Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic - United States, January 2019-January 2022

Toxic Exposures in Children: A Review of Emergency Department Transfers to a Tertiary Pediatric Hospital

Objectives

Pediatric poisonings are a common emergency department (ED) presentation. In some instances, the first hospital may not have the capability to manage a pediatric patient beyond initial stabilization, requiring transfer to a tertiary children's hospital. This study aims to describe the clinical characteristics and outcomes of pediatric transfers following various xenobiotic exposures.

Methods

We performed a retrospective analysis of patients ≤18 years transferred to a tertiary children's hospital for any intentional or unintentional xenobiotic exposure between July 1, 2021 and June 30, 2023. An electronic data query was performed using specific keywords, and then, medical record reviews were conducted by a team of emergency medicine physicians and medical toxicologists. Information regarding exposure, interventions, and disposition was collected.

Results

A total of 544 patients were identified, and 167 were included in this analysis. The median age was 15 years (IQR: 5, 17). Of the 167 patients, 134 (80.2%) were admitted to the children's hospital. Acetaminophen was the most common exposure (n = 37, 22.2%), followed by polysubstance (n = 24, 14.3%) and tetrahydrocannabinol (n = 13, 7.8%). Intravenous normal saline bolus was the most common initial intervention. Forty-eight (28.8%) patients were directly admitted from the first ED, and 119 patients were ED to ED transfers. Of those, 86 (72.3%) patients were ultimately admitted from the second ED to an inpatient unit.

Conclusion

Most transferred patients were admitted, making these transfers clinically indicated and an appropriate use of resources. When comparing characteristics of admitted versus discharged patients, no clear difference beyond age was noted.

Increased incidence of intracranial complications following pediatric sinogenic and otogenic infections in the post-COVID-19 Era: A systematic review and meta-analysis

BACKGROUND

This systematic-review and meta-analysis aims to evaluate and summarize the prevalence of pediatric intracranial complications following sinogenic or otogenic infections before and after the COVID-19 pandemic.

METHODS

A literature search was performed using the PubMed, Scopus, and CINAHL databases to answer the question: In pediatric patients, was there an increase in the prevalence or severity of intracranial complications due to sinogenic or otogenic infections during and after the COVID-19 pandemic? Publications which included primary data on patients under the age of 18 years old, focusing on intracranial complications following otogenic and sinogenic infections were included.

RESULTS

Of 1025 abstracts screened, 18 studies were included. There were no significant differences in age or sex between the two cohorts. Compared to the pre-COVID era, post-COVID infections were more likely to have neurologic complications upon presentation [11.4 % (1.6-53.0) vs 50.1 % (13.9-86.2), p < 0.01], cerebral venous sinus thrombosis (CVST) [14.1 % (10.6-18.2) vs 40.5 % (25.2-56.9), p < 0.01], intraparenchymal abscess [40.3 % (43.9-72.2) vs 54.9 % (25.2-87.1), p < 0.01], and meningitis [10.6 % (0.0-39.4) vs 40.2 % (13.4-70.8), p < 0.01]. Metronidazole use [38.7 % (31.8-46.0) vs 71.9 % (51.3-88.6), p < 0.01], craniectomy [16.1 % (1.3-42.8) vs 37.4 % (2.9-83.0), p = 0.02], and burr holes [16.8 % (11.5-23.3) vs 26.6 % (12.7-43.3), p = 0.02] were increased in the post-COVID cohort.

CONCLUSION

There are considerable differences in neurologic deficits, CVST, intraparenchymal abscesses, meningitis, and treatment modalities in pre- and post-COVID cohorts of children with intracranial complications of otorhinogenic origin. Further research is required to determine the underlying mechanism for these differences.

Connecticut Pediatric Opioid Poisoning Trends Surrounding the COVID-19 Pandemic

OBJECTIVE

Opioids are common substances involved in poisonings with increasing rates in fentanyl-related mortality since 2014. The COVID-19 pandemic compromised school attendance and supervision, which may have increased the risk of opioid ingestions in children. Our objective was to evaluate pediatric opioid poisonings in Connecticut before and during the COVID-19 pandemic.

METHODS

This cross-sectional retrospective study used emergency department (ED) discharges involving children aged 0-17 years captured in the Connecticut Injury Surveillance System. International Classification of Diseases, 10th Revision, Clinical Modification codes were used to identify discharges involving opioids (T40.0-T40.4, T40.60, T40.69, F11). The χ 2 test was used to identify differences by pre-COVID (2017-2019) and COVID (2020-2022) periods. Rates were examined by age, sex, race/ethnicity, insurance, and discharge status.

RESULTS

There were 1,386,796 ED discharges during the study period. Less than 1% involved opioid (N = 257) or fentanyl (N = 31) poisonings; no discharges were coded for both. The rate of opioid poisonings decreased 28.6%, from 2.1 to 1.5 per 10,000 ED visits. Subanalysis showed that the rate of fentanyl poisonings remained the same (0.2 per 10,000 ED visits). The rate of opioid poisonings was highest among non-Hispanic White children during both periods. However, there was a 57.7% increase in the rate of opioid poisonings in non-Hispanic Black children. The rate decreased for all other race/ethnic groups.

CONCLUSIONS

Results of our study showed a rise in opioid poisonings among non-Hispanic Black and elementary school-aged children during the COVID-19 pandemic. Future prevention efforts may choose to further investigate and understand the trends in the more vulnerable groups.

Association between Unmet Social Need and Ambulatory Quality of Care for US Children

OBJECTIVES

Children who experience socioeconomic adversity often have worse health; however, less is known about their quality of care. We sought to evaluate the association between parent/caregiver-reported socioeconomic adversity and quality of pediatric primary, acute, and chronic ambulatory care on a national level.

METHODS

This was a retrospective cohort study of 5368 representative US children (1-17 years) in the 2021 Medical Expenditure Panel Survey. Socioeconomic adversity was defined as parent/caregiver-reported food, housing, transportation, or utility insecurity in the past 12 months. Outcomes included 10 quality measures of primary, acute, and chronic care, and experience of care measured through parent/caregiver survey. We described variation in socioeconomic adversity and used multivariable regression to examine associations with quality outcomes.

RESULTS

One-third of parent/caregivers reported socioeconomic adversity. Food insecurity (23.6%) was most common followed by utility (19.5%), housing (15.0%), and transportation (4.7%) insecurity. Black (53.2%) and Hispanic (46.9%) parent/caregivers experienced the highest rates of socioeconomic adversity. Children with socioeconomic adversity received lower quality of care for four quality measures, including more frequent Emergency Department visits (Odds Ratio (OR)= 1.69 [95% Confidence Interval (CI): 1.28-2.23]), less favorable asthma medication ratio (OR=0.04 [95% CI: 0.01-0.31]), and less frequent well child (OR=0.73 [95% CI: 0.59-0.90]) and dental care (OR=0.76 [95% CI: 0.63-0.94], P < .05 for all). There were no statistically significant differences in experience of care.

