Pediatric Covid-19 hospitalizations just soared past January highs.
Why flattening the pediatric curve matters even more than for adults.
Pediatric hospitalizations for Covid-19 have rapidly increased over the last month in the United States, with the rate of daily new cases reaching an all-time high in the last few days. It's already far worse than the previous record peak in January. The data visualization below created for Inside Medicine makes it plain to see where we are and where we’ve been. Perhaps more alarming than the raw number of daily hospitalizations in children is the magnitude of the rise in recent weeks. Obviously we cannot predict whether this worrisome trend in pediatric hospitalizations will continue, level off, or drop. But we must not ignore it.
The regions having major pediatric outbreaks should serve as a warning to the rest of us. For example, in Georgia last week, around 7 out of every 100,000 children in the state—not per 100,000 pediatric coronavirus cases, but per living child—were hospitalized for Covid-19. That triples the pediatric hospitalization rate that was observed during the worst weeks of the most recent normal flu season (the winter of 2019-2020), and that’s likely a conservative estimate.†
If we dug into the reporting methodology (which I’ll do with you in the future), we would find that the rate of Covid-19 hospitalizations exceeds the usual rate of influenza hospitalizations by far more than that. Keep in mind that this unprecedented spike in pediatric Covid-19 hospitalizations is occurring in the month of August. Historically, August is the month with the fewest pediatric deaths for respiratory and infectious illnesses.
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The question on many people’s minds is whether this alarmingly rapid rise in pediatric hospitalizations reflects something about the Delta variant itself. That is distinctly possible but not yet known. It could be that Delta itself is not actually much worse for kids, but that hospitalizations have increased simply because this variant spreads faster and is just more contagious overall (that much appears certain). Therefore coronavirus is now infecting more children over a shorter period. In that way, Delta may be “raising” or “sharpening” the curve—or whatever the opposite of “flattening the curve” can be called. Given that pediatric intensive care units in some parts of the country are now completely full, taking measures to slow the virus down in these areas must be a top priority so that children do not die due to a lack of life-saving resources that are usually available in this country for any child in need. Covid-19 is rendering our assumptions about what comprises a safe systemic pediatric ICU capacity—that is, how many pediatric ICU doctors, nurses, beds, and ventilators we need in every community in order to offer everyone the care they need when they need it—woefully inadequate.
Flattening the curve matters far more for children than it ever did for adults. Why? Because study after study has shown that children requiring intensive care for Covid-19—especially intubation and mechanical ventilation—have fared far better than adults have. In fact, unlike in adults, a towering majority of children requiring mechanical ventilation for Covid-19 do manage to survive. Among adults requiring mechanical ventilation last year, around two-thirds survived, and one-third died, though various improvements in how we manage Covid-19 have probably lowered the fatality rate to under 30%. Meanwhile, one study in the CDC’s journal Morbidity and Mortality Weekly Report found that among the 5% of children hospitalized specifically for Covid-19 who also required mechanical ventilation, all of them (10 intubated children out of the 203 hospitalized covered in the study) survived. An earlier and much larger study found that 89% of children placed on mechanical ventilators survived (though the final number may have been a bit worse because there were still a few children on ventilators at the time that study was published, and those outcomes were not reported).
This means that flattening the pediatric curve to make sure that we have enough ventilators (and trained staff) could save the lives of a far higher percent of critically ill children than adults. This alone could amount to hundreds if not thousands of pediatric lives saved.
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Over the coming days and weeks, we will be watching pediatric ICU capacity all over the country closely. As schools open, things could worsen. While schools did not appear to be the largest driver of infection last year, most studies showed that schools contributed to spread in some degree. Nobody knows how Delta will change this, nor what will happen in areas where schools are no longer permitted to require masks.
I continue to believe that we can safely open many schools—those with the right combination of high vaccine rates among the eligible, frequent rapid testing, and the proper implementation of other important mitigation measures including adequate ventilation and masks. Pediatric Covid-19 remains highly unlikely to cause a severe or critical illness in any individual child. But at the population level, what is unfolding appears highly unusual, and worth taking steps to prevent, especially while we await data and authorization for vaccinations for children under 12 years old.
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Questions? Comments? Leave them below!
†Some may notice that other sections of the CDC’s influenza website estimate that far more children are hospitalized for influenza than the numbers used here. That’s because the CDC takes raw numbers of flu hospitalizations reported and then multiplies that by around 25 to get its final estimates. Around 45% of this multiplier accounts for the percent of hospitals the CDC's influenza network covers. The other 55% is meant to compensate for under-reporting and false negative tests. Such adjustments are not being made for Covid-19. Also, the Covid-19 data being reported by HHS that we used to make the visualization above covers most, but not all, US hospitals that accept pediatric patients. Therefore, the real number of pediatric Covid-19 hospitalizations is likely a bit higher than even these figures.
‡Special thanks to Dr. Kristen Panthagani for data visualization created for this Inside Medicine article and to Benjy Renton for data aggregation.
References and further reading:
An early study of pediatric Covid-19 hospitalization outcomes in the US: https://jamanetwork.com/journals/jamapediatrics/fullarticle/2766037
A more recent (though smaller) study of pediatric Covid-19 outcomes in the US: https://www.cdc.gov/mmwr/volumes/70/wr/mm7023e1.htm
An early study of adult Covid-19 outcomes among those with critical illness in the US:
https://journals.lww.com/ccmjournal/fulltext/2020/09000/icu_and_ventilator_mortality_among_critically_ill.35.aspx