SARS-CoV-2 infection in technology-dependent children: a multicenter case series.

PURPOSE: The objective of this study was to describe the clinical course and outcomes in children with technology dependence (TD) hospitalized with SARS-CoV-2 infection.
METHODS: Seventeen pediatric hospitals (15 Canadian and one each in Iran and Costa Rica) included children up to 17 years of age admitted February 1, 2020, through May 31, 2021, with detection of SARS-CoV-2. For those with TD, data were collected on demographics, clinical course and outcome.
RESULTS: Of 691 children entered in the database, 42 (6%) had TD of which 22 had feeding tube dependence only, 9 were on supplemental oxygen only, 3 had feeding tube dependence and were on supplemental oxygen, 2 had a tracheostomy but were not ventilated, 4 were on non-invasive ventilation, and 2 were on mechanical ventilation prior to admission. Three of 42 had incidental SARS-CoV-2 infection. Two with end-stage underlying conditions were transitioned to comfort care and died. Sixteen (43%) of the remaining 37 cases required increased respiratory support from baseline due to COVID-19 while 21 (57%) did not. All survivors were discharged home.
CONCLUSION: Children with TD appear to have an increased risk of COVID-19 hospitalization. However, in the absence of end-stage chronic conditions, all survived to discharge.

What is known?

Children with technology dependence have an increased risk of hospitalization with non-SARS-CoV-2 respiratory viral infections.

They appear to also be at increased risk of hospitalization and of severe disease when infected with SARS-CoV-2.

What is new?

Children with technology dependence accounted for 6% of COVID-19 admissions, verifying increased risk.

About half required increased respiratory support but the only deaths were in children with end-stage chronic conditions.

Introduction

The severity of SARS-CoV-2 infection is increased in children with comorbidities [1]. The range of severity with specific comorbidities is just starting to be described. We report outcomes in hospitalized technology-dependent children, originally defined as those “who require a medical device to compensate for the loss of a vital bodily function and substantial and ongoing nursing care to avert death or further disability” [2].

Methods

Seventeen pediatric hospitals (15 Canadian and one each in Iran and Costa Rica) included children up to 17 years of age admitted February 1, 2020, through May 31, 2021, with detection of SARS-CoV-2. Methods are fully described in our previous report [3]. Following ethics approval at all sites, data were extracted into REDCap (Research Electronic Data Capture) tools hosted at the University of Alberta [4] from medical records by physician investigators or research assistants supervised by investigators. Technology dependence (TD) was defined as baseline need for one or more of (a) tube feeds, (b) supplemental oxygen, (c) tracheostomy, (d) non-invasive ventilation (NIV) including continuous or bilevel positive airway pressure, (e) mechanical ventilation (MV), or (f) intravenous nutrition prior to admission. Data collected included demographics, reason for admission (admitted because they had COVID-19, admitted for another indication but COVID-19 acquired before or during the admission prolonged the admission, or “incidental” SARS-CoV-2 infection which did not precipitate or prolong the admission), comorbidities including type of TD, clinical course including interventions required for COVID-19, and outcome. The Strengthening the Reporting of Observational studies in Epidemiology (STROBE) guidelines were followed [5].

Data analysis was descriptive.

Results

There were 691 children entered in the database of which 334 were admitted because of COVID-19, 23 were admitted for another indication but COVID-19 prolonged the admission, and 334 had incidental SARS-CoV-2 infection.

Forty-two of the 691 children (6%) had TD (Table 1) of which 22 had feeding tube dependence only, 9 were on supplemental oxygen only, 3 had feeding tube dependence and were on supplemental oxygen, 2 had a tracheostomy but were not ventilated, 4 were on non-invasive ventilation, and 2 were on mechanical ventilation prior to admission. None required intravenous nutrition. Three of the 42 had incidental SARS-CoV-2 infection. None acquired SARS-CoV-2 infection during hospitalization. Two with end-stage underlying conditions died of respiratory failure on day 2 of admission after being transitioned to comfort care. For the remaining 37 cases, 16 (43%) required increased respiratory support from baseline due to COVID-19 while 21 (57%) did not. The increased support included supplemental oxygen only (N = 6; 16%), new NIV (N = 8; 22%) and new MV (N = 2; 5%). All survivors were eventually discharged home.

Table 1

Clinical course of admissions related to COVID-19 and admissions with incidental SARS-COV2 infection in 42 children dependent upon medical technology—the admission days refers to the entire hospitalization and not just the ICU stay