CONCLUSIONS

Socioeconomic adversity is common among US children with disproportionate impact on Black and Hispanic families. There are significant disparities in pediatric primary, acute, and chronic care quality, based on parent/caregiver-reported socioeconomic adversity, highlighting the need for systems-level interventions.

Medication Safety Counseling Practices of Pediatric Primary Care Clinicians

Medication exposures and poisonings are a major cause of pediatric morbidity and mortality. Unsafe patient practices are well documented despite the American Academy of Pediatrics recommending that pediatric primary care clinicians discuss medication safety with patients. Current clinician counseling practices for pediatric patients are unknown. Studies of adult patients suggest that physician counseling practices often focus on administration but not storage or disposal. To address this gap, we administered a web-based survey to clinically active pediatric primary care clinicians in two mid-Atlantic health care systems. Survey content focused on characteristics of medication safety counseling practices by age group, including safe medication storage, administration, and disposal. Of 151 clinicians emailed, 40 (26.5%) responded. The majority were physicians (93.5%), female (87.1%), and completed residency/clinical training in pediatrics >15 years ago (58.1%). Most (82.5%) reported having >1 pediatric patient (aged < 19 years) in their practice who experienced an unintentional or intentional medication exposure or poisoning event. Reported practices for medication safety counseling often varied by patient age but safe disposal was rarely addressed for any age group. Respondents generally felt less knowledgeable and less comfortable with providing counseling on safe disposal in comparison to safe storage and safe administration. Nearly all respondents (97%) would like to provide more counseling about medication safety, and the majority (81.3%) wanted additional educational resources. In this survey, we identified several modifiable deficits in pediatric medical counseling practices and a need for additional clinician training and resources, most notably in the content area of safe disposal.

Changing Epidemiology of Emergency Medical Services Calls for Children in the United States During the COVID-19 Pandemic and Reopening

OBJECTIVES

The objective of this study was to describe changes in the volume and types of emergency medical services (EMS) calls for children during the COVID-19 pandemic and after availability of the COVID-19 vaccine ("reopening period").

METHODS

A retrospective cross-sectional study of EMS 9-1-1 responses to children under 18 years for all causes over a 4-year period (2019-2022) reported in the National Emergency Medical Services Information System (NEMSIS) dataset. Data was stratified into three periods, Pre-pandemic, Pandemic and Reopening. We used generalized linear models to estimate the effect of the pandemic and reopening on daily call volume trends, on-scene mortality and scene disposition, correcting for seasonality and baseline effects. We performed subgroup analyses based on geographic region and diagnosis (trauma, respiratory, mental health, seizure, diabetes).

RESULTS

A total of 4,612,505 pediatric EMS 9-1-1 responses were included. Call volume for EMS showed an increasing pre-pandemic trend (+25.9%/year) followed by an acute drop in volume (-28.9%) and decreased trend (-13%/year) during the pandemic period and a rebound (+17.5%) during the reopening period that was generally conserved across all regions. Subgroup analysis by diagnosis showed similar trends among a wide variety of illnesses. There were increased odds of on-scene death for calls for traumatic (OR 1.77) and respiratory (OR 2.00) illnesses, with partial reversal in the respiratory group (OR 0.66) during the reopening period. During the pandemic, children were less likely to be transported (OR 0.70) and more likely to be non-transported (OR 1.30) and refuse care (OR 1.32), with partial reversal of these trends during the reopening period.

CONCLUSIONS

The pre-pandemic increase in EMS call volume was disrupted by an acute pandemic-related decline followed by a rebound during reopening. During the pandemic, children were more likely to present with more severe manifestations of disease processes, particularly increased on-scene death for trauma and respiratory illness, and less likely to be transported-with only partial reversal of trends in reopening.

Analysis of respiratory pathogens in pediatric acute respiratory infections in Lanzhou, Northwest China, 2019-2024

Objective

This study aimed to assess the prevalence and distribution of respiratory pathogens in children under 18 years old with Acute Respiratory Infections (ARTIs) in Lanzhou, Northwest China, from July 2019 to January 2024.

Methods

The respiratory pathogens studied were FluA, FluB, PIV, RSV, ADV, MP, CP, CB, and LP, detected by indirect immunofluorescence assay (IIF). Data were obtained from the laboratory information system (LIS) of the Lanzhou University Second Hospital. As in Lanzhou, NPIs were implemented in January 2020, and were lifted in December 2022, data were divided into pre-NPIs (July 2019 to December 2019), NPIs (January 2020 to December 2022) and post-NPIs (January 2023 to January 2024) periods for analysis. Pearson's chi-square test, ANOVA, and Fisher's exact test were used to evaluate statistical significance in variable differences, with P < 0.05 considered significant.

Results

A total of 29,659 children diagnosed with ARTIs were included in the study, with 13030(43.93%) test positive for at least one pathogen. Single-pathogen infections predominated (33.10%), while co-detection of MP and PIV was the most common among multi-pathogen cases (52.96%). Pathogen detection rates were notably higher in female children (50.62%) and preschool-aged children (53.45%) and exhibited seasonal variations, with a pronounced increase in winter (47.61%) and a peak in November (48.92%). MP had the highest detection rate (38.59%), followed by PIV (10.18%). Detection rates significantly increased following the lifting of NPIs, rising from 33.82% (SD ± 13.13) during NPIs to 64.42% (SD ± 4.67) (P < 0.001), with 2023 showing the highest detection rate (64.61%) and largest participant count (9,591). In November 2023, detection rates reached their highest level at 73.09%. Post-NPI, most pathogens, except CB and LP, demonstrated significantly higher prevalence (P<0.001).

Conclusion

In the Lanzhou region, MP and PIV were identified as the most prevalent respiratory pathogens among children with ARTIs, with peak detection rates during the winter season. Boys and school-age children exhibited higher susceptibility to these infections. NPIs played a critical role in reducing respiratory pathogen transmission. Once NPIs were lifted, a marked resurgence in pathogen incidence highlighted their impact on controlling infection spread.

Potentially Avoidable Emergency Department Transfers for Acute Pediatric Respiratory Illness

BACKGROUND

Acute pediatric respiratory illness is one of the most common reasons for emergency department (ED) transfer; however, few studies have examined predictors of potentially avoidable ED transfer (PAT) in this subpopulation. This study aimed to characterize patterns and predictors of PATs in children with acute respiratory illness.

METHODS

Cross-sectional analysis of 8,402,577 visits for patients ≤17 years from 2018 to 2019 Health Care Utilization Project State ED and Inpatient Datasets from New York, Maryland, Wisconsin, and Florida. ED transfers matched to a visit at a receiving facility with a primary diagnosis of pneumonia, croup/other upper respiratory infection (URI), bronchiolitis, or asthma were included. PAT was defined as discharge from receiving ED or within 24 hours of inpatient admission without specialized procedures, as previously described. PATs were compared with necessary transfers using a 3-level generalized linear mixed model with adjustment for patient and hospital covariates.

RESULTS

Among 4409 matched respiratory transfers, 25.5% were potentially avoidable. Most PATs originated from EDs within the third highest quartile of annual pediatric ED visits (n = 472, 42.0%). In the multivariable model, the likelihood of PAT was higher for patients with croup/other URI ((odds ratio) OR 2.72 (2.09-3.5) and if referring ED was in the highest quartile of annual pediatric ED volumes (OR 0.48 95% (confidence interval) CI 0.26-0.88).

