Emergency department utilisation by vulnerable paediatric populations during the COVID-19 pandemic

Adult Mental Health Presentations to Emergency Departments in Victoria, Australia between January 2018 and October 2020: Changes Associated with COVID-19 Pandemic Public Health Restrictions

The COVID-19 pandemic and associated public health measures altered patterns of help-seeking for mental health, with increases in emergency department utilisation reported. We examined the association between COVID-19 restrictions and adult emergency department (ED) mental health presentations in Victoria, Australia, through secondary analysis of data from 39 public EDs across the state. Participants were all patients (18+ years) presenting between 1 January 2018 and 31 October 2020 with mental health or intentional self-harm. The main outcome was number of presentations for each mental health condition, by patient age, socioeconomic status (SES), location, and ED triage category. We used a Poisson regression model to compare predicted monthly ED presentations based on trends from 2018, 2019 and 2020 (up to 31 March), with observed presentations during the initial months of the COVID-19 pandemic (1 April to 31 October 2020). There was an average of 4,967 adult mental health presentations per month pre-COVID-19 (1 January-31 March 2020) and 5,054 per month during the COVID-19 period (1 April-31 October 2020). Compared to predicted incidence, eating disorder presentations increased 24.0% in the COVID-19 period, primarily among higher SES females aged 18-24 years. Developmental/behavioural disorder presentations decreased by 19.7% for all age groups. Pandemic restrictions were associated with overall increases in monthly adult ED presentations for mental health, with some disorders increasing and others decreasing. Accessibility of acute mental health services needs to be addressed to meet changing demand and ensure services are responsive to changes in presentations resulting from future public health challenges.

A comparison of psychiatric inpatient admissions in youth before and during the COVID-19 pandemic

Background

The current understanding of the effect of COVID-19 on child and youth admissions to psychiatric inpatient units over time is limited, with conflicting findings and many studies focusing on the initial wave of the pandemic.

Objectives

This study identified changes in psychiatric inpatient admissions, and reasons for admission, including suicidality and self-harm, before and during the COVID-19 pandemic.

Method

This time series study analyzed 3,723 admissions of youth (ages 0-18.88 years) admitted to four major psychiatry inpatient units in a large Canadian city between January 1st, 2016 and December 31st, 2021. Pre-pandemic (before March 11, 2020) and during-pandemic (after March 11, 2020) trends of admissions were explored using a Bayesian structural time series model (BSTS).

Results

The model revealed that overall admissions during the pandemic period exceeded what would have been predicted in the absence of a pandemic, a relative increase of 29%. Additionally, a rise in the total number of admissions due to self-harm and suicidality (29% increase), externalizing/behavioral issues (69% increase), and internalizing/emotional issues (28% increase) provided strong evidence of increased admissions compared to what might have been expected from pre-pandemic numbers.

Conclusions

There was strong evidence of increases in psychiatric inpatient admissions during the COVID-19 pandemic compared to expected trends based on pre-pandemic data. To ensure accessible and continuous mental health supports and services for youth and their families during future pandemics, these findings highlight the need for rapid expanse of inpatient mental health services, similar to what occurred in many intensive care units across Canada.

Pattern of adult psychiatric emergencies at a tertiary care center before and after the onset of the COVID-19 pandemic

A gap exists in published data on psychiatric emergencies presenting to Indian centers over the entire pandemic. We assessed 2,048 consecutive adult psychiatric emergencies for the period April 2019-September 2021 to compare 18 months following the onset of the pandemic, with the pre pandemic year as the control. Mean age was 33.8 ± 13.6 years, with 55% females. The proportion with ICD-10 schizophrenia and related psychotic disorders (18.9% vs 15.3%; P = 0.031), mood disorders (21.8% vs 18.1%; P = 0.038), and personality disorders (3.8% vs 2%; P = 0.018) showed a significant increase during a pandemic, while those with no diagnosable illness reduced (28.6% vs 34.3%; P = 0.006). Suicidality was the reason for referral in 43%, comparable to pre pandemic year. Those with stay ≥24 hours increased (14% vs 11%; P = 0.034). Benzodiazepines remained the commonly prescribed medication, but a notable rise was seen in mood stabilizer prescriptions.

Trends in Pediatric Emergency and Inpatient Healthcare Use for Mental and Behavioral Health Among North Carolinians During the Early COVID-19 Pandemic

BACKGROUND

Widespread school closures and health care avoidance during the COVID-19 pandemic led to disruptions in access to pediatric mental health care.

METHODS

We conducted a retrospective study of emergency and inpatient administrative claims from privately insured children aged 6-20 years in North Carolina between January 2019 and December 2020. We compared rates of emergency department (ED) visits (per 100 000 person-days) and risks of hospitalizations (per 100 000 persons) with diagnosis codes in each category (mental/behavioral health; suicidal ideation, suicide attempt, and intentional self-harm [SI/SA/ISH]; and social issues) across 3 time periods (pre-pandemic, lockdown, and reopening). We calculated the proportion and 95% confidence intervals (CI) of total ED visits and total hospitalizations attributable to mental/behavioral health and SI/SA/ISH across the 3 time periods.

RESULTS

Rates of all categories of ED visits decreased from pre-pandemic to the lockdown period; from pre-pandemic to the reopening period, mental/behavioral health visits decreased but rates of SI/SA/ISH visits were unchanged. The proportion of ED visits attributable to mental/behavioral health increased from 3.5% (95% CI 3.2%-3.7%) pre-pandemic to 4.0% (95% CI 3.7%-4.3%) during reopening, and the proportion of SI/SA/ISH diagnoses increased from 1.6% (95% CI 1.4%-1.8%) pre-pandemic to 2.4% (95% CI 2.1%-2.7%) during the reopening period. Emergency care use for social issues and hospital admissions for mental/behavioral health and SI/SA/ISH diagnoses were unchanged across the study periods.

CONCLUSIONS

In the early pandemic, pediatric mental health care and acute suicidal crises accounted for increased proportions of emergency care. During pandemic recovery, understanding the populations most impacted and increasing access to preventative mental health care is critical.

COVID-19 and Neurodevelopmental Disabilities: Examining the Impact of the First 2 Years of the Pandemic on the Demand for Pediatric Inpatient Care

The COVID-19 pandemic has strained the resources of the world's healthcare systems. Most individuals with neurodevelopmental disabilities (NDDs) experience significant mental health issues and face substantial barriers in accessing appropriate supports which have been exacerbated during the pandemic. It is unknown the extent to which COVID-19 impacted the demand for and effectiveness of inpatient care for those with NDDs. The impact of COVID-19 on the number of admissions of youth with NDDs to pediatric inpatient psychiatry units, as well as their functioning and length of stay during the first two years of the pandemic was analyzed using Bayesian structural time series models. Admission data of youth with NDDs from four pediatric inpatient units in Alberta, Canada (n = 2144) was examined. Inpatient admissions of youth with NDDs significantly increased following the onset of the pandemic. Compared to the period prior to the pandemic, patients with NDDs had significantly worse overall functioning and received fewer days of treatment. These findings highlight the need for increased resources to support the mental health needs of this vulnerable population and are consistent with other studies in the general population examining the utilization of inpatient psychiatric units during the pandemic.

Emergency care utilization and patients' outcome before and after COVID-19 national lockdown in Iran: a cross-sectional study

INTRODUCTION

COVID-19 rapidly spread throughout the world. Stay-at-home and social distance strategies accompanied by fear of contamination with COVID-19 caused significant disruptions in daily life. The study focused on the impact of the COVID-19 pandemic on emergency visit and patients' outcome in the emergency department (ED).

