Clinical, Demographic Factors for Early Identification of Children at Risk for Severe COVID-19

Young mother squeezing hand sanitizer onto little daughter’s hand in the playground to prevent the spread of viruses
Researchers conducted a study to determine the clinical and demographic characteristics associated with an increased risk for severe COVID-19 infection among children.

Among children with COVID-19 infection, factors such as demographic characteristics, preexisting comorbidities, vital signs, and laboratory results may help in the early identification of those at increased risk for progression to severe disease. These findings were published in JAMA Network Open.

All children (N=167,262) younger than 19 years of age who tested positive for SARS-CoV-2 infection at 56 sites in the US prior to September 2021 were included in this analysis. Patient characteristics were assessed to determine the potential risk for hospitalization and outcomes of severe disease.

Among children included in the study, the median age was 11.9 (IQR, 6.0-16.1) years, 50.1% were boys, 55.5% were White, 25.5% had a BMI greater than 35 kg/m2, and 14.2% had at least 1 pediatric complex chronic condition (PCCC).

The researchers found that 6.1% of children included were hospitalized (6.1%), of whom 13.9% developed severe COVID-19 infection, 7.8% required mechanical ventilation, 8.5% required vasoactive-inotropic support, 0.4% required extracorporeal membrane oxygenation, and 1.3% died.

The risk for hospitalization due to severe COVID-19 infection was significantly increased among boys (odds ratio [OR], 1.37; 95% CI, 1.21-1.56; P <.001), those who were Black (OR, 1.25; 95% CI, 1.06-1.47; P =.008), those who were neither Black nor White (OR, 1.23; 95% CI, 1.04-1.45; P =.01), those with BMIs indicating obesity (OR, 1.19; 95% CI, 1.01-1.41; P =.04), and those with a PCCC (OR, 1.20; 95% CI, 1.16-1.24; P <.001). After stratification by PCCC, the researchers observed that an increased risk for hospitalization was associated with cardiovascular, cancer, neuromuscular, kidney, and respiratory conditions, as well as technology-dependent conditions.

After multivariable logistic regression was performed, the researchers found that respiratory and neuromuscular PCCCs, as well as non-White and non-Black race/ethnicity, were no longer significantly predictive of an increased risk for hospitalization due to severe COVID-19 infection.

On hospital admission, patients with severe COVID-19 infection were more likely to have decreased systolic and diastolic blood pressure measurements. They were also more likely to have decreased oxygen saturation and increased heart and respiratory rates. In addition, over the course of disease, an increased risk for progression to severe COVID-19 was found to be associated with increased concentrations of alanine aminotransferase, aspartate aminotransferase, brain-type natriuretic peptide, creatinine, D-dimer, ferritin, C-reactive protein, and procalcitonin; and decreased platelet counts and albumin concentrations.

Children with severe COVID-19 infection were more likely to receive remdesivir, anakinra, infliximab, immunomodulatory medications, systemic corticosteroids, antimicrobials, antibacterials, and antivirals (all P <.001) compared with those with moderate COVID-19 infection.

Given the ubiquitous adoption of COVID-19 testing polices for pediatric admissions, this study may have been limited as the researchers were unable to definitively verify whether some children were initially hospitalized due to COVID-19 infection vs an unrelated condition.

This study found specific patient characteristics associated with severe COVID-19 infection among children. According to the researchers, “further work is warranted to optimize translation of this knowledge into improved clinical care.”

Disclosure: Multiple authors declared affiliations with industry. Please see the original reference for a full list of disclosures.


Martin B, DeWitt PE, Russell S, et al. Characteristics, outcomes, and severity risk factors associated with SARS-CoV-2 infection among children in the US national COVID cohort collaborative. JAMA Netw Open. 2022;5(2):e2143151. doi:10.1001/jamanetworkopen.2021.43151