CONCLUSIONS

Pediatric respiratory transfers with a diagnosis of croup/other URI were the most likely to be potentially avoidable. Future implementation efforts to reduce PATs should consider focusing on croup management in EDs in the lower 3 quartiles of pediatric volume.

Impact of COVID-19 on paediatric care in Japan: Analysis of national health insurance claims data

AIM

To quantify the impact of the COVID-19 pandemic on paediatric care use compared to adult care and identify affected subdomains.

METHODS

Data from the National Database of Health Insurance Claims and Specific Health Checkups of Japan (NDB) for six fiscal years (FY2016-2021) were analysed. Pre-pandemic (FY2016-FY2019) and pandemic years (FY2020, FY2021) were compared to delineate changes in medical services for paediatric and adult patients. Virtually all individuals who received medical care in Japan during this period were included.

RESULTS

In FY2019, healthcare utilisation by the paediatric population (under 15 years) accounted for 24% of 245 million first outpatient visits, 7% of 1.2 billion follow-up visits, and 2.6% of 297 million patient-days hospitalisations. In FY2020, outpatient visits of those aged 0-4 years decreased by 44% (first visit) and 24% (follow-up visit) compared to FY2019, and hospitalisations decreased by 47%, with the largest declines observed in community medical institutions across all age groups.

CONCLUSION

The COVID-19 pandemic led to a substantial reduction in paediatric healthcare utilisation in Japan, varying by age and type of care. These findings may inform the rational allocation of healthcare resources during public health emergencies.

Identified Needs in Pediatric Education for Emergency Medicine Physicians: A Qualitative Analysis

OBJECTIVES

General emergency medicine (EM) physicians provide most pediatric emergency care in the United States, yet EM physicians feel underprepared to manage pediatric emergencies. Pediatric emergency medicine (PEM) education during EM residency is variable, and learner preferences regarding educational experiences have not been widely explored through a qualitative lens. We aimed to better describe EM physicians' PEM educational needs and preferred teaching methods.

METHODS

In 2021, as part of a survey querying senior EM residents and recent graduates from 8 diverse EM programs regarding perceived preparedness for PEM emergencies, educational needs and content delivery methods were assessed using 2 free-text questions. Qualitative analysis included deidentification and iterative coding of the data with double coding of 100% of the comments. We performed conventional content analysis of responses to identify emerging themes.

RESULTS

The overall response rate for the survey was 53% (N = 129 out of 242 eligible participants) with 84 distinct free-text responses. Major themes included: 1) desire for education regarding neonates, infants, and critically ill children, especially airway management and 2) need for help translating lessons from PEM rotations to community EM practice. Respondents desired more autonomy during training. Their preferred PEM educational modality was simulation, and they appreciated online clinical pathways for just-in-time decision support.

CONCLUSIONS

This qualitative study of EM physicians proximal to training adds to a prior needs assessment by describing in detail desired pediatric content and preferred delivery. The findings can be used to better inform the development of PEM curricula for this group of EM physicians.

General emergency physician perceptions of caring for children: A qualitative interview study

Background

Emergency physicians care for most children presenting to U.S. emergency departments (EDs). Pediatric exposure during emergency medicine (EM) residency can be variable and critically ill children are rarely encountered. A recent needs assessment revealed that emergency physicians feel less prepared to manage various conditions in children and that infants, regardless of presenting complaint, pose particular challenges. Emergency physician perceptions of the experience of caring for pediatric patients have not been widely examined through a qualitative lens.

Methods

We designed an interview-based qualitative study to explore emergency physician perspectives on pediatric patient care. We recruited emergency physicians who graduated from residency in 2015-2019 and all rotated through the same large tertiary children's hospital. Four trained interviewers conducted in-depth, one-on-one virtual interviews. An interdisciplinary team transcribed and then coded the interviews. The team performed a conventional content analysis for themes. Recruitment continued until thematic saturation was achieved.

Results

Twelve participants completed interviews. These participants trained in five diverse residency programs. Likewise, the participants now practice in a variety of settings. Three major themes emerged from the data: (1) experience and exposure are key to establishing comfort caring for children; (2) simulation, pathways, and the pediatric anesthesia rotation are educationally useful; and (3) caring for children poses unique emotional challenges. Participants shared many recommendations for future pediatric education for EM trainees, including increasing autonomy and exposure to neonates and considering how care might differ in a community setting.

Conclusions

This interview-based qualitative study elucidates key themes in recently graduated emergency physicians' perceived experience of caring for children. Our findings have important educational implications for this group of emergency physicians and those who share similar experiences in training and practice.

Nontraumatic Pediatric Head and Neck Emergencies: Resource for On-Call Radiologists

The vast array of acute nontraumatic diseases encountered in the head and neck of pediatric patients can be intimidating for radiologists in training in a fast-paced emergency setting. Although there is some overlap of pediatric and adult diseases, congenital lesions and developmental variants are much more common in the pediatric population. Furthermore, the relative incidences of numerous infections and neoplasms differ between pediatric and adult populations. Young patients and/or those with developmental delays may have clinical histories that are difficult to elicit or nonspecific presentations, underscoring the importance of imaging in facilitating accurate and timely diagnoses. It is essential that radiologists caring for children be well versed in pediatric nontraumatic head and neck emergency imaging. The authors provide an on-call resource for radiology trainees, organized by anatomic location and highlighting key points, pearls, pitfalls, and mimics of many acute nontraumatic diseases in the pediatric head and neck. ©RSNA, 2024 Supplemental material is available for this article.

Emergency Department Visits Among Adolescents for Intentional Assault, Firearm, Poison, and Self-Harm Injuries Before and During the COVID-19 Pandemic in the United States