METHOD

Administrative and clinical data of 25-hospital EDs in Kermanshah province of Iran from February 20, 2020, to February 18, 2021, were retrospectively analyzed with the comparable periods in the previous year. The incidence rate ratio (IRR) was used to compare the differences between the pandemic and the pre-pandemic period.

RESULT

The number of ED visits decreased nearly 50% after the declaration of a national lockdown. Moreover, the proportion of patients triaged in ESI 1 and 2 levels increased by 40 and 52%, respectively. The ratio of patients admitted to intensive care units and discharged against medical advice also increased significantly.

CONCLUSION

Despite the number of ED visits sharply declining, the ratio of patients who came to EDs with higher acuity significantly increased. So, health authorities must sensitize the public about life-threatening signs and symptoms in such conditions.

"The usual challenges of work are all magnified": Australian paediatric health professionals' experiences during the COVID-19 pandemic

Background

The COVID-19 pandemic has significantly increased stress and strain on health professionals. With a focus on paediatric cardiac care, this study explored health professionals' concerns about COVID-19, perceptions of the impact of pandemic on healthcare, and experiences of psychological stress.

Methods

Paediatric health professionals working at a large quaternary hospital in Australia were invited to complete a survey between June 2020 and February 2021. Demographic factors, clinical role characteristics, and anxiety and depressive symptoms were assessed. Qualitative data on experiences and perceived effects of the pandemic on paediatric cardiac care were also collected.

Results

228 health professionals (152 nurses, 37 medical doctors, 22 allied and mental health professionals, 17 medical research and administrative staff) participated in the survey (54.4% response rate, 85% women). Half the sample (52.2%) endorsed 'moderate' to 'extreme' worry about COVID-19 and 38% of participants perceived healthcare services as adversely impacted by the pandemic to a 'great' or 'very great' extent. Almost one in five health professionals reported anxiety (18%) and 11% reported depressive symptoms indicative of a need for clinical intervention. Six themes were identified in the qualitative data: (1) Concern about the consequences of visitor restrictions and disrupted patient services, (2) Intensified strain on healthcare workers, (3) Feelings of fear and loss, (4) Social isolation and disconnection, (5) Adapting to change, and (6) Gratitude.

Conclusion

Timely, tailored policies, supports, and interventions are needed to address health professionals' mental health needs during and beyond the pandemic, to minimize the far-reaching impact of situational stressors.

Pattern of Psychiatric Emergencies in Children and Adolescents at a Tertiary Care Centre After Onset of COVID-19 Pandemic

OBJECTIVES

To assess changes in profile of psychiatric emergencies in children and adolescents (aged <19 year) during the coronavirus disease 2019 (COVID-19) pandemic compared to pre-pandemic period.

METHODS

The psychiatric emergency records were analyzed for the period of April, 2019 - September, 2021 to assess the pattern and profile of mental health emergencies in children and adolescents in the period before and after the onset of the pandemic lockdown (i.e., 23 March, 2020).

RESULTS

379 consecutive child and adolescent psychiatric emergencies were identified, of which 219 were seen after the onset of pandemic. Commonest reason for referral in the pandemic group was attempted self-harm (44.3%). The ICD-10 neurotic, stress-related and somatoform disorders constituted the commonest diagnostic category, similar to pre-pandemic period. A significantly higher proportion (44% vs 28%) of children was prescribed benzodiazepines in the pandemic period, compared to the pre-pandemic period.

CONCLUSION

The average monthly psychiatric emergencies in children and adolescents showed no increase during the pandemic period. Self-harm was the commonest cause of psychiatric referral in emergency services mental health crisis in the younger population.

Influence of epidemics and pandemics on paediatric ED use: a systematic review

OBJECTIVE

To assess the impact of epidemics and pandemics on the utilisation of paediatric emergency care services to provide health policy advice.

SETTING

Systematic review.

DESIGN

Searches were conducted of Medline, EMBASE, CINAHL, Scopus, Web of Science and the Cochrane Library for studies that reported on changes in paediatric emergency care utilisation during epidemics (as defined by the WHO).

PATIENTS

Children under 18 years.

INTERVENTIONS

National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies was used.

MAIN OUTCOME MEASURES

Changes in paediatric emergency care utilisation.

RESULTS

131 articles were included within this review, 80% of which assessed the impact of COVID-19. Studies analysing COVID-19, SARS, Middle East respiratory syndrome (MERS) and Ebola found a reduction in paediatric emergency department (PED) visits, whereas studies reporting on H1N1, chikungunya virus and Escherichia coli outbreaks found an increase in PED visits. For COVID-19, there was a reduction of 63.86% (95% CI 60.40% to 67.31%) with a range of -16.5% to -89.4%. Synthesis of results suggests that the fear of the epidemic disease, from either contracting it or its potential adverse clinical outcomes, resulted in reductions and increases in PED utilisation, respectively.

CONCLUSIONS

The scale and direction of effect of PED use depend on both the epidemic disease, the public health measures enforced and how these influence decision-making. Policy makers must be aware how fear of virus among the general public may influence their response to public health advice. There is large inequity in reporting of epidemic impact on PED use which needs to be addressed.

TRIAL REGISTRATION NUMBER

CRD42021242808.

Six Diagnoses of Separation: Impact of COVID-19 on Pediatric Emergency Department Visits: A Multicenter Study

BACKGROUND

Coronavirus disease 2019 (COVID-19) arrived in the New York metropolitan area in early March 2020. Recommendations were made to self-quarantine within households and limit outside visits, including those to clinics and hospitals, to limit the spread of the virus. This resulted in a decrease in pediatric emergency department (ED) visits. However, it is unclear how this affected visits for some common diagnoses such as anxiety, appendicitis, asthma, headaches, seizures, and urinary tract infection (UTI). These diagnoses were chosen a priori, as they were felt to represent visits to the ED, for which the diagnoses would likely not be altered based on COVID exposure or quarantine due to their acute nature.

OBJECTIVES

Our goal was to investigate the effect of COVID-19 on common pediatric diagnoses seen in the pediatric ED using a large multihospital database.

METHODS

We conducted a retrospective cohort study of consecutive pediatric patients (age ≤ 21 years) between March 1 and November 30 in 2019 and 2020 in 28 hospital EDs within 150 miles of New York City. We compared the change in the number of visits from 2019 to 2020 for the following diagnoses: anxiety, appendicitis, asthma, headache, seizures, and UTI.

RESULTS

Our database contained 346,230 total pediatric visits. From 2019 to 2020, total visits decreased by 61%. Decreases for specific diagnoses were 75% for asthma, 64% for headaches, 47% for UTI, 32% for anxiety, 28% for seizures, and 18% for appendicitis (p value for each comparison < 0.0001).

CONCLUSIONS

We found a marked decrease in ED visits for six common pediatric diagnoses after COVID-19 arrived in our area. We suspect that this decrease was due to recommendations to quarantine and fear of contracting the virus. Further studies on other diagnoses and potential complications due to the delay in seeking care are needed.

Implementing best practice occupational therapist‐led environmental assessment and modification to prevent falls: A qualitative study of two regional and rural public health services in Australia

BACKGROUND

Occupational therapist-led environmental assessment and modification (EAM) is effective in reducing falls for populations at high risk. Two regional and rural public health services in Queensland devised an implementation strategy to embed best practice occupational therapist-led EAM.

