By Philip R. Fischer, MD, DTM&H
Department of Pediatric and Adolescent Medicine, Mayo Clinic, Minnesota, and Department of Pediatrics, Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
SYNOPSIS: Despite the global tragedy of the COVID-19 pandemic, clinical experience suggests that there also have been some favorable indirect effects of pandemic-induced lockdowns on pediatric health. Specifically, there are lower rates of unscheduled primary care visits, emergency department visits, and hospitalizations for medical problems – without an increase in incompletely managed serious diseases.
SOURCE: Williams TC, MacRae C, Swann OV, et al. Indirect effects of the COVID-19 pandemic on paediatric healthcare use and severe disease: A retrospective national cohort study. Arch Dis Child 2021; Jan. 15. doi 10.1136/archdischild-2020-321008. [Online ahead of print].
Despite the extensive impact of the COVID-19 pandemic, children, as compared to adults, have been affected less severely. Nonetheless, there have been concerns that lockdown measures might have prompted delays in care-seeking with a resultant worsening of serious pediatric conditions.
The first case of infection with SARS-CoV-2 in Scotland was identified on March 1, 2020, and a U.K.-wide lockdown began on March 23. The lockdown measures were eased on May 29, and schools were opened on Aug. 12. The “natural experiment” of the pandemic provided an opportunity to determine influences of COVID-19 on pediatric use of emergent healthcare and on severe pediatric disease.
Williams and colleagues used Scotland’s complete national data sets to compare pediatric care and illness from March 23 to Aug. 9, 2020, with that of previous years. Theirs was a retrospective, population-based analysis of all emergent pediatric care and specifically included data from both of Scotland’s pediatric intensive care units. The study was limited to children from birth to 14 years of age.
Unscheduled after-hours primary care visits were reduced by 64% during the five-month-long lockdown, as compared to the same parts of 2016 through 2019 (P < 0.001). Emergency department visits dropped by half (P < 0.001). Hospital admissions for medical conditions dropped by about half (P < 0.001), but hospital admissions for surgical admissions did not change significantly.
As a clue to the seriousness of clinical situations when presenting to emergency departments, Williams looked at the proportion of emergency department visits that prompted hospital admission. During the first week of the lockdown, there was an increased rate of admission following emergency department visits, but the admission rate quickly dropped to baseline after that.
There also was a reduction in the number/rate of emergent admissions for pediatric intensive care that required mechanical ventilation, but there was no increase in the severity scores displayed by patients at admission. Death rates were similar in the lockdown months of 2020 as during the same parts of the 2016-2019 years.
The authors appropriately pointed out that there was a reduction in the use of emergent medical care services during the lockdown but that there was no population-based evidence that children had negative outcomes related to the reduced use of emergency care. Wallace used the data, as summarized earlier, to claim that the reduction in the need for emergency care likely was linked to a reduction in the incidence of respiratory infections and, perhaps, a higher threshold for seeking care for common illnesses. Reassuringly, Wallace also emphasized that there was not widespread evidence of children delaying care to the point of presenting with more severe illnesses. They also noted that medical illnesses were less common during the pandemic even though surgical problems continued as before.
There is no doubt that the COVID-19 pandemic is a global tragedy. The loss of life and health is staggering. Since the beginning of the pandemic, though, it seemed clear that children were less severely affected by SARS-CoV-2 than were and are adults.
Anecdotally, pediatric hospitalists noticed a marked reduction in hospitalizations with the onset of lockdowns, social distancing, and masking in response to the COVID-19 pandemic. Although some children still developed serious illness, there seemed to be many fewer children ill with febrile illnesses, including those caused by respiratory and gastrointestinal infections. Logically, it seemed that measures instituted to reduce the spread of SARS-CoV-2 also were effective in reducing the spread of other common infections.
Now, data are emerging that support and clarify the indirect yet favorable effects of the pandemic on child health. Williams and colleagues in Scotland documented significant reductions in rates of emergency care, without an associated increase in more severe disease (as would be seen if the reduction in emergency care was merely the result of reduced use of services rather than to a reduced need for services). Perhaps one of the favorable health outcomes in the post-pandemic era will be improved health with less need for acute medical care because of ongoing implementation of personal protective measures that reduce the spread of pathogens.
