Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department

En-Pei Lee; Chun-Ting Mu; Chen-Wei Yen; Shao-Hsuan Hsia; Jainn-Jim Lin; Oi-Wa Chan; Chun-Che Chiu; Shen-Hao Lai; Wen-Chieh Yang; Chun-Yu Chen; Ya-Ting Su; Han-Ping Wu

doi:10.1016/j.ajem.2023.06.050

Predictors of disease severity and outcomes in pediatric patients with croup and COVID-19 in the pediatric emergency department

Am J Emerg Med. 2023 Oct:72:20-26. doi: 10.1016/j.ajem.2023.06.050. Epub 2023 Jul 6.

Authors

En-Pei Lee¹, Chun-Ting Mu², Chen-Wei Yen³, Shao-Hsuan Hsia¹, Jainn-Jim Lin¹, Oi-Wa Chan¹, Chun-Che Chiu⁴, Shen-Hao Lai⁵, Wen-Chieh Yang⁶, Chun-Yu Chen⁶, Ya-Ting Su⁷, Han-Ping Wu⁸

Affiliations

¹ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan.
² College of Medicine, Chang Gung University, Taoyuan, Taiwan; Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan.
³ College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Nephrology, Department of Pediatrics, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric General Medicine, Department of Pediatrics, Chang Gung Memorial Hospital, Taoyuan, Taiwan.
⁴ College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Tucheng Composite Municipal Hospital, New Taipei City, Taiwan.
⁵ College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Pulmonology, Department of Pediatrics, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
⁶ Department of Pediatric Emergency, China Medical University Children's Hospital, China Medical University, Taichung City, Taiwan; Department of Medicine, College of Medicine, China Medical University, Taichung City, Taiwan.
⁷ College of Medicine, Chang Gung University, Taoyuan, Taiwan; Division of Pediatric Endocrinology and Genetics, Department of Pediatrics, Chang Gung Memorial Hospital, Taipei, Taiwan.
⁸ Division of Pediatric Critical Care Medicine, Department of Pediatrics, Chang Gung Memorial Hospital at Linko, Kweishan, Taoyuan, Taiwan; College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Pediatrics, Chiayi Chang Gung Memorial Hospital, Chiayi, Taiwan. Electronic address: arthur1226@gmail.com.

PMID: 37453221
DOI: 10.1016/j.ajem.2023.06.050

Abstract

Background: Croup caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is an emerging disease, and data on the risk factors associated with disease severity are still limited. The Westley croup score (WS) is widely used to assess croup severity. The current study aimed to analyze biomarkers associated with the WS and clinical outcomes in patients with croup and coronavirus disease 2019 in the pediatric emergency department (PED).

Population and method: Patients diagnosed with croup caused by SARS-CoV-2 were admitted at two PEDs. Clinical data including age, WS, length of hospital stay, initial laboratory data, and treatment were analyzed. Clinical parameters were evaluated via multivariate logistic regression analysis. The best cutoff values for predicting croup severity and outcomes were identified using the receiver operating characteristic curve.

Result: In total, 250 patients were assessed. Moreover, 128 (51.2%) patients were discharged from the PED, and 122 (48.8%) were admitted to the hospital. Mild, moderate, and severe croup accounted for 63.6% (n = 159), 32% (n = 80), and 4.4% (n = 11) of all cases, respectively. A high mean age (years), neutrophil count (%), neutrophil-to-lymphocyte ratio (NLR), ALT (U/L), procalcitonin (ng/mL), and hemoglobin (g/dL) level, and length of hospital stay (days), and a low lymphocyte count (%) and blood pH were associated with croup severity and need for intensive care. Based on the multivariate logistic regression model, the NLR remained independent factors associated with croup severity and prognosis. Further, NLR was significantly correlated with WS. The area under the receiver operating characteristic curve of NLR for predicting a WS of ≥3 was 0.895 (0.842-0.948, p < 0.001), and that for predicting ICU admission was 0.795 (0.711-0.879, p < 0.001). The best cutoff values for a WS of ≥3 and ICU admission were 1.65 and 2.06, respectively.

Conclusion: NLR is correlated with WS and is a reliable, easy-to-use, and cheap biomarker for the early screening and prognosis of croup severity in the PED. A higher NLR may indicate severe croup and the need for further treatment. And the WS score remains reliable for estimating the severity of croup caused by SARS-CoV-2 and the risk of intensive care.

Keywords: COVID-19; Croup; Pediatrics; Prognostic indicator; Westley score.

MeSH terms

Biomarkers
COVID-19* / epidemiology
COVID-19* / therapy
Child
Croup*
Emergency Service, Hospital
Humans
Lymphocytes
Neutrophils
Patient Acuity
Prognosis
ROC Curve
Retrospective Studies
SARS-CoV-2

Substances

Biomarkers