METHODS

A qualitative study was conducted to compare the determinants of implementation success across the different health services, using the COM-B model of behaviour change. Six semi-structured interviews were completed with occupational therapists involved at each site, following 12 months of implementation. Interview data were triangulated with minutes from three combined site steering committee meetings, eight local steering committee meetings, and field notes. Thematic analysis was completed to compare barriers and facilitators to best practice uptake of EAM and differences in outcomes between the two sites.

RESULTS

Both sites commenced implementation with similar states of capability and motivation. After 12 months, one site considered that practice change had been embedded as noted in steering committee minutes and comments; however, the other site observed limited progress. According to the COM-B analysis, opportunity (the factors that lie outside the individual's control) had a significant influence on how both sites were able to respond to the practice change and navigate some of the unexpected challenges that emerged, including the COVID-19 pandemic. Existing team structure, multiple responsibilities of key stakeholders, differences in access to resources, and lack of connection between complementary services meant that COVID-19 disruptions were only a catalyst for unveiling other systemic issues.

CONCLUSION

This study highlights the power of external factors on influencing behaviour change for best practice implementation. Learnings from the study will provide deeper understanding of completing implementation projects in regional and rural contexts and support the future implementation of EAM in occupational therapy clinical settings.

Mental health consequences of COVID-19 suppression strategies in Victoria, Australia: a narrative review

The COVID-19 pandemic has imposed significant mental health burdens upon the general population worldwide, either directly owing to the disease or indirectly through aggressive public health measures to control spread of the virus that causes COVID-19. In this narrative review, we used a systematic approach to summarize the impact of restrictive lockdown measures on the general mental health of people living in Victoria, Australia during 2020 and to identify the groups with an increased risk of adverse mental health outcomes. A systematic database search (Ovid Medline, PsycINFO, Embase) for articles examining the mental health of Victorians in the context of the COVID-19 pandemic during 2020 yielded 88 articles, of which 15 articles were finally included in this review. We found that the general mental health of Victorians was negatively affected by COVID-19 restrictions during 2020. Although studies reported heterogeneous mental health outcomes, we found that the general population consistently used coping strategies and demonstrated mental health help-seeking behaviors in response to the restrictions. Women, children, young people, carers, people who became unemployed owing to the pandemic, and those with pre-existing psychiatric conditions had a higher risk of adverse mental health consequences during the COVID-19 pandemic in 2020.

Impact of COVID-19 on Pediatric Mental and Behavioral Health Visits to the Emergency Department

OBJECTIVES

This study aimed to describe changes in pediatric emergency department (ED) mental and behavioral health (MBH) visits before and during the early COVID-19 pandemic.

METHODS

We retrospectively reviewed medical records of patients aged from 5 to 17 years presenting to the pediatric ED of a major tertiary care hospital with MBH-related concerns from March 2017 to September 2020. We evaluated trends in MBH ED visits over the study period, specifically comparing patient demographics, diagnosis categories, and ED disposition between the pre-COVID (2019) and COVID (2020) periods using pairwise Pearson χ 2 analyses with reported odds ratios (ORs) in SAS statistical software version 9.4 (SAS Institute Inc, Cary, NC).

RESULTS

Of 8093 MBH-related visits, 58.5% were females, 85.4% were adolescents, and 62.7% self-identified as non-Hispanic. The proportion of MBH-related ED visits increased from 3.8% to 7.5% over the study period ( P < 0.0001). Although total MBH visits decreased by 17.3% from 2019 to 2020, there was a proportionate increase in MBH-to-total-ED visits, representing a 42.8% increase through 2019. Compared with 2019, there was a proportionate increase in MBH-related ED visits by females (10.6%, P < 0.0001), older adolescents (18.2%, P < 0.0001), and non-Hispanic patients (6.1%, P = 0.017) in 2020. The MBH visits in 2020 were more likely related to suicidality/self-harm (OR, 1.2; confidence interval [CI], 1.1-1.4) or substance use (OR, 1.4; CI, 1.1-1.9). Compared with 2019, there were significantly higher odds of admission (OR, 1.6; CI, 1.3-2.1) or transfer for inpatient psychiatric care (OR, 1.8; CI, 1.6-2.1) in 2020.

CONCLUSIONS

Our data suggest that the early COVID-19 pandemic had a significant impact on MBH-related ED visits. Compared with 2019, we observed a significant increase in the proportion of MBH-to-total-ED visits primarily affecting older adolescent, non-Hispanic girls with suicidality/self-harm and substance-related disorders in 2020, despite an overall decrease in the number of MBH visits during this period. There was also an increase in the proportion of visits resulting in admission or transfer for inpatient psychiatric care in 2020.

COVID-19 and mental health in Australia - a scoping review

Background

The COVID-19 outbreak has spread to almost every country around the world and caused more than 3 million deaths. The pandemic has triggered enormous disruption in people’s daily lives with profound impacts globally. This has also been the case in Australia, despite the country’s comparative low mortality and physical morbidity due to the virus. This scoping review aims to provide a broad summary of the research activity focused on mental health during the first 10 months of the pandemic in Australia.

Results

A search of the Australian literature was conducted between August-November 2020 to capture published scientific papers, online reports and pre-prints, as well as gaps in research activities. The search identified 228 unique records in total. Twelve general population and 30 subpopulation group studies were included in the review.

Conclusions

Few studies were able to confidently report changes in mental health driven by the COVID-19 context (at the population or sub-group level) due to a lack of pre-COVID comparative data and non-representative sampling. Never-the-less, in aggregate, the findings show an increase in poor mental health over the early period of 2020. Results suggest that young people, those with pre-existing mental health conditions, and the financially disadvantaged, experienced greater declines in mental health. The need for rapid research appears to have left some groups under-researched (e.g. Culturally and Linguistically Diverse populations and Indigenous peoples were not studied), and some research methods under-employed (e.g. there was a lack of qualitative and mixed-methods studies). There is a need for further reviews as the follow-up results of longitudinal studies emerge and understandings of the impact of the pandemic are refined.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13527-9.

A comparative analysis of pediatric mental health-related emergency department utilization in Montréal, Canada, before and during the COVID-19 pandemic

BACKGROUND

Reports on longitudinal trends in mental health-related (MHR) emergency department (ED) utilization spanning the pre- and post-pandemic periods are lacking, along with evidence comparing healthcare services utilization by sociodemographic subgroups. The aim of this study was to evaluate COVID-19-associated changes in MHR ED utilization among youth overall and by age, sex, and socio-economic status (SES).

METHODS

This retrospective cross-sectional study analyzed MHR ED utilization before and during the COVID-19 pandemic at a large urban pediatric tertiary care hospital in Montréal, Canada. All ED visits for children (5-11 years) and adolescents (12-17 years) between April 1, 2016 and November 30, 2021 were included. The main outcome was the monthly count of MHR ED visits. Pre-pandemic and pandemic periods were compared using an interrupted time series design. The effect of seasonality (in months), age (in years), sex (male or female), and SES (low, average, high) were compared using a generalized additive model.