Of course, the Scottish data are subject to interpretation and might not be representative of what is occurring elsewhere. Pines and colleagues characterized pediatric care in U.S. emergency departments using data from more than 2 million episodes of care.1 Adult non-COVID emergency care visits dropped by 60% in early 2020 as compared to 2019, and pediatric visits dropped even more (74% drop for children younger than 10 years of age, 67% drop for children aged 14 to 17 years).1 The declines in care utilization were seen across all types of visits, but especially with non-COVID infections; serious pediatric conditions, including appendicitis, dropped by 22%.1
Why was medical care used less frequently? Williams and colleagues credit the reduced care use to reduced illnesses. Corroboration for this idea comes from experiences during the pandemic with milder illnesses as well. In Italy, 102 children known to be susceptible to otitis media were followed remotely when in-person visits seemed unwise.2 There was notable clinical improvement in 82% of children with fewer bouts of otitis and less antibiotic use as compared to the previous year.2 In the 27% of children who were evaluated face-to-face (actually, eye-to-ear), 89% had normal middle ear evaluations.2 Although some of the improvement could have been due to the increasing age of the children, it does seem like upper airway infections and illnesses, like emergency care utilization, have decreased significantly during the era of pandemic-induced restrictions.
Pines and colleagues think that some patients actually might have avoided necessary care for ill children.1 They saw fewer serious conditions than in a previous year and wondered if some children were not getting needed care, perhaps because of concern for COVID-19 exposure.1 However, contrary data come from Germany, where the rates of appendicitis went down 13% from pre-pandemic months to otherwise similar months during lockdowns.3 In that study, most of the reduction was of uncomplicated appendicitis (suggesting that some uncomplicated appendicitis might resolve even without medical care), while the rates of complicated appendicitis remained fairly stable.3 Is childhood appendicitis different in the United States? In New York, children presenting with acute appendicitis during the pandemic had more severe disease and had worse outcomes than those presenting in 2019.4
There also are legitimate concerns that avoidance of routine pediatric care might put children at risk of otherwise preventable illnesses. In Singapore, for instance, there was a marked decrease (26% to 74% in various settings) in uptake of measles vaccine during the pandemic, leaving the population at risk of measles outbreaks.5 There were similar decreases in pneumococcal vaccine coverage.5
Are there favorable pediatric outcomes related to the COVID-19 pandemic? Yes, there clearly are reduced rates of respiratory and gastrointestinal infections causing hospitalization. There likely is less non-judicious use of antibiotics for minor infections, and there is less emergency care for several conditions. Of course, there is a risk that some children might delay necessary medical care, and there is a risk that lowered immunization coverage might open populations to new outbreaks of preventable diseases, such as measles and invasive pneumococcal infections.
- Pines JM, Zocchi MS, Black BS, et al. Characterizing pediatric emergency department visits during the COVID-19 pandemic. Am J Emerg Med 2021; Nov. 23. doi 10.1016/j.ajem.2020.11.037. [Online ahead of print].
- Torretta S, Capaccio P, Coro I, et al. Incidental lowering of otitis media complaints in otitis-prone children during COVID-19 pandemic: Not all evil comes to hurt. Eur J Pediatr 2021;180:649-652.
- Kohler F, Acar L, van den Berg A, et al. Impact of the COVID-19 pandemic on appendicitis treatment in Germany – a population-based analysis. Langenbecks Arch Surg 2021; Jan. 9. doi 10.1007/s00423-021-02081-4. [Online ahead of print].
- Gerall CD, DeFazio JR, Kahan AM, et al. Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic. J Pediatr Surg 2021; Oct. 19. doi 10.1016/j.jpedssurg.2020.10.008. [Online ahead of print].
- Zhong Y, Clapham HE, Aishworiya R, et al. Childhood vaccinations: Hidden impact of COVID-19 on children in Singapore. Vaccine 2021;39:780-785.