Long COVID—The New “Invisible” Illness: How School Nurses Can Support the Nursing and Educational Teams for Student Success

Background

COVID-19 has greatly affected the role of the school nurse in health programs. From partnering with local health departments, conducting testing and contact tracing, and creating innovative solutions to keep students and staff safe, school nurses have substantially affected their schools’ ability to respond to the virus. School nurses have risen to meet numerous challenges over the past nearly 2 years and are being called upon to face yet a new challenge and phase of the pandemic: preparing and educating staff to support students affected by symptoms of long COVID.

According to the American Academy of Pediatrics (AAP) State-level Data Report released September 2021, 5 million children have tested positive since the onset of the pandemic with the cases increasing exponentially since the early summer of 2021. For the week ending September 2, children accounted for 26.8% of reported weekly COVID-19 cases, an increase of 10% in children’s cases since the start of the pandemic (AAP, 2021a). While a majority of the current pediatric literature has focused on the acute manifestation of the SARS-CoV-2 infection and multisystem inflammatory syndrome, emerging studies have also identified that children and adolescents are not immune to developing similar symptoms of long COVID.

Definition, Clinical Manifestations, and Timeline of Long COVID

Long COVID, also known as postacute sequela of SARS-CoV-2; postacute COVID-19; chronic COVID, or the umbrella term post-COVID conditions; has been well documented in adult patients with lingering symptoms such as fatigue, headache, muscle and joint pain, respiratory, and cardiac problems (Nalbandian et al., 2021). Long-COVID conditions are defined as a wide range of new, returning or ongoing symptoms and clinical findings 4 or more weeks after infection (Centers for Disease Control and Prevention [CDC], 2021). Patients reported an increased symptom burden and prolonged recovery mainly from systemic and cognitive symptoms with substantial impact on daily life and work (Davis et al., 2021). Such signs and symptoms cannot be explained by an alternative diagnosis (Brackel et al., 2021).

Pediatric COVID “long-haulers” have also experienced pronounced and persistent symptoms such as fatigue, headache, respiratory symptoms like chest tightness and shortness of breath, heart palpitations, joint or muscle pain, orthostatic intolerance, temperature dysregulation, gastrointestinal issues such as diarrhea or stomach pain, mood/psychological symptoms, insomnia, and cognitive difficulties like “brain fog” (CDC, 2021). There has been no correlation between the severity of acute COVID and such postacute long-COVID symptoms; meaning that even if the child experienced a mild or asymptomatic COVID-19 infection, the symptoms of long COVID could be significant (CDC, 2021).

Evidence from one long-COVID study in children from the United Kingdom found that school-age children were experiencing persistent symptoms on average 8 months after infection (Buonsenso, Pujol, et al., 2021). About 25% suffered constant symptoms, 49% experienced periods of apparent recovery before return of symptoms, and 19% had prolonged period of wellness before symptoms presented (Buonsenso, Munbilt, et al., 2021). With most reports including changes in energy, mood, sleep, and appetite, the impact on a child’s daily function and school performance could be variable.

The wide variety of symptoms, severity, and timeline creates unique challenges for this population as children, adolescents, and parents alike may struggle to pinpoint or communicate such broad symptoms and make the connection to a past COVID infection. There is an urgent need to align more research and data with these numbers to understand the long-term symptoms and impact.

Emerging Clinics and Multidisciplinary Approach to Treatment

A number of rehabilitation clinics across the country have begun to offer adult multidisciplinary treatment and services for those affected by long COVID. Dedicated pediatric clinics are slowly gaining momentum as the specialized needs and long-term outcomes of this vulnerable population can vary greatly from that of adults. Again, research alongside treatment is continuously evolving to identify how and why children may present and/or recover differently than adults.

The Kennedy Krieger Institute’s Pediatric Post COVID-19 Rehabilitation Clinic in Baltimore, Maryland is one recently established clinic dedicated to supporting children and adolescents as they experience the lingering symptoms of COVID-19 affecting their neurological and physical functioning. The interdisciplinary clinic reviews ongoing symptoms and provides evaluations to create a personalized rehabilitation plan that can include specialists from pediatric rehabilitation medicine, neurology, physical therapy, behavior psychology, neuropsychology, social work, and nursing. The primary focus of the clinic has been on management strategies and treatment of overlapping symptoms of long COVID similar to that of patients diagnosed with or experiencing symptoms of postexertional malaise and myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), lightheadedness and racing heart of orthostatic intolerance (OI) or postural orthostatic tachycardia syndrome (POTS), and lingering cognitive symptoms of concussions or other brain injuries.

Moving Forward With School Planning

Such a variety of symptoms affecting a child’s physical health, cognitive development, and emotional well-being can greatly affect a child’s everyday function, school performance, and participation in youth activities. In one long-COVID pediatric study, 48% reported mild limitations (e.g., can go to school but excessively tired), 36% experienced severe limitations demonstrated by limited or no school attendance, and only 8% of the reported patients had no disruption to their life due to their symptoms (Brackel et al., 2021).

