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Underlying Medical Conditions Associated With Severe COVID-19 Illness Among Children

Educational Objective
To identify the key insights or developments described in this article
Key Points

Question  Among children with a COVID-19 diagnosis, what conditions are common, and which are associated with severe COVID-19 illness?

Findings  In this cross-sectional study of 43 465 patients aged 18 years or younger with COVID-19, more than one-quarter had 1 or more underlying condition; asthma, obesity, neurodevelopmental disorders, and certain mental health conditions were most common. Certain conditions as well as medical complexity were associated with a higher risk of severe COVID-19 illness.

Meaning  These findings expand the knowledge available regarding children with COVID-19 and could inform pediatric clinical practice and public health priorities, such as prevention and mitigation of COVID-19.


Importance  Information on underlying conditions and severe COVID-19 illness among children is limited.

Objective  To examine the risk of severe COVID-19 illness among children associated with underlying medical conditions and medical complexity.

Design, Setting, and Participants  This cross-sectional study included patients aged 18 years and younger with International Statistical Classification of Diseases, Tenth Revision, Clinical Modification code U07.1 (COVID-19) or B97.29 (other coronavirus) during an emergency department or inpatient encounter from March 2020 through January 2021. Data were collected from the Premier Healthcare Database Special COVID-19 Release, which included data from more than 800 US hospitals. Multivariable generalized linear models, controlling for patient and hospital characteristics, were used to estimate adjusted risk of severe COVID-19 illness associated with underlying medical conditions and medical complexity.

Exposures  Underlying medical conditions and medical complexity (ie, presence of complex or noncomplex chronic disease).

Main Outcomes and Measures  Hospitalization and severe illness when hospitalized (ie, combined outcome of intensive care unit admission, invasive mechanical ventilation, or death).

Results  Among 43 465 patients with COVID-19 aged 18 years or younger, the median (interquartile range) age was 12 (4-16) years, 22 943 (52.8%) were female patients, and 12 491 (28.7%) had underlying medical conditions. The most common diagnosed conditions were asthma (4416 [10.2%]), neurodevelopmental disorders (1690 [3.9%]), anxiety and fear-related disorders (1374 [3.2%]), depressive disorders (1209 [2.8%]), and obesity (1071 [2.5%]). The strongest risk factors for hospitalization were type 1 diabetes (adjusted risk ratio [aRR], 4.60; 95% CI, 3.91-5.42) and obesity (aRR, 3.07; 95% CI, 2.66-3.54), and the strongest risk factors for severe COVID-19 illness were type 1 diabetes (aRR, 2.38; 95% CI, 2.06-2.76) and cardiac and circulatory congenital anomalies (aRR, 1.72; 95% CI, 1.48-1.99). Prematurity was a risk factor for severe COVID-19 illness among children younger than 2 years (aRR, 1.83; 95% CI, 1.47-2.29). Chronic and complex chronic disease were risk factors for hospitalization, with aRRs of 2.91 (95% CI, 2.63-3.23) and 7.86 (95% CI, 6.91-8.95), respectively, as well as for severe COVID-19 illness, with aRRs of 1.95 (95% CI, 1.69-2.26) and 2.86 (95% CI, 2.47-3.32), respectively.

Conclusions and Relevance  This cross-sectional study found a higher risk of severe COVID-19 illness among children with medical complexity and certain underlying conditions, such as type 1 diabetes, cardiac and circulatory congenital anomalies, and obesity. Health care practitioners could consider the potential need for close observation and cautious clinical management of children with these conditions and COVID-19.

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Article Information

Accepted for Publication: March 31, 2021.

Published: June 7, 2021. doi:10.1001/jamanetworkopen.2021.11182

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2021 Kompaniyets L et al. JAMA Network Open.

Corresponding Author: Lyudmyla Kompaniyets, PhD, COVID-19 Response, US Centers for Disease Control and Prevention, 4770 Buford Hwy, MS S107-5, Atlanta, GA 30341 (LKompaniyets@cdc.gov).

Author Contributions: Dr Kompaniyets 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.

Concept and design: Kompaniyets, Nelson, Preston, Ko, Belay, DeSisto, Chevinsky, Schieber, Yusuf, Mac Kenzie, Wong, Gundlapalli, Goodman.

Acquisition, analysis, or interpretation of data: Kompaniyets, Agathis, Nelson, Preston, Ko, Pennington, Danielson, Chevinsky, Schieber, Yusuf, Baggs, Mac Kenzie, Wong, Boehmer, Gundlapalli, Goodman.

Drafting of the manuscript: Kompaniyets, Agathis, Nelson, Belay, DeSisto, Chevinsky, Wong, Gundlapalli.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Kompaniyets, Preston, Pennington, Chevinsky, Schieber, Baggs, Wong.

Obtained funding: Boehmer, Gundlapalli.

Administrative, technical, or material support: Kompaniyets, Agathis, Belay, Yusuf, Mac Kenzie, Boehmer, Gundlapalli.

Supervision: Kompaniyets, Ko, Belay, Danielson, Mac Kenzie, Boehmer, Gundlapalli, Goodman.

Conflict of Interest Disclosures: None reported.

Disclaimer: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the US Centers for Disease Control and Prevention (CDC) or the US Public Health Service.

Additional Contributions: The authors thank Sachin Agnihotri, MS, Indira Srinivasan, MS, David Nitschke, BS, and Kimberly Riggle, BBA (CDC COVID-19 Response Data, Analytics, and Modeling Task Force), and John House, MS (Premier Inc), for facilitating access to these data. We thank Hannah G. Rosenblum, MD (CDC COVID-19 Community Interventions and Critical Populations Task Force), Catherine E. Barrett, PhD, and Joohyun Park, PhD (CDC Division of Diabetes Translation) for providing subject matter expertise on classifying underlying medical conditions. None of these individuals received compensation beyond their regular salaries for their work on this study.

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