Purpose This study aimed to examine changes in adolescent emergency department (ED) visits for firearm, poison, self-harm, and intentional assault injuries before and during the COVID-19 pandemic and to identify sociodemographic factors influencing these variations. Methods Utilizing the Nationwide Emergency Department Sample (NEDS), the study analyzes data for intentional self-harm, poison-related, intentional assaults, and firearm injuries from 2019 to 2021 in adolescents aged 10 to 18 years. A difference-in-differences analysis was conducted to investigate the potential impacts of COVID-19 on injury-associated ED visits, accounting for adjustments related to year, patient factors, and hospital characteristics. Results There was a substantial decline in the number of all ED visits from pre-COVID to during the COVID, but we observed increases in the volume of ED visits for firearm-related injuries (13,248 to 20,611; p-value < 0.0001), poison-related injuries (147,812 to 213,753; p-Value < 0.0001), and intentional self-harm-related injuries (153,297 to 229,591; p-value < 0.0001). Conversely, intentional assault-related injuries decreased (167,614 to 154,940; p-value < 0.0001). During the COVID-19 pandemic, ED visits for intentional self-harm increased by 15% (95% CI = 1.09-1.21), intentional assault by 6% (95% CI = 1.02-1.09), and poison-related injuries by 17% (95% CI = 1.11-1.21) compared to pre-pandemic levels. Racial disparities were observed, with Black individuals having lower odds of self-harm (aOR = 0.63) and poison-related visits (aOR = 0.69) but higher odds of assault-related visits (aOR = 1.40) compared to Whites. Hispanic individuals had fewer ED visits across all injury types, while Native Americans had higher odds across all injury types. Disparities between Black and White individuals in assault-related visits narrowed during the pandemic (aOR = 1.40 to 0.94), but disparities for Native Americans in assault-related injuries widened. Insurance status influenced ED visits, with Medicaid recipients having higher odds of self-harm (aOR = 1.11) but lower odds of assault visits (aOR = 0.82) compared to those with private insurance. Uninsured adolescents had lower odds of self-harm (aOR = 0.85) and poison-related visits (aOR = 0.95), but higher odds of assault-related visits (aOR = 1.17). Gender disparities persisted, with females having higher odds of self-harm (aOR = 1.66) and poison-related visits (aOR = 1.42) but lower odds of assault-related visits (aOR = 0.91) compared to males, with these disparities widening for self-harm and poison-related visits during the pandemic. Conclusions The findings underscore the heightened vulnerability of adolescents to certain injuries during the COVID-19 pandemic. Targeted interventions and policies to support mental health, firearm safety measures, and strategies to prevent poisoning are recommended. Addressing socioeconomic disparities is necessary to mitigate the impact of intentional injuries among racially/ethnically diverse adolescents during future pandemics.

Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study

OBJECTIVES

Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap.

METHODS

A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability.

RESULTS

Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort.

CONCLUSIONS

It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland

PURPOSE

The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare.

METHODS

We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling.

RESULTS

Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4 years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic.

CONCLUSIONS

The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4 years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.

Investigating the Spatial Accessibility and Coverage of the Pediatric COVID-19 Vaccine: An Ecologic Study of Regional Health Data

The COVID-19 pandemic presented the unique challenge of having to deliver novel vaccines during a public health crisis. For pediatric patients, it was further complicated by the delayed timeline for authorizing the vaccine and the differences in dosing/products depending on the patient's age. This paper investigates the relationship between the spatial accessibility and uptake of the COVID-19 vaccine in King County, WA, USA. Public data for COVID-19 vaccine sites were used to calculate spatial accessibility using an enhanced two-step floating catchment area (E2SFCA) technique. Spatial regression analyses were performed to look at the relationship between spatial accessibility and ZIP-code-level vaccination rates. The relationships of these data with other socioeconomic and demographic variables were calculated as well. Higher rates of vaccine accessibility and vaccine coverage were found in adolescent (12- to 17-year-old) individuals relative to school-age (5- to 11-year-old) individuals. Vaccine accessibility was positively associated with coverage in both age groups in the univariable analysis. This relationship was affected by neighborhood educational attainment. This paper demonstrates how measures such as E2SFCA can be used to calculate the accessibility of the COVID-19 vaccine in a region and provides insight into some of the ecological factors that affect COVID-19 vaccination rates.

Diagnostic testing for chest pain in a pediatric emergency department and rates of cardiac disease before and during the COVID-19 pandemic: a retrospective study

Objectives

Chest pain is a common chief complaint in pediatric emergency departments (EDs). Coronavirus disease-2019 (COVID-19) has been shown to increase the risk of cardiac disease. It remains unclear how COVID-19 changed how pediatric emergency clinicians approach patients presenting with chest pain. The goal of this study was to characterize the diagnostic testing for chest pain in a pediatric ED before and during the COVID-19 pandemic.

Methods

This was a retrospective study of children between the ages of 2-17 years presenting to a pediatric ED from 1/1/2018-2/29/2020 (Pre-COVID-19) and 3/1/2020-4/30/2022 (COVID-19) with chest pain. We excluded patients with a previous history of cardiac disease.

Results

Of the 10,721 encounters during the study period, 5,692 occurred before and 5,029 during COVID-19. Patient demographics showed minor differences by age, weight, race and ethnicity. ED encounters for chest pain consisted of an average of 18% more imaging studies during COVID-19, including 14% more EKGs and 11% more chest x-rays, with no difference in the number of echocardiograms. Compared to Pre-COVID-19, 100% more diagnostic tests were ordered during COVID-19, including cardiac markers Troponin I (p < 0.001) and BNP (p < 0.001). During COVID-19, 1.1% of patients had a cardiac etiology of chest pain compared with 0.7% before COVID-19 (p = 0.03).

Conclusions

During COVID-19, pediatric patients with chest pain underwent more diagnostic testing compared to Pre-COVID-19. This may be due to higher patient acuity, emergence of multisystem inflammatory syndrome in children (MIS-C) that necessitated more extensive testing and possible changes in ED clinician behavior during COVID-19.

Examining the Effectiveness of a Digital Media Campaign at Reducing the Duration of Untreated Psychosis in New York State: Results From a Stepped-wedge Randomized Controlled Trial

BACKGROUND AND HYPOTHESIS

Longer duration of untreated psychosis (DUP) predicts worse outcomes in First Episode Psychosis (FEP). Searching online represents one of the first proactive step toward treatment initiation for many, yet few studies have informed how best to support FEP youth as they engage in early online help-seeking steps to care.

STUDY DESIGN

Using a stepped-wedge randomized design, this project evaluated the effectiveness of a digital marketing campaign at reducing DUP and raising rates of referrals to FEP services by proactively targeting and engaging prospective patients and their adult allies online.

STUDY RESULTS

Throughout the 18-month campaign, 41 372 individuals visited our website, and 371 advanced to remote clinical assessment (median age = 24.4), including 53 allies and 318 youth. Among those assessed (n = 371), 53 individuals (14.3%) reported symptoms consistent with psychotic spectrum disorders (62.2% female, mean age 20.7 years) including 39 (10.5%) reporting symptoms consistent with either Clinical High Risk (ie, attenuated psychotic symptoms; n = 26) or FEP (n = 13). Among those with either suspected CHR or FEP (n = 39), 20 (51.3%) successfully connected with care. The campaign did not result in significant differences in DUP.

CONCLUSION

This study highlights the potential to leverage digital media to help identify and engage youth with early psychosis online. However, despite its potential, online education and professional support alone are not yet sufficient to expedite treatment initiation and reduce DUP.

Trends in emergency department visits for bronchiolitis, 1993-2019

INTRODUCTION

Bronchiolitis is a leading indication for pediatric emergency department (ED) visits and hospitalizations. Our objective was to provide a comprehensive review of national trends and epidemiology of ED visits for bronchiolitis from 1993 to 2019 in the United States.

METHODS

We retrospectively reviewed the National Hospital Ambulatory Medical Care Survey (NHAMCS) reporting of ED visits for bronchiolitis for children age <2 years from 1993 to 2019. Bronchiolitis cases were identified using billing codes assigned at discharge. The primary outcome was bronchiolitis ED visit rates, calculated using NHAMCS-assigned patient visit weights. We then evaluated for temporal variation in patient characteristics, facility location, and hospitalizations among the bronchiolitis ED visits.

