Six Hospitals, United States, July–August 2021 | MMWR - CDC

Among patients hospitalized for COVID-19, 15.8% had a viral coinfection¶¶ (66.4% of whom had respiratory syncytial virus [RSV] infection). Skipdirectlytositecontent Skipdirectlytopageoptions SkipdirectlytoA-Zlink MorbidityandMortalityWeeklyReport(MMWR) SectionNavigation CDCHome Facebook Twitter LinkedIn Syndicate CharacteristicsandClinicalOutcomesofChildrenandAdolescentsAged<18YearsHospitalizedwithCOVID-19—SixHospitals,UnitedStates,July–August2021 Weekly/December31,2021/70(5152);1766–1772 Minus RelatedPages ValentineWanga,PhD1,2;MeganE.Gerdes,MPH1;DallasS.Shi,MD,PhD1,2;RewaChoudhary,MD1,2;TheresaM.Dulski,MD1,2;SophiaHsu,MSN,MPH1;OsatohamwenI.Idubor,MD1;BryantJ.Webber,MD1,2;ArthurM.Wendel,MD1;NickolasT.Agathis,MD1,2;KristiAnderson,MD1;TriciaBoyles,MHA1;SophiaK.Chiu,MD1;EleanorS.Click,MD,PhD1;JulianaDaSilva,MD1;HannahDupont,MPH1;MaryEvans,MD1;JeremyA.W.Gold,MD1;JuliaHaston,MD1,2;PamelaLogan,MD1;SusanA.Maloney,MD1;MarisolMartinez,PharmD1;PavithraNatarajan;BMBS1;KevinB.Spicer,MD,PhD1;MarkSwancutt,MD1;ValerieA.Stevens1;JessicaBrown,PhD1;GyanChandra,MBA1;MeganLight,MPH1;FrederickE.Barr,MD3;JessicaSnowden,MD3;LarryK.Kociolek,MD4;MatthewMcHugh,MPH4;DavidWessel,MD5;JoelleN.Simpson,MD5;KathleenC.Gorman,MSN5;KristenA.Breslin,MD5;RobertaL.DeBiasi,MD5;AaronThompson,MD6,7;MarkW.Kline,MD6,7;JulieA.Bloom,MD8;IlaR.Singh,MD,PhD9;MichaelDowlin9;MarkWietecha,MS,MBA10;BethSchweitzer,MS1;SapnaBamrahMorris,MD1;EmilyH.Koumans,MD1;JeanY.Ko,PhD1;AnneA.Kimball,MD1,*;DavidA.Siegel,MD1,*(Viewauthoraffiliations) ViewsuggestedcitationSummary Whatisalreadyknownaboutthistopic? PediatricCOVID-19–relatedhospitalizationratesincreasedwhenthehighlytransmissibleSARS-CoV-2B.1.617.2(Delta)variantbecamethepredominantcirculatingstrain. Whatisaddedbythisreport? AmongchildrenandadolescentswithSARS-CoV-2infectionadmittedtosixhospitalsduringJuly–August2021,77.9%werehospitalizedforacuteCOVID-19.Amongthesepatients,approximatelyonethirdaged<5yearshadaviralcoinfection(approximatelytwothirdsofwhichwererespiratorysyncytialvirus)andapproximatelytwothirdsofthoseaged12–17yearshadobesity;only0.4%ofage-eligiblepatientswerefullyvaccinated. Whataretheimplicationsforpublichealthpractice? COVID-19vaccinationandotherpreventionstrategiesareimportanttoprotectchildrenfromCOVID-19,particularlychildrenwithobesityandotherunderlyinghealthconditions. ArticleMetrics Altmetric: Citations: Views: ViewsequalspageviewsplusPDFdownloads MetricDetails TablesTable1Table2Table3ReferencesRelatedMaterialsPDFpdficon[369K]DuringJune2021,thehighlytransmissible†B.1.617.2(Delta)variantofSARS-CoV-2,thevirusthatcausesCOVID-19,becamethepredominantcirculatingstrainintheUnitedStates.U.S.pediatricCOVID-19–relatedhospitalizationsincreasedduringJuly–August2021followingemergenceoftheDeltavariantandpeakedinSeptember2021.§AsofMay12,2021,CDCrecommendedCOVID-19vaccinationsforpersonsaged≥12years,¶andonNovember2,2021,COVID-19vaccinationswererecommendedforpersonsaged5–11years.**Todate,clinicalsignsandsymptoms,illnesscourse,andfactorscontributingtohospitalizationsduringtheperiodofDeltapredominancehavenotbeenwelldescribedinpediatricpatients.CDCpartneredwithsixchildren’shospitalstoreviewmedicalrecorddataforpatientsaged<18yearswithCOVID-19–relatedhospitalizationsduringJuly–August2021.††Among915patientsidentified,713(77.9%)werehospitalizedforCOVID-19(acuteCOVID-19astheprimaryorcontributingreasonforhospitalization),177(19.3%)hadincidentalpositiveSARS-CoV-2testresults(asymptomaticormildinfectionunrelatedtothereasonforhospitalization),and25(2.7%)hadmultisysteminflammatorysyndromeinchildren(MIS-C),ararebutseriousinflammatoryconditionassociatedwithCOVID-19.§§Amongthe713patientshospitalizedforCOVID-19,24.7%wereaged<1year,17.1%wereaged1–4years,20.1%wereaged5–11years,and38.1%wereaged12–17years.Approximatelytwothirdsofpatients(67.5%)hadoneormoreunderlyingmedicalconditions,withobesitybeingthemostcommon(32.4%);amongpatientsaged12–17years,61.4%hadobesity.AmongpatientshospitalizedforCOVID-19,15.8%hadaviralcoinfection¶¶(66.4%ofwhomhadrespiratorysyncytialvirus[RSV]infection).Approximatelyonethird(33.9%)ofpatientsaged<5yearshospitalizedforCOVID-19hadaviralcoinfection.Among272vaccine-eligible(aged12–17years)patientshospitalizedforCOVID-19,one(0.4%)wasfullyvaccinated.