Developing an IHP

For students diagnosed with long-COVD conditions, the school nurse should perform an individualized health assessment and follow up with the parents/caregivers, primary healthcare provider, and multidisciplinary team or specialists as able. For example, a student newly diagnosed with orthostatic intolerance may be prescribed new daily medication or need encouragement to meet a daily fluid goal. Does the student require assistance for safety when transitioning between classes? Is the student safely able to participate in physical education or sports? Should the student have rest breaks built into their schedule? The school nurse should anticipate specific health issues and/or healthcare provider orders affecting a student in school as a result of long COVID (see Table 1).

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Table 1.

Specific Health Issues and Healthcare Provider Orders to Consider

• Description of student diagnosis or overlapping symptoms • New or adjusted medications and possible side effects • Baseline cardiac or respiratory assessment including vital sign parameters • Nutritional assessment including increased fluid or salt intake • Monitoring for fatigue or physical intolerance in the school setting • Use of mobility aids or supervision/safety considerations • Temperature accommodations for classroom and/or transportation environment • Monitoring for hypersensititives to noise, light, and sound • Use of safe physical/movement techniques; postural counter maneuvers • Stress management suggestions including rest break, adjusted school day • Development of an emergency care plan (ECP) and/or emergency evacuation plan (EEP) and staff education/training as appropriate for each

Educational and Classroom Considerations

Long COVID Kids (2021), an advocacy and support campaign, conducted a rapid online survey and collected data on over 500 children (both the United Kingdom and the United States) diagnosed with COVID between January 2020 and January 2021. The results included those experiencing symptoms for longer than 4 weeks, with a mean age of 10 years. A prevalence of neurocognitive symptoms were reported; specifically, a lack of concentration (60.6%), difficulty remembering information (45.9%), difficulty in doing everyday tasks (40%), difficulty processing information (32.7%), and short-term memory issues (32.7%; Buonsenso, Pujol, et al., 2021). Additional cognitive issues reported on the survey included struggle to find right words, difficulty understanding instruction, forgets what they are saying, difficulty with decision making, vacant look, hesitation before speaking, and difficulty with sequence or order (Buonsenso, Pujol, et al., 2021).

Using a variety of school-based and educational considerations could support student success when returning to the classroom. Whether focused on the academic schedule, instruction, physical environment, or communication and support, a list of helpful suggestions to consider are listed in Table 2. Again, recovery is dynamic and symptoms may improve before returning weeks or even months later. The school plan should be flexible to account for such variations in recovery yet remain focused on conserving energy and prioritizing demands.

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Table 2.

School-Based and Educational Considerations

Evaluation/assessment	• Team meeting 504/IEP (individualized education plan) • School-based physical therapist (PT)/occupational therapist (OT)/ speech and language pathologist (SLP) • Psychological evaluation • Educational evaluation • School nurse assessment
Scheduling	• Staggered return to school • Blended learning (i.e., in-person, virtual, hybrid, etc.) • Flexibility in scheduling • Adjusted school days • Adjusted time in arrival/dismissal/transition between class times
Environment/physical	• Avoid busy or crowded transitions, entry/exit • Preferential classroom location to reduce demands transitioning to different settings • Use of quiet space, activities, or noise-cancelling headphones • Adapted physical exercise (PE) or reduced demands during physical activity • Elevator privileges
Academic	• Prioritizing academic demands • Strategies for cognitive difficulties • Increased test taking time • Use of written instruction • Use of checklist, agenda book • Reduced or limited amount of homework • Extra set of books • Use of assistive technology • Copies of teacher notes
Communication	• Positive reinforcement, active listening, distraction techniques • Identification of an academic point person to coordinate and manage missed schoolwork • Preferred staff member (i.e., resource teacher, guidance counselor) for daily check-ins
Training	• Communication/continuing education with multidisciplinary team, healthcare providers, school nurse, school staff, etc. • Staff training of an emergency care plan (ECP) and/or emergency evacuation plan (EEP) as necessary

Conclusion

The impact of COVID-19 has affected daily life for students (i.e., changes to the delivery/setting of education, youth sports, social interactions, etc.) and in many instances exacerbated existing health concerns. Identifying and documenting changes in a student’s health and academic progress may continue to shift and evolve due to the pandemic but both remain important in creating a successful learning environment. A school nurse’s important role as a leader in student-centered care combines the standards of practice and care coordination necessary to help make it possible for a student diagnosed or experiencing symptoms of long COVID to be healthy, safe, and ready to learn. School nurses can support educators to identify at-risk students and the signs and symptoms of long COVID affecting their health and academic performance. A successful school plan, including the school nurse as part of the team, should include a combination of medical, behavioral, environmental, and educational interventions individualized to the student.

Pediatrics and adolescents are not immune to this disease or the long-term impacts of the infection. As we enter the third school year affected by the pandemic, it is not unrealistic for school health programs to be preparing and planning for students experiencing symptoms of long COVID. School nurses are in a unique position to identify some of the health and developmental trends or changes in these students, refer to specialists/health care providers, and work with their school team to create an individualized student plan for success as they continue to recover from the impact of COVID-19.■