PAPP COVID TASK FORCE

Philippine Academy of Pediatric Pulmonologists (PAPP)

FEBRUARY 8, 2022

CHIEF EDITORS

MARIA THERESA T. POLICARPIO, MD FPPS, FPAPP, FPSCCM, MMHA

ELMA G. DUEÑAS, MD, FPPS, DPAPP MHM MBA

TECHNICAL WORKING GROUP

JOSEPH DALE R. GUTIERREZ , MD, FPPS, DPAPP
JONIJOHN R. JIMENEZ, MD, FPPS, DPAPP, FPSCCM, MHA
ARNOLD NICHOLAS T. LIM, MD, DPPS, DPAPP, FPSCCM
MARIA CRISTINA H. LOZADA, MD, FPPS, DPAPP
GERARDA EMBER R. AFABLE, MD, FPPS, DPAPP
YADNEE V. ESTRERA MD, DPPS, DPAPP
JEROME V. SENEN, MD, FPPS, DPAPP, FPSCCM

CONTRIBUTORS
CHRISTIAN ALLEN L. ROXAS, MD, DPPS, DPAPP, FPSCCM
MARICHU J. DE CHAVEZ, DPPS, DPAPP
SHEILA ALMEDA -CIRILOS, MD FPPS, DPAPP
SHERRYL JANE G. MIRANDA, MD, DPPS, DPAPP, FPPSCM
TERESITA P. NARCISO, MD, FPPS, FPAPP

TASK FORCE ADVISOR

REGINA M. CANONIZADO, MD, FPPS,FPAPP
THE PAPP PULMONARY CARE OF LONG COVID IN CHILDREN

EXECUTIVE SUMMARY

There have been several reports on long-term sequelae from COVID in adults but with
paucity in children. The PAPP COVID-19 Task Force was tasked to probe on this concern
and reflected these findings in the Systematic Review on Post-Acute Sequelae of Covid-
19 (PASCI) in Pediatric Patients reported last December 7, 2021.1 The data from the
systematic review alongside available studies on PASCI or Long COVID gave way to the
formulation of this guidance.

This document focuses on pulmonary care of Long COVID in children has been created
to be an aid to clinical practice. The many other facets of Long COVID which needs a
multidisciplinary approach is highly suggested but will not be discussed in detail in this
document. This guidance will serve as a foundation for optimized respiratory supportive
care for children with Long COVID. The purpose of this document is to complement with
the World Health Organization (WHO), National Institute for Health and Care Excellence
(NICE), American Academy of Pediatrics (AAP) and the other subspecialty guidelines in
providing respiratory care for children with prolonged respiratory symptoms as part and
parcel of Long COVID manifestations reported in children and adolescents.

This is the first local document on the pulmonary care of children and adolescents with
LONG COVID. The members of the committee declare no conflict of interest in the
formulation of this manuscript. This is intended for clinicians involved in the care of
pediatric patients with suspected or confirmed to have COVID-19. Collection of several
related studies and reports on long haul COVID-19 in children was started in September
2021.

METHODOLOGY

Literature search included new guidelines and systematic reviews in pediatric Long
COVID. The bibliographic databases and concepts were defined with search terms that
include both medical subject headings (MeSH) and text words. We also searched
following websites: the WHO (https://wwwwho.int/)2, National Institute for Health and Care
Excellence (NICE) COVID-19 rapid guideline: managing the long-term effects of
COVID-19 ( https://www.nice.org.uk/guidance/ng188)3, the American Academy of
Pediatrics ( https://www.aap.org)4 and from other international society guidelines
providing specific updates on the respiratory management and monitoring whose
prolonged post-acute COVID infection were significant respiratory in character. Data
collected for this manuscript version included significant articles available until January
24, 2022.

2
Draft of the proposed scope and list of potential priority topics was performed. This was
subsequently refined to the list of priority topics and identifying relevant issues on clinical
diagnostic monitoring, management guidance and re-integration to usual daily activities for
the pediatric patient was identified. Incorporation of the recently gathered data from the
Systematic Review on PASCI in Children done by the PAPP COVID-19 Task Force Working
Group was done in the making of this guideline. In addition, we have an independent literature
searching team to search available indirect evidence from systematic reviews and/or RCTs
(randomized controlled trials), of the existing evidence. If there is a lack of higher-level quality
evidence, our panel considered observational studies and case series.

We accorded to the Grading of Recommendations Assessment, Development and Evaluation

(GRADE) basic approaches and rules and particularly considered experts’ evidence to
assess the quality of a body of evidence to make recommendations.

