Identifying long covid in children … and other research

What does long covid look like in children?

What exactly is long covid? The broad definition includes symptoms and signs that develop, persist, or relapse over time after the acute viral infection resolves. An estimated 65 million people worldwide may be affected, some with very debilitating effects. This includes large numbers of school-aged children (6-11 years old) and adolescents (12-17 years), and, as with all health conditions, the presentation isn’t necessarily the same as in adults. Myriad presentations make accurate identification tricky.

This US observational meta-cohort study (RECOVER-Pediatrics) identified 14 symptoms among 5367 school-aged children and adolescents that were more common in those with a history of acute covid infection compared with those who hadn’t been infected and so couldn’t have long covid. There were also four symptoms in school-aged children only and three in adolescents only, which highlights the need to treat the two age groups separately. Overall, high percentages of children and adolescents reported at least one prolonged symptom whether infected or uninfected (45% v 33% and 39% v 27%). The study developed a research index that will help researchers identify those children likely to have long covid. It will inform but certainly not replace clinical acumen.

JAMA doi:10.1001/jama.2024.12747

Reducing mortality in under 5s

One in 10 children in sub-Saharan Africa die before their fifth birthday. Since 1990, there’s been huge progress in reducing mortality, which is largely due to infectious disease, prematurity, and birth complications. But progress has now stalled, and the UN target of reducing the under-5 mortality to under 25 per 1000 live births will need new interventions.

The AVENIR study conducted in over 380 000 children in 4272 communities in Niger compared distribution of twice yearly azithromycin or placebo to 1-59 month old children, twice yearly azithromycin or placebo to 1-11 month olds (which is the WHO recommendation). Mortality was lowest when azithromycin was given during 1-59 months, (14% lower mortality with azithromycin compared with placebo), while mortality among 1-11 month old infants was not significantly lower (6% lower with azithromycin compared with placebo). The juggling act between reducing mortality while minimising antibiotic overuse requires more data and tough decisions.

N Engl J Med doi:10.1056/NEJMoa2312093

Pelvic floor yoga to improve urinary incontinence

Pelvic floor yoga has been recommended as a complementary treatment for urinary incontinence (UI), but it lacks a firm evidence base.

This Californian randomised trial of 240 women aged 45-90 years reporting daily urge, stress, or mixed type UI compared a 12-week programme of twice weekly group instruction and weekly self directed pelvis floor Hatha yoga (pelvic yoga) with an equivalent length programme of general muscle stretching and strengthening exercises (physical conditioning). The women kept tabs on progress with three-day voiding diaries. Both programmes helped, at least over the 12 weeks: the mean baseline UI frequency of 3.4 episodes/day at outset fell by 2.3 episodes/day with pelvic yoga and 1.9 episodes/day with physical conditioning, with similar improvements whether stress or urge symptoms predominated. However, with stress-type UI, there was no advantage to doing pelvic yoga over general conditioning exercises.

Ann Intern Med doi:10.7326/M23-3051

Media hype for semaglutide

Semaglutide: is there any ill for which it’s not being championed? Newspaper reports recently claimed it could “revolutionise healthcare by slowing down the ageing process.” Thankfully, despite the hype, serious research is exploring the scope and limitations of this anti-diabetes glucagon-like (GLP-1 receptor agonist) drug.

Heart failure with preserved (or slightly impaired) ejection fraction (HFpEF) is the commonest type of heart failure and often leads to hospital admission and death, especially in overweight or diabetic people. Previous studies found that semaglutide improved symptoms, and this new study used pooled results of four randomised trials to examine whether the drug also reduced progression and death from heart failure.

It was a mixed picture: semaglutide had no significant effect compared with placebo on cardiovascular events alone (3.1% v 3.7%), but it did reduce the risk of worsening heart failure events (2.8% v 4.7%) with no additional safety concerns. In a distressing condition with limited treatment options, this is good news but not necessarily the answer.

Lancet doi:10.1016/S0140-6736(24)01643-X

Trumping the politicians

Termination of pregnancy is a highly politicised topic in the US. Between 2020 and 2023, the proportion of non-hospital abortions in the US that were medical (using mifepristone and misoprostol) rather than surgical increased from 53% to 63%, probably because of covid and the US supreme court decision which eliminated federal protection for abortion. Whatever the driver, home medical abortion is clearly on the rise and effective, safe, and acceptable ways of delivering it are being explored.

This prospective cohort study of 510 medication abortions provided through mail-order pharmacy dispensing after an in-person eligibility screening, resulted in 97.8% complete abortions, 91.2% patient satisfaction, and few serious adverse events (0.6%). There’s now a substantial body of evidence to support the FDA decision to remove the requirement for in-person dispensing of mifepristone.

JAMA Intern Med doi:10.1001/jamainternmed.2024.1476