Cristian RocaAdriana AsturizagaNelson VillcaRamiro CabreraRaúl Copana-OlmosVladimir Aguilera-AvendañoClaudia Estrada-VillarroelMariel Andrea Forest-YepezMarcia Torrez-SantosAdela Felipa Magne-Calle2026-03-222026-03-22202410.1371/journal.pone.0283037https://doi.org/10.1371/journal.pone.0283037https://andeanlibrary.org/handle/123456789/53405Citaciones: 1COVID-19 affects children less seriously than adults; however, severe cases and deaths are documented. This study objective is to determine socio-demographic, clinical and laboratory indicators associated with severe pediatric COVID-19 and mortality at hospital entrance. A multicenter, retrospective, cross-sectional study was performed in 13 tertiary hospitals in Bolivia. Clinical records were collected retrospectively from patients less than 18 years of age and positive for SARS-CoV-2 infection. All variables were measured at hospital entrance; outcomes of interest were ICU admission and death. A score for disease severity was developed using a logistic regression model. 209 patients were included in the analysis. By the end of the study, 43 (20.6%) of children were admitted to the Intensive care unit (ICU), and 17 (8.1%) died. Five indicators were independently predictive of COVID-19 severity: age below 10 years OR: 3.3 (CI95%: 1.1–10.4), days with symptoms to medical care OR: 2.8 (CI95%: 1.2–6.5), breathing difficulty OR: 3.4 (CI95%: 1.4–8.2), vomiting OR: 3.3 (CI95%: 1.4–7.4), cutaneous lesions OR: 5.6 (CI95%: 1.9–16.6). Presence of three or more of these risk factors at hospital entrance predicted severe disease in COVID-19 positive children. Age, presence of underlying illness, male sex, breathing difficulty, and dehydration were predictive of death in COVID-19 children. Our study identifies several predictors of severe pediatric COVID-19 and death. Incorporating these predictors, we developed a tool that clinicians can use to identify children at high risk of severe COVID-19 in limited-resource settings.enCoronavirus disease 2019 (COVID-19)2019-20 coronavirus outbreakSevere acute respiratory syndrome coronavirus 2 (SARS-CoV-2)MedicineBetacoronavirusSeverity of illnessMEDLINEPandemicCoronavirus InfectionsIntensive care medicinearticle