	Admitted because of COVID-19 (N = 33)	Admitted for another indication—SARS-CoV-2 prolonged admission (N = 6)	Admitted for another indication—SARS-CoV-2 infection did not prolong the admission (N = 3)a
Home feeding tube dependence (N = 22)	N = 16	N = 6	N = 0
	Ward: observation (N = 6, admitted for 1,2, 3, 4, 10 and 28 days)	Ward: (N = 5), of which 1 required supplemental oxygen
	Ward: supplemental oxygen (N = 4, admitted for 1, 2, 5 and 20 days)	ICU: NIV
	ICU: supplemental oxygen and vasopressors (admitted for 3 days)
	ICU: NIV (N = 3 admitted for 15, 15 and 16 days)
	ICU: MV (admitted for unknown duration)
	Ward: NIV but died 2 days (no MV, palliative)
Home supplemental oxygen (N = 9)	N = 7	N = 0	N = 2
	Ward: supplemental oxygen (N = 3 admitted for 3, 7 and 9 days) and in ICU (N = 1 – admitted for 5 days)
	ICU: HFNC (admitted for 47 days)
	ICU: NIV (N = 2 admitted for 9 and 18 days)
Home feeding tube dependence and supplemental oxygen (N = 3)	N = 2	N = 0	N = 1
	ICU: HFNC (admitted for 8 and 22 days)
Home tracheostomy ± supplemental oxygen ± feeding tube dependence (N = 2)	N = 2	N = 0	N = 0
	ICU: NIV (both admitted 16 days)
Home non-invasive ventilation ± supplemental oxygen ± feeding tube dependence (N = 4)	N = 4	N = 0	N = 0
	Ward: NIV (N = 1 admitted for 2 days) and in ICU (N = 1 admitted 1 day)
	Ward: NIV but died 2 days after admission (no MV, palliative)
	ICU: MV (admitted 12 days)
Home mechanical ventilation ± supplemental oxygen ± tube feeds (N = 2)	N = 2	N = 0	N = 0
	ICU: MV ICU (admitted for 7 days)
	Ward: MV (admitted for 15 days)

HFNC high-frequency nasal canula; ICU intensive care unit; MV mechanical ventilation; NIV non-invasive ventilation including continuous or bilevel positive airway pressure

aDetails of clinical course are not provided as SARS-CoV-2 did not precipitate or prolong the admission

Discussion

We describe 42 children with TD and SARS-CoV-2 infection admitted to 15 centers over 17 months of which 40 survived to discharge. About half required increased respiratory support from baseline.

Children with TD accounted for 33 of 334 children (10%) admitted because of COVID-19 during the study period. A study from Ontario reported that children with medical complexity (defined as “complex underlying chronic health conditions that are typically associated with significant functional status limitation”, encompassing TD and many other conditions) accounted for only 0.67% of the population [6]. This suggests that children with TD were at markedly increased risk of hospitalization with COVID-19 during our study period. It seems likely that some of the brief admissions early in the current study were due to uncertainty about the natural history of infection in children with TD. Now that we know that even children with significant comorbidities often have mild infection, hospitalization rates may be lower. It is unlikely that any of the children in our study were immunized as most were preschool aged and vaccines were just becoming available for 12-to-15-year-olds when the study ended. Hospitalization rates for children with TD may have decreased further with immunization given that most children with TD are immunocompetent so should have a normal response to vaccines. Length of stay was often prolonged (Table 1) but it is possible that admission duration will decrease over time as we learn how to optimize COVID-19 therapeutics.

It is not surprising that TD appears to be a risk factor for COVID-19 hospitalization. It is well known that children with TD stemming from disorders of the respiratory tract were at increased risk of severe disease when infected with respiratory viruses prior to the SARS-CoV-2 pandemic [7]. The contribution of type of virus, age, and nature and severity of comorbidities remains to be established. Two years into the pandemic, there are still minimal published data on the severity of COVID-19 in children with TD. One of the initial case series of 48 children admitted to intensive care units with COVID-19 reported that 19 (40%) had medical complexity (defined as “children who had a long-term dependence on technological support [including tracheostomy] associated with developmental delay and/or genetic anomalies”) [8]. In a study of 2293 children hospitalized because of COVID-19, the adjusted risk ratio of severe COVID-19 in children with feeding tube dependence was 2.0 (95% CI 1.5‒2.5; P < 0.0001) [9]; risk with other types of TD was not reported in this study. In a study of 43,465 children seen in an emergency department with a primary or secondary diagnosis of COVID-19, the adjusted risk ratio was 1.96 (95% CI 1.63–2.37) for hospitalization and 1.25 (95% CI 1.07–1.47) for severe COVID-19, using the TD definition that we used but also including children awaiting organ transplant) [10].

One limitation of our study and of the previous studies of children with TD is that they are not population based. We do not know how many children with TD were infected with SARS-CoV-2 and not diagnosed or not hospitalized. Eventually, review of large administrative databases may allow quantification of the risk of hospitalization and of severe COVID-19 in children with TD. Our cohort was collected before the Delta and then Omicron variants predominated and before vaccines were offered to younger children. One site did not include all cases as the physician entering cases relocated.

In conclusion, the novel finding from the current study is that even in the era prior to the availability of COVID-19 vaccines for children, those with TD hospitalized with COVID-19 all survived to discharge unless they had end-stage chronic conditions. Caregivers and healthcare professionals should continue to recognize the increased vulnerability of the TD population and that all should receive COVID-19 vaccines. They should be reassured that most children with TD have a relatively uneventful course even if hospitalized with COVID-19.