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SHORT COMMUNICATION
Demographic predictors of hospitalization and mortality in US
children with COVID-19
Alvaro Moreira1&Kevin Chorath2&Karthik Rajasekaran2&Fiona Burmeister1&Mubbasheer Ahmed3&Axel Moreira3
Received: 17 October 2020 / Revised: 11 January 2021 / Accepted: 15 January 2021
#The Author(s), under exclusive licence to Springer Verlag GmbH, DE part of Springer Nature 2021
Abstract
Understanding which children are at increased risk for poor outcome with COVID 19 is critical. In this study, we link pediatric
population based data from the US Center for Disease Control and Prevention to COVID 19 hospitalization and in hospital
death. In 27,045 US children with confirmed COVID 19, we demonstrate that African American [OR 2.28 (95% CI: 1.93, 2.70)]or mixed race [OR 2.95 (95% CI: 2.28, 3.82)] and an underlying medical condition [OR 3.55 (95% CI: 3.14, 4.01)] are strong
predictors for hospitalization. Death occurred in 39 (0.19%) of 20,096 hospitalized children; children with a prior medical
condition had an increased odd for death [OR 8.8 (95% CI: 3.7, 21.1)].
Conclusion : Hospitalization and in hospital death are rare in children diagnosed with COVID 19. However, children at higher
risk for these outcomes include those with an underlying medical condition, as well as those of African American descent.
Keywords COVID 19 .SARS CoV 2 .Pediatric .Children .COVID NET
Abbreviations
CDC Centers for Disease Control
and Prevention
CI Confidence intervalCOVID 19 Coronavirus disease 2019
COVID NET COVID 19 Associated
Hospitalization Surveillance
Network
MIS C Multisystem inflammatory
syndrome in children
NH Non Hispanic
OR Odds ratio
Introduction
As of January 19, 2021, more than 23M cases of COVID 19have been confirmed in the USA [1 ]. A recent report from the
American Academy of Pediatrics and the Children ’sH o s p i t a lWhat is Known:
•Demographic factors are independent prognosticators of poor outcome in children with COVID-19.
What is New:
•Children with an underlying medical condition and those from an African American or mixed race/ethnicity are at high risk for COVID-19
hospitalization.
•History of a comorbidity supersedes age, gender, and race/ethnicity as a risk factor for in-hospital pediatric COVID-19 death.
Communicated by Nicole Ritz
*Alvaro Moreira
[email protected]
Kevin Chorath
[email protected]
Karthik Rajasekaran
[email protected]
Fiona Burmeister
[email protected]
Mubbasheer Ahmed
[email protected]
Axel Moreira
[email protected]
1Department of Pediatrics, University of Texas Health San Antonio,7702 Floyd Curl Drive, San Antonio, TX 78229, USA
2University of Pennsylvania, Philadelphia, PA, USA
3Baylor College of Medicine, Houston, TX, USAhttps://doi.org/10.1007/s00431 021 03955 x
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Association estimates nearly 2.5M total COVID 19 cases in
US children [2]. Previous studies have shown that age, gender,
race/ethnicity, and underlying medical conditions are independent risk factors for poor outcome in COVID 19 [3 6].
Understanding the role these factors play in severe acute re
spiratory syndrome coronavirus 2 (SARS CoV 2) may informclinicians, researchers, and governing agencies which children
are at highest risk for severe COVID 19. Thus, our goal was to
quantify the relationship between demographic factors and USpediatric COVID 19 hospitalization and death.
Methods
The Centers for Disease Control and Prevention COVID 19
associated hospitalization surveillance network (CDC
COVID NET) is a population based system that captureslaboratory confirmed COVID 19 cases in over 250 US
acute care hospitals [7]. s . The CDC COVID NET is com
prised of demographic variables (e.g., gender, age group, race
and ethnicity, medical conditions) and date of positive SARS
CoV 2 test, as well as outcomes, including hospitalization and
mortality. Evidence of COVID 19 cases were evaluated for apostive detection of SARS CoV 2 via nasopharyngeal/throat
swabs or serologic testing.The database stratifies the variables
as follows:
&Age group: stratified to 0 9 years or 10 19 years
&Gender: male or female
&Race and ethnicity: White, Non Hispanic (NH); Black,
NH; Hispanic/Latino; Asian, NH; Multiple/other, NH,Hawaiian/Pacific Islander, NH; Alaskan/American
Indian, NH
&Medical condition: yes or no
&Hospitalization: yes or no
&Death: yes or no
Our primary outcomes were hospitalization and in hospital
mortality. The data from the CDC COVID NET was
downloaded on August 17, 2020, and captured pediatricCOVID 19 rates in the USA between March 2, 2020, and
July 16, 2020. Although the database included a total of
229,052 children, we only included children that had completeinformation (e.g., no missing data). We examined the associ
ation of age, gender, race and ethnicity, and medical condition
on hospitalization, followed by in hospital mortality. The following underlying illnesses yielded a “yes”answer on the
“medical condition ”field: asthma, autoimmune disease, car
diovascular disease, chronic lung disease, gastrointestinal/liver disease, hypertension, immune suppression, metabolic
disease, neurologic disease, obesity, pregnancy, renal disease,
or other disease.All demographic variables were included in the multivari
able logistic regression model. Odds ratios (OR) with 95%confidence intervals (CI) were calculated. A pvalue < 5%
was considered statistically significant. Analyses were per
formed in STATA (version 13, College Station, TX). Since
the data is publicly available and reported in a de identifiedfashion, ethical approval to analyze the data was not warranted
by local authorities.
