Pediatric critical COVID-19 and mortality in a multinational cohort

Abstract

Objectives: To understand the international epidemiology of critical pediatric COVID-19 and compare presentation, treatments, and outcomes of younger (<2 years) and older (>2 years) children. Design: Prospective, observational study from April 1 to December 31, 2020 Setting: International multicenter study from 55 sites from North America, Latin America, and Europe. Participants: Patients <19 years old hospitalized with critical COVID-19 Interventions: none Main outcomes measured: Clinical course, treatments, and outcomes were compared between younger and older children. Multivariable logistic regression was used to calculate adjusted odds ratios (aOR) for hospital mortality. Results: 557 subjects (median age, 8 years; 24% <2 years) were enrolled from 55 sites (63% Latin American). Half had comorbidities. Younger children had more respiratory findings (56% vs 44%), viral pneumonia (45% vs 29%), and treatment with invasive ventilation (50% vs 37). Gastrointestinal (28% vs 69%) or mucocutaneous (16% vs 44%) findings, vasopressor requirement (44% vs 60%), and MIS-C (15% vs 40%) were less common in younger children. Hospital mortality was 10% overall but 15% in younger children (odds ratio 1.89 [95%CI 1.05-3.39]). When adjusted for age, sex, region, and illness severity, mortality-associated factors included cardiac (aOR 2.6; 95%CI 1.07-6.31) or pulmonary comorbidities (aOR 4.4; 95%CI 1.68-11.5), admission hypoxemia (aOR 2.33; 95%CI 1.24-4.37), and lower respiratory symptoms (aOR 2.83; 95%CI 1.49-5.39). Gastrointestinal (aOR 0.49; 95%CI 0.26-0.92) or mucocutaneous symptoms (aOR 0.31; 95%CI 0.15-0.64), treatment with intravenous immune globulin (aOR 0.33; 95%CI 0.17-0.65), and MIS-C (aOR 0.26; 95%CI 0.11-0.64) were associated with lower mortality. Conclusions: We identified age-related differences in presentation and mortality for critical pediatric COVID-19 that should prompt more attention to improving management in younger children, especially in developing countries.

Pediatric ARDS phenotypes in critical COVID-19: implications for therapies and outcomes

“…In addition, patients who met the case definition for MIS-C were also included, even lacking a confirmed microbiological diagnosis of SARS-CoV-2 infection, to include all the causes of pediatric critical COVID-19, requiring PICU admission, as previously defined. 11,12,22,23 Patients with a clinical and microbiological profile of SARS-CoV-2 infection at PICU admission, receiving invasive MV, and meeting PALICC criteria for PARDS 24 , were included in the analysis. Pneumonia severity was based on PAHO definitions 25 .…”

“…Pediatric COVID-19 critical illness is heterogeneous and infrequent [10][11][12] . The most common causes of admission to the pediatric intensive care unit (PICU) are respiratory failure and multisystem inflammatory syndrome in children (MIS-C), [10][11][12][13][14][15] . Nonetheless, cases of non-cardiopulmonary involvement are frequent [14][15][16] .…”

“…While the low morbidity and mortality in the general pediatric population is reassuring, there is a significant gap in knowledge in identifying high-risk subgroups, such as those who develop pediatric ARDS (PARDS) or multiorgan failure. 11,12,16 Invasive mechanical ventilation (MV) for pediatric COVID-19 at PICU has been reported between 30 to 70% in different cohorts 11,13,15,[17][18][19] . Surprisingly, specific information on PARDS related to COVID-19 is scarce.…”

Comparison of Interleukin-6 Plasma Concentration in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Pediatric Sepsis

“…The first group included 44 Pediatric Intensive Care Unit admissions due to sepsis before the COVID-19 pandemic ( 11 ). We collected 27 cases with MIS-C from Yagnam et al ( 12 ) and 39 patients from the Critical Coronavirus and Kids Epidemiological Study (CAKE) ( 13 ) for the MIS-C group.…”

Innate and Adaptive Immunity Imbalance With Severe COVID-19 Pneumonia in Children and Adults

“…As we know now, one of the most leading causes of mortality in both children and adult is COVID-19 pneumonia ( 8 ) because distinct immunological responses to viral infections can exist in each of which and result in severe damage to vital organs, such as pulmonary, especially in adult patients ( 9 ). Aberrant immune responses include lymphopenia, particularly T lymphocytes (both CD4+ T and CD8+ T cells), cytokine storm, and hyper-inflammatory responses that play a critical role in the pathology of SARS-CoV-2 ( 1 , 10 ).…”