The quality of evidence reflects whether the extent to which our confidence estimating the
effect is adequate to support a particular recommendation. The level of evidence was
categorized as “high quality”, “moderate quality”, “low quality”, or “very low quality”. The
domains of the risk of bias, imprecision, inconsistency, indirectness and publication bias will
constitute the decreasing level of certainty of the evidence and will be considered in the rating
of evidence included.

The recommendations were classified as “strong” or “weak.” In specific recommendations,

we used “should” or “strongly recommend” for strong recommendations; whereas, “suggest”
or “consider” was used for weak ones.

The evidence is rapidly changing and this guidance will be updated to reflect the same as
evidence becomes available. Please take note that this interim guideline will have to undergo
revisions and editing as new evidence will set in before it will be published in the final form.
The final articles registered in this document were those that were warranted valid enough
for citation (systematic reviews and meta-analyses ) in Pediatric Long COVID were prioritized
among other articles as they grant the most accurate findings) available during the period of
literature search.

3
CONTENTS Page

Executive Summary…………………………………………………………………….. 2
Methodology………………………………………………………………………….. 2
Introduction…………………………………………………………………………… 5
Definition of Terms………………………………………………………………………… 5
Identifying Clinical Symptoms ……………………………………………………… 6
Pediatric Assessment
Recommendation 1 ………………………………………………………………. 7
Laboratory Assessment
Recommendation 2…………….…………………………………………………….. 7
Special Conditions in Pediatric Long COVID……………………………..……….. 9

Respiratory Management of Symptoms and Well Being………………………… 9

Recommendation 3……………………………………………………………….. 9
Deep Breathing Exercises for Adolescents……………………………………. 11
Deep Breathing Exercises for Younger Children……………………………… 11

Return to Usual Activities after Acute COVID-19 Infection……………………… 12

Recommendation 4……………………………………………………………….. 12
Algorithm on Return to Play after COVID-19 Infection……………………….. 13
Recommendation 5……………………………………………………………….. 14
Gaps in knowledge and Further Recommendations………………………………. 16
References……………………………………………………………………………. 17
Appendices…………………………………………………………………………… 19

4
Introduction
In January 03, 2022 about 306 million individuals were confirmed to have COVID-19
globally. There has been an alarming increase to 373 million cases in January 24, 2022
as seen in the World Health Organization dashboard.5

A proportion of those infected with SARS-CoV-2 experience long-term symptoms. The

proposed nomenclature of these spectrum of prolonged symptoms has evolved including
terms – Long COVID, long-haul COVID or the WHO-recommended post COVID-19
condition.2,3,4 Post-acute Sequelae of COVID-19 Infection (PASCI) a synonymous term
referring to a prolonged heterogeneous condition which can also occur in children after
COVID-19 infection.1,6

The signs and symptoms of “Long COVID” are highly variable among individuals, and
are usually non-specific. Long COVID is highly prevalent in the adult population, but a
systematic review showed that it significantly affects the pediatric population 1,7

Definition of Terms

Acute COVID-19
Signs and symptoms of COVID-19 for up to 4 weeks.3

Ongoing symptomatic COVID-19

Signs and symptoms of COVID-19 from 4 weeks up to 12 weeks.3

Post COVID-19 Condition

Occurs in individuals with a history of probable or confirmed SARS-CoV-2 infection,
usually 3 months from the onset of COVID-19 with symptoms that last for at least 2
months and cannot be explained by an alternative diagnosis.2

Long COVID
Is commonly used to describe signs and symptoms that continue or develop after acute
COVID-19. It includes both ongoing symptomatic COVID-19 ( from 4 to 12 weeks ) and post
-COVID-19 syndrome ( 12 weeks or more ). 3

A clinical case definition of post COVID-19 condition is based on existing evidence

objectively assessed by means of the Delphi methodology by the WHO International
Classification of Diseases (ICD)- ICD-10U09 which is also in agreement with the NICE
guidelines. 3 The American Academy of Pediatrics uses the 3 months or the 12 week time
table post-acute infection4; however, since more research is still being done and with a
relatively lower prevalence as compared to adults, uniform definitions for children have
yet to be given.

5
Identifying Clinical Symptoms

Presently the exact definition of “Long COVID” in children reported in a systematic review
showed that the common symptoms of long COVID in children and adolescents include
the following – fatigue, weakness/asthenia, fever, poor appetite, weight loss.1

These common symptoms have an impact on the daily functioning of the patient. Reports
states that these may be new onset from the acute COVID-19 episode or persistent
from the acute illness which may be relapsing or fluctuating in character.2

Figure 1. Timetable and symptoms of post-acute COVID-19 in children. Acute COVID-19 infection usually lasts up
to 4 weeks after symptom onset. By then, infectious SARS-CoV2 virus from the upper respiratory tract may not be
detected. Post-acute COVID-19 is defined as persistence and/or development of symptoms after the acute illness
that have continued for more than 12 weeks. It may affect different organ systems in the body and present with
various symptoms. Frequently observed symptoms in post-acute COVID-19 in children are summarized.1

Children and young people were reported to have difficulty doing everyday tasks about
≥4 weeks ( 4 weeks or more ) after acute COVID-19 illness. Expert witnesses and the
NICE panel overwhelmingly agreed that poor performance or absenteeism at education,
work, or training was a “red flag” for both children and adults.3 Recognition of these
symptoms could signify systemic sequelae of the acute SAR-CoV2 infection and warrants
evaluation and possible referral to multidisciplinary team.

