Though severe COVID-19 infections in children are uncommon, children and young adults with comorbidities are at increased risk for critical illness during COVID-19 infections, according to a new study in Journal of the Pediatric Infectious Diseases Society.
The meta-analysis looked at critical COVID-19, defined as an invasive mechanical ventilation requirement, intensive care unit admission, or death, in 70 studies published from March 2020 to August 2023 and found a nearly 10-fold increased risk in kids who have two or more underlying medical conditions.
"We selected studies that included patients aged ≤21 years with confirmed COVID-19 and provided enough data to estimate the odds ratio (OR) of critical disease for a given risk factor," the authors said.
The studies collectively examined 172,165 children, adolescents, and young adults with COVID-19 in 45 countries.
Heart disease adds to the risk
In healthy children with no comorbidities, the absolute risk of critical disease from COVID-19 was 4% (95% confidence interval [CI], 1% to 10%).
Compared with no comorbidities, the pooled odds ratio (OR) for critical disease was 3.95 (95% CI, 2.78 to 5.63) for the presence of one comorbidity and 9.51 (95% CI, 5.62 to 16.06) for two or more comorbidities.
The highest critical risk factor was age under 1 month, with 7 studies on 1,290 infants aged under 1 month showing that 20% had critical illness. But the authors warned that that number includes premature infants and may not be widely representative of the true risk to full-term babies.
Fifty-one studies assessed the risk of cardiac and pulmonary (heart and lung) comorbidities, including congenital heart disease, high blood pressure, heart failure, cardiomyopathies, valvular disease, septal defects, arrhythmias, and pulmonary hypertension.
The rate of critical disease among 2,372 children with cardiovascular disease in these studies was 30% (95% CI, 23% to 37%), and the pooled odds ratio was 3.60 (95% CI, 2.81 to 4.61), the authors said.
Previous pulmonary conditions were a risk factor for severity, with a pooled critical disease rate of 24% (95% CI, 17% to 33%) and an OR of 2.15 (95% CI, 1.66 to 2.75).
Seizure disorders pose substantial risk
"Few studies examined the extent to which poorly controlled asthma modifies the severity of COVID-19 in children," the authors said. Children with controlled asthma showed no significant risk for severe disease, but uncontrolled asthma more than doubled the risk of developing severe COVID-19 (adjusted risk ratio, 2.24; 95% CI, 1.54 to 3.27).
.Few studies examined the extent to which poorly controlled asthma modifies the severity of COVID-19 in children
One study found that children, however, who were hospitalized for asthma within 12 months of the study, were at increased for acute COVID-19 severity (adjusted OR, 2.9; 95% CI, 2.6 to 3.3).
Children with seizure disorders and other neurologic complications had more than triple the odds of critical illness compared to the general pediatric population (OR 3.40; 95% CI, 2.70 to 4.29).
In addition, obesity, diabetes, and compromised immune systems were also tied to statistically significant odd ratios greater than 2.
"The current management of COVID-19 in the pediatric population is multifaceted, requiring a balanced assessment of the potential risks and benefits of various therapeutic agents, as well as a comprehensive evaluation of the myriad underlying risk factors that may predispose children to more severe disease," the authors concluded. "Although our study is subject to certain limitations, it contributes evidence on several risk factors that are clearly associated with a more severe disease trajectory."
