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Assessment of 135 794 Pediatric Patients Tested for Severe Acute Respiratory Syndrome Coronavirus 2 Across the United States

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Key Points

Question  What is the epidemiology across the United States of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection among pediatric patients undergoing diagnostic testing for the virus?

Findings  In this cohort study using electronic health records for 135 794 US pediatric patients in 7 children’s health systems, 96% of patients tested had negative results, and rates of severe cardiorespiratory presentation of coronavirus disease 2019 (COVID-19) illness were low. Minority race/ethnicity, chronic illness, and increasing age were associated with SARS-CoV-2 infection.

Meaning  This study suggests that for most pediatric patients, the risk of SARS-CoV-2 infection appears low, but higher concern may be warranted for patients with medically complex conditions or those of minority race/ethnicity.


Importance  There is limited information on severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing and infection among pediatric patients across the United States.

Objective  To describe testing for SARS-CoV-2 and the epidemiology of infected patients.

Design, Setting, and Participants  A retrospective cohort study was conducted using electronic health record data from 135 794 patients younger than 25 years who were tested for SARS-CoV-2 from January 1 through September 8, 2020. Data were from PEDSnet, a network of 7 US pediatric health systems, comprising 6.5 million patients primarily from 11 states. Data analysis was performed from September 8 to 24, 2020.

Exposure  Testing for SARS-CoV-2.

Main Outcomes and Measures  SARS-CoV-2 infection and coronavirus disease 2019 (COVID-19) illness.

Results  A total of 135 794 pediatric patients (53% male; mean [SD] age, 8.8 [6.7] years; 3% Asian patients, 15% Black patients, 11% Hispanic patients, and 59% White patients; 290 per 10 000 population [range, 155-395 per 10 000 population across health systems]) were tested for SARS-CoV-2, and 5374 (4%) were infected with the virus (12 per 10 000 population [range, 7-16 per 10 000 population]). Compared with White patients, those of Black, Hispanic, and Asian race/ethnicity had lower rates of testing (Black: odds ratio [OR], 0.70 [95% CI, 0.68-0.72]; Hispanic: OR, 0.65 [95% CI, 0.63-0.67]; Asian: OR, 0.60 [95% CI, 0.57-0.63]); however, they were significantly more likely to have positive test results (Black: OR, 2.66 [95% CI, 2.43-2.90]; Hispanic: OR, 3.75 [95% CI, 3.39-4.15]; Asian: OR, 2.04 [95% CI, 1.69-2.48]). Older age (5-11 years: OR, 1.25 [95% CI, 1.13-1.38]; 12-17 years: OR, 1.92 [95% CI, 1.73-2.12]; 18-24 years: OR, 3.51 [95% CI, 3.11-3.97]), public payer (OR, 1.43 [95% CI, 1.31-1.57]), outpatient testing (OR, 2.13 [1.86-2.44]), and emergency department testing (OR, 3.16 [95% CI, 2.72-3.67]) were also associated with increased risk of infection. In univariate analyses, nonmalignant chronic disease was associated with lower likelihood of testing, and preexisting respiratory conditions were associated with lower risk of positive test results (standardized ratio [SR], 0.78 [95% CI, 0.73-0.84]). However, several other diagnosis groups were associated with a higher risk of positive test results: malignant disorders (SR, 1.54 [95% CI, 1.19-1.93]), cardiac disorders (SR, 1.18 [95% CI, 1.05-1.32]), endocrinologic disorders (SR, 1.52 [95% CI, 1.31-1.75]), gastrointestinal disorders (SR, 2.00 [95% CI, 1.04-1.38]), genetic disorders (SR, 1.19 [95% CI, 1.00-1.40]), hematologic disorders (SR, 1.26 [95% CI, 1.06-1.47]), musculoskeletal disorders (SR, 1.18 [95% CI, 1.07-1.30]), mental health disorders (SR, 1.20 [95% CI, 1.10-1.30]), and metabolic disorders (SR, 1.42 [95% CI, 1.24-1.61]). Among the 5374 patients with positive test results, 359 (7%) were hospitalized for respiratory, hypotensive, or COVID-19–specific illness. Of these, 99 (28%) required intensive care unit services, and 33 (9%) required mechanical ventilation. The case fatality rate was 0.2% (8 of 5374). The number of patients with a diagnosis of Kawasaki disease in early 2020 was 40% lower (259 vs 433 and 430) than in 2018 or 2019.

Conclusions and Relevance  In this large cohort study of US pediatric patients, SARS-CoV-2 infection rates were low, and clinical manifestations were typically mild. Black, Hispanic, and Asian race/ethnicity; adolescence and young adulthood; and nonrespiratory chronic medical conditions were associated with identified infection. Kawasaki disease diagnosis is not an effective proxy for multisystem inflammatory syndrome of childhood.

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Article Information

Accepted for Publication: September 30, 2020.

Published Online: November 23, 2020. doi:10.1001/jamapediatrics.2020.5052

Corresponding Author: L. Charles Bailey, MD, PhD, Department of Pediatrics, Children’s Hospital of Philadelphia, 2716 South St, 11th Floor, Philadelphia, PA 19146 (

Author Contributions: Dr Bailey 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. Dr Bailey and Ms Razzaghi contributed equally to the work reported here.

Concept and design: Bailey, Razzaghi, Christakis, Rao, Sofela, Forrest.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Bailey, Razzaghi, Camacho, Rao, Sofela, Bruno, Forrest.

Critical revision of the manuscript for important intellectual content: Bailey, Razzaghi, Burrows, Bunnell, Christakis, Eckrich, Kitzmiller, Lin, Magnusen, Newland, Pajor, Ranade, Rao, Sofela, Zahner, Bruno.

Statistical analysis: Bailey, Razzaghi, Burrows, Bunnell, Forrest.

Obtained funding: Forrest.

Administrative, technical, or material support: Bailey, Burrows, Bunnell, Camacho, Christakis, Eckrich, Kitzmiller, Lin, Magnusen, Pajor, Ranade, Rao, Sofela, Zahner, Bruno.

Supervision: Bailey, Razzaghi, Forrest.

Conflict of Interest Disclosures: Drs Bailey, Bunnell, Magnusen, and Pajor and Mss Razzaghi and Zahner reported receiving grants from the Patient-Centered Outcomes Research Institute (PCORI) during the conduct of the study. Dr Magnusen reported receiving grants from People Centered Research Foundation during the conduct of the study. Ms Ranade reported receiving grants from PEDSnet during the conduct of the study. No other disclosures were reported.

Funding/Support: This work was funded by PCORI (RI-CRN-2020-007).

Role of the Funder/Sponsor: Neither PCORI nor its representatives participated directly in any of the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; or decision to submit the manuscript for publication.

Disclaimer: Dr Christakis is editor of JAMA Pediatrics; he was not involved in the editorial review and decision for this manuscript.

Additional Contributions: The authors would like to thank the following people from the PEDSnet Data Coordinating Center at the Children’s Hospital of Philadelphia: Susan Hague, MS, and Shweta Chavan, MSEE, for managing the data operations and ensuring the availability of the data used for analyses; and Kimberley Dickinson, BS, and Levon Utidjian, MD, for their contributions in reviewing data quality for analyses. They were not compensated for their contributions.

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