Family members and caregivers of children and adolescents need good discharge advise
after acute COVID-19. Information on what to expect and when to seek medical advice
should be given especially if common symptoms of Long COVID are present.

6
Pediatric Assessment
Recommendation 1

In children and adolescents with Long COVID-19, it is suggested that they be evaluated
clinically in an in person/face-to face basis at the time of reporting. They should be
monitored and managed on a symptom- based approach by a multidisciplinary team.3,4

( Low quality evidence, Weak recommendation )

Rationale

Pediatric patients with long COVID characteristics are to be managed symptomatically,

with emphasis on a holistic support while avoiding over-investigations.8 Management of
long COVID is a multidisciplinary undertaking , and covers the full range of physical and
mental health concerns. The extent of follow-up and monitoring should be individualized,
and should include plans for the treatment of fatigue and respiratory symptoms.

Assessment may be conducted face-to-face or virtually, depending on healthcare

resources and patient preference. A detailed clinical history is emphasized, focusing on
the symptoms, and what is important to the patient. It is recommended that assessment
ideally BE done face to face, to facilitate early recognition and management of post-
COVID-19 sequelae. If consultation is face-to-face, the clinician may identify concerns
that the patient may not even be aware of which would not have reported had virtual
consultation been done. 9

Laboratory Assessment

After a thorough history and physical examination, laboratory tests may be selectively
requested for specific clinical indications. These laboratory tests or diagnostic
examinations may help identify underlying conditions and exclude other diagnoses.6,8

Recommendation 2

In children and adolescents with Long COVID-19 who have significant exercise
intolerance and respiratory illness, it is suggested that they should be evaluated by a
specialist and undergo the following laboratory tests parameters at 4-6 weeks after
discharge from acute COVID -19 illness

1. Pulse Oximetry
2. Chest Xray
3. Pulmonary Function Test /Spirometry
4. 6-minute walk test

Children with Long COVID-19 with progressive and persistent symptoms after initial
evaluation should undergo a follow up Chest x ray at 12 weeks .6
( Low quality evidence, Weak recommendation )
7
The British Thoracic Society recommends that Covid-19 patients who have had significant
respiratory illness should have a follow-up chest x-ray at 12 weeks for new, persistent, or
progressive symptoms.6 Based on a systematic review, Dobkin recorded pediatric
patients with PASCI as to having opacities on chest x-ray 10, although a more specific
description of the opacities were not mentioned. A study last 2020 reported that only
15/119 (13%) of people had evidence of COVID-related lung disease at 4-6 weeks after
hospital discharge. The investigators concluded that a chest X-ray is a poor marker of
recovery, as there were notable abnormalities in other investigations, regardless of a
normal chest X-ray.9

Most studies stated that a number of patients were still experiencing significant
breathlessness at follow-up after acute COVID-19. In the evaluation of these patients,
pulmonary function test ( spirometry ) and exercise test ( 6 minute walk test ) were
commonly used.8 The 6-minute Walk Test (6MWT) measures the distance that a patient
can quickly walk on a flat, hard surface (typically a 100-ft hallway) within a 6-minute time
period. 11

In prospective analysis of children with persistent symptoms, 45% of patients who

underwent pulmonary function test due to cardiorespiratory symptoms had abnormal
findings; such as mild obstruction with low FEV1 on spirometry and air trapping on lung
volume studies. In this analysis, despite mild radiographic and spirometric findings, these
were observed in a significant number of patients, emphasizing the importance of
pulmonary function evaluation.12

The NICE panel considered that baseline diagnostic examinations, such as blood tests,
chest X-rays and exercise tolerance tests may be useful and should be performed for
most patients. The panel emphasized the importance of clinical judgment and that specific
tests should only serve as an adjunct for the holistic assessment for further
management.3

8
SPECIAL CONDITIONS IN PEDIATRIC LONG COVID
In children and adolescents with Long COVID-19 who have persistent symptoms
involving other organ systems, a multidisciplinary approach to management is highly
suggested.

Specific referral to a specialist for further management is recommended. Patients and

their caregivers must at all times be fully informed of the management plan.

