Are children born prematurely more likely to need intensive care when they come to the emergency department with a serious viral respiratory illness?

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Prematurity is a recognized risk factor for respiratory morbidity, but its association with illness severity across different viral causes in contemporary emergency department (ED) cohorts has not been well studied. This study evaluated the association between prematurity and the severity of molecularly confirmed acute viral respiratory illness (AVRI) in children presenting to the ED.

Researchers conducted a retrospective cohort study of pediatric ED encounters from January 1, 2019, through December 31, 2025. Eligible children were aged 0–18 years and had clinically significant AVRI, defined as respiratory distress with hypoxemia or hypercarbia. They also had respiratory viral PCR testing that identified at least one pathogen. Prematurity was defined as birth before 37 completed weeks of gestation.

Outcomes included the types of respiratory support required, intensive care unit (ICU) admission, hospital length of stay (LOS), and mortality. The researchers used multivariable logistic regression for binary outcomes and a generalized linear model with a gamma distribution and log link for LOS, adjusting for age, sex, year, and viral agents.

A total of 16,518 encounters met the inclusion criteria: 2,384 involved children born preterm and 14,134 involved children born at term. Children in the preterm encounters were younger: 21 months versus 26 months in the term encounters.

The most frequently detected pathogens were rhinovirus and/or enterovirus (RV/EV), found in 6,432 encounters (38.9%); respiratory syncytial virus (RSV), in 2,427 (14.7%); adenovirus, in 1,523 (9.2%); parainfluenza, in 1,315 (8.0%); influenza, in 858 (5.2%); and human metapneumovirus, in 600 (3.6%). Coinfection occurred in 12.4% of encounters and was more common in preterm than term encounters (14.3% versus 12.1%; p = 0.003).

Compared with children born at term, children born preterm more frequently required supplemental oxygen (39.0% versus 30.2%), high-flow nasal cannula (HFNC; 23.8% versus 16.4%), noninvasive positive pressure ventilation (13.0% versus 8.6%), and invasive mechanical ventilation (4.3% versus 2.0%). All these comparisons had p < 0.001.

After adjustment, prematurity was independently associated with higher odds of pediatric intensive care unit (PICU) admission (adjusted odds ratio, 1.57; 95% confidence interval, 1.43–1.72; p < 0.001) and approximately 17% longer hospital LOS. Mortality was rare (0.09%) and did not differ between the groups.

The researchers concluded that prematurity was associated with greater respiratory support requirements, a greater likelihood of PICU admission, and longer hospital stays among children presenting to the ED with clinically significant AVRI.