***Approximatelyonehalf(54.0%)ofpatientshospitalizedforCOVID-19receivedoxygensupport,29.5%wereadmittedtotheintensivecareunit(ICU),and1.5%died;ofthoserequiringrespiratorysupport,14.5%requiredinvasivemechanicalventilation(IMV).AmongpediatricpatientswithCOVID-19–relatedhospitalizations,manyhadsevereillnessandviralcoinfections,andfewvaccine-eligiblepatientshospitalizedforCOVID-19werevaccinated,highlightingtheimportanceofvaccinationforthoseaged≥5yearsandotherpreventionstrategiestoprotectchildrenandadolescentsfromCOVID-19,particularlythosewithunderlyingmedicalconditions. DatawerecollectedfromsixU.S.children’shospitalslocatedinareaswithhighCOVID-19incidenceduringJuly–August2021(Arkansas,DistrictofColumbia,Florida,Illinois,Louisiana,andTexas).†††Datafromhospitalizedpatientsaged<18yearswithCOVID-19orSARS-CoV-2infection§§§wereabstractedfromelectronicmedicalrecordsusingREDCapsoftware(version11.1.8;VanderbiltUniversity).Patientswerecategorized¶¶¶byreasonforhospitalization:1)acuteCOVID-19,2)incidentalpositiveSARS-CoV-2testresult,or3)MIS-C.Patientdemographiccharacteristics,medicalhistory,coinfections,anddiseaseseverity,includingneedforanddurationofrespiratorysupport,ICUadmission,IMV,extracorporealmembraneoxygenation(ECMO),****anddeathswereabstractedfromthemedicalrecord.AmongpatientshospitalizedforCOVID-19,presenceofunderlyingmedicalconditions(includingobesity),††††viralcoinfection,andillnesscourseweredescribedbyagegroup.Pearson’schi-squareandKruskal-Wallistestswereusedtocomparecategoricalandcontinuousvariables,respectively;p–values<0.05wereconsideredstatisticallysignificant.AllanalyseswereconductedusingSAS(version9.4;SASInstitute)andR(Version4.0.3;RFoundationforStatisticalComputing).ThisactivitywasreviewedbyCDCandtheotherparticipatinginstitutionsandwasconductedconsistentwithapplicablefederallawandCDCpolicy.§§§§ Among915patientsaged<18years,713(77.9%)werehospitalizedforCOVID-19,177(19.3%)hadincidentalSARS-CoV-2infections,and25(2.7%)hadMIS-C(Table1).Amongall915patients,22.5%wereaged<1year,18.3%wereaged1–4years,21.5%wereaged5–11years,and37.7%wereaged12–17years.Amongthe713patientshospitalizedforCOVID-19,approximatelyonehalf(373;52.3%)weremale,210(29.5%)werenon-HispanicWhitepersons,202(28.3%)werenon-HispanicBlackpersonsorAfricanAmericanpersons(Black),and211(29.6%)wereHispanicpersons. Amongthe713patientshospitalizedforCOVID-19,32.5%,51.3%,and16.1%hadzero,oneortwo,andthreeormoreunderlyingmedicalconditions,respectively(Table2).Themostcommonconditionswereobesity(32.4%),asthmaorreactiveairwaydisease(16.0%),andfeedingtubedependence(8.3%).Amongpatientsaged12–17years,61.4%hadobesity(60.5%ofwhomhadsevereobesity).Amongpatientsaged5–11years,33.6%hadobesity(60.4%ofwhomhadsevereobesity).AmongpatientshospitalizedforCOVID-19,210(29.5%)hadICUadmissions,eight(1.1%)receivedECMO,and11(1.5%)died.Ofthe385(54.0%)patientshospitalizedforCOVID-19whoreceivedoxygensupport,high-flownasalcannulawasthemostcommonhighestlevelofsupport(142;36.9%);56(14.5%)patientsreceivedIMV.Acrossallagegroups,themedianhospitalstaywas3days,andthemedianIMVdurationwas7days.Patientsaged12–17yearshadthelongestmedianhospitalizations(4days)andIMVrequirement(9.5days).Viralcoinfectionwascommonamongpatientsaged<1year(32.4%)and1–4years(36.1%);overall,approximatelytwothirdsofviralcoinfectionswerewithRSV(Table2). Among272vaccine-eligiblepatientshospitalizedforCOVID-19,one(0.4%)wasfullyvaccinatedand12(4.4%)werepartiallyvaccinatedwithanmRNACOVID-19vaccineatthetimeofhospitalization(Table1). AhigherpercentageofpatientshospitalizedforCOVID-19withanyunderlyingconditionwereadmittedtotheICU(34.7%)comparedwiththosewithoutanunderlyingcondition(18.5%)(p<0.001)(Table3).Thedurationofhospitalizationwaslongerforpatientswithobesity(median=4days[IQR=2.0–7.5days])thanthatforthosewithoutobesity(median=2days[IQR=1.0–5.0days])(p<0.001).AhigherproportionofpatientswithobesitywereadmittedtotheICU(41.1%)thanwerethosewithoutobesity(23.9%)(p<0.001).Ahigherproportionofpatientswithviralcoinfectionrequiredoxygensupport(69.0%)comparedwiththosewithoutviralcoinfection(51.2%)(p<0.001). Top Discussion