COVID-19 Hospitalizations for Children May Be Overcounted

Marcia Frellick

May 19, 2021

Editor's note: Find the latest COVID-19 news and guidance in Medscape's Coronavirus Resource Center.

The numbers of children hospitalized with COVID-19 may be overstated because such counts include many asymptomatic patients who may have entered the hospital for a different reason, according to a small study published online today in Hospital Pediatrics.

Lauren Kushner, MD, medical fellow in pediatric infectious diseases at Stanford University School of Medicine, Stanford, California, and colleagues say the distinction between children hospitalized with asymptomatic SARS-CoV-2 infections and those hospitalized for COVID-19 disease is critical to understand the impact of the disease in the patients under age 18.

Dr Roshni Mathew

Roshni Mathew, MD, clinical associate professor of pediatrics in infectious diseases at Stanford, told Medscape Medical News the team decided to do the study because there were reports nationally of increasing numbers of children in the hospital with COVID. They wanted to assess the disease burden in their own institution and to understand whether COVID was the reason for the hospitalization.  

Understanding the true disease burden is important in making policy on a broad scale, such as when and how to open schools, Mathew noted.

Nearly Half Had No Symptoms

They found that nearly half of those who test positive for the virus never develop symptoms of COVID-19. While cases of COVID-19 in hospitalized children are being reported to departments of health, the reasons for hospitalization are not necessarily being included as well, Mathew said.

Many come into the hospital for broken bones or appendicitis or for cancer treatments. When they get tested for SARS-CoV-2, some come back positive.

The researchers analyzed COVID-19 data from Lucile Packard Children's Hospital Stanford between May 10, 2020, when the hospital started testing all inpatients for COVID-19, and February 10, 2021.

In those 9 months, 117 children either had a positive test for the SARS-CoV-2 virus or were hospitalized for multisystem inflammatory syndrome in children (MIS-C).

The researchers reviewed the charts of the patients to determine which of the admissions were likely as a result of COVID-19. They also classified the severity.

Of the 117 patients, they found 46 (39.3%) had asymptomatic COVID; 33 (28.2%) had mild to moderate disease; nine (7.7%) had severe illness; 15 (12.8%) had critical illness; and 14 (12%) had MIS-C.

They explain that patients with mild to moderate disease had COVID symptoms but did not need supplemental oxygen; those with severe disease needed oxygen but not ventilation; and those critically ill needed ventilation and may have had sepsis or multiorgan failure.

"Given the high proportion of asymptomatic or mild disease in children, pediatric SARS-CoV-2 hospitalization rates may be more reflective of community prevalence and overestimate the true burden of disease," the authors write.

Numbers Also Confirm Important Information

Mathew said it's still important to know whether children are testing positive and are asymptomatic because of the potential to transmit the infection and protocols that need to be followed.

Sean O'Leary, MD, vice chair of the American Academy of Pediatrics  Committee on Infectious Diseases, told Medscape Medical News that reporting methods differ by state and there is much variation in how COVID-19 infection is classified in hospitals.

He said he wasn't surprised by the number of asymptomatic infections in hospitalized children from the Stanford study and said Children's Hospital Colorado in Aurora, where he practices, also counts some asymptomatic infections in the COVID-19 hospitalizations.

However, he said, "I was a little surprised that their number of hospitalizations was only 117, because we've had over 1200 in a similar time period."

O'Leary said it can be difficult to discern the role COVID is playing in the hospitalization.

If a child, for instance, comes in with a respiratory infection and he or she is hospitalized on oxygen and tests positive for COVID, it can be difficult to determine what drove the hospitalization, he noted.

It's important not to lose sight of the fact that this study also confirms that children can become critically ill with the disease and can die, O'Leary said.

"Death from COVID-19 is a clear outcome and we know that, depending on whose numbers you are using, somewhere between 300 and 600 children have died from COVID in the US," he said.

Additionally, O'Leary said, "For every childhood death, that's the end of a spectrum. There are many, many hospitalizations that go with that."

Vaccinating Children?

Mathew said the confirmation of severe disease in the study is also an argument for children 12 and older getting the Pfizer COVID-19 vaccine — and those younger than 12 receiving it when one is available.

The authors and O'Leary note that a limitation of the study is that data were collected at a single site retrospectively.

"However, our proportion of asymptomatic patients is similar to other investigations," the authors write.

Mathew said the message of the study is that to understand the true burden of COVID-19 in children, "we need to know why the child was admitted and also the severity of COVID in that child."

No external funding for this study was reported. The study authors have disclosed no relevant financial relationships.     

Hosp Pediatr. Published online May 19, 2021. Full text     

Marcia Frellick is a freelance journalist based in Chicago. She has previously written for the Chicago Tribune, Science News and Nurse.com and was an editor at the Chicago Sun-Times, the Cincinnati Enquirer, and the St. Cloud (Minnesota) Times. Follow her on Twitter at @mfrellick

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