RESULTS

There were a total of 437,147 ED visits (204,215 unique patients) during the 5-year study period of which 9748 (5.8%) were MHR visits (7,686 unique patients). We observed an increase of 69% (95% CI, + 53% to  + 85%; p = 0.001) in the mean monthly count of MHR ED visits during the pandemic period, which remained significant after adjusting for seasonality (44% increase, 95% CI, + 38% to  + 51%; p = 0.001). The chance of presenting for a MHR ED visit increased non-linearly with age. There were increased odds of presenting for a MHR ED visit among girls between the pre-pandemic and pandemic periods (OR 1.42, 95% CI 1.29-1.56). No difference by SES group during and before the COVID-19 pandemic was found [OR 1.01, 95% CI 0.89-1.15 (low); OR 1.09, 95% CI 0.96-1.25 (high)].

CONCLUSIONS

Our study shows important increases in MHR ED utilization among youth, and especially among girls, during the first 20 months of the COVID-19 pandemic, highlighting the need for sustained, targeted and scalable mental health resources to support youth mental health during the current and future crises.

Impact of COVID-19 public health restrictions on hospital admissions for young infants in Victoria, Australia

AIM

Strict public health measures during the COVID-19 pandemic led to less support for infants and their parents. We aimed to characterise the frequency and nature of infant admissions to the Royal Children's Hospital (RCH), Melbourne in 2020, compared to the previous year.

METHODS

A retrospective review of medical records identified infants ≤3 months admitted to the general medicine unit, RCH from March to September in 2019 and 2020. Diagnoses potentially related to the impact of public health measures and reduced family and community supports were identified and compared to all infant diagnoses across both years. Clinical characteristics and need for referral for additional supports or mental health services were also ascertained.

RESULTS

There were fewer admissions for infants ≤3 months in 2020 (n = 411) compared to 2019 (n = 678), with a threefold increase in admissions with a primary or secondary diagnosis of feeding difficulties, growth disturbance, infant irritability or maternal mental health concerns (191/411; 46% vs. 97/678; 14%). There were more infants of first-time parents (112/191; 59% vs. 44/97; 45%) and a reduction in the number of admissions due to infection (145/411; 35%; vs. 467/678; 69%).

CONCLUSION

During the COVID-19 pandemic, there was a threefold increase in admissions for infants ≤3 months due to poor growth, feeding difficulties, irritability and maternal mental health concerns in 2020 compared to 2019. These findings may inform future pandemic planning and policy development to ensure maintenance of community supports such as maternal child health nurse (MCHN) service delivery for young infants.

Integrated Child and Family Hub models for detecting and responding to family adversity: protocol for a mixed-methods evaluation in two sites

INTRODUCTION

Integrated community healthcare Hubs may offer a 'one stop shop' for service users with complex health and social needs, and more efficiently use service resources. Various policy imperatives exist to implement Hub models of care, however, there is a dearth of research specifically evaluating Hubs targeted at families experiencing adversity. To contribute to building this evidence, we propose to co-design, test and evaluate integrated Hub models of care in two Australian community health services in low socioeconomic areas that serve families experiencing adversity: Wyndham Vale in Victoria and Marrickville in New South Wales.

METHODS AND ANALYSIS

This multisite convergent mixed-methods study will run over three phases to (1) develop the initial Hub programme theory through formative research; (2) test and, then, (3) refine the Hub theory using empirical data. Phase 1 involves co-design of each Hub with caregivers, community members and practitioners. Phase 2 uses caregiver and Hub practitioner surveys at baseline, and 6 and 12 months after Hub implementation, and in-depth interviews at 12 months. Two stakeholder groups will be recruited: caregivers (n=100-200 per site) and Hub practitioners (n=20-30 per site). The intervention is a co-located Hub providing health, social, legal and community services with no comparator. The primary outcomes are caregiver-reported: (i) identification of, (ii) interventions received and/or (iii) referrals received for adversity from Hub practitioners. The study also assesses child, caregiver, practitioner and system outcomes including mental health, parenting, quality of life, care experience and service linkages. Primary and secondary outcomes will be assessed by examining change in proportions/means from baseline to 6 months, from 6 to 12 months and from baseline to 12 months. Service linkages will be analysed using social network analysis. Costs of Hub implementation and a health economics analysis of unmet need will be conducted. Thematic analysis will be employed to analyse qualitative data.

ETHICS AND DISSEMINATION

Royal Children's Hospital and Sydney Local Health District ethics committees have approved the study (HREC/62866/RCHM-2020). Participants and stakeholders will receive results through meetings, presentations and publications.

TRIAL REGISTRATION NUMBER

ISRCTN55495932.

Review: Mental health impacts of the COVID-19 pandemic on children and youth - a systematic review

BACKGROUND

The COVID-19 pandemic has posed an unprecedented threat to global mental health. Children and adolescents may be more susceptible to mental health impacts related to their vulnerable developmental stage, fear of infection, home confinement, suspension of regular school and extracurricular activities, physical distancing mandates, and larger scale threats such as global financial recessions and associated impacts. Our objective was to review existing evidence of the COVID-19 pandemic's global impact on the mental health of children and adolescents <19 years of age and to identify personal and contextual factors that may enhance risk or confer protection in relation to mental health outcomes.

METHODS

We conducted a search of peer-reviewed and preprint research published in English from January 1, 2020, to February 22, 2021. We included studies collecting primary data on COVID-19-related mental health impacts on children and adolescents. We graded the strength of included articles using the Oxford Centre for Evidence-Based Medicine rating scheme.

RESULTS

Our search and review yielded 116 articles presenting data on a total of 127,923 children and adolescents; 50,984 child and adolescent proxy reports (e.g., parents, healthcare practitioners); and >3,000 chart reviews. A high prevalence of COVID-19-related fear was noted among children and adolescents, as well as more depressive and anxious symptoms compared with prepandemic estimates. Older adolescents, girls, and children and adolescents living with neurodiversities and/or chronic physical conditions were more likely to experience negative mental health outcomes. Many studies reported mental health deterioration among children and adolescents due to COVID-19 pandemic control measures. Physical exercise, access to entertainment, positive familial relationships, and social support were associated with better mental health outcomes.

CONCLUSIONS

This review highlights the urgent need for practitioners and policymakers to attend to and collaborate with children and adolescents, especially those in higher risk subgroups, to mitigate short- and long-term pandemic-associated mental health effects.

Potential indirect impacts of the COVID-19 pandemic on children: a narrative review using a community child health lens

▪In this narrative review, we summarise the vast and burgeoning research on the potential and established indirect impacts on children of the COVID-19 pandemic. We used a community child health lens to organise our findings and to consider how Australia might best respond to the needs of children (aged 0-12 years). ▪We synthesised the literature on previous pandemics, epidemics and natural disasters, and the current COVID-19 pandemic. We found clear evidence of adverse impacts of the COVID-19 pandemic on children that either repeated or extended the findings from previous pandemics. ▪We identified 11 impact areas, under three broad categories: child-level factors (poorer mental health, poorer child health and development, poorer academic achievement); family-level factors that affect children (poorer parent mental health, reduced family income and job losses, increased household stress, increased abuse and neglect, poorer maternal and newborn health); and service-level factors that affect children (school closures, reduced access to health care, increased use of technology for learning, connection and health care). ▪There is increasing global concern about the likely disproportionate impact of the current pandemic on children experiencing adversity, widening existing disparities in child health and developmental outcomes. ▪We suggest five potential strategy areas that could begin to address these inequities: addressing financial instability through parent financial supplements; expanding the role of schools to address learning gaps and wellbeing; rethinking health care delivery to address reduced access; focusing on prevention and early intervention for mental health; and using digital solutions to address inequitable service delivery.

