PC1018: Severe Outcomes of sars-cov-2 Infection in Children: A Systematic Review and Meta-analysis

Background: Severe outcomes do occur in SARS-CoV-2 infected children however the estimates vary dramatically between reports often to due variations in population, country economic status, study risk of bias and time-period. There we sough to provide clarity regarding the risk of severe outcomes in SARS-CoV-2 infected children through the conduct of a systematic review and meta-analysis focused on estimating the risk of severe or critical outcomes stratified by setting and other key variables.

Methods: To estimate the proportion of SARS-CoV-2 infected children experiencing hospitalization, intensive care unit (ICU) admission, severe outcomes and death, we searched PubMed, Embase, and MedRxiv for studies published between Dec 1, 2019, and May 28, 2021. References of relevant systematic reviews were also screened. We included cohort or cross-sectional studies reporting on at least one outcome measure (i.e. hospitalization, ICU admission, severe outcomes, death) for greater than or equal to 100 children less than 21 years old within 28 days of SARS-CoV-2 positivity; no language restrictions were applied. Two independent reviewers performed data extraction and risk of bias assessment. Estimates were pooled using random effects models. We adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The main outcomes were the percentage of SARS-CoV-2 positive children experiencing hospitalization, ICU admission, severe outcome and death.

Results: 118 studies representing 3,324,851 SARS-CoV-2 infected children from 68 countries were included. Community-based studies (N=49) reported that 4.2% (95%CI: 3.4-5.1%) of children were hospitalized, 0.5% (95%CI: 0.3-0.8%) were admitted to the ICU, 0.6% (95%CI: 0.1-1.5%) experienced a ‘severe’ outcome and 0.02% (95%CI: 0.001-0.05%) died. Hospital-based screening studies (N=38) reported that 24.3% (95%CI: 19.2-29.8%) of children were hospitalized, 2.9% (95%CI: 2.1-3.9%) were admitted to the ICU, 2.5% (95%CI: 1.4-3.8%) experienced a severe outcome, and 0.2% (95%CI: 0.02-0.5%) died. Studies of hospitalized children (N=31) reported that 10.1% (95%CI: 6.1-14.9%) of children required ICU admission, 6.7% (95%CI: 1.9-13.9%) had a severe outcome and 1.1% (95%CI: 0.2-2.3%) died. Low risk of bias studies, those from high-income countries, and those reporting outcomes later in the pandemic presented lower estimates. However, studies reporting outcomes after May 31, 2020, compared to earlier publications, had higher proportions of hospitalized patients requiring ICU admission and experiencing severe outcomes.

Conclusion: One in 25 SARS-CoV-2 infected children were hospitalized, with rates being higher early in the pandemic. Severe outcomes, ICU admission and death were uncommon, however estimates vary by study population, pandemic timing, study risk of bias, and economic status of the country.