RESULTS

There were an estimated 8 million ED visits for bronchiolitis for children <2 years between 1993 and 2019. Bronchiolitis ED visits rates ranged from 28 to 36 per 1000 ED visits from 1993 to 2010 and increased significantly to 65 per 1000 ED visits in the 2017-2019 time period (p < 0.001). There was no significant change over time in patient age, sex, race and ethnicity, insurance status, hospital type, or triage level upon ED presentation. Approximately half of bronchiolitis ED visits occurred in the winter months throughout the study period.

CONCLUSION

In this analysis of 27 years of national data, we identified a recent rise in ED visit rates for bronchiolitis, which have almost doubled from 2010 to 2019 following a period of relative stability between 1993 and 2010.

Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

Benralizumab in children with severe eosinophilic asthma: Pharmacokinetics and long-term safety (TATE study)

BACKGROUND

Benralizumab is an anti-interleukin-5 receptor α monoclonal antibody approved as an add-on maintenance treatment for patients with uncontrolled severe asthma. Prior Phase 3 studies have evaluated benralizumab in patients aged ≥12 years with severe uncontrolled asthma. The TATE study evaluated the pharmacokinetics (PK), pharmacodynamics (PD), and safety of benralizumab treatment in children.

METHODS

TATE was an open-label, Phase 3 study of benralizumab in children aged 6-11 years from the United States and Japan (plus participants aged 12-14 years from Japan) with severe eosinophilic asthma. Participants received benralizumab 10/30 mg according to weight (<35/≥35 kg). Primary endpoints included maximum serum concentration (Cmax ), clearance, half-life (t1/2 ), and blood eosinophil count. Clearance and t1/2 were derived from a population PK (popPK) analysis. Safety and tolerability were also assessed.

RESULTS

Twenty-eight children aged 6-11 years were included, with an additional two participants from Japan aged 12-14 years also included in the popPK analysis. Mean Cmax was 1901.2 and 3118.7 ng/mL in the 10 mg/<35 kg and 30 mg/≥35 kg groups, respectively. Clearance was 0.257, and mean t1/2 was 14.5 days. Near-complete depletion of blood eosinophils was shown across dose/weight groups. Exploratory efficacy analyses found numerical improvements in mean FEV1 , mean ACQ-IA, patient/clinician global impression of change, and exacerbation rates. Adverse events occurred in 22/28 (78.6%) of participants; none led to discontinuation/death.

CONCLUSION

PK, PD, and safety data support long-term benralizumab in children with severe eosinophilic asthma, and were similar to findings in adolescents and adults.

TRIAL REGISTRATION

ClinicalTrials.gov-ID: NCT04305405.

Impact of virtual care on planned rechecks in a pediatric emergency department: a quality improvement project

BACKGROUND

In the absence of accessible urgent follow-up options, emergency physicians may use an in-person recheck (planned return visit) to the Emergency Department (ED) as a safety net for discharged patients. In-person rechecks require travel, triage, and waiting time for patients and families and contribute to ED census. Many of these visits do not result in further investigation or changes in management but can provide reassurance for the family and care providers. We aimed to reduce the volume of in-person rechecks to our ED through an urgent virtual follow-up process.

METHODS

We conducted a quality improvement project using iterative process mapping and Plan-Do-Study-Act cycles to develop and implement a new model of care for virtual rechecks. An interdisciplinary team tested and refined the virtual care process from December 2020 to June 2022. Outcome, process and balancing measures were tracked continuously and analyzed using statistical process control.

RESULTS

Baseline data revealed that the majority of in-person rechecks were for young infants with bronchiolitis. Post-implementation of the new process, 50% of all virtual rechecks were for respiratory illnesses. Use of virtual rechecks increased steadily to an average of 6.5 per 1000 ED visits with 58% of all rechecks now completed virtually. The number of in-person rechecks did not decrease during the study period. Virtual rechecks triggered an in-person ED visit in 5.2% of virtual recheck instances. There was no increase in unplanned return ED visits or admissions after implementation of virtual rechecks.

CONCLUSION

Virtual rechecks can be safely implemented to allow urgent reassessment of patients following an ED visit. Virtual rechecks could be a useful tool for addressing planned reassessments in the pediatric ED, especially during surges of respiratory illness.

Characteristics of pediatric behavioral health emergencies in the prehospital setting

OBJECTIVE

Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters.

METHODS

We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use.

RESULTS

Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61).

CONCLUSIONS

Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

Incidence of Pediatric Urinary Tract Infections Before and During the COVID-19 Pandemic

IMPORTANCE

Urinary tract infection (UTI) is common in children, but the population incidence is largely unknown. Controversy surrounds the optimal diagnostic criteria and how to balance the risks of undertreatment and overtreatment. Changes in health care use during the COVID-19 pandemic created a natural experiment to examine health care use and UTI diagnosis and outcomes.

OBJECTIVES

To examine the population incidence of UTI in children and assess the changes of the COVID-19 pandemic regarding UTI diagnoses and measures of UTI severity.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective observational cohort study used US commercial claims data from privately insured patients aged 0 to 17 years from January 1, 2016, to December 31, 2021.

EXPOSURE

Time periods included prepandemic (January 1, 2016, to February 29, 2020), early pandemic (April 1 to June 30, 2020), and midpandemic (July 1, 2020, to December 31, 2021).

MAIN OUTCOMES AND MEASURES

The primary outcome was the incidence of UTI, defined as having a UTI diagnosis code with an accompanying antibiotic prescription. Balancing measures included measures of UTI severity, including hospitalizations and intensive care unit admissions. Trends were evaluated using an interrupted time-series analysis.

RESULTS

The cohort included 13 221 117 enrollees aged 0 to 17 years, with males representing 6 744 250 (51.0%) of the population. The mean incidence of UTI diagnoses was 1.300 (95% CI, 1.296-1.304) UTIs per 100 patient-years. The UTI incidence was 0.86 per 100 patient-years at age 0 to 1 year, 1.58 per 100 patient-years at 2 to 5 years, 1.24 per 100 patient-years at 6 to 11 years, and 1.37 per 100 patient-years at 12 to 17 years, and was higher in females vs males (2.48 [95% CI, 2.46-2.50] vs 0.180 [95% CI, 0.178-0.182] per 100 patient-years). Compared with prepandemic trends, UTIs decreased in the early pandemic: -33.1% (95% CI, -39.4% to -26.1%) for all children and -52.1% (95% CI, -62.1% to -39.5%) in a subgroup of infants aged 60 days or younger. However, all measures of UTI severity decreased or were not significantly different. The UTI incidence returned to near prepandemic rates (-4.3%; 95% CI, -32.0% to 34.6% for all children) after the first 3 months of the pandemic.

CONCLUSIONS AND RELEVANCE

In this cohort study, UTI diagnosis decreased during the early pandemic period without an increase in measures of disease severity, suggesting that reduced overdiagnosis and/or reduced misdiagnosis may be an explanatory factor.