Impact of COVID-19 lockdowns on hospital presentations and admissions in the context of low community transmission: evidence from time series analysis in Melbourne, Australia

BACKGROUND

Melbourne, Australia, successfully halted exponential transmission of COVID-19 via two strict lockdowns during 2020. The impact of such restrictions on healthcare-seeking behaviour is not comprehensively understood, but is of global importance. We explore the impact of the COVID-19 pandemic on acute, subacute and emergency department (ED) presentations/admissions within a tertiary, metropolitan health service in Melbourne, Australia, over two waves of community transmission (1 March to 20 September 2020).

METHODS

We used 4 years of historical data and novel forecasting methods to predict counterfactual hospital activity for 2020, assuming absence of COVID-19. Observed activity was compared with forecasts overall, by age, triage category and for myocardial infarction and stroke. Data were analysed for all patients residing in the health service catchment area presenting between 4 January 2016 and 20 September 2020.

RESULTS

ED presentations (n=401 805), acute admissions (n=371 723) and subacute admissions (n=15 676) were analysed. Substantial departures from forecasted presentation levels were observed during both waves in the ED and acute settings, and during the second wave in subacute. Reductions were most marked among those aged >80 and <18 years. Presentations persisted at expected levels for urgent conditions, and ED triage categories 1 and 5, with clear reductions in categories 2-4.

CONCLUSIONS

Our analyses suggest citizens were willing and able to present with life-threatening conditions during Melbourne's lockdowns, and that switching to telemedicine did not cause widespread spill-over from primary care into ED. During a pandemic, lockdowns may not inhibit appropriate hospital attendance where rates of infectious disease are low.

Registered psychiatric service use, self-harm and suicides of children and young people aged 0-24 before and during the COVID-19 pandemic: a systematic review

BACKGROUND

The COVID-19 pandemic has impacted on psychiatric symptoms of children and young people, but many psychiatric services have been disrupted. It is unclear how service use, self-harm and suicide has changed since the pandemic started. To gain timely information, this systematic review focused on studies based on administrative data that compared psychiatric service use, self-harm and suicide before and during the pandemic among children and young people.

METHODS AND FINDING

A systematic review of studies published in English from 1 January 2020 to 22 March 2021 was conducted, using the Web of Science, PubMed, Embase and PsycINFO databases. Increases or reductions in service use were calculated and compared using percentages. Of the 2,676 papers retrieved, 18 were eligible for the review and they provided data from 19 countries and regions. Most studies assessed changes during the early phase of the COVID-19 pandemic, from March to July 2020, and three assessed the changes until October 2020. Fifteen studies reported a total of 21 service use outcomes that were quantitively examined. More than three-quarters of the 21 outcomes (81%) fell by 5-80% (mean reduction = 27.9%, SD = 35%). Ten of the 20 outcomes for psychiatric emergency department (ED) services reduced by 5% to 80% (mean = 40.1%, SD = 34.9%) during the pandemic. Reductions in service use were also recorded for ED visits due to suicide ideation and self-harm, referrals to secondary mental health services, psychiatric inpatient unit admissions and patients receiving treatment for eating disorders. However, there were also some increases. Suicide rate and the number of ED visits due to suicide attempts have increased, and there was an increase in the number of treatment sessions in a service that provided telemedicine.

CONCLUSION

Most of the studies showed reductions in the use of psychiatric services by children and young people during the early phase of the pandemic and this highlighted potential delays or unmet needs. Suicide rate has increased during the second wave of the pandemic. Further studies are needed to assess the pattern of service use in the later phases of the COVID-19 pandemic.

COVID-19 pandemic lockdown effect on neonatal hospital admissions from the community

BACKGROUND

The lockdowns imposed by countries due to COVID-19 pandemic had enormous impact on healthcare. Our goal is to determine consequences of the COVID-19 pandemic lockdown on neonatal hospitalizations and disease incidence in our hospital.

METHODS

Observational retrospective study comparing newborns admitted to the neonatal care unit (NCU) from emergency department (ED). Newborns were distributed in two groups according to the date of the lockdown (22/3/2020): pre-lockdown group (12 month before) and post-lockdown group (12 month after). Categorical variables were compared according to chi square test and continuous variables with Mann-Whitney test. A Bonferroni corrected p-value < 0.006 was considered statistically significant. The monthly hospitalization rate between the two groups was analyzed with Generalized Method of Moments - System.

RESULTS

We included 99 patients, 65/99 (65.7%) in the pre-lockdown group and 34/99 (34.3%) in the post-lockdown group. Pre-lockdown group: median age at hospitalization 19 (10-26) days, duration of symptoms 12 (5.5-36) hours. Post-lockdown group: median age at hospitalization 16 (6-24) days, duration of symptoms 14 (6-72) hours. The incidence of contagious disease was higher in the pre-lockdown group: 27/65 (41.5%) versus 3/34 (8.8%) in post-lockdown group (p = 0.001). No statistically significant difference in gestational age, gender, age at hospitalization, duration of symptoms and length of stay.

CONCLUSION

Lockdown decreased admissions in NCU due to the decrease in contagious infections. The similar duration of symptoms before age at hospitalization in the two groups might indicate that health care accessibility has been maintained.

Significant Reduction in Pediatric, Population-Based Hospital Admissions Due To COVID-19 in Malta

OBJECTIVE

This population-based, retrospective study aimed to determine whether there was a drop in pediatric admissions during the first year of COVID-19 in Malta, as reported in other centers worldwide, as well as to determine any differences in patient characteristics when compared to the previous year.

MATERIALS AND METHODS

All unplanned pediatric medical admissions to Mater Dei Hospital from March 1, 2020 (a few days before the first case of COVID-19 in Malta) till February 28, 2021 (study period) and the corresponding period in 2019/20 (control period) and characteristics of patients admitted during the first 10 weeks (first wave of COVID-19) were analyzed.

RESULTS

Pediatric admissions dropped by 57.7% during the first year of COVID-19 (1601 vs. 3789 in 2019). During the first wave of COVID-19, a higher percentage of neonates were admitted in 2020 when compared to all other ages. There was a lower prevalence of respiratory illnesses during the first wave of COVID-19 (31.6% vs. 47.5% in 2019, P < .001), with a higher prevalence of cases related to child abuse or adverse socio-economic circumstances (2020, 9 [3.4%] vs 1 [0.1%] in 2019, P < .001). Following school closures, a drop in communicable disease admissions was recorded (68 [42.2%] vs. 421 [70.3%] in 2019, P < .001). A negative correlation between daily pediatric admissions and active COVID-19 cases in Malta was noted (r (68) = -0.33, P = .005).

CONCLUSION

The drop in admissions likely represents fear of contracting COVID-19 in hospital environments, together with a decline in communicable diseases due to school closures. Guardians' concerns must be alleviated as best as possible by effective public health measures.

The impact of the COVID-19 pandemic on paediatric health service use within one year after the first pandemic outbreak in New South Wales Australia - a time series analysis

Background

The first wave of the COVID-19 pandemic hit New South Wales (NSW) Australia in early 2020, followed by a sharp state-wide lockdown from mid-March to mid-May. After the lockdown, there had been a low level of community transmission of COVID-19 over a year. Such pandemic experiences provide unique opportunity to understand the impact of the pandemic on paediatric health service use as countries emerge from the pandemic.

