Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized With Laboratory-Confirmed COVID-19

COVID-NET, 14 States, March 1-July 25, 2020

Lindsay Kim, MD; Michael Whitaker, MPH; Alissa O'Halloran, MSPH; Anita Kambhampati, MPH; Shua J. Chai, MD; Arthur Reingold, MD; Isaac Armistead, MD; Breanna Kawasaki, MPH; James Meek, MPH; Kimberly Yousey-Hindes, MPH; Evan J. Anderson, MD; Kyle P. Openo, DrPH; Andy Weigel, MSW; Patricia Ryan, MSc; Maya L. Monroe, MPH; Kimberly Fox, MPH; Sue Kim, MPH; Ruth Lynfield, MD; Erica Bye, MPH; Sarah Shrum Davis, MPH; Chad Smelser, MD; Grant Barney, MPH; Nancy L. Spina, MPH; Nancy M. Bennett, MD; Christina B. Felsen, MPH; Laurie M. Billing, MPH; Jessica Shiltz, MPH; Melissa Sutton, MD; Nicole West, MPH; H. Keipp Talbot, MD; William Schaffner, MD; Ilene Risk, MPA; Andrea Price; Lynnette Brammer, MPH; Alicia M. Fry, MD; Aron J. Hall, DVM; Gayle E. Langley, MD; Shikha Garg, MD

Disclosures

Morbidity and Mortality Weekly Report. 2020;69(32):1081-1088. 

In This Article

Abstract and Introduction

Introduction

Most reported cases of coronavirus disease 2019 (COVID-19) in children aged <18 years appear to be asymptomatic or mild.[1] Less is known about severe COVID-19 illness requiring hospitalization in children. During March 1–July 25, 2020, 576 pediatric COVID-19 cases were reported to the COVID-19–Associated Hospitalization Surveillance Network (COVID-NET), a population-based surveillance system that collects data on laboratory-confirmed COVID-19–associated hospitalizations in 14 states.[2,3] Based on these data, the cumulative COVID-19-associated hospitalization rate among children aged <18 years during March 1–July 25, 2020, was 8.0 per 100,000 population, with the highest rate among children aged <2 years (24.8). During March 21–July 25, weekly hospitalization rates steadily increased among children (from 0.1 to 0.4 per 100,000, with a weekly high of 0.7 per 100,000). Overall, Hispanic or Latino (Hispanic) and non-Hispanic black (black) children had higher cumulative rates of COVID-19–associated hospitalizations (16.4 and 10.5 per 100,000, respectively) than did non-Hispanic white (white) children (2.1). Among 208 (36.1%) hospitalized children with complete medical chart reviews, 69 (33.2%) were admitted to an intensive care unit (ICU); 12 of 207 (5.8%) required invasive mechanical ventilation, and one patient died during hospitalization. Although the cumulative rate of pediatric COVID-19–associated hospitalization remains low (8.0 per 100,000 population) compared with that among adults (164.5),* weekly rates increased during the surveillance period, and one in three hospitalized children were admitted to the ICU, similar to the proportion among adults. Continued tracking of SARS-CoV-2 infections among children is important to characterize morbidity and mortality. Reinforcement of prevention efforts is essential in congregate settings that serve children, including childcare centers and schools.

COVID-NET conducts population-based surveillance for laboratory-confirmed COVID-19–associated hospitalizations in 99 counties in 14 states (California, Connecticut, Colorado, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee, and Utah), representing all 10 U.S. Department of Health and Human Services regions.[2,3] Laboratory-confirmed COVID-19–associated hospitalizations among residents in a predefined surveillance catchment area who had a positive SARS-CoV-2 molecular test during hospitalization or up to 14 days before admission are included in surveillance. SARS-CoV-2 tests are ordered at the discretion of the treating health care provider. Trained surveillance officers perform medical chart abstractions for all identified cases. Patients aged <18 years hospitalized with COVID-19 during March 1–July 25, 2020, were included in this analysis. Weekly and cumulative COVID-19–associated hospitalization rates were calculated using the number of catchment area residents hospitalized with COVID-19 as the numerator and the National Center for Health Statistics vintage 2019 bridged-race postcensal population estimates as the denominator.§ Descriptive analyses were conducted using all available data; however, for clinical interventions, treatments, and outcomes, only those hospitalizations with complete medical chart review and a discharge disposition (i.e., discharged alive or died during hospitalization) were included. Obesity was defined as body mass index (kg/m2) ≥95th percentile for age and sex based on CDC growth charts among children aged ≥2 years; this was not evaluated for children <2 years. All analyses were conducted using SAS statistical software (version 9.4; SAS Institute). COVID-NET activities were determined by CDC to be public health surveillance. Participating sites obtained approval for COVID-NET surveillance from their respective state and local Institutional Review Boards, as required.

