Age, comorbidities predict severe COVID-19 in children

Extremes of age, comorbid conditions, and elevated C-reactive protein (CRP) are associated with severe COVID-19 in children, according to a study.

“Counseling of families with children with comorbid medical conditions should include a discussion of increased risk of severe illness,” the researchers said. “Healthcare providers may consider screening for CRP at admission to inform the need for critical care.”

This retrospective study included 454 children with positive SARS-CoV-2 infection from March to July 2020 at the Children’s Hospital Colorado in Aurora, Colorado, US. The researchers analysed the risk factors for severe disease as defined by hospital admission, respiratory support, or critical care. They also conducted univariable and multivariable analyses.

Of the patients, 42.1 percent were females (median age 11 years) and 55.0 percent identified as Hispanic. Multivariable analyses revealed the following predictors for hospital admission: age 0–3 months (adjusted odds ratio [aOR], 7.85; p<0.0001) or >20 years (aOR, 5.1; p=0.03); preterm birth history (aOR, 3.7; p=0.03); comorbidities such as immunocompromise (aOR, 3.5; p=0.004), gastrointestinal condition (aOR, 2.7; p=0.009), diabetes (aOR, 6.6; p=0.04), asthma (aOR, 2.2; p=0.04); and specific symptoms at presentation. [Pediatr Infect Dis J 2021;40:e137-e145]

Age 0–3 months or >20 years, asthma, gastrointestinal condition, and similar symptoms at presentation also predicted respiratory support. In addition, elevated CRP correlated with the need for critical care, with median of 17.7 mg/dL (interquartile range [IQR], 5.3–22.9) vs 1.95 mg/dl (IQR, 0.7–5.5), among patients who required critical care relative to those who did not (OR, 1.2; p=0.2).

“Findings from this study can inform paediatric providers and public health officials to tailor clinical management, pandemic planning, and resource allocation,” the researchers said. “Additional research should evaluate approaches to mitigate these risk factors and explore associations of ethnicity and COVID-19 in children.”

Other studies also found that children with comorbidities, particularly medically complex patients, could be at higher risk of hospitalization and critical care. In the current study, one-third of children with a gastrointestinal comorbidity required a gastrostomy or jejunostomy tube, supporting the association of severe COVID-19 with medical complexity. [JAMA Pediatr 2020;174:e202430; J Pediatr 2020;223:199-203.e1; JAMA Pediatr 2020;174:868-873]

Obesity has also been found to be independently associated with severe COVID-19 in adults, with the same trend being seen in children. Factors contributing to this association included increased prevalence of other medical comorbidities, obesity-related complications, race/ethnicity, and socioeconomic or behavioural factors. [Obesity (Silver Spring) 2020;28:1195-1199; Int J Obes (Lond) 2020;44:1807-1809; MMWR Morb Mortal Wkly Rep 2020;69:382-386; Aging (Albany NY) 2020;12:12410-12421; MMWR Morb Mortal Wkly Rep 2020;69:1081-1088; Obesity (Silver Spring) 2020;28:1184-1186]

“Obesity and severe obesity in our cohort were significantly associated with admission and respiratory support; however, due to missing data, we were not able to include this variable in the multivariable analyses,” the researchers said.

Data used in the current study were limited to those available in the electronic health record. Most participants had available data, but information for some outpatient cases were lacking. Furthermore, changing recommendations on whom to test might have affected the findings.

“[T]he early focus on testing only symptomatic admitted children may have skewed our cohort toward the inclusion of more ill children, but only 6.9 percent of our cohort were diagnosed while testing was restricted, so we do not anticipate this created significant bias,” the researchers said.