Underlying illness, respiratory infection raise risk for severe COVID in kids

Nurse giving oxygen to sick boy
Nurse giving oxygen to sick boy

Visivasnc / iStock

Of two new studies on severe COVID-19 in children, the first finds that more than one in four had an underlying medical condition, and the second shows that kids diagnosed as having acute lower respiratory tract infection (ALRI) were over twice as likely to require invasive mechanical ventilation.

Type 1 diabetes, obesity, heart problems

In the first study, published today in JAMA Network Open, researchers from the US Centers for Disease Control and Prevention used the Premier Healthcare Database Special COVID-19 Release, which houses data from 872 hospitals, to study 43,465 patients 18 and younger who visited an emergency department or were hospitalized for severe COVID-19 from March 2020 to January 2021.

They found that 28.7% of all COVID-19 patients had at least one chronic condition, the most common of which were asthma (10.2%), neurodevelopmental disorders (3.9%), anxiety and fear-related conditions (3.2%), depression (2.8%), and obesity (2.5%). Underlying illness were identified in 62.9% of hospitalized COVID-19 patients.

The strongest risk factors for hospitalization included type 1 diabetes (adjusted risk ratio [aRR], 4.60) and obesity (aRR, 3.07), while type 1 diabetes (aRR, 2.38) and cardiac and circulatory congenital disorders (aRR, 1.72) were the strongest risks for severe illness.

Prioritizing public health, vaccination efforts

Among children younger than 2 years, prematurity was a risk factor for severe COVID-19 disease (aRR, 1.83). Chronic and complex chronic illnesses were risk factors for hospitalization (aRRs, 2.91 and 7.86, respectively) and serious illness (aRRs,1.95 and 2.86).

Chronic conditions tied to a higher risk of COVID-19 hospitalization of children of any age were epilepsy and/or convulsions (aRR, 1.97); dependence on medical support, such as a feeding tube (aRR, 1.96); trauma and stress-related disorders (aRR, 1.82); neurodevelopmental disorders (aRR, 1.64); type 2 diabetes (aRR, 1.59); depression (aRR, 1.58); essential high blood pressure (aRR, 1.51); anxiety and fear-related disorders (aRR, 1.47); and asthma (aRR, 1.23).

Among the 4,302 children admitted to a hospital with COVID-19, risk intensive care unit (ICU) admission, mechanical ventilation, or death was highest in those with type 1 diabetes (aRR, 2.38), cardiac and circulatory congenital disorders (aRR, 1.72), and epilepsy and/or convulsions (aRR, 1.71).

Other conditions linked to higher risk of poor outcomes included obesity (aRR, 1.42); essential high blood pressure (aRR, 1.39); sleep disorders such as sleep apnea (aRR, 1.26); and dependence on medical support (aRR, 1.25).

Of all COVID-19 patients, 29.6% were admitted to the ICU, 9.9% were hospitalized, 6.4% required invasive mechanical ventilation, and 0.9% died. Median patient age was 12 years (range, 4 to 16), 52.8% were female, 33.0% were Hispanic or Latino, and 24.1% were Black.

The researchers said that public health mitigation efforts and vaccine prioritization should be considered for children with chronic underlying diseases. "Health care practitioners can consider the potential need for cautious clinical management of children with these conditions and COVID-19," they concluded. "Further epidemiologic investigation could provide insight into the causal pathways underlying our findings and identify other factors that place children at increased risk of severe COVID-19 illness."

Death, need for mechanical ventilation

In a letter to the editor late last week in the Journal of Infection, Vivian Botelho Lorenzo, MD, and Cristiana Nascimento-Carvalho, MD, PhD, both of the Federal University of Bahia School of Medicine in Salvador, Brazil, described a retrospective study of 210 children younger than 17 years admitted to a pediatric ICU with severe ALRI from April 2020 to April 2021. The median age was 2.8 years.

Of the 210 ALRI patients, 29.5% tested positive for COVID-19, 15.7% needed mechanical ventilation, and 3.8% died. COVID-19 patients were more likely than their peers to need mechanical ventilation (25.8% vs 11.5%) and to die (8.1% vs 2.0%). Boys and patients with sickle cell disease were more likely than others to test positive for COVID-19 (67.7% vs 52.7%; 6.5% vs 0%).

Among all patients, the most common ALRI symptoms were shortness of breath (98.1%), cough (68.6%), and fever (57.6%), while the most common signs were oxygen concentration below 92% (73.3%), needing respiratory support (62.4%), and dehydration (39.5%). The researchers note that wheezing at admission was more likely to be a symptom in those who weren't admitted (21.0% vs 38.5%, respectively).

More than one in three patients also had an underlying medical condition (34.3%), the most common of which were chronic lung disease (18.6%), neurological diseases other than epilepsy (7.1%), and epilepsy (5.2%). Also, three of the five COVID-19 patients who died had an underlying condition, with two diagnosed as having cerebral palsy and one having floppy infant syndrome.

The researchers noted that amid the coronavirus pandemic, about two-thirds of patients were hospitalized with severe ALRIs without COVID-19. "In 2016, 3 years before the beginning of the current COVID-19 pandemic, ALRI was estimated to cause 652,572 deaths among children younger than 5 years all over the world," they wrote. "Therefore, besides SARS-CoV-2, other causative agents remain causing severe ALRI."

The authors said that clinicians should be aware that children with severe ALRI and COVID-19 need mechanical ventilation more often than other patients and that children with sickle cell disease should be prioritized for COVID-19 vaccination.

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