InthisstudyofsixU.S.hospitalsduringJuly–August,2021,approximatelythreequartersofpediatricpatientswithCOVID-19–relatedhospitalizationswerehospitalizedforCOVID-19.ThemajorityofthosehospitalizedforCOVID-19wereBlackorHispanicandwereaged<5or12–17years.Approximatelyonethirdofpatientsaged<1and1–4yearshadaviralcoinfection,approximatelyonethirdofpatientsaged5–11yearsandapproximatelytwothirdsofpatientsaged12–17yearshadobesity.Lessthan1%ofvaccine-eligiblepatientswerefullyvaccinatedagainstCOVID-19. FiveofthesixhospitalshadpoliciestotestallpediatricpatientsforSARS-CoV-2uponadmissionduringthestudyperiod,allowingfordetectionofincidentalpositiveSARS-CoV-2testresults.However,theproportionofsuchpatientswassmallerinthisstudycomparedwiththatinapreviousreport(1).Patientsaged0–4and12–17yearsaccountedfor79%ofCOVID-19–relatedhospitalizationsinthisstudy,whichisconsistentwithdatafromotherhospitalsandcommunities(2).Amonghospitalizedchildrenaged<5years,mostwereaged<1year,whichmightreflectclinicalpracticedifferences,becauseinfantsmightbemorelikelytobehospitalizedwithmilderdiseasethanolderchildren(3).MostpatientswereBlackorHispanicinthisstudy;anearlierstudydemonstratedhigherhospitalizationratesamongBlackorHispanicchildrencomparedwithWhitechildren(1). ApproximatelytwothirdsofpatientshospitalizedforCOVID-19,including83%and88%ofpatientsaged5–11and12–17years,respectively,hadoneormoreunderlyingmedicalconditions.ApproximatelytwothirdsofpatientshospitalizedforCOVID-19aged12–17yearshadobesity.Comparedwithpatientswithoutobesity,thosewithobesityrequiredhigherlevelsandlongerdurationofcare.Thesefindingsareconsistentwithpreviousreports(4)andhighlighttheimportanceofobesityandothermedicalconditionsasriskfactorsforsevereCOVID-19inchildrenandadolescents. TheproportionsofpatientsadmittedtoICUandwhorequiredIMVaresimilartothoseinpriorreports,whichpredominantlyincludedhospitalizedpediatricCOVID-19patientsbeforeDeltavariantpredominance(2,5).AdolescentsweremorelikelytorequireICUadmissionandoxygensupportcomparedwithotheragegroupsandrequiredthelongestmediandurationofIMV.ThemediandurationofIMVoverall(7days)isconsistentwithpreviousreports(6,7).Approximatelyonehalfofpatientsaged1–4yearsrequiredoxygensupport,whichmightberelatedtothehighproportionwithviralcoinfection.ThisstudyoccurredduringJuly–August2021,thefirstperiodduringtheCOVID-19pandemicwithhighcirculationofRSV¶¶¶¶andotherrespiratoryviruses.Comparedwithpriorstudies(2,5),thisstudyfoundahighproportionofpatientshadhigh-flownasalcannulaasthehighestlevelofrespiratorysupport(37%),whichmightreflectachangeinpracticetoavoidintubationorthehighproportionofviralcoinfections,includingRSV. OnNovember2,2021,CDCrecommendedCOVID-19vaccinationsforchildrenaged5–11years(8).AsofJuly31,2021,29%ofU.S.personsaged12–17yearswerefullyvaccinatedagainstCOVID-19.*****Inthisstudy,only0.4%ofvaccine-eligibleadolescentshospitalizedforCOVID-19werefullyvaccinated.Hospitalizationrateshavebeenshowntobe10timeshigheramongunvaccinatedadolescentscomparedwithfullyvaccinatedadolescents(2).Similarly,thisstudydemonstratesthatunvaccinatedchildrenhospitalizedforCOVID-19couldexperienceseverediseaseandreinforcestheimportanceofvaccinationofalleligiblechildrentoprovideindividualprotectionandtoprotectthosewhoarenotyeteligibletobevaccinated. Thefindingsinthisreportaresubjecttoatleastfivelimitations.First,thedatacamefromonlysixhospitals,fiveofwhichareinthesouthernU.S.region.TheproportionofadolescentswithobesityinthesouthernUnitedStatesishigherthaninotherregions,†††††whichmightexplainthehighratesofobesitydescribedinthisreport.Therefore,findingsmightnotbegeneralizabletootherareas.Second,findingsmightreflectdifferencesinpracticesbyhospitalsorchangesinpracticeovertimeandmightnotreflectdifferencesinseverityofCOVID-19relatedtotheDeltavariant.Third,incompleteormissingdatainmedicalrecordsmightleadtounderreportingandunderestimationofdetailssuchasCOVID-19vaccinationfrequencies.Fourth,atthetimeofhospitalization,personsaged12–15yearshadonlybeenvaccine-eligiblefor2–3months(9),possiblycontributingtothelowvaccinationratesobserved.Finally,hospitalsidentifiedpatientsforreviewbasedonpositivepolymerasechainreactionandantigenSARS-CoV-2testresultsandhospitalizationduringthestudyperiod.Therefore,proportionsofpatientswithMIS-Carelikelyunderestimated. AmongpediatricpatientswithCOVID-19–relatedhospitalizations,manyhadsevereillnessandviralcoinfections,andfewvaccine-eligiblepatientshospitalizedforCOVID-19werevaccinated.ThesedatahighlighttheimportanceofCOVID-19vaccinationforthoseaged≥5yearsandotherpreventionstrategiestoprotectchildrenandadolescentsfromCOVID-19,particularlythosewithobesityandotherunderlyinghealthconditions.FurtherresearchandsurveillanceforviralcoinfectionswithSARS-CoV-2inpediatricpatientscaninformpublichealthandcapacityplanning(10). TopAcknowledgments