Results
Hospitalization
A total of 27,045 US children with COVID 19 were included
in this report. The majority ( n= 18,924; 70.0%) of children
were between the ages of 10 and 19 years with a similargender distribution (please refer to Table 1). Hispanic/
Latino, White, non Hispanic, and Black, non Hispanic totaled
90.3% of the population. Thirty nine percent ( n= 10,438) of
the children had an underlying medical condition.
Of the 27,045 children, 1,274 (4.7%) required hospitaliza
tion. Multivariate analysis demonstrated that age,
race/ethnicity, and medical conditions were significant features for hospitalization. Specifically, COVID 19 positive
children < 10 years of age [OR 1.5 (95% CI 1.3, 1.7)] who
were Black or of mixed race/ethnicity, and with a medicalcondition [OR 3.6 (95% CI 3.1, 4.0)] associated with a higher
odd for hospitalization (see Table 2).
Mortality
Mortality data was available for 20,096 (74.3%) individ
uals that were hospitalized (refer to Table 3). Death
occurred in 39 (0.19%) hospitalized children.Demographic differences observed between survivors
and non survivors included race and an underlying med
ical condition. Children who were black, non Hispanic[OR 3.0 (95% CI 1.3, 6.7)], and those with an under
lying medical condition [OR 8.8 (95% CI 3.7, 21.1)]
had an increased odd for death. Please see Table 4for
more details.
Discussion
In a large US cohort of confirmed COVID 19 children, wefound that hospitalization occurred 4.7% of the time with an
in hospital mortality rate of 0.19%. Cases of COVID 19 were
more frequently observed in children older than 10 years ofage and those of Hispanic/Latino and White, non Hispanic
race/ethnicity. However, children more likely to be hospital
ized or die were Black, non Hispanic and children with an1660 Eur J Pediatr (2021) 180:1659–1663
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underlying health condition. Interestingly, medical condition
was the strongest risk factor for a poor outcome.Our data showed that Black, non Hispanic and Hispanic
children were 2.5 times more likely than White children to
be hospitalized and 5 times more likely to die after infectionwith SARS CoV 2. Several reasons exist for this continued
pattern of disproportionate impact of COVID 19 in minorities.
First, parents are among the greatest vector of the disease tochildren [6]. As such, parents who work in high “viral con
tact”jobs are more likely to be minorities. For example,
Williams et al. [8 ] described that many of the industries
(e.g., gyms, hair salons, restaurants) that remained open dur
ing the pandemic are driven by workers who are predominant
ly minority. Second, poverty is more common among minority groups. A study by Adhikari and colleagues [9 ] concluded
that counties with higher rates of poverty and those with morediverse populations had significantly higher infection anddeath rates compared to counties with a substantial White
population. Next, lower socioeconomic status is intricately
linked to larger household sizes, crowding, and therefore morecross infection [10]. This emphasized the needed to untangle
the differences in immunologic response to SARS CoV 2
based on race/ethnicity [11].
