Children admitted to pediatric intensive care units with COVID-19 who were underweight were at higher risk of acute respiratory distress syndrome, invasive mechanical ventilation, prolonged hospitalization, and mortality compared with patients with normal weight, according to findings from an observational, multicenter Brazilian study.
Researchers analyzed 432 patients aged 1 month to 18 years who were admitted to 36 pediatric intensive care units (PICUs) in Brazil between March 2020 and December 2021. COVID-19 diagnosis was confirmed by RT-PCR from respiratory samples or by blood serology for IgA, IgM, or IgG antibodies.
The study was a secondary analysis of a larger cohort. Nutritional status was assessed using World Health Organization growth criteria based on body mass index-for-age, weight-for-age, and stature-for-age z scores. Patients classified as thin, severely thin, or low weight-for-age were grouped as underweight. Patients were otherwise categorized as having normal weight or overweight. Prolonged length of stay was defined as hospitalization longer than the 75th percentile of the study sample.
Among the cohort, 54 patients, or 13%, were underweight; 302, or 70%, had normal weight; and 76, or 18%, had overweight. Overall, 200 patients, or 46%, were aged 24 months or younger, and 10 patients, or 2%, died.
In unadjusted analyses, underweight patients were more likely to be aged 24 months or younger, to have 2 or more comorbidities, and to have influenza B or H1N1 co-detection. They also had higher rates of invasive mechanical ventilation (IMV), acute respiratory distress syndrome (ARDS), and mortality compared with patients in the other weight categories.
After adjustment for age group, comorbidities, and viral coinfection using Poisson regression, underweight status remained associated with respiratory and hospitalization outcomes. Compared with patients with normal weight, underweight patients had an 83% higher risk of IMV, a 47% higher risk of prolonged hospitalization, and more than twice the risk of ARDS.
Mortality findings suggested an association but were imprecise. Six deaths occurred among 54 underweight patients compared with 4 deaths among 302 patients with normal weight and none among 76 patients with overweight. In adjusted analysis, underweight status was associated with higher mortality risk, with a relative risk of 8.20 and a 95% CI of 1.86 to 36.02. The researchers cautioned that the low number of deaths and wide confidence interval limited the precision of the estimate.
The study did not identify an independent association between overweight status and adverse outcomes. Mortality could not be estimated in the overweight group because no deaths occurred in that category. Short stature also was not independently associated with clinical outcomes after adjustment.
The researchers identified several limitations: measurement bias due to inconsistent recording across hospitals, retrospective collection of anthropometric data from medical records, reliance on BMI-for-age and weight-for-age rather than direct body composition measures, and wide confidence intervals around the mortality estimate given the low number of deaths. They also noted that regional socioeconomic disparities in Brazil could limit generalizability of the nutritional status distribution to other settings.
“In conclusion, nutritional status was a significant predictor of clinical severity in critically ill pediatric patients with COVID-19,” wrote lead study author Gabriela Rupp Hanzen Andrades, of the Pontifical Catholic University of Rio Grande do Sul in Porto Alegre, Brazil, and colleagues. The researchers added that the findings “highlight the importance of incorporating nutritional assessment, prevention, and management as part of standard care for pediatric patients with COVID-19.”
Disclosures: The researchers declared no conflicts of interest. The study was supported by the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior–Brasil and Brazilian COVID-19 research funding programs.
Source: Pediatric Pulmonology
