Characteristics and Clinical Outcomes of Children and Adolescents Aged <18 Years Hospitalized With COVID-19

Abbreviation: MIS-C = multisystem inflammatory syndrome in children.
*The six children's hospitals were in Arkansas, District of Columbia, Florida, Illinois, Louisiana, and Texas.
^†Patients hospitalized for COVID-19 included patients with acute COVID-19 as the primary reason for hospitalization or with acute COVID-19 as a secondary or contributing reason for hospitalization, based on chart review.
^§Patients with MIS-C as the reason for hospitalization included patients who met the clinical case definition for MIS-C (clinically severe illness requiring hospitalization in a person aged <21 years with fever, laboratory evidence of inflammation, multisystem [≥2] organ involvement and no alternative plausible diagnosis, and evidence of current or recent SARS-CoV-2 infection by reverse transcription polymerase chain reaction, serology or antigen test, or COVID-19 exposure within the 4 weeks preceding symptom onset [https://emergency.cdc.gov/han/2020/han00432.asp]) and were hospitalized for diagnosis and management of MIS-C, based on chart review.
^¶Other race/ethnicity includes Asian, Native Hawaiian or Other Pacific Islander, American Indian or Alaska Native, and Other (not specified).
**Fully vaccinated was defined as having received 2 doses of an mRNA-based COVID-19 vaccine ≥14 days before the hospital admission date. Partially vaccinated was defined as having received only 1 dose of an mRNA-based COVID-19 vaccine ≥14 days before hospitalization. All vaccinated patients in this study received the Pfizer-BioNTech (BNT162b2) vaccine.

Abbreviations: BiPAP = bilevel positive airway pressure; BMI = body mass index; CPAP = continuous positive airway pressure; ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit; IMV = invasive mechanical ventilation; RAD = reactive airway disease; RSV = respiratory syncytial virus.
*Patients hospitalized for COVID-19 included patients with acute COVID-19 as the primary reason for hospitalization or with acute COVID-19 as a secondary or contributing reason for hospitalization, based on chart review.
^†The six children's hospitals were in Arkansas, District of Columbia, Florida, Illinois, Louisiana, and Texas.
^§Clinical characteristics and outcomes were compared among groups using Pearson's chi-square test for categorical variables and a Kruskal-Wallis test for nonnormally distributed variables.
^¶Metabolic and endocrine conditions included dyslipidemia, obesity, thyroid disorder, type 1 diabetes, type 2 diabetes, and other endocrine disorders.
**For children aged ≥2 years, height and weight were used to calculate BMI (kg/m²). BMI percentiles were calculated using BMI, age, and sex. Those children with BMI percentiles ≥95th percentile were considered to have obesity and those with BMI ≥120% of the 95th percentile were considered to have severe obesity. BMI data extracted from charts were used if height or weight was missing. If BMI was missing or unable to be calculated, a diagnosis of obesity recorded in charts was used and severity of obesity was unable to be assessed. Obesity was not assessed for children aged <2 years.
^††Neurologic and developmental conditions included attention deficit hyperactivity disorder, autism spectrum disorder, cerebral palsy, cognitive disfunction, muscular dystrophy, neural tube defect or spina bifida, neurologic or neurodevelopmental disorder, neuropathy, plegias or paralysis, preterm birth (for children aged <2 years only), seizure disorder, and wheelchair/walker-dependence or bed-bound status.
^§§Respiratory conditions included active tuberculosis, asthma or reactive airway disease, chronic hypoxemic respiratory failure with oxygen or ventilator dependence, cystic fibrosis, current smoking or e-cigarette use, tracheostomy dependence, and other chronic lung diseases.
^¶¶Gastrointestinal or hepatic conditions included Crohn's disease, feeding tube dependence, liver disease, malnutrition, ulcerative colitis, and other gastrointestinal disorders.
***Psychiatric conditions included anxiety, borderline personality disorder, depression, substance use disorder, and other psychiatric diagnoses.
^†††Patients were considered to have a viral coinfection if they had ≥1 of the following infections: type A influenza, type B influenza, unspecified influenza, coronavirus 229e, coronavirus hku1, coronavirus nl63, coronavirus 0c43, respiratory syncytial virus, adenovirus, parainfluenza type 1, parainfluenza type 2, parainfluenza type 3, parainfluenza type 4, human metapneumovirus, rhinovirus enterovirus, or other viral coinfection.

Abbreviations: BIPAP = bilevel positive airway pressure; BMI = body mass index; CPAP = continuous positive airway pressure; ECMO = extracorporeal membrane oxygenation; ICU = intensive care unit; IMV = invasive mechanical ventilation; RSV = respiratory syncytial virus.
*Patients hospitalized for COVID-19 included patients with acute COVID-19 as the primary reason for hospitalization or with acute COVID-19 as a secondary or contributing reason for hospitalization, based on chart review.
^†The six children's hospitals were in Arkansas, District of Columbia, Florida, Illinois, Louisiana, and Texas.
^§For children aged ≥2 years, height and weight were used to calculate BMI (kg/m²). BMI percentiles were calculated using BMI, age, and sex. Those children with BMI percentiles ≥95th percentile were considered to have obesity, and those with BMI ≥120% of the 95th percentile were considered to have severe obesity. BMI data extracted from charts were used if height or weight was missing. If BMI was missing or unable to be calculated, a diagnosis of obesity recorded in charts was used and severity of obesity was unable to be assessed. Obesity was not assessed for children aged <2 years.
^¶Clinical characteristics and outcomes were compared among groups using Pearson's chi-square test for categorical variables and a Kruskal-Wallis test for nonnormally distributed variables.
**Patients were considered to have a viral coinfection if they had ≥1 of the following infections: type A influenza, type B influenza, unspecified influenza, coronavirus 229e, coronavirus hku1, coronavirus nl63, coronavirus 0c43, respiratory syncytial virus, adenovirus, parainfluenza type 1, parainfluenza type 2, parainfluenza type 3, parainfluenza type 4, human metapneumovirus, rhinovirus, enterovirus, or other viral coinfection.