The following are the recommended diagnostic tests used to monitor children and
adolescents with on going symptoms of Long COVID as well as those who may need
urgent referral:
• Complete blood count (CBC)
• Kidney and liver function tests
• C‐reactive protein
• Ferritin
• B‐type natriuretic peptide (BNP)

Other diagnostic evaluation tools relevant to the cognitive, psychological and psychiatric
domains may be performed. Other less critical physical findings found in the evaluation,
that if considered together, may pose as a problem which may then warrant further
investigation.

MANAGEMENT OF RESPIRATORY SYMPTOMS AND WELL-BEING

Recommendation 3

Established symptomatic treatments for managing the common symptoms of Long

COVID-19 can be given. These should include, but are not limited to, treatment of
specific complications and control of co-morbidities such as asthma and atopy.
However, there lack of evidence for any specific pharmacologic intervention to treat
the condition (Long COVID-19) itself.

(Low quality evidence; Strong recommendation)

Table 1: Management of Respiratory Symptoms and General Well-being

Non-pharmacologic Pharmacologic
Supported self-management and monitoring Symptomatic treatment

Breathing exercises and techniques Control of co-morbidities

Pulmonary rehabilitation Treatment of specific complications

Emotional and Mental Health Support Individualized treatment plans

9
Currently, there is lack of evidence for any pharmacologic intervention to specifically
treat Long COVID-19, despite a substantial population experiencing prolonged
symptoms after COVID-19 infection. Post-acute COVID-19 symptoms vary widely.1
Among the most common complaints are fatigue, headache, musculoskeletal pain,
irritability and dizziness.1

The management of patients with Long COVID-19 address these symptoms and should
be individualized. Self-assessment and monitoring is encouraged. Referrals to specialists
made if warranted. The specialist’s evaluation and management should be based on
current clinical practice guidelines.

Although radiographic and spirometric findings were mild in some studies 6, they were
observed in majority of the patients. These findings supported the importance of
pulmonary evaluation and the potential benefits of bronchodilators and inhaled
corticosteroids on a case-to-case basis.

The NICE panel3 noted the lack of evidence for pharmacological treatments for Long
COVID-19. The panel also expressed concern over the use of interventions to manage
short term symptoms that might cause harm in the longer term, hence the need to advise
caution over such interventions, including over the counter medicines. This is where
referrals to specialists are of utmost importance.

Majority of the patients will recover in time, however recovery is usually slow. Self-
management involves emphasis on general health, rest and recreation, and gradual
increase in activity. A pulse oximeter and diary, for home monitoring may be useful in the
evaluation of patients with persistent dyspnea.6 Recognized non-pharmacological
strategies for managing dyspnea include breathing exercises, pulmonary rehabilitation
and maintaining optimal body positioning for postural relief.

Cough, dyspnea and exercise intolerance are common respiratory symptoms of Long
COVID-19.1 These symptoms are best managed with breathing exercises. The aim of
breathing exercise strategies is to normalize breathing and to increase the efficiency of
the respiratory muscles, leading to less energy expenditure, less airway irritation, less
fatigue, and improve breathlessness.8

Deep Breathing Exercises

There are no specific deep breathing exercises specifically designed to assist in the
recovery from COVID-19 or during long COVID. However, literature suggests engaging
in deep breathing exercises reconditions the muscles of respiration, restores/improves
vital capacity, and can serve as an adjunct for the treatment of anxiety.13 Ideally, deep
breathing exercises should be done for about 5-10 minutes per session with frequency
depending on the patient’s tolerance. Patients may begin with one session a day and
progress to more sessions as improvement ensues.

10
Deep breathing exercises for Adolescents

Pursed Lip Breathing

This type of breathing exercise reduces the number of breaths that the patient takes and
keeps his/her airways open longer.
1. To perform this exercise, the patient is asked to breathe slowly and deeply through
his/her nose over a period of 3-4 seconds.
2. Instruct the patient to hold the breath for another 3-4 seconds before exhaling twice
as long from the mouth with pursed lips.
3. The process may be repeated as many times as tolerated.

Diaphragmatic Breathing
1. Instruct the patient to breathe in slowly and deeply through his/her nose over a
period of 3-4 seconds.
2. Instruct the patient to be mindful of how his/her abdomen rises during inspiration
and falls during expiration by placing his/her hand over the abdomen.
3. With relaxed shoulders and neck, exhale out through the mouth at least two to three
times as long as the inhalation.
4. The process may be repeated as many times as tolerated.

Deep breathing exercises for Younger Children

Deep beathing exercises can be performed even by younger patients. The following are
activities that can help in facilitating the performance of deep breathing exercises in the
young.