During March 1–July 25, 576 children hospitalized with COVID-19 were reported to COVID-NET. Infants aged <3 months accounted for 18.8% of all children hospitalized with COVID-19 (Table). The median patient age was 8 years (interquartile range [IQR] = 9 months–15 years), and 292 (50.7%) were males. Among 526 (91.3%) children for whom race and ethnicity information were reported, 241 (45.8%) were Hispanic, 156 (29.7%) were black, 74 (14.1%) were white; 24 (4.6%) were non-Hispanic Asian or Pacific Islander; and four (0.8%) were non-Hispanic American Indian/Alaska Native.

The cumulative COVID-19–associated hospitalization rate among children aged <18 years during the surveillance period was 8.0 per 100,000 and was highest among children aged <2 years (24.8); rates were substantially lower in children aged 2–4 years (4.2) and 5–17 years (6.4) (Figure 1). Overall weekly hospitalization rates among children increased steadily during the surveillance period (from 0.1 to 0.4 per 100,000, with a weekly high of 0.7 per 100,000; trend test, p<0.001) (Figure 1). COVID-19–associated hospitalization rates were higher among Hispanic and black children than among white children (Figure 2); the rates among Hispanic and black children were nearly eight times and five times, respectively, the rate in white children.

Figure 1.

Cumulative (A) and weekly (B) COVID-19–associated hospitalization rates*,† among children aged <18 years, by age group — COVID-NET, 14 states§, March 1–July 25, 2020
Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network.
*Number of children in each age group hospitalized with COVID-19 per 100,000 population.
Figure B shows the 3-week moving average of weekly hospitalization rates for children in each age group hospitalized with COVID-19 per 100,000 population. A trend test was conducted using weighted linear regression, where the weight for each week was the inverse of the variance. Trend test overall (<18 years): p-value <0.001.
§Counties included in COVID-NET surveillance: California (Alameda, Contra Costa, and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Montgomery, Prince George's, Queen Anne's, St. Mary's, Somerset, Talbot, Washington, Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan, and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe, Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne, and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison, Morrow, Perry, Pickaway, and Union counties); Oregon (Clackamas, Multnomah, and Washington counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner, Williamson, and Wilson counties); and Utah (Salt Lake County).
Data are preliminary, and case counts and rates for recent hospital admissions are subject to lag. As data are received each week, previous case counts and rates are updated accordingly.

Figure 2.

Cumulative COVID-19-associated hospitalization rates* among children aged <18 years, by age group and race/ethnicity — COVID-NET, 14 states, March 1–July 25, 2020§,¶
Abbreviation: COVID-NET = Coronavirus Disease 2019–Associated Hospitalization Surveillance Network.
*Number of children aged <18 years hospitalized with COVID-19 per 100,000 population.
Counties included in COVID-NET surveillance: California (Alameda, Contra Costa, and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Montgomery, Prince George's, Queen Anne's, St. Mary's, Somerset, Talbot, Washington, Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan, and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe, Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne, and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison, Morrow, Perry, Pickaway, and Union counties); Oregon (Clackamas, Multnomah, and Washington counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner, Williamson, and Wilson counties); and Utah (Salt Lake County).
§Data are preliminary, and case counts and rates for recent hospital admissions are subject to lag. As data are received each week, prior case counts and rates are updated accordingly. As of July 25, 2020, 50 (8.7%) of 576 pediatric hospitalized cases were missing data on race and ethnicity.
Rates are not shown among non-Hispanic Asian or Pacific Islanders and non-Hispanic American Indian/Alaska Natives because of small case counts, leading to unstable estimates. All non-Hispanic American Indian/Alaska Native hospitalized children were aged 5–17 years.