Methods

We examined the difference between the observed and the predicted numbers of inpatient admissions and emergency department (ED) attendances, respectively, related to chronic, acute infectious and injury conditions, for each month during the COVID-19 period (January 2020-February 2021), based on the numbers from 2016 to 2019, using records from two major paediatric hospitals in NSW. All analyses were conducted using autoregressive error models and were stratified by patient age, sex and socioeconomic status.

Findings

Health service use was significantly lower than predicted for admissions and/or ED attendances related to chronic conditions, acute infections, and injury during the lockdown in 2020. Change in health service use varied by chronic conditions, from the largest decrease for respiratory conditions (40-78%) to non-significant change for cancer and mental health disorders. After the lockdown, health service use for most health conditions returned to pre-COVID-19 predicted levels. However, for mental health disorders, increased health service use persisted from June 2020 up to February 2021 by 30-55%, with higher increase among girls aged 12-17 years and those from socioeconomically advantaged areas. There was persistently lower health service use for acute infections and increased health service use for injuries. Differences by socio-demographic factors were noted for mental health disorders and injuries.

Interpretation

The immediate return to pre-COVID-19 levels for most chronic conditions after the first lockdown in NSW highlights the healthcare needs for children affected by chronic conditions. Persistently lower health service use for acute infections is likely attributable to the decreased social contact. Sustained and targeted mental health support is essential to address the potentially increased demand for services among children during and beyond the pandemic.

Funding

Financial Markets Foundation for Children Chair (RL, NN), NHMRC Investigator Grant (APP1197940) (NN), NHMRC Career Development fellowship (GNT1158954) (SW)

Increased paediatric emergency mental health and suicidality presentations during COVID-19 stay at home restrictions

Objective

Anecdotal reports indicate an increase in mental health presentations and acuity to EDs during the COVID‐19 pandemic and associated stay at home restrictions. Paediatric and adolescent data to confirm this are unavailable in the Australian setting.

Methods

Retrospective electronic medical record review of all ED patients with mental health discharge codes at a large tertiary children's hospital in Australia during the period of stay at home restrictions from 1 April to 30 September 2020 compared with the same dates in 2019.

Results

We found a 40% decrease in ED presentations (18 935–11 235) with a concurrent 47% increase in mental health presentations (809–1190) to ED during the study periods between 2019 and 2020. This resulted in an increase of 100 mental health admissions from ED. Diagnoses with greatest percentage increases were eating disorders, social issues and suicidality. We found suicidality presentation numbers were highest in June to September 2020 compared with 2019. Patients with a diagnosis of suicidality had a higher rate of re‐presentation in 2020 (1.83 presentations per patient) compared to 2019 (1.38 presentations per patient).

Conclusions

Despite an overall decrease in ED presentations, the absolute increase in mental health presentations for children and adolescents during the stay at home restriction period was pronounced. It is unclear how sustained this change and the impact on mental health resource use will be post‐pandemic.

Experience of Healthcare Access in Australia during the First Year of the COVID-19 Pandemic

Changes in health-seeking behaviours and challenges in accessing care have been reported during the COVID-19 pandemic. This qualitative study examines Australian experiences related to healthcare access during the early months of the pandemic. The study aimed to identify key areas of concern as well as opportunities for services to prevent, manage and treat health concerns when normal access was disrupted. Fifty-nine semi-structured interviews were analysed. Participants were interviewed between August and December in 2020 over telephone or Zoom and were located across Australia. Rapid identification of themes with an audio recordings technique was used to generate themes from the data. Participants described a variety of influences on their health-seeking behaviours, resulting in decisions to delay care or being unable to reach care. Many individuals accessed health services via telehealth and offered a range of perceptions and views on its effectiveness and appropriateness. The findings illustrate that maintenance of health and access to healthcare and psychosocial support were compromised for some individuals, leading to negative impacts on both mental and physical health. This highlights the need to provide mechanisms to facilitate a person's ability to access care in a timely manner during a pandemic.

Impact of COVID-19 on a paediatric emergency service

COVID-19 has significantly affected the use of health care worldwide and, consequently, admissions to hospital emergency services. The aim of this study is to describe the change of the activity of a Paediatric Emergency Service (PES) of a tertiary hospital during the pandemic. A retrospective cohort study with analysis of visits to the PES from March 30 to June 30, 2020, and comparison with homologous periods in the previous 3 years (2017-2019).A total of 53,883 episodes were analysed, with a median age of 5.8 years, and 53% were boys. In 2020, there was a 60% reduction in the number of admissions (p < 0.001). There was a significant increase in referral by the public medical advice phone line of the National Health Service (NHS) (18.5% vs 5.4%) and Emergency Medical Services (EMS) (5.1% vs 4.2%). Urgent patients decreased (31.2% vs 38.3%), and non-urgent patients increased (7.5% vs 1.7%). There was a significant reduction in school (0.4% vs 7.1%) and sports accidents (0.1% vs 1.2%) and an increase in other accidents (falls, wounds, burns, and dog bites) (12.2% vs 6.3%). Hospitalisation rate was higher (5.7% vs 3.1%, p < 0.001). The infection rate for SARS-CoV-2 was 1.1%, all with mild illness or asymptomatic.Conclusion: The pandemic brought a marked reduction in emergency admissions and a decrease in urgent situations but an increase in accidents, such as falls, wounds, burns, and dog bites. Despite the low infection rate for SARS-CoV-2, there were increased referrals by the phone line of NHS and EMS and a higher admission in the ward. What is Known: • The number of admissions to emergency services significantly decreased during the COVID-19 pandemic, particularly in the paediatric population, whom has a milder disease than adults. • Diseases that justify urgent/emergent hospital admission continue to exist and the eventual delay in seeking health care might lead to a worse prognosis. What is New: • Despite the low rate of SARS-CoV-2 infection in children, there was an increase in referrals by the phone line of the National Health Service and Emergency Medical Services. • The global admission rate to the ward increased but there were no admissions to intensive care or deaths.

Impact of COVID-19 outbreak in acute bronchiolitis: Lesson from a tertiary Italian Emergency Department

AIM

To assess the impact of the coronavirus disease 2019 (COVID-19) outbreak on pediatric emergency department (ED) visits for acute bronchiolitis during the epidemic season.

METHODS

A retrospective analytical cross-sectional study was performed in our hospital, analyzing medical charts of all children under 2 years of age with a diagnosis of acute bronchiolitis admitted to our ED in the last years. Demographics and clinical data of patients affected with acute bronchiolitis during the 2020-2021 season-COVID-19 outbreak-were compared to those of the 5 previous years.

RESULTS

We observed an average drop of 84% of the rate of acute bronchiolitis managed by pediatricians in ED in 2020-2021 compared with bronchiolitis seasons of 5 previous years. We also reported, during the COVID-19 outbreak, a higher number of children affected by acute bronchiolitis referred to ED as Emergency Consultations who required hospitalization. Regarding etiological agents, no differences in respiratory virus circulation, especially RSV, were observed in the two groups. The multivariate analysis showed no correlation between the diagnosis of RSV bronchiolitis and COVID-19 period or prematurity; lower age was associated with an increased likelihood of exhibiting RSV bronchiolitis (odds ratio 0.9; 95% confidence interval 0.86-0.95 p < .01).

CONCLUSION

Our data emphasize the reduction in the rate of admission to pediatric ED for acute bronchiolitis during the COVID-19 outbreak, regardless of changes in circulating respiratory viruses. Therefore we want to highlight the importance of nonpharmacological preventive hygiene measures that should be maintained even at the end of the COVID-19 outbreak.