Playing with Bubbles

A great way to help encourage deep breathing is by playing with bubbles. This can be
done individually or as a tandem activity with an adult or older child. A bubble toy loop
and detergent solution is needed before starting the activity.
1. Ask the child to take a big breath in, with his/her abdomen pushing out, holding the
breath for 3-4 seconds
2. Ask the child to blow out slowly and gently with pursed lips through the bubble toy
loop to create bubbles.
3. The child can repeat the entire process as many times as tolerated.
Blowing out birthday candles

A variation of playing bubbles is blowing out birthday candles. This involves more child
imagination.
1. Ask the child to imagine that he/she will be blowing out birthday candles on a
cake.
2. Instruct him/her to breathe in as deep as he/she can and hold the breath for 3-4
seconds.
3. Breath out as strong as he/she can to blow out the birthday candles.
4. Ask the child to repeat this as many times as he/she can.

11
 RETURN TO USUAL ACTIVITIES AFTER ACUTE COVID-19

RECOMMENDATION 4

Children and adolescents recovering from COVID-19 illness may return to play or
activity after a DOH prescribed completed isolation period and a minimum of 10 days
without symptoms. The child should have no cardiorespiratory symptoms when
performing normal daily activities, and activities should progress gradually, based on
tolerance. 14,16

( High quality evidence; Strong recommendation)

Children should return to play once all of the following criteria are met:

1. Completed Department of Health (DOH) prescribed isolation period at time of

diagnosis
2. The minimum amount of symptom-free time has passed from symptom onset
3. Can perform all activities of daily life expected for age
4. No signs/symptoms of illness reported by caregiver or upon evaluation
5. Physician clearance has been given, if indicated

As of this time of writing , there is no evidence- based approach to the guidance given
for resumption of physical activity after a COVID-19 illness. One recommendation is the
gradual resumption of physical activity guided by one’s physical tolerance. Seven
symptom free days is considered reasonable time after which physical activities may be
resumed with an initial two weeks of minimal exertion.14, 15

The American Academy of Pediatrics (AAP) provided an algorithm presenting the

recommendations for children and adolescents returning to sports and regular activities
after an acute COVID-19 infection. Once cleared by a physician, children under 12 can
return to sports and physical education classes as their own tolerance allows. More
specific steps are laid out for those who are 12 and older. 16 (See Figure 2 below )

12
Figure 2. Adapted from the American Academy of Pediatrics. COVID-19 Interim Guidance:
Return to Sports and Physical Activity ( January 28,2022) 16.
*See Appendix B for the AHA 14-element screening evaluation

13
 Figure 3. Adapted from the American Academy of Pediatrics. COVID-19 Interim Guidance:
Return to Sports and Physical Activity ( January 28,2022) 16

RECOMMENDATION 5

Athletes recovering from COVID-19 illness should have a specialist consultation with
appropriate evaluation before resuming intense physical activity or training. A gradual
return to physical activity is recommended.

(High quality evidence; Strong recommendation)

There are no evidence-based guidelines available on athletes returning to sports activity

after COVID-19 infection. Sequelae of COVID-19 illness that may affect an athlete’s
sports performance include pulmonary compromise, cardiovascular complications, and
neuromuscular or cognitive dysfunction.17, 18 It is recommended that a specialist
consultation be done to asses the athlete’s medical fitness to resume training.19

14
A return to sports activity may be started after an asymptomatic period of at least 7 days.
The English and Scottish Institute of Sports Guidance recommends that the athlete
should be able to walk 500m on the flat without feeling excessive fatigue or
breathlessness before re-starting strenuous physical activities.20 A gradual increase in
exercise is recommended. The gradual increase in exercise is prioritized in the sequential
order of an increase in exercise frequency, duration then intensity. 14

Recovering patients who have symptoms of severe breathlessness or chest pain, and
symptoms suggestive of myocardial injury warrant a thorough physical examination and
investigations such as 12-lead ECG. In the event of abnormal findings, a cardiology
consult is recommended and additional work-ups may include 2D echocardiography and
serum troponin levels. Among those who had severe COVID-19 with documented
myocarditis, both European and US guidelines recommend exercise restrictions for 3 to
6 months. 15, 16, 21, 22

Athletes returning to activity after a COVID-19 illness progress through five stages. A
minimum of 1 to 2 days is recommended for each stage, and may be adjusted according
to the patient’s age, comorbidities, or severity of COVID illness. The athlete will be
monitored closely, and the clinician should be in communication with the athlete
throughout the different stages.14

A suggested pre-evaluation form adapted from the American Academy of Pediatrics

may be used for young athletes recovering from acute COVID-19 if deemed applicable in
the local setting ( Please see Appendix C ). It is best to teach patients and their parents
to monitor for chest pain, shortness of breath, new palpitations or syncope . If these
occurs physical activity should be stopped at once and immediate consult with a
pediatrician or specialist in an in-person/face-to face basis be done.