A past medical history of an underlying condition was the
strongest risk factor for poor outcome in US children withCOVID 19. An earlier report in Morbidity and Mortality
Weekly Report noted that Hispanic and non Hispanic Black
children had a higher prevalence of underlying conditionswhen compared to White children (45.7% vs. 29.8% vs.14.9%, respectively) [5]. Similarly, our analysis of 27,045
pediatric cases of COVID 19 found that Black, nonTable 1 Demographic
characteristics of hospitalized US
children with COVID 19Variable Total ( n27,045) Non
hospitalized
(n25,771)Hospitalized
(n1,274)pvalue
Age <0 . 0 1
0 9 years 8,121 7,639 (94.1%) 482 (5.9%)
1019 years 18,924 18,132 (95.8%) 792 (4.2%)
Sex 0.99
Female 13,959 13,299 (95.3%) 660 (4.7%)
Male 13,086 12,472 (95.3%) 614 (4.7%)
Race/ethnicity <0 . 0 1
White, NH 7,974 7,717 (96.8%) 257 (3.2%)
Black, NH 4,224 3,876 (91.8%) 348 (8.2%)
Hispanic/Latino 12,236 11,697 (95.6%) 539 (4.4%)
Asian, NH 972 936 (96.3%) 36 (3.7%)
Multiple/other, NH 980 894 (91.2%) 86 (8.8%)
Hawaiian/Pacific Islander, NH 478 471 (98.5%) 7 (1.5%)
Alaskan/American Indian, NH 181 180 (99.4%) 1 (0.6%)
Comorbidity <0 . 0 1
No 16,607 16,195 (97.5%) 412 (2.5%)
Yes 10,438 9,576 (91.7%) 862 (8.3%)
NHnon Hispanic
Table 2 Multivariable logistic regression evaluating risk factors
associated with US pediatric COVID 19 hospitalization ( n27,045)
Variable Odds ratio 95% CI pvalue
Age
0 9 years 1.48 1.31 1.67 < 0.01
1019 years 1 (reference)
Sex
Female 1.03 0.92 1.16 0.56
Male 1 (reference)
Race/ethnicity
White, NH 1 (reference)
Black, NH 2.28 1.93 2.70 < 0.01
Hispanic/Latino 1.38 1.19 1.61 < 0.01
Asian, NH 1.11 0.78 1.61 0.56
Multiple/other, NH 2.95 2.28 3.82 < 0.01
Hawaiian/Pacific Islander, NH 0.25 0.12 0.54 < 0.01
Alaskan/American Indian, NH 0.20 0.03 1.42 0.11
Comorbidity
No 1 (reference)
Yes 3.55 3.14 4.01 < 0.01
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Hispanic children had a higher proportion of comorbidities
when compared to White children (49.6% vs. 37.3%). Our
findings that comorbidity and minority populations are atincreased risk for COVID 19 death is reiterated in a study
by Ahmed et al. [12]. Another recent meta analysis examined
the association of pediatric comorbidities with COVID 19 in
fection. In 42 studies, encompassing 275,661 children,
Tsankov et al. summarized that children with comorbidities
had a relative risk ratio of 1.79 for severe COVID 19 infectionand 2.81 for COVID 19 related mortality.
There are limitations to our study. First, although the data is
derived from 14 states, it only represents 10% of the US population. Second, missing data was common in the database
which decreased our overall sample size from 229,052 chil
dren to 27,045 pediatric cases. In particular, medical conditions had more than 50% of the data unknown or missing.
Despite finding that a history of medical conditions impacts
the trajectory of childhood COVID 19, the database is notgranular in providing the specific conditions for each patient.
To our knowledge, this is the largest pediatric evaluation
investigating demographic information as risk factors ofCOVID 19 hospitalization and death. Implications from our
study are threefold: (i) gender may not play a significant role
in childhood COVID 19 severity, (ii) race and ethnicity, andunderlying medical conditions, are vital risk factors for
COVID 19 hospitalization or death, and (iii) younger age increases hospitalization risk, but not d eath. Future studies
should focus on unraveling the mechanisms underpinning
poor COVID 19 outcomes in Black, non Hispanic children,
as well as those with medical conditions.Table 3 Demographic
characteristics of COVID 19
positive children with in hospitaldeathVariable Total ( n
20,096)Survivors ( n
20,057)Non survivor ( n
39)pvalue
Age 0.69
0 9 years 6,104 6,091 (99.8%) 13 (0.2%)
1019 years 13,992 13,966 (99.8%) 26 (0.2%)
Sex 0.95
Female 10,415 10,395 (99.8%) 20 (0.2%)
Male 9,681 9,662 (99.8%) 19 (0.2%)
Race/ethnicity <0 . 0 1
White, NH 6,231 6,222 (99.9%) 9 (0.1%)
Black, NH 3,182 3,166 (99.5%) 16 (0.5%)
Hispanic/Latino 8976 8,965 (99.9%) 11 (0.1%)
Asian, NH 645 645 (100%) 0 (0%)
Multiple/other, NH 677 674 (99.6%) 3 (0.4%)
Hawaiian/Pacific Islander,
NH273 273 (100%) 0 (0%)
Alaskan/American Indian,
NH112 112 (100%) 0 (0%)
Comorbidity <0 . 0 1
No 12,581 12,575 (99.95%) 6 (0.05%)
Yes 7,515 7,482 (99.6%) 33 (0.4%)
NHnon Hispanic
Table 4 Multivariable logistic regression evaluating risk factors
associated with pediatric COVID 19 in hospital death ( n20,096)
Variable Odds ratio 95% CI pvalue
Age
0 9 years 1.24 0.63 2.43 0.53
1019 years 1 (reference)
Sex
Female 0.98 0.52 1.85 0.96
Male 1 (reference)
Race/ethnicity
White, NH 1 (reference)
Black, NH 2.96 1.30 6.73 0.01
Hispanic/Latino 0.88 0.36 2.13 0.78
Asian, NH 1
Multiple/other, NH 3.33 0.90 12.37 0.07
Hawaiian/Pacific Islander, NH 1
Alaskan/American Indian, NH 1
Comorbidity
No 1 (reference)
Yes 8.82 3.68 21.1 < 0.01
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Authors ’Contributions Drs. Alvaro and Axel Moreira conceptualized
and designed the study, drafted sections of the initial manuscript, carried
out the analyses, and supervised the project.