The impact of lockdown on pediatric ED visits and hospital admissions during the COVID19 pandemic: a multicenter analysis and review of the literature

The coronavirus disease 2019 pandemic has enormous impact on society and healthcare. Countries imposed lockdowns, which were followed by a reduction in care utilization. The aims of this study were to quantify the effects of lockdown on pediatric care in the Netherlands, to elucidate the cause of the observed reduction in pediatric emergency department (ED) visits and hospital admissions, and to summarize the literature regarding the effects of lockdown on pediatric care worldwide. ED visits and hospital admission data of 8 general hospitals in the Netherlands between January 2016 and June 2020 were summarized per diagnosis group (communicable infections, noncommunicable infections, (probable) infection-related, and noninfectious). The effects of lockdown were quantified with a linear mixed effects model. A literature review regarding the effect of lockdowns on pediatric clinical care was performed. In total, 126,198 ED visits and 47,648 admissions were registered in the study period. The estimated reduction in general pediatric care was 59% and 56% for ED visits and admissions, respectively. The largest reduction was observed for communicable infections (ED visits: 76%; admissions: 77%), whereas the reduction in noninfectious diagnoses was smaller (ED visits 36%; admissions: 37%). Similar reductions were reported worldwide, with decreases of 30-89% for ED visits and 19-73% for admissions.Conclusion: Pediatric ED utilization and hospitalization during lockdown were decreased in the Netherlands and other countries, which can largely be attributed to a decrease in communicable infectious diseases. Care utilization for other conditions was decreased as well, which may indicate that care avoidance during a pandemic is significant. What is Known: • The COVID-19 pandemic had enormous impact on society. • Countries imposed lockdowns to curb transmission rates, which were followed by a reduction in care utilization worldwide. What is New: • The Dutch lockdown caused a significant decrease in pediatric ED utilization and hospitalization, especially in ED visits and hospital admissions because of infections that were not caused by SARS-CoV-2. • Care utilization for noninfectious diagnoses was decreased as well, which may indicate that pediatric care avoidance during a pandemic is significant.

Emergency department presentations in the Southern District of New Zealand during the 2020 COVID-19 pandemic lockdown

OBJECTIVE

To assess changes in presentations to EDs during the COVID-19 pandemic lockdown in the Southern Region of New Zealand.

METHODS

We conducted a retrospective audit of patients attending EDs in the Southern District Health Board (SDHB), from 1 March to 13 May 2020. We made comparisons with attendances during the same period in 2019. The 2020 study period included 'pre-lockdown' (1 March-25 March), 'level 4 (strict) lockdown' (26 March-27 April) and 'level 3 (eased) lockdown' (28 April-13 May).

RESULTS

Patient volumes reduced in all SDHB EDs during levels 4 and 3, mostly representing a loss of low acuity patients (Australasian Triage Scale 3, 4 and 5), although high-acuity presentations also declined. Average patient age increased by 5 years; however, the proportions of sexes and ethnicities did not change. Presentations of cerebrovascular accidents and appendicitis did not change significantly. Trauma, mental health, acute coronary syndrome and infectious respiratory presentations decreased significantly during level 4, and infectious respiratory presentations decreased further in level 3.

CONCLUSIONS

Within the SDHB, patient volumes reduced during levels 4 and 3 of our lockdown, with reduced low-acuity presentations. High-acuity patient numbers also declined. Trauma, mental health, alcohol-related, infectious respiratory and acute coronary syndrome presentations declined while cerebrovascular accident and appendicitis numbers showed little to no change.

Paediatric presentations to Christchurch Hospital Emergency Department during COVID-19 lockdown

AIM

To describe the variation in volumes and types of paediatric presentations to a tertiary emergency department in New Zealand during the national level 4 lockdown for COVID-19.

METHODS

A retrospective, comparative cohort study in Christchurch Hospital Emergency Department, New Zealand.

RESULTS

There was a 37% reduction in all emergency presentations during the 33-day lockdown period. Paediatric presentations reduced significantly more than non-paediatric presentations (53% paediatric vs. 34% non-paediatric, P < 0.00001). The decrease in both overall and paediatric presentations was significantly different than similar periods in 2019 and 2018 (P < 0.00001). The proportion of New Zealand European paediatric presentations during lockdown increased by 6.09% (P = 0.01), while Pacific peoples decreased by 3.36% (P = 0.005). The proportion of <1-year-old presentations increased by 5.56% (P = 0.001), while 11-15 years decreased by 7.91% (P = 0.0001). Respiratory-related paediatric presentations decreased by 30% and proportional decreased by 4.92% (P = 0.001).

CONCLUSION

This study has identified a significant reduction in paediatric presentations to a tertiary emergency department in New Zealand during the national Alert Level 4 Lockdown for COVID-19. The proportional increase in the <1-year-old group may suggest a greater need for community-based child health services during the COVID-19 pandemic. Mental health support services may also need to adapt and expand to provide adequate psychological support for children during this crisis. Recognising the needs of these vulnerable groups will be critical during the ongoing COVID-19 pandemic in addition to informing response plans for similar events in the future.

Editors' Note and Special Communication: Research Priorities in Child and Adolescent Mental Health Emerging From the COVID-19 Pandemic

Over the last year, the coronavirus disease 2019 (COVID-19) pandemic has resulted in profound disruptions across the globe, with school closures, social isolation, job loss, illness, and death affecting the lives of children and families in myriad ways. In an Editors' Note in our June 2020 issue,¹ our senior editorial team described this Journal's role in advancing knowledge in child and adolescent mental health during the pandemic and outlined areas we identified as important for science and practice in our field. Since then, the Journal has published articles on the impacts of the pandemic on child and adolescent mental health and service systems,^2-5 which are available in a special collection accessible through the Journal's website.⁶ Alongside many opinion papers, the pace of publication of empirical research in this area is rapidly expanding, covering important issues such as increased frequency of mental health symptoms among children and adolescents^3,5,7-10 and changes in patterns of clinical service use such as emergency department visits.^11-14 As the Senior Editors prepared that Editors' Note, they were acutely aware that the priorities that they identified were broad and generated by only a small group of scientists and clinicians. Although this had the advantage of enabling us to get this information out to readers quickly, we decided that a more systematic approach to developing recommendations for research priorities would be of greater long-term value. We were particularly influenced by the efforts of the partnership between the UK Academy of Medical Scientists and a UK mental health research charity (MQ: Transforming Mental Health) to detail COVID-19-related research priorities for "Mental Health Science" that was published online by Holmes et al. in The Lancet Psychiatry in April 2020.¹⁵ Consistent with its focus on mental health research across the lifespan, several recommendations highlighted child development and children's mental health. However, a more detailed assessment of research priorities related to child and adolescent mental health was beyond the scope of that paper. Furthermore, the publication of that position paper preceded the death of George Floyd at the hands of Minneapolis police on May 25, 2020, which re-energized efforts to acknowledge and to address racism and healthcare disparities in the United States and many other countries. To build upon the JAACAP Editors' Note¹ and the work of Holmes et al.,¹⁵ we conducted an international survey of professionals-practitioners and researchers-working on child and adolescent development and pediatric mental health to identify concerns about the impact of the pandemic on children, adolescents, and their families, as well as what is helping families navigate these impacts, and the specific research topics that are of greatest importance.

