Severe COVID-19 Illness Most Often Affects Children With Comorbidities

Steve Cimino

May 11, 2020

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Pediatric patients with significant comorbidities appear to be at increased risk of severe COVID-19 illness, according to a preliminary study on COVID-19 in North American pediatric ICUs (PICUs).

"Consistent with the few other initial reports on COVID-19 on children, our study found the clinical course of COVID-19 to be far less severe and the hospital outcomes to be better in critically ill children than those reported in adults," wrote Lara S. Shekerdemian, MD, of the Texas Children's Hospital in Houston, and coauthors. The study was published in JAMA Pediatrics.

To determine the impact of COVID-19 on children in North America during the early stages of this global pandemic, the researchers launched a multicenter cross-sectional study of 48 COVID-19-positive children who were admitted to 46 participating PICUs during March 14–April 3. A total of 52% (n = 25) of the children were male and their median age was 13 years; 17% (8) of the children were less than 1 year of age, 13% (6) were aged 1-5 years, 15% (7) were 6-10 years, and 56% (27) were 11-21 years. Of the 46 hospitals, 30 did not admit any critically ill children with confirmed COVID-19 infections during the study period, including all six hospitals in Canada.

Significant preexisting comorbidities were heavily present in this cohort, with 50% (n = 24) having 1, 17% (n = 8) having 2, and 19% (n = 9) having 3 or more. Forty percent of the children had medically complex comorbidities; other comorbidities included immune suppression/malignancy, obesity, diabetes, seizures, congenital heart disease, sickle cell disease, and chronic lung disease.

A total of 69% (n = 33) of patients were seriously or critically ill upon admission, 25% (n = 12) required vasoactive drugs, and 23% (n = 11) had two or more organ systems fail.

In regard to treatment, 61% of patients (n = 28) received targeted therapies. The most frequently used was hydroxychloroquine in 21 patients – alone in 11 and in combination in 10, with azithromycin in 7, with remdesivir in 1, with tocilizumab in 1, and with azithromycin and tocilizumab in 1. Azithromycin was used in one patient alone. Remdesivir was used as a single agent in two patients and in combination in six.

Eighty-one percent of patients (n = 39) required respiratory support that exceeded their baseline, although 21 of the 39 (54%) were managed noninvasively. The other 18 (38%) children required endotracheal or tracheostomy ventilation, and adjunctive ventilatory interventions or extracorporeal therapies were required in 6 (13%) children.

At the time the study was published, 2 of the 18 children requiring ventilation had died; 3 still required mechanical ventilation, 7 had discontinued mechanical ventilation but remained hospitalized, and 6 had been discharged. The two patients who died were aged 12 and 17 years; the authors noted that "both had preexisting comorbidities and developed multisystem organ failure, and one had gram-negative sepsis prior to developing COVID-19."

In total, 15 patients (31%) remained hospitalized, with 5 still in critical condition; 1 child was still receiving extracorporeal membrane oxygenation. The median length of stays in both the PICU and the hospital were 5 (3-9) days and 7 (4-13) days, respectively.

"This study confirms the suspicions that, while children are being hospitalized, they tend to have better outcomes than adults," said Lenore Jarvis, MD, a pediatric ED doctor who is a member of the Pediatric News editorial advisory board. "Their case fatality rate is certainly less, and children appear to have fewer or less severe complications than adults. But I do say that with a disclaimer: Children are still getting sick from this. I work at a children's hospital and we have hospitalized a number of COVID-19 patients, in the PICU and otherwise. They're not immune." Dr. Jarvis was not involved with this study.

The authors acknowledged their study's limitations, including limited availability of effective testing for COVID-19 during the study period, potentially leading to severely ill children not being tested for various reasons. In addition, they noted that, although most of the 15 children who remained hospitalized appeared to be recovering, the follow-up period of only 7 days "does not exclude the possibility of worse outcomes yet to evolve in this cohort."

Dr. Shekerdemian and associates also said "our presentation here of the experimental therapies provided in this series of severely ill children with COVID-19 is purely descriptive and does not imply any possible benefit from these therapies."

One doctor reported receivinggrants from the Health Resources Services Administration. No other relevant financial disclosures were reported. Dr. Jarvis did not have any relevant financial disclosures.

SOURCE: Shekerdemian LS et al. JAMA Pediatr. 2020 May 11. doi: 10.1001/jamapediatrics.2020.1948.

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