Among 222 (38.5%) of 576 children with information on underlying medical conditions, 94 (42.3%) had one or more underlying conditions (Table). The most prevalent conditions included obesity (37.8%), chronic lung disease (18.0%), and prematurity (gestational age <37 weeks at birth, collected only for children aged <2 years) (15.4%). Hispanic and black children had higher prevalences of underlying conditions (45.7% and 29.8%, respectively) compared with white children (14.9%). Reported signs and symptoms upon hospital admission differed by age: fever or chills were the most common sign and symptom overall (54%) and were most prevalent among children aged <2 years (74.6%). Gastrointestinal symptoms, including nausea or vomiting, abdominal pain, or diarrhea, were reported by 42% of hospitalized children overall.

A medical chart review was completed for 208 (36.1%) children. Median duration of hospitalization was 2.5 days (IQR = 1–5 days). Among 67 children who had a chest radiograph during hospitalization, 44 (65.7%) radiographs showed an infiltrate or consolidation. Among 14 children with chest computed tomography results available, ground-glass opacities (a nonspecific sign indicating infection or alveolar disease) was reported in 10. COVID-19 investigational treatments were only administered to 12 (5.8%) children, all aged 5–17 years; nine received remdesivir. Intravenous immunoglobulin was received by 14 of 208 (6.7%) children. Sixty-nine children (33.2%) were admitted to the ICU for a median of 2 days (IQR = 1–5 days). Invasive mechanical ventilation was required by 12 (5.8%) of 207 children. Since June 18, a discharge diagnosis of multisystem inflammatory syndrome in children (MIS-C) has been systematically collected**; overall, nine (10.8%) of 83 children with completed chart reviews for whom information about MIS-C was systematically collected received a diagnosis of MIS-C. Among 208 children with a discharge disposition, one child (0.5%) with multiple underlying conditions died during hospitalization.

*https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/index.html.
Counties in COVID-NET surveillance: California (Alameda, Contra Costa, and San Francisco counties); Colorado (Adams, Arapahoe, Denver, Douglas, and Jefferson counties); Connecticut (New Haven and Middlesex counties); Georgia (Clayton, Cobb, DeKalb, Douglas, Fulton, Gwinnett, Newton, and Rockdale counties); Iowa (one county represented); Maryland (Allegany, Anne Arundel, Baltimore, Baltimore City, Calvert, Caroline, Carroll, Cecil, Charles, Dorchester, Frederick, Garrett, Harford, Howard, Kent, Montgomery, Prince George's, Queen Anne's, St. Mary's, Somerset, Talbot, Washington, Wicomico, and Worcester counties); Michigan (Clinton, Eaton, Genesee, Ingham, and Washtenaw counties); Minnesota (Anoka, Carver, Dakota, Hennepin, Ramsey, Scott, and Washington counties); New Mexico (Bernalillo, Chaves, Dona Ana, Grant, Luna, San Juan, and Santa Fe counties); New York (Albany, Columbia, Genesee, Greene, Livingston, Monroe, Montgomery, Ontario, Orleans, Rensselaer, Saratoga, Schenectady, Schoharie, Wayne, and Yates counties); Ohio (Delaware, Fairfield, Franklin, Hocking, Licking, Madison, Morrow, Perry, Pickaway, and Union counties); Oregon (Clackamas, Multnomah, and Washington counties); Tennessee (Cheatham, Davidson, Dickson, Robertson, Rutherford, Sumner, Williamson, and Wilson counties); and Utah (Salt Lake County).
§ https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covidview/purpose-methods.html.
US Department of Health and Human Services, Title 45 Code of Federal Regulations 46, Protection of Human Subjects.
**MIS-C is a hyperinflammatory condition that can affect multiple organs in a child who has a current or recent infection with SARS-CoV-2.

processing....