15
Gaps in Knowledge in Pediatric Long COVID-19

Since the start of the pandemic, studies on the clinical presentation and outcomes
have largely involved adult patients, as the older population is more frequently and
severely affected by SARS-COV-2 infection. Similarly, studies on long COVID-19 are
now more frequently reported among adults compared to children.

• Epidemiologic data are lacking on long-term COVID-19 in children across

all disease severities (mild to critical COVID-10). A promising new study on
the long-term physical and mental health effects of COVID-19 in children was
spearheaded by the US National Institutes of Health. The study which is part of
the Researching COVID to enhance Recovery (RECOVER) Initiative recently
commenced recruitment.23

• A prolonged inflammatory response has been postulated to be the underlying

pathophysiology of COVID-1924, however the exact pathophysiology of long
COVID-19 in the pediatric age group remains to be a subject of research
interest.

• Furthermore, gaps remain on the long-term effects of SARS-CoV-2 infection

on pulmonary function in infants and children, and this aspect may be
systematically reviewed.

• There is a significant heterogeneity in the outcome of interest resulting in

difficulty to obtain standardized patient’s long-term symptoms from COVID-
19 25 especially on the correlation based on the severity of their acute COVID-
19 infection.

• Moreover, there is lack of studies to determine the specific risk factors for
long-covid in children and that more studies are needed as well on long-term
COVID-19 symptoms in both vaccinated and unvaccinated children to obtain stronger
conclusions.

• Specific data on the correlation of respiratory symptoms with diagnostic

findings and respiratory exercise testing in children is lacking especially in a
specific time interval from symptoms.

• Among those children with pre-existing comorbidity such as bronchial asthma,

there is lack of published data on pulmonary function test among known
asthmatic children versus non asthmatics with Long COVID.

16
REFERENCES
1
Almeda-Cirilos, Sheila, et al. (2021) Systematic Review on the Clinical Presentation of Post-acute
Sequelae of COVID-19 Infection in Pediatric Patients. Unpublished manuscript.
2
A clinical case definition of post COVID-19 condition by a Delphi consensus, (6 October 2021)
https://www.who.int/publications/i/item/WHO-2019-nCoV-Post_COVID-19_condition-
Clinical_case_definition-2021.1
3
COVID-19 rapid guideline: managing the long-term effects of COVID-19 NICE guideline
[NG188] (Published: 18 December 2020 Last updated: 11 November 2021)
https://www.nice.org.uk/guidance/ng188

4
American Academy of Pediatrics (2021 ) Post-COVID-19 conditions in children and adolescents.
https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/post-covid-
19-conditions-in-children-and-adolescents/

5
WHO Coronavirus (COVID-19) Dashboard. ( January 24,2022 ) https://covid19.who.int
6
Greenhaigh, Trisha, et al.( 2020), Management of post-acute Covid 19 in primary care. BMJ
2020;370:m3026 http://dx.doi.org/10.1136/bmj.m3026
7 Asadi-Pooya, Ali, et al ( 2021 ). Long Covid in Children and Adolescents. World Journal of Pediatrics
https://doi.org/10.1007/s12519-021-00457-6
8 Chaplin, Steve (2021 ). Summary of Joint Guideline on the management of Long Covid.

wchh.onlinelibrary.wiley.com. https://doi.org/10.1002/psb.1941
9
D'Cruz, Rebecca F., Waller, Michael D., Perrin, Felicity et al. (2020) Chest radiography is a poor
predictor of respiratory symptoms and functional impairment in survivors of severe COVID-19
pneumonia. ERJ Open Research
10
Dobkin, S. L., Collaco, J., & McGrath-Morrow, S. (2021). Protracted Respiratory Findings in Children
Post-COVID-19 Infection. Authorea Preprints. https://doi.org/10.22541/AU.162513383.35044135/V1
11
ATS Committee on Proficiency Standards for Clinical Pulmonary Function Laboratories (2002).
ATS statement: guidelines for the six-minute walk test. American journal of respiratory and critical
care medicine, 166(1), 111–117. https://doi.org/10.1164/ajrccm.166.1.at1102
12
Ashkenazi-Hoffnung, L., Shmueli, E., Ehrlich, S., Ziv, A., Bar-On, O., Birk, E., Lowenthal, A., & Prais,
D. (2021). Long COVID in Children: Observations From A Designated Pediatric Clinic. The Pediatric
infectious disease journal, 10.1097/INF.0000000000003285. Advance online publication.
https://doi.org/10.1097/INF.0000000000003285
13
Apple, R. W., Dickson, C. A., Cabral, M. D. I. (2021). Integrated Behavioral Health in Pediatric
Practice First Edition, Elsevier.
14
OConnor, Francis, et al ( 2021) . COVID-19: Return to play or strenuous activity following
infection.https://www.uptodate.com/contents/covid-19-return-to-play-or-strenuous-activity-following-
infection