AnthonyBastiand,TroyBienemy,JerryBridgham,JoyceDalton,LauraFisher,BarretFlagg,JenniferGiovanni,KaraHollis,AshokKurian,BrendanJackson,AmyKnight,VeenaNagarajan,AimeeOssman,EmilyPaganelli,GeorginaPeacock,NicolePereira-Abara,TrescenaPreacher,AndreaRomaniuk,LeilaSahni,SusanStark,SherrySweek,DaniellaVanDerMerwe,JamesVersalovic. TopCorrespondingauthor:ValentineWanga,[email protected]. Top1CDCCOVID-19ResponseTeam;2EpidemicIntelligenceService,CDC;3ArkansasChildren’s,LittleRock,Arkansas;4Ann&RobertH.LurieChildren’sHospitalofChicago,Chicago,Illinois;5Children’sNationalHospital,Washington,DC;6Children’sHospitalNewOrleans,NewOrleans,Louisiana;7TulaneUniversitySchoolofMedicineandLSUHealth,NewOrleans,Louisiana;8DepartmentofPediatrics,BaylorCollegeofMedicine,Houston,Texas;9DepartmentofPathologyandImmunology,BaylorCollegeofMedicine,Houston,Texas;10Children’sHospitalAssociation,Washington,DC. Top AllauthorshavecompletedandsubmittedtheInternationalCommitteeofMedicalJournalEditorsformfordisclosureofpotentialconflictsofinterest.IlaR.SinghreportsfundingfromtheNationalInstitutesofHealth(NIH)asacoinvestigatorforgrantno.R61HD105593tocharacterizepediatricCOVID-19.RobertaL.DeBiasireportsgrantsupportandcontractsforCOVID-19andMIS-C,unrelatedtothecurrentwork;consultingfeesfromI-ACTforChildren;honorariafromtheInfectiousDiseasesinChildrenConference(NYC)andChildren’sHospitalColoradoInfectiousDiseasesConference(Denver);andunpaidmembershipontheboardofthePediatricInfectiousDiseasesSociety.LarryK.KociolekreportsagrantfromtheWalderFoundationChicagoCoronavirusAssessmentNetworkInitiative,institutionalsupportfromMerckandNIH/NIAID;andhonorariaforeducationaleventsatNorthwestCommunityHospitalandNemours/duPontChildren’sHospital.JessicaSnowdenreportsinstitutionalsupportfromNIHOfficeoftheDirector–ECHOprogramandNIH/NHLBI–RECOVERprogram,unrelatedtothecurrentwork.FrederickE.Barrreportsapplicationofpatent17364280withAsklepionPharmaceuticalsforL-citrullinetopreventortreatendothelialdysfunction.SapnaBamrahMorrisandSophiaK.ChiureportmembershiponadatasafetymonitoringboardinastudyofivermectinfortreatmentofsevereCOVID-19inGhana.SophiaHsureportsownershipof5sharesofModernastockand7sharesofNovavaxstock,andownershipwithinthepast36months(butnocurrentownership)ofstockinBioNTech,GileadSciences,andPfizer.TheresaM.Dulskireportsthatherhusbandreceivesrestrictedstockunitsaspartofhiscompensationfromhisemployer,acancerdiagnosticscompanythatalsoperformsCOVID-19testing.Nootherpotentialconflictsofinterestweredisclosed. Top *Theseauthorscontributedequallytothisreport. †https://www.cdc.gov/coronavirus/2019-ncov/variants/delta-variant.html;https://covid.cdc.gov/covid-data-tracker/#variant-proportions(AccessedSeptember15,2021). §https://covid.cdc.gov/covid-data-tracker/#new-hospital-admissions ¶https://www.cdc.gov/mmwr/volumes/70/wr/mm7020e1.htm?s_cid=mm7020e1_w **https://www.cdc.gov/mmwr/volumes/70/wr/mm7045e1.htm?s_cid=mm7045e1_w ††COVID-19wasconfirmedwithlaboratorydetectionofSARS-CoV-2byreversetranscription–polymerasechainreactionorantigentest. §§PatientswithMIS-CasthereasonforhospitalizationincludedpatientswhomettheclinicalcasedefinitionforMIS-C(clinicallysevereillnessrequiringhospitalizationinapersonaged<21yearswithfever,laboratoryevidenceofinflammation,multisystem[≥2]organinvolvementandnoalternativeplausiblediagnosis,andevidenceofcurrentorrecentSARS-CoV-2infectionbyreversetranscriptionpolymerasechainreaction,serologyorantigentest,orCOVID-19exposurewithinthe4weeksprecedingsymptomonset[https://emergency.cdc.gov/han/2020/han00432.asp])andwerehospitalizedfordiagnosisandmanagementofMIS-C,basedonchartreview. ¶¶Patientswereconsideredtohaveaviralcoinfectioniftheyhad≥1ofthefollowinginfections:typeAinfluenza,typeBinfluenza,unspecifiedinfluenza,coronavirus229e,coronavirushku1,coronavirusnl63,coronavirus0c43,respiratorysyncytialvirus,adenovirus,parainfluenzatype1,parainfluenzatype2,parainfluenzatype3,parainfluenzatype4,humanmetapneumovirus,rhinovirus,enterovirus,orotherviralcoinfection. ***Fullyvaccinatedwasdefinedashavingreceived2dosesofanmRNA-basedCOVID-19vaccine≥14daysbeforehospitaladmissiondate.Partiallyvaccinatedwasdefinedashavingreceivedonly1doseofanmRNA-basedCOVID-19vaccine≥14daysbeforehospitalization.AllvaccinatedpatientsinthisstudyreceivedthePfizer-BioNTech(BNT162b2)vaccine. †††AconveniencesampleofsixhospitalswasselectedamongmembersoftheChildren’sHospitalAssociation.AllhospitalswereinjurisdictionswithahighlevelofCOVID-19communitytransmissionduringJuly–August2021;thesejurisdictionswerenotrepresentedbytheCOVID-NETsurveillancesystem.https://www.cdc.gov/coronavirus/2019-ncov/covid-data/covid-net/purpose-methods.html §§§COVID-19diagnosisindicatedinmedicalrecordorbasedonpositiveSARS-CoV-2testresult(antigenorpolymerasechainreaction/nucleicacidamplificationtest,orantibodytestamongpatientswithadiagnosisofMIS-C). ¶¶¶Abstractorsselectedthecategorythatbestfittheoverallreasonforhospitalization,withadjudicationbyprojectleaders,andthroughauditsof5%ofallcharts. ****ECMOisaformofadvancedlifesupportusedinpatientswithmedicallyrefractoryrespiratoryorcardiacfailure. ††††Forchildrenaged≥2years,heightandweightwereusedtocalculatebodymassindex(BMI)(kg/m2).BMIpercentileswerecalculatedusingBMI,age,andsex.ChildrenwithBMIpercentiles≥95%wereconsideredtohaveobesity(https://www.cdc.gov/obesity/childhood/defining.html)andthosewithBMI≥120%ofthe95thpercentilewereconsideredtohavesevereobesity.BMIdataextractedfromchartswasusedifheightorweightwasmissing.IfBMIwasmissingorunabletobecalculated,adiagnosisofobesityrecordedinchartswasusedandseverityofobesitywasunabletobeassessed.Obesitywasnotassessedforchildrenaged<2years. §§§§45C.F.R.part46,21C.F.R.part56;42U.S.C.Sect.241(d);5U.S.C.Sect.552a;44U.S.C.Sect.3501etseq. ¶¶¶¶https://emergency.cdc.gov/han/2021/han00443.asp;https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html *****https://covid.cdc.gov/covid-data-tracker/#vaccination-demographics-trends †††††https://nccd.cdc.gov/dnpao_dtm/rdPage.aspx?rdReport=DNPAO_DTM.ExploreByTopic&islClass=OWS&islTopic=&go=GO TopReferences WoodruffRC,CampbellAP,TaylorCA,etal.;COVID-NETsurveillanceteam.RiskfactorsforsevereCOVID-19inchildren.Pediatrics2021;e2021053418.https://doi.org/10.1542/peds.2021-053418externaliconPMID:34686570externalicon DelahoyMJ,UjamaaD,WhitakerM,etal.;COVID-NETSurveillanceTeam.HospitalizationsassociatedwithCOVID-19amongchildrenandadolescents—COVID-NET,14States,March1,2020–August14,2021.MMWRMorbMortalWklyRep2021;70:1255–60.https://doi.org/10.15585/mmwr.mm7036e2externaliconPMID:34499627externalicon AntoonJW,GrijalvaCG,ThurmC,etal.FactorsassociatedwithCOVID-19diseaseseverityinUSchildrenandadolescents.JHospMed2021;16:603–10.https://doi.org/10.12788/jhm.3689externaliconPMID:34613896externalicon KompaniyetsL,AgathisNT,NelsonJM,etal.UnderlyingmedicalconditionsassociatedwithsevereCOVID-19illnessamongchildren.JAMANetwOpen2021;4:e2111182.https://doi.org/10.1001/jamanetworkopen.2021.11182externaliconPMID:34097050externalicon FernandesDM,OliveiraCR,GuerguisS,etal.;Tri-StatePediatricCOVID-19ResearchConsortium.Severeacuterespiratorysyndromecoronavirus2clinicalsyndromesandpredictorsofdiseaseseverityinhospitalizedchildrenandyouth.JPediatr2021;230:23–31.e10.https://doi.org/10.1016/j.jpeds.2020.11.016externaliconPMID:33197493externalicon NewthCJ,VenkataramanS,WillsonDF,etal.;EuniceShriverKennedyNationalInstituteofChildHealthandHumanDevelopmentCollaborativePediatricCriticalCareResearchNetwork.Weaningandextubationreadinessinpediatricpatients.PediatrCritCareMed2009;10:1–11.https://doi.org/10.1097/PCC.0b013e318193724dexternaliconPMID:19057432externalicon ChaoJY,DerespinaKR,HeroldBC,etal.Clinicalcharacteristicsandoutcomesofhospitalizedandcriticallyillchildrenandadolescentswithcoronavirusdisease2019atatertiarycaremedicalcenterinNewYorkCity.JPediatr2020;223:14–19.e2.https://doi.org/10.1016/j.jpeds.2020.05.006externaliconPMID:32407719externalicon WoodworthKR,MouliaD,CollinsJP,etal.TheAdvisoryCommitteeonImmunizationPractices’interimrecommendationforuseofPfizer-BioNTechCOVID-19vaccineinchildrenaged5–11years—UnitedStates,November2021.MMWRMorbMortalWklyRep2021;70:1579–83.https://doi.org/10.15585/mmwr.mm7045e1externaliconPMID:34758012externalicon FoodandDrugAdministration.Pfizer-BioNTechCOVID-19vaccineEUAamendmentreviewmemorandum.SilverSpring,MD:USDepartmentofHealthandHumanServices,FoodandDrugAdministration;2021.https://www.fda.gov/media/148542/downloadexternalicon MalekifarP,PakzadR,ShahbahramiR,etal.ViralcoinfectionamongCOVID-19patientgroups:anupdatesystematicreviewandmeta-analysis.BioMedResInt2021;2021:5313832.https://doi.org/10.1155/2021/5313832externaliconPMID:34485513externalicon Top TABLE1.DemographiccharacteristicsandCOVID-19vaccinationstatusofhospitalizedpatientsaged<18yearswithapositiveSARS-CoV-2testresultordiagnosisofCOVID-19,byreasonforhospitalization—sixhospitals,*UnitedStates,July–August2021 Characteristic Reasonforhospitalization,no.