SCCM Resource Library-61-Risk Factors for Severe COVID-19 Illness in Children: Analysis of the VIRUS: COVID-19 Registry

Video Transcription

My name is Sandeep Tripathi, and I am a Pediatric Intensivist at the OSF St. Francis Medical Center in Peoria.  I will be presenting my research on the risk factors for severe COVID-19 in children, which is based on the analysis of the Society of Critical Care Medicine's virus registry for  COVID-19. Due to the rapidly evolving pandemic, the data presented here is slightly different  from what was submitted in the abstract, but it is most current at the time of recording this presentation.  This slide lists the co-investigators who directly contributed to the research. In addition, all investigators of the SCCM virus COVID-19 registry contributed as collaborative  co-authors. The virus registry is funded in part by the Gordon and Betty Moore Foundation and Jensen Research and Development. I do not have any conflict of interest to disclose.  It has now been more than a year since COVID-19 was first identified. As we are all well aware, COVID-19 is a severe disease in the elderly population with high  morbidity and mortality estimates as high as 40%. Preliminary reports in children showed a generally good outcome.  There are, however, a certain subset of children who develop significant morbidity from COVID-19. Currently, there is limited information on characteristics of these patients.  The primary objective of this research was to compare the clinical characteristics of ICU patients who had severe disease versus those who had moderate disease.  We also described the demographics and clinical characteristics of children in the participating institutions who died from COVID-19.  For this study, we included all children less than 18 years of age who were admitted to the participating ICUs in the Discovery Network virus registry from February to July of 2020.  The Society of Critical Care Medicine's Discovery Network designed and implemented the COVID-19  registry in March 2020, aptly named as Virus Infection and Respiratory Illness Universal Study. It involves a cross-sectional registry of all eligible adult and pediatric patients  who required hospitalization from COVID. Data collection form for this registry is based on REDCap with robust data reporting and monitoring.  One of the hallmarks of this registry is the development of a public dashboard with almost  a real-time display of the current patient enrollment and their various important demographic characteristics.  At the time of recording this presentation, there were 954 pediatric patients entered in the registry from 55 US sites.  In addition, there are more than seven international pediatric sites. As expected, adult network is much bigger with more than 43,000 hospital admissions  and 8,000 ICU admissions as of mid-December. Most of the prior studies use ICU admission as an indicator for severe disease.  Because of wide variation in ICU admission thresholds and geographical cohorting, we defined severe disease in patients who required invasive respiratory and hemodynamic support  or had immortality. Thus, the severe disease was defined as a need for one or more of either positive pressure  ventilation, use of inotropes or vasopressors, or use of pulmonary vasodilator therapy, ECMO, or new renal replacement therapy.  All patients who had mortality were also included in this category. All patients who are admitted to the ICU but did not require any of the above were categorized  as moderate disease. In addition to the standard descriptive and comparative analysis, we did a multivariable logistic regression to assess factors associated with severe COVID-19.  Because of low number of missing data, we did not perform sensitivity analysis and missingness was assumed to be missing at random.  Out of 466 children meeting inclusion and exclusion criteria during the study period, 195 were admitted to the ICU, out of which 84 met the criteria for severe disease, while  111 were categorized as mild or moderate disease. The median age of the patient was 10 years, with 45% between the ages of 13 and 17 years.  42% of patients were obese based on BMI percentiles. 44% met the criteria of MIS-C, and almost half had pre-existing medical condition or comorbidity.  Viral co-infection was only noted in 7 patients, while 32 patients, or 16.4% patients, had bacterial superinfection.  The median PRISM and PILOD score at the time of admission were 4 and 3, respectively. 34% of patients did not require any respiratory support.  Invasive and non-invasive ventilation was needed in 23% and 20% of patients. Regular nasal cannula was the most frequent mode of respiratory support and was used in  30% of the patients. ECMO was used in 6 patients. The most common therapeutic medication was use of steroids, which was used on 32% of the patients.  A total of 8 patients died from COVID-19 with a mortality rate of 4.1%. Among the patients who survived, the ICU and hospital length of stay were 4.5 and 7.8 days, respectively.  Invasive ventilator duration was 6 days. The median age of non-survivors was 13 years.  Only one patient was between 2 and 5 years of age, with most being adolescents. MIS-C was diagnosed in 62% of the patients, and any comorbidity was present in 87%, with  62% having 3 or more comorbidities. All the patients who died presented with 3 or more signs or symptoms at presentation.  There was similar distribution of sex and race and ethnicity and body mass index between the categories of moderate disease and severe disease.  Almost 24% of patients with severe disease had bacterial superinfection, as compared to 11% of patients with moderate disease.  A higher proportion of patients with severe disease had a diagnosis of MIS-C and had comorbidities.  Three or more comorbidities were present in 29% of patients with severe disease, as compared to 16% of patients with moderate disease.  Neurological comorbidities were more common in patients with severe disease. However, this difference did not reach statistical significance.  As expected, the hospital and ICU length of stay in patients with severe disease was longer in comparison to patients with mild to moderate disease.  The potential risk factors for severe disease identified with a p-value of less than 0.1 in univariate analysis and a priori defined variables of age category, sex, race, and  admitting hospital were included in the multivariable model to determine independent risk factors for severe disease.  Only report of MIS-C, bacterial superinfection, and presence of 3 or more comorbidities were independently associated with the risk of severe disease with an odds ratio of 2.7,  2.5, and 2.3, respectively. To conclude, we have observed that children who were admitted in the participating ICUs in the registry with COVID-19 had an overall good prognosis.  We identified characteristics associated with severe disease, including high number of comorbidities, bacterial superinfections, and diagnosis of MIS-C.  The main strength of our study is its multicentric involvement with robust and reliable data source.  Our study is different from prior studies because of strictly defined category of severe disease rather than using ICU admission as a criteria of severe disease.  This study shows comparative description of our demographics and outcomes versus the contemporary multicentric studies.  We had the largest sample size, although our number of centers were less than the other studies.  Almost 50% of all patients across all studies who required ICU admissions had comorbidities with an ICU mortality rate between 4% to 8%.  Risk factors for severe disease from our studies are not directly comparable to the study from  UK and Europe, as our definition of severe disease is a subset of ICU admission as opposed to risk factors for ICU admissions in the studies by Swan and Gottsinger.  This study has limitations inherent to the registry analysis with missing data and potential for uncontrolled confounding and selection bias.  Retrospective studies such as ours can describe association but do not establish causality. Thank you.