Dr. Ahmed assisted with conceptualization, wrote sections of the ini
tial manuscript, and critically reviewed and revised the manuscript.
Drs. Chorath and Rajasekaran and Ms. Burmeister assisted with con
ceptualization and critically reviewed and revised the manuscript.
All authors approved the final manuscript as submitted and agree to be
accountable for all aspects of the work.
Funding Parker B. Francis fellowship grant. The Francis Foundation had
no role in the design or conduct of this study.
Data availability Publicly available data.
Declarations
Ethics approval and consent to participate Not applicable.
Consent for publication Not applicable.
Conflict of interest The authors declare no conflict of interest.
Code availability Not applicable.
References
1. COVID Data Tracker. Centers for Disease Control and Prevention.
Covid.cdc.gov/covid data tracker/#cases_totalcases. Accessed 19
Jan 2021
2. Children and COVID 19: State Level Data Report. American
Academy of Pediatrics. Services.aap.org/en/pages/2019 novel
coronavirus covid 19 infections/children and covid 19 state leveldata report. Accessed 19 Jan 2021
3. Götzinger F, Santiago García B, Noguera Julián A, Lanaspa M,
Lancella L, Calò Carducci FI, Gabrovska N, Velizarova S, PrunkP, Osterman V, Krivec U, Lo Vecchio A, Shingadia D, Soriano
Arandes A, Melendo S, Lanari M, Pierantoni L, Wagner N,L'Huillier AG, Heininger U, Ritz N, Bandi S, Krajcar N, Rogli ć
S, Santos M, Christiaens C, Creuven M, Buonsenso D, Welch SB,
Bogyi M, Brinkmann F, Tebruegge M, Pfefferle J, Zacharasiewicz
A, Berger A, Berger R, Strenger V, Kohlfürst DS, Zschocke A,Bernar B, Simma B, Haberlandt E, Thir C, Biebl A, vandenDriessche K, Boiy T, van Brusselen D, Bael A, Debulpaep S,
Schelstraete P, Pavic I, Nygaard U, Glenthoej JP, Heilmann
Jensen L, Lind I, Tistsenko M, Uustalu Ü, Buchtala L, Thee S,Kobbe R, Rau C, Schwerk N, Barker M, Tsolia M, Eleftheriou I,Gavin P, Kozdoba O, Zsigmond B, Valentini P, Iva škeviciene I,
Ivaškevicius R, Vilc V, Schölvinck E, Rojahn A, Smyrnaios A,
Klingenberg C, Carvalho I, Ribeiro A, Starshinova A, Solovic I,Falcón L, Neth O, Minguell L, Bustillo M, Gutiérrez Sánchez AM,Guarch Ibáñez B, Ripoll F, Soto B, Kötz K, Zimmermann P,
Schmid H, Zucol F, Niederer A, Buettcher M, Cetin BS,
Bilogortseva O, Chechenye va V, Demirjian A, Shackley F,
McFetridge L, Speirs L, Doherty C, Jones L, McMaster P,Murray C, Child F, Beuvink Y, Makwana N, Whittaker E,
Williams A, Fidler K, Bernatoniene J, Song R, Oliver Z, Riordan
A (2020) COVID 19 in children and adolescents in Europe: a multinational, multicentre cohort study. Lancet Child Adolesc Health4(9):653 6614. Shekerdemian LS, Mahmood NR, Wolfe KK et al (2020)
Characteristics and outcomes of children with coronavirus disease2019 (COVID 19) infection admitted to us and canadian pediatricintensive care units [published online ahead of print, 2020 May 11].JAMA Pediatr. https://doi.org/10.1001/jamapediatrics.2020.1948
5. Kim L, Whitaker M, O ’Halloran A, Kambhampati A., Chai S.J.,
Reingold A., Armistead I., Kawasaki B., Meek J., Yousey HindesK., Anderson E.J., Openo K.P., Weigel A., Ryan P., Monroe M.L.,Fox K., Kim S., Lynfield R., Bye E., Shrum Davis S., Smelser C.,
