1. The case fatality rate in children and adolescents across Europe is less than 1%, whereas, in the elderly, it is close to 10%.
2. Age under one month, male sex, history of lower respiratory tract infection (LRTI), and pre-existing medical conditions were significantly associated with requiring intensive care unit admission.
Evidence Rating Level: 2 (Good)
Study Rundown: There is scant evidence around the impact of COVID-19 on children and adolescents. This multicenter cohort study aimed to evaluate the effect of COVID-19 among 582 European children aged 18 and under in 21 European countries. The median participant age was five years. The majority of COVID-positive patients were admitted to the hospital; yet, only a few required intensive care unit (ICU) admission. In particular, newborn males and those with signs and symptoms of lower respiratory tract infection (LRTI) were significantly more likely to be admitted to the ICU, as were those with comorbidities. Other risk factors for ICU admission included fever), viral infection, and findings of pneumonia or acute respiratory distress syndrome on a chest X-ray. This study was limited by non-comprehensive SARS-CoV-2 testing in some countries due to capacity issues; given screening thresholds for SARS-CoV-2 varied among countries, the total number of COVID-19 cases in children and adolescents may be under- or over-predicted. The study was also limited to data from children and adolescents with generally more severe disease requiring contact with a hospital setting. Finally, polymerase chain reaction (PCR) assays differed across centers, which may have precluded complete test standardization. Nonetheless, this is the largest multicenter cohort study on COVID-19 in children to date.
In-depth [retrospective cohort]: This multicenter cohort study used the Pediatric Tuberculosis Network European Trials Group and involved 82 health care centers across 25 European countries. Individuals aged 18 eyars or older with laboratory-confirmed SARS-CoV-2 infection between April 1 and 24 2020 were included, and factors associated with ICU admission and initiation of medical therapy was examined using univariable and multivariable logistic regression.
Among 582 patients with confirmed SARS-CoV-2 infection, 363 (62%) were hospitalized and 48 (8%) required ICU admission. 145 (25%) patients had pre-existing medical conditions, including COPD (n=29), malignancy (n=27), neurological disorders (n=26), congenital heart disease (n=25), chromosomal abnormalities (n=10), and chronic kidney disease (n=9). In total, 75 (13%) patients required supplemental oxygen therapy, while one (<1%) needed extracorporeal membrane oxygenation. Patients with viral infection were significantly more likely to require respiratory and/or inotropic support, and ICU admission. Individuals younger than 1 month (odds ratio [OR] 5.06, 95% confidence intervals [CI] 1.72 to 14.87, p=0.0035), male sex (OR 2.12, 95% CI 1.06 to 4.21, p=0.033], having LRTI signs and symptoms (OR 10.46, 95% CI 5.16 to 21.23, p<0.0001], and those with pre-existing medical conditions (OR 3.27, 95% CI 1.67 to 6.42, p=0.0015) were more likely to be admitted to the ICU. In terms of treatment, antiviral and immunomodulatory drug initiation was significantly associated with malignancy (OR 6.3, 95% CI 2.8 to 14.2), cardiac disease (OR 4.2, 95% CI 1.8 to 10.0), respiratory disease (OR 6.5, 95% CI 3.0 to 14.2), immunosuppressive therapy (OR 6.5, 95% CI 3.0 to 14.2), chemotherapy (OR 6.1, 95% CI 2.6 to 14.1), pneumonic (OR 4.5, 95% CI 2.3 to 8.6) or ARDS (OR 22.3, 95% CI 2.7 to 180.5) findings on chest X-ray, and viral co-infection (OR 5.5, 95% CI 2.5 to 12.2), (p<0.0001 for all). Only 4 out of 582 patients died by the end of the study period (case fatality rate [CFR] 0.69%, 95% CI 0.20 to 1.82); 460 (80%) participants were cleared of any sequelae upon termination of study, and 23 (4%) were still symptomatic. In general, this study showed that COVID-19 is largely associated with mild disease, with severe manifestations being infrequent, among children and adolescents, relative to adults. Similar to in adults, severe COVID-19 disease in children is highly associated with requiring hospital admission, with a subset of patients requiring ICU admission and ventilatory support.
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