Parenting During the COVID-19 Pandemic

Parenting during the COVID-19 pandemic was an unprecedented experience for many families around the world. With the sudden closure of schools and child care centers and the implementation of stay-at-home orders, parents were required to adjust to a new normal, one that required them to take on numerous responsibilities, all with diminished levels of social support. These changes resulted in a wide range of experiences, from feelings of overwhelm and stress to gratitude for time that was often not a reality in the hustle-bustle of everyday life in pre-pandemic times. This chapter discusses parenting during the COVID-19 pandemic, reviewing the impact on parental mental health, the impact on the parent-child relationship, and the implications for families and societal support.

Sustainably Implementing Social Determinants of Health Interventions in the Pediatric Emergency Department

This Viewpoint discusses 5 principal challenges and opportunities for the sustainable implementation of social determinants of health interventions in emergency department settings.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study

OBJECTIVES

The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services.

METHODS

This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs.

RESULTS

The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled.

CONCLUSION

Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.

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.

Shifts in ophthalmic care utilization during the COVID-19 pandemic in the US

BACKGROUND

Healthcare restrictions during the COVID-19 pandemic, particularly in ophthalmology, led to a differential underutilization of care. An analytic approach is needed to characterize pandemic health services usage across many conditions.

METHODS

A common analytical framework identified pandemic care utilization patterns across 261 ophthalmic diagnoses. Using a United States eye care registry, predictions of utilization expected without the pandemic were established for each diagnosis via models trained on pre-pandemic data. Pandemic effects on utilization were estimated by calculating deviations between observed and expected patient volumes from January 2020 to December 2021, with two sub-periods of focus: the hiatus (March-May 2020) and post-hiatus (June 2020-December 2021). Deviation patterns were analyzed using cluster analyses, data visualizations, and hypothesis testing.

RESULTS

Records from 44.62 million patients and 2455 practices show lasting reductions in ophthalmic care utilization, including visits for leading causes of visual impairment (age-related macular degeneration, diabetic retinopathy, cataract, glaucoma). Mean deviations among all diagnoses are 67% below expectation during the hiatus peak, and 13% post-hiatus. Less severe conditions experience greater utilization reductions, with heterogeneities across diagnosis categories and pandemic phases. Intense post-hiatus reductions occur among non-vision-threatening conditions or asymptomatic precursors of vision-threatening diseases. Many conditions with above-average post-hiatus utilization pose a risk for irreversible morbidity, such as emergent pediatric, retinal, or uveitic diseases.

CONCLUSIONS

We derive high-resolution insights on pandemic care utilization in the US from high-dimensional data using an analytical framework that can be applied to study healthcare disruptions in other settings and inform efforts to pinpoint unmet clinical needs.

Telehealth: Navigating the COVID-19 Pandemic and Beyond: The Sickle Cell Unit Experience

Introduction: To examine the use of telehealth for delivery of health care in persons with sickle cell disease in a resource-constrained country during the COVID-19 pandemic. Methods: This study was a retrospective review of patient encounters at the Sickle Cell Unit (SCU), Jamaica during a 3-year period, March 10, 2019 to March 9, 2022 and a comparison of endpoints between 1 year before and 2 years during the pandemic. Primary endpoints of registration numbers, day-care admissions, and study visits were obtained from logbooks and the electronic medical records. Additional endpoints included well visits, hydroxyurea (HU) visits, and bone pain crisis. Results: Patients registered at the clinic on 17,295 occasions, with 7,820 in the pre-pandemic year decreasing by 43.8% and 35% in the 2 subsequent pandemic years. Overall, study visits increased by 4.9% and 1.3% in the pandemic years. They increased in adults by 13.1% and 8.9% but fell by 3.2% and 6.2% in children. Fewer people were seen in the pandemic years, with children showing a 20.7% decline in numbers. Tele-visits accounted for 31.4% of all study visits during the pandemic years and increased by 23.6% between the pandemic years. There were more well-visits and HU visits, but fewer pain visits and day-care admissions in the pandemic years. Conclusions: The SCU maintained health care delivery for a high-risk population during the pandemic, with tele-visits mitigating the short-fall from in-person visits. Tele-visits may be more acceptable to adults with a chronic illness and may be a suitable alternative for delivering health care.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019)

STUDY OBJECTIVE

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.

RESULTS

In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.

CONCLUSION

Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Addressing the Pediatric Mental Health Crisis in Emergency Departments in the US: Findings of a National Pediatric Boarding Consensus Panel

BACKGROUND

In 2021, several professional organizations declared a national state of emergency in child and adolescent mental health. Rising volume and acuity of pediatric mental health emergencies, coupled with reduced access to inpatient psychiatric care, has caused tremendous downstream pressures on EDs resulting in long lengths of stay, or "boarding", for youth awaiting psychiatric admission. Nationally, boarding times are highly heterogeneous, with medical / surgical patients experiencing much shorter boarding times compared to patients with primary mental health needs. There is little guidance on best practices in the care of the pediatric patient with significant mental health need "boarding" in the hospital setting.

OBJECTIVE

There is a significant increase in the practice of "boarding" pediatric patients within emergency departments and inpatient medical floors while awaiting psychiatric admission. This study aims to provide consensus guidelines for the clinical care of this population.

METHODS

Twenty-three panel participants of fifty-five initial participants (response rate 41.8%) committed to completing four successive rounds of questioning using Delphi consensus gathering methodology. Most (70%) were child psychiatrists and represented 17 health systems.

RESULTS

Thirteen participants (56%) recommended maintaining boarded patients in the emergency department, while 78% indicated a temporal limit on boarding in the emergency department should prompt transfer to an inpatient pediatric floor. Of this group, 65% recommended a 24-hour threshold. Most participants (87%) recommended not caring for pediatric patients in the same space as adults. There was unanimous agreement that emergency medicine or hospitalists maintain primary ownership of patient care, while 91% agreed that child psychiatry should maintain a consultative role. Access to social work was deemed most important for staffing, followed by behavioral health nursing, psychiatrists, child life, rehabilitative services, and lastly, learning specialists. There was unanimous consensus that daily evaluation is necessary with 79% indicating vitals should be obtained every 12 hours. All agreed that if a child psychiatric provider is not available on-site, a virtual consultation is sufficient to provide mental health assessment.

CONCLUSIONS

This study highlights findings of the first national consensus panel regarding the care of youth boarding in hospital-based settings and provides promising beginnings to standardizing clinical practice while informing future research efforts.

National trends in prehospital penetrating trauma in 2020 and 2021

OBJECTIVE

Prior studies identified increased penetrating trauma rates during the earlier phase of the COVID-19 pandemic, but there is limited study of penetrating trauma rates in 2021 or at a national level. We evaluated trends in prehospital encounters for penetrating trauma in 2020 and 2021 using a national database.

METHODS

We conducted a retrospective analysis of the National Emergency Medicinal Services (EMS) Information System (NEMSIS) combined 2018-2021 databases of prehospital encounters. We calculated penetrating trauma yearly and monthly rates with 95% confidence; both overall and for each census region. We compared trauma rates in 2020 and 2021 to combined 2018/2019.