17
15
Salman, D., Vishnubala, D., Le Feuvre, P., Beaney, T., Korgaonkar, J., Majeed, A., & McGregor,
A. H. (2021). Returning to physical activity after covid-19. BMJ (Clinical research ed.), 372,
m4721. https://doi.org/10.1136/bmj.m4721
16
American Academy of Pediatrics (2022) COVID-19 Interim Guidance: Return to Sports and
Physical Activity. https://www.aap.org/en/pages/2019-novel-coronavirus-covid-19-
infections/clinical-guidance/covid-19-interim-guidance-return-to-sports/
17
Moulson, N., Petek, B. J., Drezner, J. A., Harmon, K. G., Kliethermes, S. A., Patel, M. R., Baggish,
A. L., & Outcomes Registry for Cardiac Conditions in Athletes Investigators (2021). SARS-CoV-2
Cardiac Involvement in Young Competitive Athletes. Circulation, 144(4), 256–266.
https://doi.org/10.1161/CIRCULATIONAHA.121.054824
18
Martinez, M. W., Tucker, A. M., Bloom, O. J., Green, G., DiFiori, J. P., Solomon, G., Phelan, D.,
Kim, J. H., Meeuwisse, W., Sills, A. K., Rowe, D., Bogoch, I. I., Smith, P. T., Baggish, A. L.,
Putukian, M., & Engel, D. J. (2021). Prevalence of Inflammatory Heart Disease Among
Professional Athletes With Prior COVID-19 Infection Who Received Systematic Return-to-Play
Cardiac Screening. JAMA cardiology, 6(7), 745–752.
https://doi.org/10.1001/jamacardio.2021.0565
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Cipollaro, L., Giordano, L., Padulo, J., Oliva, F., & Maffulli, N. (2020). Musculoskeletal symptoms in
SARS-CoV-2 (COVID-19) patients. Journal of orthopaedic surgery and research, 15(1), 178.
https://doi.org/10.1186/s13018-020-01702-w
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Elliott, N., Martin, R., Heron, N., Elliott, J., Grimstead, D., & Biswas, A. (2020). Infographic.
Graduated return to play guidance following COVID-19 infection. British journal of sports
medicine, 54(19), 1174–1175. https://doi.org/10.1136/bjsports-2020-102637
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Exercise After Coronavirus Disease 2019 (COVID-19) Infection. JAMA cardiology, 5(10), 1085–
1086. https://doi.org/10.1001/jamacardio.2020.2136
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Verwoert, G. C., de Vries, S. T., Bijsterveld, N., Willems, A. R., Vd Borgh, R., Jongman, J. K.,
Kemps, H., Snoek, J. A., Rienks, R., & Jorstad, H. T. (2020). Return to sports after COVID-19:
a position paper from the Dutch Sports Cardiology Section of the Netherlands Society of
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and the Netherlands Heart Foundation, 28(7-8), 391–395. https://doi.org/10.1007/s12471-020-
01469-z
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Buonsenso, D., Munblit, D., De Rose, C., Sinatti, D., Ricchiuto, A., Carfi, A., & Valentini, P. (2021).
Preliminary evidence on long COVID in children. Acta paediatrica (Oslo, Norway : 1992), 110(7),
2208–2211. https://doi.org/10.1111/apa.15870
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Groff, D., Sun, A., Ssentongo, A. E., Ba, D. M., Parsons, N., Poudel, G. R., Lekoubou, A., Oh, J.
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e2128568. https://doi.org/10.1001/jamanetworkopen.2021.28568
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APPENDIX

Appendix A

Six-Minute Walk Test

Brief Description

The 6-minute Walk Test (6MWT) measures the distance that a patient can quickly walk
on a flat, hard surface (typically a 100-ft hallway) within a 6-minute time period. 11

Indications for the Six-Minute Walk Test

The indications for performing this test include the following:

(1) to measure the response to medical interventions in patients with moderate
to severe heart or lung disease

(2) to measure the functional status of patients or functional exercise level for daily
physical activities

(3) to provide pretreatment and post-treatment comparisons and serve as a

predictor of morbidity and mortality among patients with different health
conditions or those undergoing surgical procedures. It is absolutely
contraindicated among patients with unstable angina or myocardial infarction
during the previous month.