Video Summary

Dr. Sandeep Tripathi, a Pediatric Intensivist, presents his research on risk factors for severe COVID-19 in children. The study analyzed data from the Society of Critical Care Medicine's COVID-19 registry. The research aimed to compare clinical characteristics of ICU patients with severe disease versus those with moderate disease, as well as describe the demographics and characteristics of children who died from COVID-19. The study included children under 18 years old admitted to participating ICUs from February to July 2020. Factors associated with severe disease were identified, including comorbidities, bacterial superinfection, and a diagnosis of MIS-C. The study highlights the importance of understanding risk factors in children with COVID-19.

Asset Subtitle

Pediatrics, Crisis Management, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Sandeep Tripathi, MD, MS

Introduction/Hypothesis: A very small proportion of children who get infected with the novel coronavirus (COVID-19) have a severe disease requiring ICU care. Little is known about what risk factors are associated with severe disease in children. The purpose of this study was to compare characteristics of children with 'severe' disease defined as those requiring ICU admission vs. 'moderate' disease (hospital but not ICU admission) using the VIRUS: COVID 19 registry.

Methods: Retrospective analysis of the Society of Critical Care Medicine VIRUS: COVID-19 registry encompassing children hospitalized at 49 participating sites between 02/20 to 07/20. Patient demographics and clinical presentations were compared among patients who required ICU admission vs. those who did not. Univariate and Multivariate logistic regression was performed using JMP.

Results: Data was available for 398 children, of which 181 (45.4%) were admitted to ICU. Children who required ICU admission were older (10 years vs. 3.67 years, p<0.01) and were more likely to be African American (28.8% versus 17.8%, p= 0.02). A higher proportion of patients who required ICU admission have pre-existing conditions (58.2% vs. 44.3%, p= 0.01). Asthma was the most common pre-existing condition; but, a higher proportion of ICU admits had a diagnosis of asthma (14.2% vs. 7.52%, p= 0.01). The most common presenting symptom was fever; however, this did not differ between groups. Nausea/vomiting (38.4% vs. 22.1%, p<0.01), dyspnea (31.8% vs 17.7%, p<0.01) and abdominal pain (25.2% vs. 14.1%, p<0.01) were more common in patients requiring ICU admission. A significantly higher proportion of patients who required ICU had multisystem inflammatory syndrome of childhood [MIS-C (45.9% vs. 6.8%, p<0.01)] and acute kidney injury (9.34% vs. 1.7%, p<0.01). Race (AA vs white, odds ratio 1.9, p = 0.02) and age (p <0.01) were associated with the risk of ICU admission on multi variate logistic regression. Presence of preexisting conditions was not significant after accounting for age and race (p=0.07).

Conclusions: Preliminary data suggest that children requiring ICU admissions for severe COVID-19 infections are more likely to be older and from African American race. Asthma is the most common preexisting condition. Gastrointestinal complains are more likely in severe COVID infections.

Meta Tag

Content Type Presentation

Knowledge Area Pediatrics

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag COVID-19

Year 2021

Keywords

Pediatric Intensivist

severe COVID-19

children

risk factors

clinical characteristics

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