RESULTS

There were 67,457 (rate of 0.30%) penetrating traumas in 2018, 86,054 (0.30%) in 2019, 95,750 (0.37%) in 2020, and 98,040 (0.34%) in 2021. Nationally, trauma rates were higher from March 2020 to July 2021 than baseline. Penetrating trauma rates from May-December 2021 were lower than May-December of 2020. All census regions similarly had increased trauma rates during from March 2020 to July 2021.

CONCLUSION

We identified elevated rates of trauma on 2020 that lasted until July of 2021 that was present in all US census regions.

Inter-hospital Variation in COVID-19 Era Pediatric Hospitalizations by Age Group and Diagnosis

BACKGROUND

Mitigation strategies and public responses to coronavirus disease 2019 (COVID-19) varied geographically and may have differentially affected burden of pediatric disease and hospitalization practices. We aimed to quantify hospital-specific variation in hospitalizations during the COVID-19 era.

METHODS

Using Pediatric Health Information Systems data from 44 Children's Hospitals, this retrospective multicenter analysis compared hospitalizations of children (1 day-17 years) from the COVID-19 era (March 1, 2020-June 30, 2021) to prepandemic (January 1, 2017-December 31, 2019). Variation in the magnitude of hospital-specific decline between eras was determined using coefficients of variation (CV). Spearman's test was used to assess correlation of variation with community and hospital factors.

RESULTS

The COVID-19 era decline in hospitalizations varied between hospitals (CV 0.41) and was moderately correlated with declines in respiratory infection hospitalizations (r = 0.69, P < .001). There was no correlation with community or hospital factors. COVID-19 era changes in hospitalizations for mental health conditions varied widely between centers (CV 2.58). Overall, 22.7% of hospitals saw increased admissions for adolescents, and 29.5% saw increases for newborns 1 to 14 days, representing significant center-specific variation (CV 2.30 for adolescents and 1.98 for newborns).

CONCLUSIONS

Pandemic-era change in hospitalizations varied across institutions, partially because of hospital-specific changes in respiratory infections. Residual variation exists for mental health conditions and in groups least likely to be admitted for respiratory infections, suggesting that noninfectious conditions may be differentially and uniquely affected by local policies and hospital-specific practices enacted during the COVID-19 era.

Seasonal Trends in Emergency Department Visits for Mental and Behavioral Health Conditions Among Children and Adolescents Aged 5-17 Years - United States, January 2018-June 2023

Mental and behavioral health conditions among school-aged children, including substance use disorders and overall emotional well-being, are a public health concern in the United States. Timely data on seasonal patterns in child and adolescent conditions can guide optimal timing of prevention and intervention strategies. CDC examined emergency department (ED) visit data from the National Syndromic Surveillance Program for 25 distinct conditions during January 2018-June 2023 among U.S. children and adolescents aged 5-17 years, stratified by age group. Each year, during 2018-2023, among persons aged 10-14 and 15-17 years, the number and proportion of weekly ED visits for eight conditions increased in the fall school semester and remained elevated throughout the spring semester; ED visits were up to twice as high during school semesters compared with the summer period. Among children aged 5-9 years, the number and proportion of visits increased for five mental and behavioral health conditions. Seasonal increases in ED visits for some conditions among school-aged children warrant enhanced awareness about mental distress symptoms and the challenges and stressors in the school environment. Systemic changes that prioritize protective factors (e.g., physical activity; nutrition; sleep; social, community, or faith-based support; and inclusive school and community environments) and incorporate preparedness for increases in conditions during back-to-school planning might improve child and adolescent mental health.

The long-term boomerang effect of COVID-19 on admissions for non-COVID diseases: the ECIEN-2022 study

Since COVID-19 pandemic started, many changes have been seen in the cycling patterns of pediatric pathologies. On year 2020, we described the initial effects of COVID-19, with a significant decrease in emergency visits and admissions, but 2 years later the situation seems to be reversed. Our study bridges a literature gap by exploring the lasting effects of COVID-19 on pediatric non-COVID admissions, particularly the resurgence of respiratory illnesses. ECIEN-2022 is a single-center, retrospective, observational-study conducted 3 years after the pandemic onset, to describe the long-term effects of COVID-19 in pediatric admissions for non-COVID diseases. Admissions during year 2022 were compared with the Pre-Pandemic Period (PPP: 2015-2019). Pediatric Emergency Department (P-ED) visits, hospital, and Intensive Care Unit (P-ICU) admissions were compared across pre- and post-pandemic periods. Monthly distribution and year-waves are presented. P-ED monthly visits (mean and Standard deviation (SD) raised from 3521 (533) in the PPP to 3775 (996) in 2022 (p < 0.001). Monthly hospital admissions in the 3rd quarter of the Pre-Pandemic Period were 111.7/month (SD:29), dropped to 88.5(SD:6.5) in 2020 and raised to 149(SD:38.8) in 2022 (p = 0.036). An increase in respiratory illnesses was observed in 2022 compared to PPP; Bronchiolitis increased 38%, bronchitis 56%, and admissions for Respiratory Syncytial Virus 67%.  Conclusion: COVID-19 pandemic has had a significant impact on the use and nature of pediatric health services. The initial decrease has been followed by a boomerang effect with an increase of cases, mainly due to an increase in respiratory infections when pandemic control measures and social restrictions have been lifted. It is essential to maintain an active surveillance and monitorization of these patterns to ensure appropriate healthcare access and utilization. What is Known: • COVID-19 pandemic initially led to a significant decrease in emergency visits and admissions for non-COVID diseases. What is New: • ECIEN-2022 study investigated the long-term effects of COVID-19 on pediatric admissions for non-COVID diseases, detecting a "boomerang effect" with an increase in pediatric admissions for non-COVID diseases in year 2022. • Pediatric Emergency Department visits and hospital admissions for non-COVID diseases, especially those due to respiratory infections, increased significantly in 2022 when compared to the Pre-Pandemic Period.

Firearm Injuries in Lower Opportunity Neighborhoods During the COVID Pandemic

OBJECTIVES

We aimed to describe changes in pediatric firearm injury rates, severity, and outcomes after the coronavirus disease 2019 stay-at-home order in Los Angeles (LA) County.

METHODS

A multicenter, retrospective, cross-sectional study was conducted on firearm injuries involving children aged <18-years in LA County before and after the pandemic. Trauma activation data of 15 trauma centers in LA County from the Trauma and Emergency Medicine Information System Registry were abstracted from January 1, 2018, to December 31, 2021. The beginning of the pandemic was set as March 19, 2020, the date the county stay-at-home order was issued, separating the prepandemic and during-pandemic periods. Rates of firearm injuries, severity, discharge capacity, and Child Opportunity Index (COI) were compared between the groups. Analysis was performed with χ2 tests and segmented regression.

RESULTS

Of the 7693 trauma activations, 530 (6.9%) were from firearm injuries, including 260 (49.1%) in the prepandemic group and 270 (50.9%) in the during-pandemic group. No increase was observed in overall rate of firearm injuries after the stay-at-home order was issued (P = .13). However, firearm injury rates increased in very low COI neighborhoods (P = .01). Mechanism of injury, mortality rates, discharge capacity, and injury severity score did not differ between prepandemic and during-pandemic periods (all P values ≥.05).

