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Research Letter | Infectious Diseases
Characteristics and Disease Severity of US Children and Adolescents
Diagnosed With COVID-19
Leigh Ellyn Preston, DrPH; Jennifer R. Chevinsky, MD; Lyudmyla Kompaniyets, PhD; Amy M. Lavery, PhD; Anne Kimball, MD;
Tegan K. Boehmer, PhD; Alyson B. Goodman, MD
Introduction
In 2020, more than 2 000 000 pediatric COVID-19 cases were reported in the United States.1
Although approximately half of pediatric patients with COVID-19 experience mild disease, some
children require admission to intensive care units or use of invasive mechanical ventilation.2We
conducted a cohort study to estimate adjusted associations between demographic and clinicalcharacteristics and severe COVID-19 among hospitalized pediatric patients.
Methods
Discharge data from 869 medical facilities that contributed inpatient and emergency departmentencounters to the Premier Healthcare Database Special COVID-19 Release (PHD-SR) (release date,December 9, 2020), an administrative all-payer database capturing approximately 20% of UShospitalizations,
3were used to describe patients 18 years or younger who had an inpatient or
emergency department encounter with a primary or secondary COVID-19 discharge diagnosis fromMarch 1 through October 31, 2020. The International Statistical Classification of Diseases, Tenth
Revision, Clinical Modification (ICD-10-CM) diagnosis code U07.1 was used from April 1 through
October 31, 2020, and code B97.29 was used from March 1 through April 30, 2020. The discharge
Table. Demographic and Clinical Characteristics, Care Setting, and Severity of Patients 18 Years or Younger With COVID-19, United States,
March to October 2020a
CharacteristicNo. (%)
Total pediatric
cohort in PHD-SRbPediatric COVID-19cohortHospitalized withCOVID-19Hospitalized withsevere COVID-19
cICU admissionInvasive mechanicalventilation
Total, No. 1 945 831 20 714 2430 756 747 172
Portion of pediatric COVID-19 cohort, % NA 100 11.7 3.6 3.6 0.8
Sex
Female 966 861 (49.7) 10 950 (52.8) 1344 (55.3) 352 (46.6) 345 (46.2) 72 (41.9)
Male 976 884 (50.2) 9742 (47.0) 1083 (44.6) 404 (53.4) 402 (53.8) 100 (58.1)
Age, y
0-1 726 354 (37.3) 3606 (17.4) 632 (26.0) 153 (20.2) 152 (20.4) 43 (25.0)
2-5 305 500 (15.7) 2458 (11.9) 245 (10.1) 104 (13.8) 103 (13.8) 22 (12.8)
6-11 327 429 (16.8) 3497 (16.9) 274 (11.3) 119 (15.7) 119 (15.9) 20 (11.6)
12-18 586 548 (30.1) 11 153 (53.8) 1279 (52.6) 380 (50.3) 373 (49.9) 87 (50.6)
Race/ethnicityd
Non-Hispanic or Latino
White 935 117 (48.1) 5083 (24.5) 639 (26.3) 194 (25.7) 191 (25.6) 38 (22.1)
Black 358 139 (18.4) 5054 (24.4) 478 (19.7) 184 (24.3) 182 (24.4) 50 (29.1)
Asian 43 897 (2.3) 396 (1.9) 56 (2.3) 21 (2.8) 21 (2.8) Suppressede
Other 149 797 (7.7) 1370 (6.6) 191 (7.9) 59 (7.8) 59 (7.9) Suppressede
Hispanic or Latino 364 012 (18.7) 8148 (39.3) 936 (38.5) 258 (34.1) 255 (34.1) 55 (32.0)
Unknown 94 869 (4.9) 663 (3.2) 130 (5.4) 40 (5.3) 39 (5.2) Suppressede
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Open Access. This is an open access article distributed under the terms of the CC-BY License.
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data were also used to estimate associations between demographic and clinical characteristics and
severe COVID-19 among pediatric patients hospitalized with COVID-19. This study was reviewed bythe Centers for Disease Control and Prevention and was deemed exempt from institutional reviewboard oversight per 45 CFR §46.101(b)(4) and exempt from patient informed consent based on 45CFR §164.506(d)(2)(ii)(B) because the disclosed PHD-SR data are considered deidentified. This studyfollowed the Strengthening the Reporting of Observational Studies in Epidemiology ( STROBE)
reporting guideline.