(%) Overall COVID-19† IncidentalpositiveSARS-CoV-2testresult MIS-C§ N=915(100) n=713(77.9) n=177(19.3) n=25(2.7) Age,yrs,median(IQR) 8.0(1.3-14.0) 8.0(1.0-14.0) 9.0(2.0-14.0) 8.0(4.0-13.0) Agegroup,yrs <1 206(22.5) 176(24.7) 29(16.4) 1(4.0) 1–4 167(18.3) 122(17.1) 36(20.3) 9(36.0) 5–11 197(21.5) 143(20.1) 47(26.6) 7(28.0) 12–17 345(37.7) 272(38.1) 65(36.7) 8(32.0) Sex Female 437(47.8) 340(47.7) 87(49.2) 10(40.0) Male 478(52.2) 373(52.3) 90(50.8) 15(60.0) Race/Ethnicity White,non-Hispanic 277(30.3) 210(29.5) 59(33.3) 8(32.0) BlackorAfricanAmerican,non-Hispanic 260(28.4) 202(28.3) 48(27.1) 10(40.0) Hispanic 267(29.2) 211(29.6) 52(29.4) 4(16.0) Other,Non-Hispanic¶ 42(4.6) 35(4.9) 6(3.4) 1(4.0) Unknown 69(7.5) 55(7.7) 12(6.8) 2(8.0) COVID-19vaccinationstatus Eligibleforvaccination(aged12–17yrs)** 345(37.7) 272(38.1) 65(36.7) 8(32.0) Fullyvaccinated 3(0.9) 1(0.4) 2(3.1) 0(—) Partiallyvaccinated 18(5.2) 12(4.4) 4(6.2) 2(25.0) Notvaccinated 224(64.9) 196(72.1) 22(33.8) 6(75.0) Unknownvaccinationstatus 100(29.0) 63(23.2) 37(56.9) 0(—) Ineligibleforvaccination(aged<12yrs) 570(62.3) 441(61.9) 112(63.3) 17(68.0) Abbreviation:MIS-C=multisysteminflammatorysyndromeinchildren. *Thesixchildren’shospitalswereinArkansas,DistrictofColumbia,Florida,Illinois,Louisiana,andTexas. †PatientshospitalizedforCOVID-19includedpatientswithacuteCOVID-19astheprimaryreasonforhospitalizationorwithacuteCOVID-19asasecondaryorcontributingreasonforhospitalization,basedonchartreview. §PatientswithMIS-CasthereasonforhospitalizationincludedpatientswhomettheclinicalcasedefinitionforMIS-C(clinicallysevereillnessrequiringhospitalizationinapersonaged<21yearswithfever,laboratoryevidenceofinflammation,multisystem[≥2]organinvolvementandnoalternativeplausiblediagnosis,andevidenceofcurrentorrecentSARS-CoV-2infectionbyreversetranscriptionpolymerasechainreaction,serologyorantigentest,orCOVID-19exposurewithinthe4weeksprecedingsymptomonset[https://emergency.cdc.gov/han/2020/han00432.asp])andwerehospitalizedfordiagnosisandmanagementofMIS-C,basedonchartreview. ¶Otherrace/ethnicityincludesAsian,NativeHawaiianorOtherPacificIslander,AmericanIndianorAlaskaNative,andOther(notspecified). **Fullyvaccinatedwasdefinedashavingreceived2dosesofanmRNA-basedCOVID-19vaccine≥14daysbeforethehospitaladmissiondate.Partiallyvaccinatedwasdefinedashavingreceivedonly1doseofanmRNA-basedCOVID-19vaccine≥14daysbeforehospitalization.AllvaccinatedpatientsinthisstudyreceivedthePfizer-BioNTech(BNT162b2)vaccine. Top TABLE2.Hospitalizationandillnesscourseamongchildrenandadolescentsaged<18yearshospitalizedforCOVID-19,*byagegroup—sixhospitals,†UnitedStates,July–August2021 Characteristic Agegroup,yrs,no.(%) Overall <1 1–4 5–11 12–17 p-value§ (N=713) (n=176) (n=122) (n=143) (n=272) No.ofunderlyingmedicalconditions None 232(32.5) 124(70.5) 51(41.8) 25(17.5) 32(11.8) <0.001 1–2 366(51.3) 47(26.7) 46(37.7) 89(62.2) 184(67.6) ≥3 115(16.1) 5(2.8) 25(20.5) 29(20.3) 56(20.6) Fivemostprevalentconditionsbysystem Metabolicorendocrine¶ 258(36.2) 2(1.1) 17(13.9) 59(41.3) 180(66.2) <0.001 Obesity** 231(32.4) — 16(13.1) 48(33.6) 167(61.4) Obesity 90(39.0) — 14(87.5) 17(35.4) 59(35.3) <0.001 Severeobesity 131(56.7) — 1(6.3) 29(60.4) 101(60.5) Obesity,unknownseverity 10(4.3) — 1(6.3) 2(4.2) 7(4.2) Neurologicordevelopmental†† 144(20.2) 41(23.3) 33(27.0) 28(19.6) 42(15.4) 0.038 Seizuredisorder 57(8.0) 6(3.4) 15(12.3) 14(9.8) 22(8.1) 0.033 Respiratory§§ 142(19.9) 7(4.0) 18(14.8) 34(23.8) 83(30.5) <0.001 AsthmaorRAD 114(16.0) 2(1.1) 12(9.8) 26(18.2) 74(27.2) <0.001 Gastrointestinalorhepatic¶¶ 85(11.9) 12(6.8) 28(23.0) 16(11.2) 29(10.7) <0.001 Feedingtubedependent 59(8.3) 7(4.0) 23(18.9) 13(9.1) 16(5.9) <0.001 Psychiatric*** 58(8.1) 0(—) 0(—) 13(9.1) 45(16.5) <0.001 Depression 23(3.2) 0(—) 0(—) 1(0.7) 22(8.1) <0.001 Multipleadmissions Yes 28(3.9) 4(2.3) 5(4.1) 6(4.2) 13(4.8) 0.607 No 685(96.1) 172(97.7) 117(95.9) 137(95.8) 259(95.2) Unknown 14(2.4) 3(1.9) 2(2.0) 2(1.9) 6(2.7) Hospitallengthofstay,mediandays(IQR) 