The severity of illness and overall survival of infants and children infected with COVID-19 is far better than that reported for adults. However, pediatric patients with pre-existing conditions, such as developmental or genetic anomalies, have an increased risk of poor outcomes when infected, according to a preliminary report from pediatric intensive care units (PICUs) in the United States that was published in JAMA Pediatrics.
[Editor’s note: The New York State Department of Health issued an advisory regarding cases of pediatric multisystem inflammatory syndrome potentially associated with COVID-19.]
Researchers from the International COVID-19 PICU Collaborative conducted a retrospective review of medical record of pediatric patients admitted to 46 PICUs in North America with confirmed COVID-19 infection between March 14 and April 3, 2020, with follow-up until April 10. Patient data included demographic information as well as comorbidities and mode of COVID-19 presentation. Clinical outcomes at the time of data closure included survival, duration of ventilation, and lengths of ICU and hospital stay.
Severity of illness was divided into 4 categories:
- Mild disease including fever, sore throat, cough, and/or myalgia with no dyspnea
- Moderate disease with fever, dyspnea, and/or chest imaging consistent with SARS-CoV-2 pneumonia
- Severe disease as defined as mild and moderate disease with new or increased supplemental oxygen and/or ventilator support
- Critical disease involving respiratory failure requiring mechanical ventilation, acute respiratory distress syndrome, shock or systemic inflammatory response syndrome, and/or multiorgan failure.
Of the 48 children meeting the inclusion criteria, 25 (52%) were boys; median age, 13. The number of critically ill patients admitted to individual PICUs in the sample ranged from 1 to 17 with a median of 3 admissions per unit. The diagnosis of COVID-19 in patients was confirmed through nasal swabs. “Significant comorbidities were prevalent in this pediatric cohort” noted the researchers: a total of 24 patients (50%) had 1 comorbidity, 8 (17%) had 2, and 9 (19%) had ≥3.
On admission, 33 patients (69%) were severely or critically ill, 12 (25%) required vasoactive drugs, and while respiratory failure affected most children, 11 experienced failure of ≥2 organ systems. Thirty-nine patients (81%) required respiratory support; of these, 18 patients (38%) required endotracheal or tracheostomy ventilation. The most common therapy used to treat patients was hydroxychloroquine followed by azithromycin, remdesivir, and tocilizumab.
Of the 18 critically ill children at the time of publication, 2 have died, 3 children still require mechanical ventilation, 7 have discontinued mechanical ventilation but remain hospitalized, and 6 have been discharged. The overall fatality rate was 4.2%. The 2 patients who died were aged 12 and 17 years, and both had preexisting comorbidities and developed multisystem organ failure; 1 had gram-negative sepsis prior to developing COVID-19.
Fifteen children (31%) are still hospitalized, including 5 in critical condition with 1 still receiving extracorporeal membrane oxygen. For patients who completed PICU stay (either died or were discharged), the median PICU and hospital length of stay were 5 and 7 days, respectively.
“Consistent with the few other initial reports on COVID-19 in 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,” concluded the authors.
Shekerdemian LS, Mahmood NR, Wolfe KK, et al; International COVID-19 PICU Collaborative. Characteristics and outcomes of children with coronavirus disease 2019 (COVID-19) infection admitted to US and Canadian pediatric intensive care units. [published online May 11, 2020]. JAMA Pediatr. doi:10.1001/jamapediatrics.2020.1948.