Severe COVID-19 was defined as care requiring treatment in an intensive care unit or step-down
unit, involving use of invasive mechanical ventilation, or resulting in death. We used the Agency forHealthcare Research and Quality Chronic Condition Indicator tool
4to identify chronic conditions
using ICD-10-CM diagnoses from January 1, 2019, up to and including the child’s initial COVID-19
encounter. Race/ethnicity was defined by information in patient medical records in the PHD-SR.Figure. Adjusted Odds Ratios (ORs) of Severe COVID-19 Among Hospitalized Patients 18 Years or Younger
Severe illness
less likelySevere illness
more likely
10 1 0.1
Adjusted OR (95% CI)Characteristics
Presence of chronic conditionAdjusted OR
(95% CI)
Non-Hispanic BlackbNon-Hispanic Asianb
1.31 (0.99-1.75)
1.10 (0.77-1.58)
0.83 (0.66-1.05)
0.85 (0.53-1.35)1.36 (0.84-2.18)Male 1.52 (1.26-1.83)3.27 (2.44-4.37)
Age 6-11 ya1.53 (1.04-2.23)
1.53 (1.11-2.13) Age 2-5 ya
0.95 (0.75-1.21) Age 0-1 ya
1.04 (0.78-1.37) Hispanic or Latinob
Self-pay, indigent, or charityc
Other insurancecPublic insurancecNon-Hispanic other raceb1.34 (0.73-2.47)An increased association of severe COVID-19 was
observed in patients with 1 or more chronic conditionsvs those with none, in male vs female patients, and inchildren aged 2 through 5 years or 6 through 11 years vschildren aged 12 through 18 years. An increasedassociation was also found in male vs female patients.Non-Hispanic Black and Hispanic or Latino childrenwith COVID-19 were overrepresented compared withall pediatric patients in the Premier HealthcareDatabase Special COVID-19 Release.
aThe reference group is patients aged 12 to 18 years.
bThe reference group is Non-Hispanic White patients.
cThe reference group is patients with privateinsurance.Table. Demographic and Clinical Characteristics, Care Setting, and Severity of Patients 18 Years or Younger With COVID-19, United States,
March to October 2020a(continued)
CharacteristicNo. (%)
Total pediatric
cohort in PHD-SRbPediatric COVID-19cohortHospitalized withCOVID-19Hospitalized withsevere COVID-19
cICU admissionInvasive mechanicalventilation
Health insurance
Private 637 384 (32.8) 4591 (22.2) 530 (21.8) 180 (23.8) 177 (23.7) 43 (25.0)
Public (Medicare or Medicaid) 1 111 053 (57.1) 14 108 (68.1) 1716 (70.6) 516 (68.3) 510 (68.3) 113 (65.7)
Self-pay, indigent, or charity 109 408 (5.6) 961 (4.6) 79 (3.3) 29 (3.8) 29 (3.9) Suppressede
Other 87 986 (4.5) 1054 (5.1) 105 (4.3) 31 (4.1) 31 (4.2) Suppressede
Presence of ≥1 chronic conditionsf
Yes 495 959 (25.5) 6047 (29.2) 1659 (68.3) 637 (84.3) 630 (84.3) Suppressede
No 1 449 872 (74.5) 14 667 (70.8) 771 (31.7) 119 (15.7) 117 (15.7) Suppressede
Abbreviations: ICU, intensive care unit; NA, not applicable; PHD-SR, Premier Healthcare
Database Special COVID-19 Release.
aThe source for table data are the PHD-SR (release date, December 9, 2020).
bThe total pediatric cohort in the PHD-SR includes all patients 18 years or younger withan emergency department or inpatient encounter from January 1 through October1, 2020.
cSevere COVID-19 was defined as requiring care in an intensive care or step-down unit,requiring invasive mechanical ventilation, or resulting in death among patients with 1 ormore hospitalizations.
dChildren of Hispanic or Latino ethnicity were coded as Hispanic or Latino race/ethnicity.Children with known race and either non-Hispanic/Latino ethnicity or unknownethnicity were coded as non-Hispanic White, non-Hispanic Black, non-Hispanic Asian,or non-Hispanic other race/ethnicity. Children with unknown race and unknownethnicity were coded as unknown race/ethnicity.
eCell entries with fewer than 10 patients are suppressed per Premier Inc data useagreements.
fThe presence of chronic conditions was assessed using the Agency for HealthcareResearch and Quality algorithm. For patients with COVID-19, chronic conditions wereassessed using all encounters from January 1, 2019, up to and including the initialCOVID-19 encounter. For the total pediatric cohort, which includes patients withoutCOVID-19, chronic conditions were assessed using all encounters from January 1, 2019,up to and including the first encounter from March 1 through October 31, 2020.JAMA Network Open | Infectious Diseases Characteristics and Disease Severity of US Children and Adolescents Diagnosed With COVID-19
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Adjusted odds ratios (AORs) and 95% CIs for severe COVID-19 were calculated using a
multivariable generalized estimating equations model adjusting for within-facility correlation, age,
sex, race/ethnicity, insurance type, and presence of chronic conditions. Statistical analysis wasperformed using SAS version 9.4 (SAS Institute Inc). The a priori significance level was set at P= .05;
all hypothesis testing was 2-sided.
Results
Among 20 714 pediatric patients with COVID-19, 10 950 (52.9%) were girls, 11 153 (5 3.8%) were aged
12 to 18 years, 8148 (39.3%) were Hispanic or Latino individuals, 5054 (24.4%) were non-HispanicBlack individuals. Among these patients with COVID-19, 6047 (29.2%) had 1 or more chronicconditions (Table).