3.0(1.0–7.0) 3.0(1.0–6.8) 3.0(2.0–4.5) 3.0(1.0–7.0) 4.0(2.0–8.0) 0.187 AdmittedtoICU Yes 210(29.5) 34(19.3) 31(25.4) 37(25.9) 108(39.7) <0.001 No 503(70.5) 142(80.7) 91(74.6) 106(74.1) 164(60.3) TotallengthofstayinICU,mediandays(IQR) 3.0(1.0–7.0) 3.0(1.0–6.8) 3.0(2.0–4.5) 3.0(1.0–7.0) 4.0(2.0–8.0) 0.187 Highestlevelofrespiratorysupportrequired Nooxygensupport 328(46.0) 94(53.4) 57(46.7) 82(57.3) 95(34.9) <0.001 Oxygensupport 385(54.0) 82(46.6) 65(53.3) 61(42.7) 177(65.1) Nasalcannula 111(28.8) 22(26.8) 14(21.5) 24(39.3) 51(28.8) Mask 7(1.8) 0(—) 2(3.1) 1(1.6) 4(2.3) CPAPorBiPAP 69(17.9) 5(6.1) 10(15.4) 11(18.0) 43(24.3) High-flownasalcannula 142(36.9) 43(52.4) 32(49.2) 14(23.0) 53(29.9) IMV 56(14.5) 12(14.6) 7(10.8) 11(18.0) 26(14.7) DurationonIMV,mediandays(IQR) 7.0(4.0–14.0) 6.0(4.8–12.3) 6.0(2.0–11.5) 5.5(1.8–10.3) 9.5(5.0–21.3) 0.596 ECMOrequired Yes 8(1.1) 1(0.6) 1(0.8) 1(0.7) 5(1.8) 0.567 No 705(98.9) 175(99.4) 121(99.2) 142(99.3) 267(98.2) DurationonECMO,mediandays(IQR) 12.0(5.5–17.8) 1.0(1.0–1.0) 13.0(13.0–13.0) — 15.0(11.0–26.0) 0.247 Viralcoinfection††† 113(15.8) 57(32.4) 44(36.1) 6(4.2) 6(2.2) <0.001 RSV 75(66.4) 42(73.7) 26(59.1) 4(66.7) 3(50.0) <0.001 Dischargestatus Dischargedalive 702(98.5) 174(98.9) 122(100.0) 142(99.3) 264(97.1) 0.231 Deceased 11(1.5) 2(1.1) 0(—) 1(0.7) 8(2.9) Abbreviations:BiPAP=bilevelpositiveairwaypressure;BMI=bodymassindex;CPAP=continuouspositiveairwaypressure;ECMO=extracorporealmembraneoxygenation;ICU=intensivecareunit;IMV=invasivemechanicalventilation;RAD=reactiveairwaydisease;RSV=respiratorysyncytialvirus. *PatientshospitalizedforCOVID-19includedpatientswithacuteCOVID-19astheprimaryreasonforhospitalizationorwithacuteCOVID-19asasecondaryorcontributingreasonforhospitalization,basedonchartreview. †Thesixchildren’shospitalswereinArkansas,DistrictofColumbia,Florida,Illinois,Louisiana,andTexas. §ClinicalcharacteristicsandoutcomeswerecomparedamonggroupsusingPearson’schi-squaretestforcategoricalvariablesandaKruskal-Wallistestfornonnormallydistributedvariables. ¶Metabolicandendocrineconditionsincludeddyslipidemia,obesity,thyroiddisorder,type1diabetes,type2diabetes,andotherendocrinedisorders. **Forchildrenaged≥2years,heightandweightwereusedtocalculateBMI(kg/m2).BMIpercentileswerecalculatedusingBMI,age,andsex.ThosechildrenwithBMIpercentiles≥95thpercentilewereconsideredtohaveobesityandthosewithBMI≥120%ofthe95thpercentilewereconsideredtohavesevereobesity.BMIdataextractedfromchartswereusedifheightorweightwasmissing.IfBMIwasmissingorunabletobecalculated,adiagnosisofobesityrecordedinchartswasusedandseverityofobesitywasunabletobeassessed.Obesitywasnotassessedforchildrenaged<2years. ††Neurologicanddevelopmentalconditionsincludedattentiondeficithyperactivitydisorder,autismspectrumdisorder,cerebralpalsy,cognitivedisfunction,musculardystrophy,neuraltubedefectorspinabifida,neurologicorneurodevelopmentaldisorder,neuropathy,plegiasorparalysis,pretermbirth(forchildrenaged<2yearsonly),seizuredisorder,andwheelchair/walker-dependenceorbed-boundstatus. §§Respiratoryconditionsincludedactivetuberculosis,asthmaorreactiveairwaydisease,chronichypoxemicrespiratoryfailurewithoxygenorventilatordependence,cysticfibrosis,currentsmokingore-cigaretteuse,tracheostomydependence,andotherchroniclungdiseases. ¶¶GastrointestinalorhepaticconditionsincludedCrohn’sdisease,feedingtubedependence,liverdisease,malnutrition,ulcerativecolitis,andothergastrointestinaldisorders. ***Psychiatricconditionsincludedanxiety,borderlinepersonalitydisorder,depression,substanceusedisorder,andotherpsychiatricdiagnoses. †††Patientswereconsideredtohaveaviralcoinfectioniftheyhad≥1ofthefollowinginfections:typeAinfluenza,typeBinfluenza,unspecifiedinfluenza,coronavirus229e,coronavirushku1,coronavirusnl63,coronavirus0c43,respiratorysyncytialvirus,adenovirus,parainfluenzatype1,parainfluenzatype2,parainfluenzatype3,parainfluenzatype4,humanmetapneumovirus,rhinovirusenterovirus,orotherviralcoinfection. Top TABLE3.Hospitalizationandillnesscourseamongchildrenandadolescentsaged<18yearshospitalizedforCOVID-19*bypresenceofunderlyingmedicalconditions,obesity,andviralcoinfection—sixhospitals,†UnitedStates,July–August2021 Characteristic No.