip of the iceberg,” she says.

This feature was published in the Fall/Winter 2022 issue. Download the full issue. 



Palacios S, Krivchenia K, Eisner M, Young B, Ramilo O, Mejias A, Lee S, Kopp BT. Long-term pulmonary sequelae in adolescents post-SARS-CoV-2 infection. Pediatr Pulmonol. 2022 Jul 1. doi: 10.1002/ppul.26059. Epub ahead of print.

Image credit: Nationwide Children’s

About the author

Mary a freelance science writer and blogger based in Boston. Her favorite topics include biology, psychology, neuroscience, ecology, and animal behavior. She has a BA in Biology-Psychology with a minor in English from Skidmore College in Saratoga Springs, NY, and a PhD from Brown University, where she researched bat echolocation and bullfrog chorusing.