Barney G., Spina N.L., Bennett N.M., Felsen C.B., Billing L.M.,
Shiltz J., Sutton M., West N., Talbot H.K., Schaffner W., Risk I.,Price A., Brammer L., Fry A.M., Hall A.J., Langley G.E., Garg S.,COVID NET Surveillance Team, COVID NET Surveillance
Team, Coates A., Daily Kirley P., Libby T., Roland J., Alden N.,
Herlihy R., McLafferty S., Clogher P., Kayalioglu H., Maslar A.,Misiorski A., Niccolai L., Olson D., Parisi C., Fawcett E.,Gretzinger S., Lengacher K., Williams J., Blythe D., Brooks A.,
Park R., Wilson M., Como Sabetti K., Danila R., Cline C.,
Angeles K., Eisenberg N., Flores K., Habrun C., Hancock E.,Khanlian S., Novi M., Phipps E., Salazar Sanchez Y., Dufort E.,Muse A., Bushey S., Gaitan M., Kurtz R.A., Owusu Dommey A.,
Snyder L., Michaelis K., Seeley K., Markus T., Chatelain R.,
George A., Hill M., McCullough L., Spencer M., Swain A.,McCaffrey K., Holstein R., Meador S., Wortham J.Hospitalization rates and characteristics of children aged <18 years
hospitalized with laboratory confirmed COVID 19 COVID
NET, 14 states, March 1 July 25, 2020. MMWR Morb MortalWkly Rep 2020;69:1081 1088
6. Hoang A, Chorath K, Moreira A et al (2020) COVID 19 in 7780
pediatric patients: a systematic review. EClinicalMedicine 24:100433
7. Coronavirus disease 2019 associated hospitalization surveillance
network (COVID NET). Centers for Disease Control and
Prevention. Cdc.gov/coronavirus/2019 ncov/covid datacovid net/
purpose methods.html . Last accessed on 9.17.2020
8. Williams JC, Anderson N, Holloway T, Samford E 3rd, Eugene J,
Isom J. Reopening the United States: Black and Hispanic workers
are essential and expendable again [published correction appears in
Am J Public Health. 2021 Jan;111(1):e2]. Am J Public Health2020;110(10):1506 1508. https://doi.org/10.2105/AJPH.2020.
305879
9. Adhikari S, Pantaleo NP, Feldman JM, Ogedegbe O, Thorpe L,
Troxel AB (2020) Assessment of community level disparities incoronavirus disease 2019 (COVID 19) infections and deaths inlarge US metropolitan areas. JAMA Netw Open 3(7):e2016938.
https://doi.org/10.1001/jamanetworkopen.2020.16938
10. Sze S, Pan D, Nevill CR, Gray LJ, Martin CA, Nazareth J, Minhas
JS, Divall P, Khunti K, Abrams KR, Nellums LB, Pareek M (2020)
Ethnicity and clinical outcomes in COVID 19: a systematic review
and meta analysis. EClinicalMedicine. 29:100630. https://doi.org/
10.1016/j.
eclinm.2020.100630
11. Tal Y, Adini A, Eran A, Adini I (2020) Racial disparity in Covid 19
mortality rates a plausible explanation. Clin Immunol 217:108481. https://doi.org/10.1016/j.clim.2020.108481
12. Ahmed M, Advani S, Moreira A, Zoretic S, Martinez J, Chorath K,
Acosta S, Naqvi R, Burmeister Morton F, Burmeister F, Tarriela A,
Petershack M, Evans M, Hoang A, Rajasekaran K, Ahuja S,
Moreira A (2020) Multisystem inflammatory syndrome in children:
a systematic review. EClinicalMedicine. 26:100527. https://doi.org/10.1016/j.eclinm.2020.100527
Publisher ’sn o t e Springer Nature remains neutral with regard to jurisdic
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