(%) Underlyingmedicalcondition Obesity§ Viralcoinfection Yes(n=481) No(n=232) p-value¶ Yes(n=231) No(n=482) p-value¶ Yes(n=113) No(n=600) p-value¶ Multipleadmissions Yes 23(4.8) 5(2.2) 0.137 12(5.2) 16(3.3) 0.317 3(2.7) 25(4.2) 0.621 No 458(95.2) 227(97.8) 219(94.8) 466(96.7) 110(97.3) 575(95.8) Hospitallengthofstay,mediandays(IQR) 3.0(2.0–7.0) 2.0(1.0–4.0) <0.001 4.0(2.0–7.5) 2.0(1.0–5.0) <0.001 3.0(2.0–6.0) 3.0(1.0–6.0) 0.085 AdmittedtoICU Yes 167(34.7) 43(18.5) <0.001 95(41.1) 115(23.9) <0.001 36(31.9) 174(29.0) 0.618 No 314(65.3) 189(81.5) 136(58.9) 367(76.1) 77(68.1) 426(71.0) ICUlengthofstay,mediandays(IQR) 4.0(1.0–8.0) 2.0(1.0–4.0) 0.023 4.0(2.0–8.0) 3.0(1.0–6.5) 0.014 4.0(1.8–10.3) 3.0(1.0–7.0) 0.37 Highestlevelofrespiratorysupportrequired None 199(41.4) 129(55.6) <0.001 61(26.4) 267(55.4) <0.001 35(31.0) 293(48.8) <0.001 Oxygensupport 282(58.6) 103(44.4) 170(73.6) 215(44.6) 78(69.0) 307(51.2) Nasalcannula 77(27.3) 34(33.0) 47(27.6) 64(29.8) 10(12.8) 101(32.9) Mask 6(2.1) 1(1.0) 2(1.2) 5(2.3) 1(1.3) 6(2.0) CPAPorBIPAP 62(22.0) 7(6.8) 43(25.3) 26(12.1) 8(10.3) 61(20.0) High-flownasalcannula 91(32.3) 51(49.5) 55(32.4) 87(40.5) 46(59.0) 96(31.3) IMV 46(16.3) 10(9.7) 23(13.5) 33(15.3) 13(16.7) 43(14.0) IMVduration,mediandays(IQR) 8.0(4.0–15.0) 5.5(1.0–6.8) 0.161 8.0(5.0–14.5) 6.0(3.8–13.5) 0.472 6.0(5.0–13.0) 7.0(3.0–14.5) 0.804 ECMOrequired Yes 5(1.0) 3(1.3) 1.000 5(2.2) 3(0.6) 0.147 2(1.8) 6(1.0) 0.821 No 476(99.0) 229(98.7) 226(97.8) 479(99.4) 111(98.2) 594(99.0) ECMOduration,mediandays(IQR) 15.0(11.0–26.0) 1.0(0.5–7.0) 0.101 15.0(11.0–26.0) 1.0(0.5–7.0) 0.101 7.0(4.0–10.0) 13.0(8.0–23.3) 0.505 Viralcoinfection** 49(10.2) 64(27.6) <0.001 7(3.0) 106(22.0) <0.001 113(100.0) 0(—) <0.001 RSV 31(63.3) 44(68.8) <0.001 2(28.6) 73(68.9) <0.001 75(66.4) 0(—) <0.001 Dischargestatus Dischargedalive 472(98.1) 230(99.1) 0.517 227(98.3) 475(98.5) 0.595 111(98.2) 591(98.5) 0.81 Deceased 9(1.9) 2(0.9) 4(1.7) 7(1.5) 2(1.8) 9(1.5) Abbreviations:BIPAP=bilevelpositiveairwaypressure;BMI=bodymassindex;CPAP=continuouspositiveairwaypressure;ECMO=extracorporealmembraneoxygenation;ICU=intensivecareunit;IMV=invasivemechanicalventilation;RSV=respiratorysyncytialvirus. *PatientshospitalizedforCOVID-19includedpatientswithacuteCOVID-19astheprimaryreasonforhospitalizationorwithacuteCOVID-19asasecondaryorcontributingreasonforhospitalization,basedonchartreview. †Thesixchildren’shospitalswereinArkansas,DistrictofColumbia,Florida,Illinois,Louisiana,andTexas. §Forchildrenaged≥2years,heightandweightwereusedtocalculateBMI(kg/m2).BMIpercentileswerecalculatedusingBMI,age,andsex.ThosechildrenwithBMIpercentiles≥95thpercentilewereconsideredtohaveobesity,andthosewithBMI≥120%ofthe95thpercentilewereconsideredtohavesevereobesity.BMIdataextractedfromchartswereusedifheightorweightwasmissing.IfBMIwasmissingorunabletobecalculated,adiagnosisofobesityrecordedinchartswasusedandseverityofobesitywasunabletobeassessed.Obesitywasnotassessedforchildrenaged<2years. ¶ClinicalcharacteristicsandoutcomeswerecomparedamonggroupsusingPearson’schi-squaretestforcategoricalvariablesandaKruskal-Wallistestfornonnormallydistributedvariables. **Patientswereconsideredtohaveaviralcoinfectioniftheyhad≥1ofthefollowinginfections:typeAinfluenza,typeBinfluenza,unspecifiedinfluenza,coronavirus229e,coronavirushku1,coronavirusnl63,coronavirus0c43,respiratorysyncytialvirus,adenovirus,parainfluenzatype1,parainfluenzatype2,parainfluenzatype3,parainfluenzatype4,humanmetapneumovirus,rhinovirus,enterovirus,orotherviralcoinfection. TopSuggestedcitationforthisarticle:WangaV,GerdesME,ShiDS,etal.CharacteristicsandClinicalOutcomesofChildrenandAdolescentsAged<18YearsHospitalizedwithCOVID-19—SixHospitals,UnitedStates,July–August2021.MMWRMorbMortalWklyRep2021;70:1766–1772.DOI:http://dx.doi.org/10.15585/mmwr.mm705152a3externalicon. MMWRandMorbidityandMortalityWeeklyReportareservicemarksoftheU.S.DepartmentofHealthandHumanServices. UseoftradenamesandcommercialsourcesisforidentificationonlyanddoesnotimplyendorsementbytheU.S.Departmentof HealthandHumanServices.Referencestonon-CDCsitesontheInternetare providedasaservicetoMMWRreadersanddonotconstituteorimply endorsementoftheseorganizationsortheirprogramsbyCDCortheU.S. DepartmentofHealthandHumanServices.CDCisnotresponsibleforthecontent ofpagesfoundatthesesites.URLaddresseslistedinMMWRwerecurrentasof thedateofpublication. AllHTMLversionsofMMWRarticlesaregeneratedfromfinalproofsthroughanautomatedprocess. 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