The Post-Acute Sequelae of SARS-CoV-2 in Children and Youth (PECOS) study, funded through the National Institutes of Health RECOVER initiative, has offered one of the most comprehensive pictures to date of how children fare after COVID-19 infection. By comparing infected children with an uninfected control cohort followed over the same pandemic period, the study identified 20 symptoms occurring more frequently after infection, spanning constitutional, gastrointestinal, neurologic, and musculoskeletal domains, with patterns that shifted by age and evolved.

To help pediatricians translate these findings into practice, Contemporary Pediatrics spoke with Roberta L. DeBiasi, MD, MS, chief of the Division of Pediatric Infectious Diseases at Children's National Hospital and Research Institute, about which symptoms clinicians should watch for, how to counsel families, and what the study's cardiology and mental health findings mean for everyday care. She also outlines the questions that remain unanswered as research into pediatric long COVID continues.^1,2

Q&A

Contemporary Pediatrics: The PECOS study identified 20 symptoms that were more commonly reported in children after COVID-19 infection. What should pediatricians know about the most common long-COVID symptoms, and how can they distinguish these from other conditions they see in practice?

Roberta L. DeBiasi, MD, MS: Pediatricians should be aware that children who have recovered from even mild COVID infections can have one or more prolonged symptoms occur following recovery from their initial illness. In younger children, this includes unexplained fevers and dry, persistent cough. In older children, this includes (1) constitutional symptoms, such as fatigue and post-exertional malaise; (2) gastrointestinal symptoms, such as constipation, diarrhea, nausea, vomiting, and decreased appetite; and (3) neurologic symptoms, such as headache and forgetfulness. In older children, muscle and joint pain, as well as dysmenorrhea, can occur, usually with later onset after resolution of the initial infection than the other mentioned symptoms. Since all of these symptoms can occur in children at a background rate (as was seen in uninfected controls in our study), there is not a specific way to distinguish the presence of these symptoms in any given patient as due to COVID vs other conditions. However, in children presenting with these symptoms, a history about recent COVID infection should be obtained, and particularly in patients with a constellation of these symptoms without any other etiology, the possibility of a post-COVID illness should be considered.

Contemporary Pediatrics: One of the key findings was that post-COVID symptoms varied by age and evolved over time. How should pediatricians approach follow-up and monitoring for children and adolescents who have recovered from COVID-19?

DeBiasi: Children recovering from a recent COVID infection may have no additional or prolonged symptoms following recovery, may have only one or more mild symptoms that do not interfere with their normal activities, or, in some cases, more significant or prolonged symptoms in one or more categories that impact their daily functioning. From our current study, we have not identified specific risk factors to predict which patients will develop prolonged symptoms, how severe they will be, or if they will be transient or more persistent. However, pediatricians should be educated and aware of this spectrum of outcomes after recovery from COVID, so that if a patient presents with one or more of these complaints after recent COVID infection, they can educate and validate their patients that this could be part of a post-COVID syndrome. These patients may benefit from referral to a center that can offer a multidisciplinary approach to evaluating and providing treatment plans in partnership with the primary care pediatrician for these children. At this time, there is not a specific follow-up or monitoring approach that is recommended for all children recovering from COVID. However, in children who do develop post-recovery symptoms, their pediatrician should be aware of this entity and able to advocate for their patients.

Contemporary Pediatrics: The study found that children with prior COVID-19 reported worse physical and cognitive functioning, fatigue, pain, and sleep disturbances, but similar rates of anxiety and depression compared with uninfected peers. How do these findings help us understand the direct effects of infection versus the broader effects of the pandemic?

DeBiasi: The importance of including an uninfected control group of children who also went through the same period of the pandemic is highlighted by this finding. Although anxiety and depression were present in a significant proportion of children enrolled in the study, there was no difference between those that had COVID infection or were uninfected. This is not altogether unsurprising, as social isolation, school disruption, and overall stress on children during the pandemic period were the same regardless of infection status. However, the other findings were observed to be more common in infected children compared to their uninfected peers, suggesting a more specific effect of infection itself.

Contemporary Pediatrics: The cardiology analysis found no evidence of long-term heart dysfunction in children following COVID-19 infection, even among those reporting chest pain or fatigue. How might these findings influence pediatricians' evaluation and counseling of families concerned about cardiac complications?

DeBiasi: Children in this study had an extensive cardiac evaluation, including EKG, echocardiography, and, in a subset, cardiac MRI. Although there is still additional analysis to be completed, the currently published study focuses on cardiac strain, a measure of cardiac function. The finding that cardiac function was not impaired in the infected group of children is very reassuring that, overall, COVID infection does not seem to cause long-term cardiac deficits in infected children, and that the reason for the fatigue and chest pain that some children experience during recovery is not due to impaired cardiac function.

Contemporary Pediatrics: Looking ahead, how do you expect the PECOS findings to shape clinical care for children with post-COVID concerns, and what unanswered questions about pediatric long COVID still need further study?

DeBiasi: It is our hope that the findings from the PECOS study will raise awareness among caregivers and patients that even mild COVID infections in children can result in a spectrum of post-recovery symptoms, which may differ by age. Awareness of these symptoms may assist providers in identifying children who may benefit from referral and partnership with a multidisciplinary program with expertise in the diagnosis and care of children with post-COVID syndromes. There are many unanswered questions that are under active study, including the mechanism(s) of the symptoms observed in patients with long COVID, which patients are at highest risk, and how to predict who is more likely to develop long COVID, biomarkers to assist in the diagnosis and confirmation of long COVID, and which treatments are most helpful to patients suffering from prolonged symptoms. Collaboration between clinicians, researchers, and patients, combined with robust clinical databases and biobanks, as have been developed in the PECOS study, is likely to provide answers to these important questions and improve diagnosis and care of this population.

References

1. New research reveals COVID-19's long-term impact on kids. Children's National Hospital. June 5, 2026. Accessed July 20, 2026. https://innovationdistrict.childrensnational.org/new-research-reveals-covid-19s-long-term-impact-on-kids/

2. Montealegre Sanchez GA, Yonts AB, Mateja A, et al. Pediatric SARS-CoV-2 outcomes study (PECOS): 12-month longitudinal analysis of post-COVID symptoms in infected versus uninfected participants. Pediatr Res. Published online 2026. doi:10.1038/s41390-026-05002-7