The impact of the COVID-19 pandemic on child health and the provision of Care in Paediatric Emergency Departments: a qualitative study of frontline emergency care staff

Background

The COVID-19 pandemic and subsequent public health guidance to reduce the spread of the disease have wide-reaching implications for children’s health and wellbeing. Furthermore, paediatric emergency departments (EDs) have rapidly adapted provision of care in response to the pandemic. This qualitative study utilized insight from multidisciplinary frontline staff to understand 1) the changes in paediatric emergency healthcare utilization during COVID-19 2) the experiences of working within the restructured health system.

Methods

Fifteen semi-structured interviews were conducted with frontline staff working in two paediatric EDs and two mixed adult and children EDs. Participants included emergency medicine clinicians (n = 5), nursing managerial staff (n = 6), social workers (n = 2) and nursing staff (n = 2). Thematic Analysis (TA) was applied to the data to identify key themes.

Results

The pandemic and public health restrictions have had an adverse impact on children’s health and psychosocial wellbeing, compounded by difficulty in accessing primary and community services. The impact may have been more acute for children with disabilities and chronic health conditions and has raised child protection issues for vulnerable children. EDs have shown innovation and agility in the structural and operational changes they have implemented to continue to deliver care to children, however resource limitations and other challenges must be addressed to ensure high quality care delivery and protect the wellbeing of those tasked with delivering this care.

Conclusions

The spread of COVID-19 and subsequent policies to address the pandemic has had wide-reaching implications for children’s health and wellbeing. The interruption to health and social care services is manifesting in myriad ways in the ED, such as a rise in psychosocial presentations. As the pandemic continues to progress, policy makers and service providers must ensure the continued provision of essential health and social services, including targeted responses for those with existing conditions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-06284-9.

Effect of COVID-19 lockdown on hospital admissions and mortality in rural KwaZulu-Natal, South Africa: interrupted time series analysis

OBJECTIVE

To assess the effect of lockdown during the 2020 COVID-19 pandemic on daily all-cause admissions, and by age and diagnosis subgroups, and the odds of all-cause mortality in a hospital in rural KwaZulu-Natal (KZN).

DESIGN

Observational cohort.

SETTING

Referral hospital for 17 primary care clinics in uMkhanyakude District.

PARTICIPANTS

Data collected by the Africa Health Research Institute on all admissions from 1 January to 20 October: 5848 patients contributed to 6173 admissions.

EXPOSURE

Five levels of national lockdown in South Africa from 27 March 2020, with restrictions decreasing from levels 5 to 1, respectively.

OUTCOME MEASURES

Changes and trends in daily all-cause admissions and risk of in-hospital mortality before and at each stage of lockdown, estimated by Poisson and logistic interrupted time series regression, with stratification for age, sex and diagnosis.

RESULTS

Daily admissions decreased during level 5 lockdown for infants (incidence rate ratio (IRR) compared with prelockdown 0.63, 95% CI 0.44 to 0.90), children aged 1-5 years old (IRR 0.43, 95% CI 028 to 0.65) and respiratory diagnoses (IRR 0.57, 95% CI 0.36 to 0.90). From level 4 to level 3, total admissions increased (IRR 1.17, 95% CI 1.06 to 1.28), as well as for men >19 years (IRR 1.50, 95% CI 1.17 to 1.92) and respiratory diagnoses (IRR 4.26, 95% CI 2.36 to 7.70). Among patients admitted to hospital, the odds of death decreased during level 5 compared with prelockdown (adjusted OR 0.48, 95% CI 0.28 to 0.83) and then increased in later stages.

CONCLUSIONS

Level 5 lockdown is likely to have prevented the most vulnerable population, children under 5 years and those more severely ill from accessing hospital care in rural KZN, as reflected by the drop in admissions and odds of mortality. Subsequent increases in admissions and in odds of death in the hospital could be due to improved and delayed access to hospital as restrictions were eased.

Impact of lockdown and school closure on children's health and well-being during the first wave of COVID-19: a narrative review

BACKGROUND

In the context of containment measures against the COVID-19 pandemic, the aims were to examine the impact of lockdown and school closures on childs' and adolescents' health and well-being and social inequalities in health.

METHODS

Literature review by searching five databases until November 2020. We included quantitative peer-reviewed studies reporting health and well-being outcomes in children (0-18 years) related to closure measures' impact due to COVID-19. A pair of authors assessed the risk of bias of included studies. A descriptive and narrative synthesis was carried out.

FINDINGS

Twenty-two studies, including high-income, middle-income and low-income countries, fulfilled our search criteria and were judged not to have an increased risk of bias. Studies from Australia, Spain and China showed an increase in depressive symptoms and decrease in life satisfaction. A decrease in physical activity and increase in unhealthy food consumption were shown in studies from two countries. There was a decrease in the number of visits to the emergency department in four countries, an increase in child mortality in Cameroon and a decrease by over 50% of immunisations administered in Pakistan. A significant drop of 39% in child protection medical examination referrals during 2020 compared with the previous years was found in the UK, a decrease in allegations of child abuse and neglect by almost one-third due to school closures in Florida, and an increase in the number of children with physical child abuse trauma was found in one centre in the USA.

INTERPRETATION

From available reports, pandemic school closure and lockdown have adverse effects on child health and well-being in the short and probably long term. We urge governments to take the negative public health consequences into account before adopting restrictive measures in childhood.

WITHDRAWN: COVID-19 related acute decline in paediatric admissions in Malta, a population-based study

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Epidemiology and clinical features of emergency department patients with suspected and confirmed COVID-19: A multisite report from the COVID-19 Emergency Department Quality Improvement Project for July 2020 (COVED-3)

Objective

The aim of the present study was to describe the epidemiology and clinical features of patients presenting to the ED with suspected and confirmed COVID‐19.

Methods

The COVID‐19 ED (COVED) Project is an ongoing prospective cohort study in Australian EDs. This analysis presents data from eight sites across Victoria and Tasmania for July 2020 (during Australia's ‘second wave’). All adult patients who met criteria for ‘suspected COVID‐19’ and underwent testing for SARS‐CoV‐2 in the ED were eligible for inclusion. Study outcomes included a positive SARS‐CoV‐2 test result and mechanical ventilation.

Results

In the period 1 July to 31 July 2020, there were 30 378 presentations to the participating EDs and 2917 (9.6%; 95% confidence interval 9.3–9.9) underwent testing for SARS‐CoV‐2. Of these, 50 (2%) patients returned a positive result. Among positive cases, two (4%) received mechanical ventilation during their hospital admission compared to 45 (2%) of the SARS‐CoV‐2 negative patients (odds ratio 1.7, 95% confidence interval 0.4–7.3; P = 0.47). Two (4%) SARS‐CoV‐2 positive patients died in hospital compared to 46 (2%) of the SARS‐CoV‐2 negative patients (odds ratio 1.7, 95% confidence interval 0.4–7.1; P = 0.49). Strong clinical predictors of a positive SARS‐CoV‐2 result included self‐reported fever, non‐smoking status, bilateral infiltrates on chest X‐ray and absence of a leucocytosis on first ED blood tests (P < 0.05).

Conclusion

In this prospective multi‐site study from July 2020, a substantial proportion of ED patients required SARS‐CoV‐2 testing, isolation and enhanced infection prevention and control precautions. Presence of SARS‐CoV‐2 on nasopharyngeal swab was not associated with death or mechanical ventilation.