Risk Factors for Mortality and Intensive Care Requirements Among Pediatric Patients Hospitalized with COVID-19 in the United States

Background: Though the ongoing pandemic has generated an overwhelming amount of information on COVID-19, there remains limited data on conditions that are associated with serious outcomes among hospitalized pediatric patients

Objectives: To describe the factors associated with intensive care unit (ICU) admission, mechanical ventilation use, and mortality among pediatric patients hospitalized with COVID-19 in the United States.

Methods: Using chargemaster data from 297 hospitals, we identified pediatric patients with a COVID-19 diagnosis admitted to the hospital between February 2020 and December 2021. The associations between baseline characteristics and serious outcomes (ICU, ventilation, mortality) were evaluated by estimating the risk of experiencing each outcome by hospital day 60 (using an inverse-probability of censoring weighted estimator of cumulative risk). Patients who were still hospitalized at time of data abstraction were censored. For all outcomes, hospital discharge was treated as a competing risk. For ICU admission and ventilation, death was also treated as a competing risk.

Results: Among 6631 pediatric patients, 615 were admitted to the ICU, 313 received ventilation, and 59 died. The overall risk of ICU within 60 days after admission is 9.3%, and the factors associated with the greatest risk for ICU are Census Division (Mountain Division: 16.3% risk of ICU by day 60), hospital size (hospitals with 300-499 beds: 19.1% risk), and hospital type (major teaching hospitals: 10.8% risk). The overall risk of being placed on ventilation by hospital stay day 60 is 4.8%, and the characteristics found in patients with the highest risk are acute respiratory distress syndrome at admission (59.9% risk) and acute respiratory failure at admission (17.9% risk). The overall risk of mortality by day 60 is 0.9%, and, the highest-risk characteristics are acute respiratory distress syndrome at admission (16.2% risk), disseminated intravascular coagulation at admission (13.6% risk), congestive heart failure at admission (10.2% risk), and systemic inflammatory response syndrome at admission (7.8% risk).

Conclusions: In a large cohort of hospitalized pediatric patients, we describe the factors associated with high risk of ICU admission, receipt of mechanical ventilation, and mortality. Hospital characteristics and geographic location have stronger associations with ICU admission than any health history variables or diagnoses at admission. Acute respiratory diagnoses at admission have the strongest associations with being placed on a ventilator. Acute conditions diagnosed at admission, including acute respiratory distress syndrome, disseminated intravascular coagulation, and congestive heart failure have the strongest associations with mortality.