Pediatric inflammatory bowel disease (IBD) patients have a relatively low risk of severe COVID-19, even when receiving biologic and other immune-suppressive therapies, according to an analysis of two international databases.
“This finding may reassure parents of children with IBD who are debating the safety of sending their children back to school in the fall,” wrote Erica J. Brenner, MD, of the University of North Carolina in Chapel Hill, and colleagues.
The study, published online in Clinical Gastroenterology and Hepatology, found that of 209 IBD patients age 18 and younger from 23 countries, the hospitalization rate was just 7% compared with the 33%-66% rates that have been reported by the same group, as well as others, for adult IBD patients with COVID-19.
The pediatric data support findings from a Chinese series that children are at lower risk for complicated COVID-19, as well as the recent recommendation of Europe’s Paediatric IBD Porto group to continue maintenance treatment for children with IBD during the coronavirus pandemic, Brenner and co-authors noted.
“These data are really reassuring in reminding our patients of the importance and safety of continuing their IBD medication — That’s the main takeaway message,” Andrew B. Grossman, MD, of Children’s Hospital of Pennsylvania (CHOP) in Philadelphia, told MedPage Today.
Grossman was not involved with the study, but his center maintains a database of pediatric IBD patients who contract COVID-19, and he said the data in the study by Brenner’s group are consistent with what he has seen at CHOP in terms of disease severity and hospitalization.
Brenner and co-authors found the presence of the following factors to be associated with hospitalization:
- Comorbid conditions other than IBD: 50% hospitalized vs 12% of those without comorbidities (P<0.01)
- Moderate or severe IBD activity: 64% vs 15% (P<0.01 overall)
- Gastrointestinal symptoms: 71% vs 19% (P<0.01)
- Sulfasalazine/mesalamine use: 57% vs 21% (P=0.01), which remained a risk factor after adjusting for disease activity (aOR 4.2, 95% CI 1.3-14.1)
- Steroid use: 29% vs 8% (P=0.03)
The investigators examined data from March to October 1, 2020, drawn from the Surveillance Epidemiology of Coronavirus Under Research Exclusion for Inflammatory Bowel Disease (SECURE-IBD) database and the COVID-19 database of the Paediatric IBD Porto group of the European Society for Paediatric Gastroenterology Hepatology and Nutrition. Both registries were created in March of this year to monitor COVID-19 outcomes in IBD patients.
The mean age of patients in the study cohort was 15 years, and 46% were female. The most common IBD treatment was anti-tumor necrosis factor monotherapy (48%), followed by sulfasalazine/mesalamine (23%). The majority (86%) of IBD patients had no comorbidities.
No deaths occurred, but 14 children required hospitalization, two of whom required mechanical ventilation in the intensive care unit. One of these, a 6-year-old child with colitis on sulfasalazine/mesalamine, developed Kawasaki-like multisystem inflammatory syndrome. The other child developed a concurrent secondary infection, and both cases resolved favorably, the first with steroids and the second with multiple antimicrobials.
In a recent report, a 14-year-old boy with Crohn’s disease who developed multisystem inflammatory syndrome improved immediately with infliximab therapy.
Paralleling data from adults, anti-TNF monotherapy correlated with a decreased likelihood of hospital admission: 7% vs 51% (P<0.01).
“Ultimately, what the study shows is that parents don’t need to treat their children [with IBD] differently from kids without IBD when making that difficult decision [about whether to send their children back to school],” Grossman said.
Brenner and co-authors cautioned that the reported cases in the study likely under-represent the actual case burden, since most pediatric COVID-19 manifestations are mild or asymptomatic with no SARS-CoV2 testing indicated. For example, the Chinese series of 1,213 children found that 55.9% of COVID-19 cases were asymptomatic or mild and only 5.9% were severe.
“Additionally, mild cases may be under-reported,” Brenner’s team continued. “Thus, the low observed hospitalization rate is likely an overestimation of the true hospitalization rate.”
The study was funded by the Helmsley Charitable Trust and Clinical Translational Science Awards, with additional funding from Pfizer, Takeda, Janssen, AbbVie, Lilly, Genentech, Boehringer Ingelheim, Bristol Myers Squibb, Celltrion, and Arena Pharma.
Brenner reported having no conflicts of interest; co-authors reported financial relationships with AbbVie, Lilly, Janssen, Pfizer, Takeda, and other companies.
Grossman had no competing interests to disclose.