As there are potential safety issues with the 6-minute walk test, testing should be
performed in a suitable and well-equipped location. Emergency provisions should include
oxygen, sublingual nitroglycerine, aspirin, and B-2 agonists, and the technician should be
adept in handling emergencies. It should be ideally performed in a pulmonary diagnostic
center.

The 6MWT may be performed indoors or outdoors. Based on the American Thoracic
Society( ATS) guidelines, the technical aspects include a 30-meter walking course with
the length of the corridor marked every 3 meters. A cone should mark the turnaround
points and a starting line marks the beginning and end of each 60-m lap. 11

Preparations for the Exercise Proper

Comfortable clothing and appropriate shoes should be worn. Habitual walking aids
(walker, cane etc), regular maintenance medication or oxygen supplementation may be
continued to be used during the test. Recommendations before the test such as a light
meal avoiding active exercise within 2 hours of the test is advised.

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Interpretation

The 6MWT is a reliable measure of the functional status of patients with at least
moderately severe impairment. In cases of interpreting the results as single
measurements, document the age, height, weight, and sex which independently affects
the 6MWD in healthy children and adolescents. It is also used to determine the response
to therapeutic interventions for pulmonary and cardiac disease.

The American Thoracic Society recommends that a change in 6MWD is expressed as an

absolute value. When the 6MWD is decreased, it may be prudent to do pulmonary
function studies, cardiac function tests, and measurements of ankle-arm index and
muscle strength, as well as assessments on the nutritional status, orthopedic function,
and cognitive function.

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 Appendix B

The ACC/AHA Recommendations for Congenital and Genetic Heart Disease Screenings in Youth *

The 14-Element Cardiovascular Screening Checklist for Congenital and Genetic Heart Disease:

Personal history:

1. Chest pain/discomfort/tightness/pressure related to exertion

2. Unexplained syncope/near-syncope*
3. Excessive exertional and unexplained dyspnea/fatigue or palpitations, associated with exercise
4. Prior recognition of a heart murmur
5. Elevated systemic blood pressure
6. Prior restriction from participation in sports
7. Prior testing for the heart, ordered by a physician

Family history:

8. Premature death (sudden and unexpected, or otherwise) before age 50 attributable to heart disease
in ≥1 relative
9. Disability from heart disease in close relative <50 y of age
10. Hypertrophic or dilated cardiomyopathy, long-QT syndrome, or other ion channelopathies, Marfan
syndrome, or clinically significant arrhythmias; specific knowledge of certain cardiac conditions in
family members

Physical examination:

11. Heart murmur**

12. Femoral pulses to exclude aortic coarctation
13. Physical stigmata of Marfan syndrome
14. Brachial artery blood pressure (sitting position)***

*Judged not to be of neurocardiogenic (vasovagal) origin; of particular concern when occurring during or
after physical exertion.
**Refers to heart murmurs judged likely to be organic and unlikely to be innocent; auscultation should be
performed with the patient in both the supine and standing positions (or with Valsalva maneuver),
specifically to identify murmurs of dynamic left ventricular outflow tract obstruction.
***Preferably taken in both arms.

Source: Maron, B. J., Friedman, R. A., Kligfield, P., Levine, B. D., Viskin, S., Chaitman, B. R., Okin, P. M., Saul, J. P., Salberg, L., Van Hare, G. F.,
Soliman, E. Z., Chen, J., Matherne, G. P., Bolling, S. F., Mitten, M. J., Caplan, A., Balady, G. J., Thompson, P. D., & American Heart Association
Council on Clinical Cardiology, Advocacy Coordinating Committee, Council on Cardiovascular Disease in the Young, Council on Cardiovascular
Surgery and Anesthesia, Council on Epidemiology and Prevention, Council on Functional Genomics and Translational Biology, Council on Quality
of Care and Outcomes Research, and American College of Cardiology (2014). Assessment of the 12-lead ECG as a screening test for detection of
cardiovascular disease in healthy general populations of young people (12-25 Years of Age): a scientific statement from the American Heart
Association and the American College of Cardiology. Circulation, 130(15), 1303–1334. https://doi.org/10.1161/CIR.0000000000000025

21
 Appendix C

Suggested Pre-Participation Evaluation Forms for Young Athletes

B.1 The American Academy of Pediatrics Preparticipation Evaluation Forms (History Form)

Source: AAP Website ( https://downloads.aap.org/AAP/PDF/PPE_History-form-7-30-21.pdf)

22
B.1 The Preparticipation Evaluation Forms (History Form) (continued)

Source: AAP Website ( https://downloads.aap.org/AAP/PDF/PPE_History-form-7-30-21.pdf)

23
B.1 The Preparticipation Evaluation Forms (Physical Examination Form)

Source: AAP Website ( https://downloads.aap.org/AAP/PDF/PPE_Physical-Exam-7-30-21.pdf)

24