Children Hospitalized With COVID-19 in 2020: One in Three Needed Intensive Care

Most reported coronavirus infections in children under 18 seemed to cause mild or no symptoms, but less was known about severe illness in children. CDC's COVID-NET — population-based surveillance of lab-confirmed COVID-19 hospitalizations in 99 counties in 14 states, covering all 10 HHS regions — looked at children hospitalized from March 1 to July 25, 2020.

Key findings

• 576 children were hospitalized with COVID-19.
• The cumulative hospitalization rate among children was 8.0 per 100,000 — low compared with 164.5 among adults.
• Weekly rates rose steadily over the period, from 0.1 to 0.4 per 100,000, peaking at 0.7.
• Among children whose medical charts were fully reviewed, one in three (33.2%) was admitted to an intensive care unit — about the same share as adults (32.0%).
• Rates were far higher among Hispanic and Black children than white children.

The 14 states were California, Colorado, Connecticut, Georgia, Iowa, Maryland, Michigan, Minnesota, New Mexico, New York, Ohio, Oregon, Tennessee and Utah. Cases counted if the child had a positive SARS-CoV-2 molecular test during the hospital stay or within 14 days before admission; tests were ordered at clinicians' discretion.

Who was hospitalized

Cumulative (A) and weekly (B, 3-week moving average) COVID-19 hospitalization rates per 100,000 children, by age group, COVID-NET, 14 states, March–July 2020. CDC.

• Infants under 3 months made up 18.8% of hospitalized children; teenagers aged 12–17, 41.8%.
• The median age was 8 years; 50.7% were boys.

The rates among Hispanic and Black children were nearly eight and five times the rate in white children. Of the 526 hospitalized children with race and ethnicity recorded, 45.8% were Hispanic, 29.7% Black, 14.1% white, 4.6% Asian or Pacific Islander and 0.8% American Indian or Alaska Native.

Cumulative COVID-19 hospitalization rates per 100,000 children by age group and race and ethnicity, COVID-NET, March–July 2020. CDC.

Underlying conditions and symptoms

Of 222 children with information on underlying conditions, 94 (42.3%) had at least one — 53.4% of those aged 5–17.

Of the 94 children with an underlying condition, 45.7% were Hispanic, 29.8% Black and 14.9% white.

On admission, fever or chills was the most common complaint (54% overall, 74.6% of children under 2). Gastrointestinal symptoms — nausea or vomiting, abdominal pain or diarrhea — were reported by 42%. Cough (29.5%) and shortness of breath (22.3%) were also common.

Hospital course (208 children with complete chart reviews)

• Median stay: 2.5 days.
• Chest X-rays: 44 of 67 showed an infiltrate or consolidation. On CT, 10 of 14 had ground-glass opacities.
• ICU: 69 (33.2%) admitted, for a median of 2 days.
• Mechanical ventilation: 12 of 207 (5.8%) — far less often than among adults (18.6%).
• Treatments: only 12 (5.8%), all aged 5–17, got investigational COVID-19 treatments, 9 of them remdesivir; 14 (6.7%) received intravenous immune globulin and 19 (9.1%) systemic steroids.
• MIS-C (multisystem inflammatory syndrome in children, tracked systematically from June 18): diagnosed in 9 of 83 (10.8%).
• Deaths: one child with multiple underlying conditions died.

What it means

• Children can become severely ill with COVID-19; one in three hospitalized children needed intensive care, yet deaths were rare — similar to other reports, even among children with severe complications like MIS-C. By comparison, among children hospitalized with seasonal flu, ICU admission estimates have ranged from 16% (without underlying conditions) to 25% (with them), with in-hospital deaths under 1%.
• The reasons for racial and ethnic disparities aren't fully understood. One hypothesis is that Hispanic adults are overrepresented in frontline jobs with little chance to distance, which could affect the children in their households.
• Obesity was the most common underlying condition, as in other studies. It affects almost one in five U.S. children and is more common among Black and Hispanic children, so understanding its link to severe COVID-19 matters for prevention.
• Prevention efforts should be reinforced where children gather, including child care centers and schools. Children should wash their hands often and keep social distance, and those 2 and older should wear a mask around people outside their family.

Limitations

1. Cases depended on clinician-ordered tests, so rates are likely underestimates.
2. Rates are preliminary and may change.
3. Treatment and outcome data came from a convenience sample of children with complete chart reviews — about 60% of pediatric cases hadn't been reviewed — which skewed toward infants under 6 months, with two sites contributing more than half.
4. MIS-C wasn't tracked systematically until June 18, and molecular tests can miss about half of MIS-C patients, so its share is likely underestimated.

Sources

Based on Kim L, Whitaker M, O'Halloran A, et al., "Hospitalization Rates and Characteristics of Children Aged <18 Years Hospitalized with Laboratory-Confirmed COVID-19 — COVID-NET, 14 States, March 1–July 25, 2020," Morbidity and Mortality Weekly Report, Centers for Disease Control and Prevention; a work of the United States government in the public domain. The imported copy was cut off in two places; the missing text and the report's table were taken from the same report's full text in PubMed Central (PMC7440125).