More Insight on Which Kids Are Most at Risk for Severe COVID-19

Certain underlying medical conditions, as well as complex chronic illnesses exacerbated the risk for severe COVID-19 in children, researchers found in a cross-sectional study.

The strongest risk factors for COVID-19 hospitalization included type I diabetes (adjusted risk ratio 4.60, 95% CI 3.91-5.42) and obesity (aRR 3.07, 95% CI 2.66-3.54), reported Lyudmyla Kompaniyets, PhD, and colleagues from the CDC.

Type I diabetes (aRR 2.38, 95% CI 2.06-2.76), cardiac and circulatory congenital anomalies (aRR 1.72, 95% CI 1.48-1.99), and epilepsy and/or convulsions (aRR, 1.71, 95% CI 1.41-2.08) were strong risk factors for developing severe COVID-19 illness, the authors wrote in JAMA Network Open.

Chronic disease (aRR 1.95, 95% CI 1.69-2.26) and complex chronic disease (aRR 2.86, 95% CI 2.47-3.32, respectively) were also risk factors for severe COVID-19 illness in children, they noted.

“Throughout this pandemic, pediatric practitioners have been making decisions extrapolated from adult data […] To provide the best care for children, we need pediatric-specific data,” Jennifer Schuster, MD, of Children’s Mercy Kansas City in Kansas City, Missouri and Annabelle de St Maurice, MD, of University of California, Los Angeles, stated in an accompanying editorial.

Kompaniyets and colleagues said that previous studies found risk factors for severe COVID-19 in children included young age (under 1) or children who have pre-existing medical conditions (e.g., asthma, diabetes, congenital heart disease, obesity, or neurologic conditions). However, previous generalizations have been marginalized by small sample sizes and inadequate follow-ups.

In this study, patient data was collected from a database involving over 800 hospitals where pediatric patients age 18 or younger were seen in the emergency department or were inpatients from March 2020 to January 2021. Patients were excluded if they lacked gender data.

The main outcomes of the study were hospitalization as well as severe illness (defined as ICU admission, invasive mechanical ventilation, or death) during hospitalization.

Overall, there were 43,465 patients included. Average participant age was 12 and 52% were girls, while 33% were Hispanic/Latino, 30% were white, and 24% were non-Hispanic Black. The authors noted more than half the sample consisted of adolescents ages 12-18, and the results were most reflective of that age group.

There were 10% of children hospitalized with COVID-19. Of those, just under 30% were admitted to the ICU. There were 6.4% of patients who received invasive mechanical ventilation and 0.9% of patients died.

About 29% of participants with COVID-19 had underlying medical conditions, as well as 63% of participants hospitalized with COVID-19.

Asthma was the most common underlying condition (10.2%), followed by neurodevelopmental disorders (3.9%), anxiety and fear-related disorders (3.2%), and depressive disorders (2.8%).

“Interestingly, trauma and stressor-related disorders, anxiety and fear-related disorders, and depressive disorders were also associated with hospitalization, reflecting the toll that the pandemic has taken on pediatric mental health,” editorialists Schuster and de St Maurice wrote.

A CDC spokesperson told MedPage Today on behalf of Kompaniyets that children with complex chronic disease included “the presence of malignant neoplasms or multiple chronic conditions,” and these children “were more likely to be hospitalized or get severely ill than children without chronic disease.”

Other underlying medical conditions linked to higher risk of severe COVID-19 illness were obesity, essential hypertension, and sleep/wake disorders, including sleep apnea.

In children age 1 or younger, premature birth was a risk factor for severe COVID-19 (aRR 1.83, 95% CI 1.47-2.29), the authors said.

Limitations of this study include the use of ICD-10-CM diagnostic codes, so pre-existing conditions may have been underestimated. Since some hospitals could have misclassified ICD codes, the estimation of hospitalization risk could be biased. This study examined frequent chronic conditions, omitting rare or acute conditions that could have been additional risk factors. Since it only included data from the children’s emergency department visits or hospitalization, it cannot be generalized for all pediatric COVID-19 cases.

Schuster and de St Maurice also noted a potential confounder in type I diabetes.

“Although type 1 diabetes was associated with hospitalization, admission may have been related to diabetic ketoacidosis (DKA) rather than COVID-19. At some hospitals, children with DKA may be routinely cared for in the ICU, due to need for continuous medication infusions and close monitoring of vital signs,” the editorialists said.

A CDC spokesperson told MedPage Today on behalf of Kompaniyets that, “these findings highlight the serious clinical and public health implications of underlying medical conditions in children” and that children with chronic disease and their close contacts should continue to be prioritized for vaccines.

“When making care plans for their COVID-19 patients, healthcare providers can consider the risk for severe outcomes in patients with specific underlying conditions and complex chronic disease,” the CDC spokesperson said.