Congenital cardiac disease also a risk factor for hospitalization, severe disease

Type 1 diabetes and obesity were the two most common medical conditions associated with hospitalization for Covid-19 in a cross-sectional study involving more than 43,000 children and teens with SARS-CoV-2 infection, researchers from the CDC reported.

Having type 1 diabetes was associated with a more than four-fold increased risk for Covid-19-related hospitalization in the study, while a three-fold increase in hospitalization risk was identified in children who were obese.

The strongest risk factors for developing severe Covid-19 symptoms among the pediatric and adolescent patients were type 1 diabetes (adjusted risk ratio, 2.38; 95% CI, 2.06-2.76) and congenital cardiac and circulatory conditions (aRR, 1.72; 95% CI, 1.48-1.99), with prematurity a significant risk factor for severe illness among children younger than 2 years of age (aRR, 1.83; 95% CI, 1.47-2.29).

Children with complex chronic diseases were almost eight times more likely to require hospitalization and three times more likely to progress to severe Covid-19, compared to children without chronic diseases, the study authors wrote in JAMA Network Open.

“Public health prevention and vaccine prioritization efforts might consider the potential for severe Covid-19 illness among children with these underlying medical conditions and chronic disease,” wrote CDC researcher Lyudmyla Kompaniyets, PhD, and colleagues. “Future epidemiologic investigation could provide insight into the causal pathways underlying our findings and identify other factors that place children at increased risk of severe Covid-19 illness.”

In their study, Kompaniyets and colleagues characterized the current understanding of Covid-19 illness in children as “limited,” with most prior studies including small sample sizes with short or no follow-up. They sought to address these limitations using data from the large electronic administrative hospital-based, all-payer Premier Healthcare Database, Special Covid-19 Release (PHD-SR), which includes more than 3 million children and adolescent and 900 U.S. hospitals.

The study included data on 43,465 patients age 18 and younger treated at 872 U.S. hospitals as inpatients or in emergency departments with a primary or secondary Covid-19 diagnosis from March of 2020 through the end of January 2021 (median age 12 years, 52.8% female). More than half of the study cohort were between the ages of 12 and 18 years.

Just over 1-in-4 (28.7%) had separate underlying medical conditions, with the most commonly diagnosed conditions being asthma (10.2%), neurodevelopmental disorders (3.9%), anxiety and fear-related disorders (3.2%), depressive disorders (2.8%), and obesity (2.5%).

The strongest risk factors for hospitalization were type 1 diabetes (aRR, 4.60; 95% CI, 3.91-5.42) and obesity (aRR, 3.07; 95% CI, 2.66-3.54).

Having a chronic or complex chronic disease, defined using the pediatric medical complexity algorithm (PMCA), were risk factors for hospitalization, with aRRs of 2.91 (95% CI, 2.63-3.23) and 7.86 (95% CI, 6.91-8.95).

Chronic and complex chronic disease were also risk factors for severe Covid-19 illness, with aRRs of 1.95 (95% CI, 1.69-2.26) and 2.86 (95% CI, 2.47-3.32), respectively.

“Our finding that levels of medical complexity represent a risk factor for severe Covid-19 illness identifies a previously unidentified higher risk population, not clearly described in prior literature,” Kompaniyets and colleagues wrote.

Study limitations cited by the researchers included the possibility of misclassification due to the reliance on ICD-10-CM diagnostic codes to identify Covid-19 and the inability to determine causal relationships between the conditions identified and severe Covid-19 due to the study design.

In an accompanying commentary, Jennifer E. Schuster, MD, of Children’s Mercy Kansas City hospital and Annabelle de St. Maurice, MD, of the University of California, Los Angeles, identified other potential study limitations.

“Less common medical conditions, including malignant neoplasms, may not have been well represented in this database, and only conditions with a frequency of more than 0.7% were included in the analysis,” they wrote.

In addition, the majority of children included in the analysis were adolescents, and “risk factors differed when the data were age stratified, suggesting recommendations for Covid-19 management and prevention should also vary by age.”

“Lastly, attributing associations can be difficult,” they wrote. “Children with underlying medical conditions may have been more likely to receive Covid-19 testing and require hospitalization for reasons unrelated to Covid-19.”

For example, the observed association between type 1 diabetes and hospitalization and severe Covid-19, defined by ICU admission, may have been related to diabetic ketoacidosis (DKA) rather than Covid-19, and children with cardiac disorders may be more likely to be tested for Covid-19 due to pre-procedure testing protocols.

They concluded that a better understanding of specific risk factors for severe Covid-19 among pediatric patients is needed “to guide treatment and preventative strategies, including use of monoclonal antibodies and vaccines.”

“When vaccines are licensed for children, risk-based prioritization for pediatrics may be necessary given limited vaccine supply,” they wrote. “Current Covid-19 prophylaxis targets pediatric groups based on adult risk factors and/or pediatric non–Covid-19 respiratory illnesses. Throughout this pandemic, pediatric practitioners have been making decisions extrapolated from adult data. This study identifies factors associated with severe pediatric Covid-19 and highlights the need for multicenter collaborations and dedicated funding to study pediatric Covid-19. To provide the best care for children, we need pediatric-specific data.”

  1. Having type 1 diabetes was associated with a more than four-fold increased risk for Covid-19-related hospitalization, while a three-fold increase in hospitalization risk was identified in children who were obese.

  2. Children with complex chronic diseases were almost eight times more likely to require hospitalization and three times more likely to progress to severe Covid-19, compared to children without chronic diseases.

Salynn Boyles, Contributing Writer, BreakingMED™

The researchers reported no relevant conflicts of interest, but they stipulated that the”findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the U.S. CDC or the US Public Health Service.”

Commentary co-author Jennifer Schuster reported receiving clinical trial support from Merck unrelated to this study.

Cat ID: 926

Topic ID: 79,926,933,914,12,795,926,138,252,927,928,918