Among the cohort of 2430 pediatric patients (11.7%) who were hospitalized with COVID-19, 756
(31.1%) experienced severe COVID-19. An increased association of severe COVID-19 was observedamong patients with 1 or more chronic conditions vs those with none (AOR, 3.27; 95% CI, 2.44-4.37);in children aged 2 through 5 years or 6 through 11 years vs those aged 12 through 18 years (AORs, 1.53;95% CI, 1.11-2.13 and 1.53; 95% CI, 1.04-2.23, respectively); and in male vs female patients (AOR, 1.52;95% CI, 1.26-1.83) (Figure). There was no statistically significant association between race/ethnicity or insurance type and severe COVID-19.
Discussion
In this cohort study, nearly one-third (756 [31.1%]) of hospitalized pediatric patients with COVID-19experienced severe COVID-19, which is consistent with previous findings.
2Our analysis revealed an
increased association of severe COVID-19 in younger children (those aged 2-11 years) compared witholder children (those aged 12-18 years). Although admission to an intensive care unit for youngerchildren may indicate an abundance of caution by clinicians or facility and administrativerequirements rather than disease severity, this finding has important clinical and resource planningimplications for facilities and clinicians.
Our results suggest that existing chronic conditions and male sex are independently associated
with severe COVID-19. Consistent with previous reports, non-Hispanic Black and Hispanic or Latinochildren with COVID-19 were overrepresented compared with all pediatric patients in the PHD-SR.
5
We found no statistically significant association between severe disease and race/ethnicity amonghospitalized patients when controlling for covariates.
This study has some limitations. First, risk factors associated with severe disease from acute
COVID-19 vs multisystem inflammatory syndrome in children cannot be differentiated, as the lattercondition does not have its own ICD-10-CM diagnosis code. Second, chronic conditions could be
underlying, co-occurring, or sequelae of COVID-19 illness. Third, certain chronic conditions might beunderdiagnosed in inpatient medical records.
6Fourth, we were unable to evaluate associations
among infants younger than 12 months.
Although most children with COVID-19 experience mild illness, some children develop serious
illness that leads to hospitalization, use of invasive mechanical ventilation, and death. Understandingfactors associated with severe COVID-19 disease among children could help inform prevention andcontrol strategies. Reducing infection risk through community mitigation strategies is critical forprotecting children from COVID-19 and preventing poor outcomes.
ARTICLE INFORMATION
Accepted for Publication: February 18, 2021.
Published: April 9, 2021. doi:10.1001/
jamanetworkopen.2021.5298JAMA Network Open | Infectious Diseases Characteristics and Disease Severity of US Children and Adolescents Diagnosed With COVID-19
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Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Preston LE
et al. JAMA Network Open.
Corresponding Author: Alyson B. Goodman, MD, COVID-19 Response Team, Centers for Disease Control and
Prevention, 4770 Buford Hwy, MS S107-5, Atlanta, GA 30341 ([email protected]).
Author Affiliations: COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, Georgia
(Preston, Chevinsky, Kompaniyets, Lavery, Kimball, Boehmer, Goodman); Epidemic Intelligence Service, Center for
Surveillance, Epidemiology, and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, Georgia
(Chevinsky, Kimball); Commissioned Corps, US Public Health Service, Rockville, Maryland (Boehmer, Goodman).
Author Contributions: Dr Preston had full access to all of the data in the study and takes responsibility for the
integrity of the data and the accuracy of the data analysis.
Concept and design: Preston, Chevinsky, Kompaniyets, Kimball, Goodman.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Preston, Chevinsky, Kompaniyets, Kimball, Goodman.
Critical revision of the manuscrip t
for important intellectual content: All authors.
Statistical analysis: Preston, Chevinsky.
Obtained funding: Boehmer.
Administrative, technical, or material support: Preston, Chevinsky, Kompaniyets, Lavery.
Supervision: Kompaniyets, Boehmer, Goodman.
Conflict of Interest Disclosures: None reported.
Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily repre sent
the official position of
the Centers for Disease Control and Prevention (CDC). All information and materials in this
article are the original work of the authors.
Additional Contributions: We thank the following individuals from the CDC COVID-19 Response Team: Sachin
Agnihotri, MS, David Nitschke, BS, Indira Srinivasan, MS, and Kimberly Riggle, BBA, fo r facilitating access to the
data set; and Zhaohui Cui, PhD, Melissa L. Danielson, MSPH, Gonza Namulanda, DrPH, Audrey F. Pennington, PhD,
Lyna Z. Schieber, MD, Brook Belay, MD, James Baggs, PhD, Adi V. Gundlapalli, MD, and William R. Mac Kenzie, MD
(also with the Commissioned Corps US Public Health Service), for assistance with concept and manuscript
development. We also thank John House, MS (Premier Inc), for providing data consultation for the Premier
Healthcare Database Special COVID-19 Release. None of these individuals received any compensation beyond their
usual salary.
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