New insights into how COVID-19 variants affected children with tracheostomy

When the COVID-19 pandemic began, many of the hardest questions centered on children with medical complexity. Clinicians knew these patients were vulnerable to respiratory infections, but there was little data to guide care as COVID-19 evolved into new variants. For children with tracheostomy, even small respiratory changes can lead to rapid deterioration, making that uncertainty especially concerning.

Acute respiratory infections are already the leading cause of illness and death in children with tracheostomy. Hospital admissions for concern of bacterial tracheostomy-associated infection are common, and viral infections often complicate care. As COVID-19 spread and changed over time, clinicians needed clearer evidence about how this virus behaved in a population living with very limited respiratory reserve.

What the study examined

To address that gap, researchers from six children’s hospitals, including Children’s National Hospital, conducted a multicenter prospective cohort study examining COVID-19 outcomes in children with tracheostomy. The study followed 103 children across 108 hospital admissions. All were hospitalized for concern of bacterial tracheostomy-associated infection and tested positive for COVID-19 at the time of admission. The analysis spanned the early or alpha, delta, and omicron variant periods.

These were not mild cases. Across every variant, most children required increased respiratory support during hospitalization. Between 76 and 89 percent needed more oxygen, and 35 to 67 percent required increased ventilatory support. While deaths were uncommon, mortality still occurred in 3 to 6 percent of cases. COVID-19 posed real risk for children with tracheostomy, regardless of variant.

Key findings by variant

While overall risk remained high, the delta period stood out. Children hospitalized during the delta wave were significantly more likely to receive dexamethasone than those hospitalized during the early or alpha period. Nearly 80 percent of children hospitalized during delta received steroids, compared with 40 percent during alpha.

This difference aligned with other signals of increased inflammation. C-reactive protein levels were significantly higher during delta infections, suggesting a stronger inflammatory response. Clinicians also observed clinically meaningful increases in ventilatory support during the delta period. Some differences did not reach statistical significance due to smaller sample sizes, but the pattern reflected what many providers experienced during that phase of the pandemic.

“We were seeing children who already had very limited respiratory reserve needing more support during delta infections,” said Andrea Hahn, MD, MS, a pediatric infectious disease physician at Children’s National and study author. “This kind of data helps put those clinical experiences into context and gives us evidence to better guide care for this population.”

Omicron infections looked different. Children hospitalized during the omicron period were less likely to present with hypoxia or require increases in ventilator settings compared to those hospitalized during alpha or delta. This mirrors broader pediatric trends showing that omicron often caused less severe lower respiratory disease, even as it spread more easily.

That distinction matters, but it does not eliminate risk. Many children with tracheostomy infected during the omicron period still required hospitalization, oxygen support and close monitoring as even modest respiratory changes can escalate quickly for these medically complex children.

A surprising vaccination gap

One of the most striking findings in the study was persistently low COVID-19 vaccination rates. Across all three variant periods, only 10 to 17 percent of children were vaccinated prior to hospitalization. Those rates did not meaningfully increase over time, even as vaccines became widely available and pediatric vaccination rates rose nationally.

This was unexpected. Children with tracheostomy are at higher risk for severe respiratory illness, yet they appeared less likely to be vaccinated than children overall. The study could not determine why, but it raises important questions about access, caregiver concerns, and how vaccination guidance is communicated to families of children with medical complexity.

What this means for clinicians and families

This is the largest study published to date examining COVID-19 outcomes in children with tracheostomy. It confirms that vulnerability persisted across variants and that changes in variant behavior did not eliminate risk. It also points to clear opportunities to strengthen prevention efforts and better support families navigating complex care decisions.

Read the full study, “Comparing COVID-19 Variants in Children Hospitalized for Concern of Tracheostomy-associated Infection: A Multicenter Prospective Cohort Study” in The Pediatric Infectious Disease Journal. Additional authors from Children’s National include Margaret Lois Rush, MD.