Authors and Disclosures

Valentine Wanga, PhD^1,2, Megan E. Gerdes, MPH¹, Dallas S. Shi, MD, PhD^1,2, Rewa Choudhary, MD^1,2, Theresa M. Dulski, MD^1,2, Sophia Hsu, MSN, MPH¹, Osatohamwen I. Idubor, MD¹, Bryant J. Webber, MD^1,2, Arthur M. Wendel, MD¹, Nickolas T. Agathis, MD^1,2, Kristi Anderson, MD¹, Tricia Boyles, MHA¹, Sophia K. Chiu, MD¹, Eleanor S. Click, MD, PhD¹, Juliana Da Silva, MD¹, Hannah Dupont, MPH¹, Mary Evans, MD¹, Jeremy A.W. Gold, MD¹, Julia Haston, MD^1,2, Pamela Logan, MD¹, Susan A. Maloney, MD¹, Marisol Martinez, PharmD¹, Pavithra Natarajan, BMBS¹, Kevin B. Spicer, MD, PhD¹, Mark Swancutt, MD¹, Valerie A. Stevens¹, Jessica Brown, PhD¹, Gyan Chandra, MBA¹, Megan Light, MPH¹, Frederick E. Barr, MD³, Jessica Snowden, MD³, Larry K. Kociolek, MD⁴, Matthew McHugh, MPH⁴, David Wessel, MD⁵, Joelle N. Simpson, MD⁵, Kathleen C. Gorman, MSN⁵, Kristen A. Breslin, MD⁵, Roberta L. DeBiasi, MD⁵, Aaron Thompson, MD^6,7, Mark W. Kline, MD^6,7, Julie A. Bloom, MD⁸, Ila R. Singh, MD, PhD⁹, Michael Dowlin⁹, Mark Wietecha, MS, MBA¹⁰, Beth Schweitzer, MS¹, Sapna Bamrah Morris, MD¹, Emily H. Koumans, MD¹, Jean Y. Ko, PhD¹, Anne A. Kimball, MD^1,* and David A. Siegel, MD^1,*

¹CDC COVID-19 Response Team; ²Epidemic Intelligence Service, CDC; ³Arkansas Children's, Little Rock, Arkansas; ⁴Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; ⁵Children's National Hospital, Washington, DC; ⁶Children's Hospital New Orleans, New Orleans, Louisiana; ⁷Tulane University School of Medicine and LSU Health, New Orleans, Louisiana; ⁸Department of Pediatrics, Baylor College of Medicine, Houston, Texas; ⁹Department of Pathology and Immunology, Baylor College of Medicine, Houston, Texas; ¹⁰Children's Hospital Association, Washington, DC.

Corresponding author
Valentine Wanga, qdy0@cdc.gov.

All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. Ila R. Singh reports funding from the National Institutes of Health (NIH) as a coinvestigator for grant no. R61HD105593 to characterize pediatric COVID-19. Roberta L. DeBiasi reports grant support and contracts for COVID-19 and MIS-C, unrelated to the current work; consulting fees from I-ACT for Children; honoraria from the Infectious Diseases in Children Conference (NYC) and Children's Hospital Colorado Infectious Diseases Conference (Denver); and unpaid membership on the board of the Pediatric Infectious Diseases Society. Larry K. Kociolek reports a grant from the Walder Foundation Chicago Coronavirus Assessment Network Initiative, institutional support from Merck and NIH/NIAID; and honoraria for educational events at Northwest Community Hospital and Nemours/duPont Children's Hospital. Jessica Snowden reports institutional support from NIH Office of the Director–ECHO program and NIH/NHLBI–RECOVER program, unrelated to the current work. Frederick E. Barr reports application of patent 17364280 with Asklepion Pharmaceuticals for L-citrulline to prevent or treat endothelial dysfunction. Sapna Bamrah Morris and Sophia K. Chiu report membership on a data safety monitoring board in a study of ivermectin for treatment of severe COVID-19 in Ghana. Sophia Hsu reports ownership of 5 shares of Moderna stock and 7 shares of Novavax stock, and ownership within the past 36 months (but no current ownership) of stock in BioNTech, Gilead Sciences, and Pfizer. Theresa M. Dulski reports that her husband receives restricted stock units as part of his compensation from his employer, a cancer diagnostics company that also performs COVID-19 testing. No other potential conflicts of interest were disclosed.

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Summary

What is already known about this topic?

Pediatric COVID-19–related hospitalization rates increased when the highly transmissible SARS-CoV-2 B.1.617.2 (Delta) variant became the predominant circulating strain.

What is added by this report?

Among children and adolescents with SARS-CoV-2 infection admitted to six hospitals during July–August 2021, 77.9% were hospitalized for acute COVID-19. Among these patients, approximately one third aged <5 years had a viral coinfection (approximately two thirds of which were respiratory syncytial virus) and approximately two thirds of those aged 12–17 years had obesity; only 0.4% of age-eligible patients were fully vaccinated.

What are the implications for public health practice?

COVID-19 vaccination and other prevention strategies are important to protect children from COVID-19, particularly children with obesity and other underlying health conditions.