CONCLUSIONS

Although there was no overall increase in pediatric firearm injuries during the pandemic, there was a disproportionate increase in areas of very low neighborhood COI. Further examination of community disparity should be a focus for education, intervention, and development.

Perspectives on preparedness for pediatric emergencies after residency: A needs assessment

Background

General emergency physicians provide most pediatric emergency care in the United States yet report more challenges managing emergencies in children than adults. Recommendations for standardized pediatric emergency medicine (PEM) curricula to address educational gaps due to variations in pediatric exposure during emergency medicine (EM) training lack learner input. This study surveyed senior EM residents and recent graduates about their perceived preparedness to manage pediatric emergencies to better inform PEM curricula design.

Methods

In 2021, senior EM residents and graduates from the classes of 2020 and 2019 across eight EM programs with PEM rotations at the same children's hospital were recruited and surveyed electronically to assess perceived preparedness for 42 pediatric emergencies and procedures by age: infants under 1 year, toddlers, and children over 4 years. Preparedness was reported on a 5-point Likert scale with 1 or 2 defined as "unprepared." A chi-square test of independence compared the proportion of respondents unprepared to manage each condition across age groups, and a p-value < 0.05 demonstrated significance.

Results

The response rate was 53% (129/242), with a higher response rate from senior residents (65%). Respondents reported feeling unprepared to manage more emergency conditions in infants compared to other age groups. Respondents felt least prepared to manage inborn errors of metabolism and congenital heart disease, with 45%-68% unprepared for these conditions across ages. A heat map compared senior residents to recent graduates. More graduates reported feeling unprepared for major trauma, impending respiratory failure, and pediatric advanced life support algorithms.

Conclusions

This study, describing the perspective of EM senior residents and recent graduates, offers unique insights into PEM curricular needs during EM training. Future PEM curricula should target infant complaints and conditions with lower preparedness scores across ages. Other centers training EM residents could use our findings and methods to bolster PEM curricula.

Impacts of routine varicella vaccination program and COVID-19 pandemic on varicella and herpes zoster incidence and health resource use among children in Japan

PURPOSE

To determine the epidemiological trends in pediatric varicella and herpes zoster incidence and changes in healthcare resource use from 2005 to 2022 using a nationally representative database in Japan.

MATERIALS AND METHODS

We conducted a retrospective observational study consisting of 3.5 million children with 177 million person-months during 2005-2022 using Japan Medical Data Center (JMDC) claims database in Japan. We investigated trends in incidence rates of varicella and herpes zoster and changes in healthcare resource use (e.g., antiviral use, office visits, and healthcare costs) over 18 years. Interrupted time-series analyses were used to investigate the impact of the routine varicella vaccination program in 2014 and infection prevention measures against COVID-19 on incidence rates of varicella and herpes zoster and related healthcare utilization.

RESULTS

After the introduction of the routine immunization program in 2014, we observed level changes in incidence rates (45.6 % reduction [95 %CI, 32.9-56.0] of varicella cases, antiviral use (40.9 % reduction [95 %CI, 25.1-53.3]), and relevant healthcare costs (48.7 % reduction [95 %CI, 38.2-57.3]). Furthermore, infection prevention measures against COVID-19 were associated with additional level changes in varicella rates (57.2 % reduction [95 %CI, 44.5-67.1]), antiviral use (65.7 % reduction [59.7-70.8]), and healthcare costs (49.1 % [95 %CI, 32.7-61.6]). In contrast, the changes in incidence and healthcare costs for herpes zoster were relatively small, which showed 9.4 % elevated level change with a decreasing trend and 8.7 % reduced level change with a decreasing trend after the vaccine program and the COVID-19 pandemic. The cumulative incidence of herpes zoster in children born after 2014 was lower than that before 2014.

CONCLUSIONS

Varicella incidence and healthcare resource use were largely affected by the routine immunization program and infection prevention measures against COVID-19, while these impacts on herpes zoster were relatively small. Our study indicates that immunization and infection prevention measures largely changed pediatric infectious disease practices.

National Assessment of Pediatric Readiness of US Emergency Departments During the COVID-19 Pandemic

Importance

The National Pediatric Readiness Project assessment provides a comprehensive evaluation of the readiness of US emergency departments (EDs) to care for children. Increased pediatric readiness has been shown to improve survival for children with critical illness and injury.

Objectives

To complete a third assessment of pediatric readiness of US EDs during the COVID-19 pandemic, to examine changes in pediatric readiness from 2013 to 2021, and to evaluate factors associated with current pediatric readiness.

Design, Setting, and Participants

In this survey study, a 92-question web-based open assessment of ED leadership in US hospitals (excluding EDs not open 24 h/d and 7 d/wk) was sent via email. Data were collected from May to August 2021.

Main Outcomes and Measures

Weighted pediatric readiness score (WPRS) (range, 0-100, with higher scores indicating higher readiness); adjusted WPRS (ie, normalized to 100 points), calculated excluding points received for presence of a pediatric emergency care coordinator (PECC) and quality improvement (QI) plan.

Results

Of the 5150 assessments sent to ED leadership, 3647 (70.8%) responded, representing 14.1 million annual pediatric ED visits. A total of 3557 responses (97.5%) contained all scored items and were included in the analysis. The majority of EDs (2895 [81.4%]) treated fewer than 10 children per day. The median (IQR) WPRS was 69.5 (59.0-84.0). Comparing common data elements from the 2013 and 2021 NPRP assessments demonstrated a reduction in median WPRS (72.1 vs 70.5), yet improvements across all domains of readiness were noted except in the administration and coordination domain (ie, PECCs), which significantly decreased. The presence of both PECCs was associated with a higher adjusted median (IQR) WPRS (90.5 [81.4-96.4]) compared with no PECC (74.2 [66.2-82.5]) across all pediatric volume categories (P < .001). Other factors associated with higher pediatric readiness included a full pediatric QI plan vs no plan (adjusted median [IQR] WPRS: 89.8 [76.9-96.7] vs 65.1 [57.7-72.8]; P < .001) and staffing with board-certified emergency medicine and/or pediatric emergency medicine physicians vs none (median [IQR] WPRS: 71.5 [61.0-85.1] vs 62.0 [54.3-76.0; P < .001).

Conclusions and Relevance

These data demonstrate improvements in key domains of pediatric readiness despite losses in the health care workforce, including PECCs, during the COVID-19 pandemic, and suggest organizational changes in EDs to maintain pediatric readiness.

Smart Thermometer-Based Participatory Surveillance to Discern the Role of Children in Household Viral Transmission During the COVID-19 Pandemic

Importance

Children's role in spreading virus during the COVID-19 pandemic is yet to be elucidated, and measuring household transmission traditionally requires contact tracing.

Objective

To discern children's role in household viral transmission during the pandemic when enveloped viruses were at historic lows and the predominance of viral illnesses were attributed to COVID-19.

Design, Setting, and Participants

This cohort study of a voluntary US cohort tracked data from participatory surveillance using commercially available thermometers with a companion smartphone app from October 2019 to October 2022. Eligible participants were individuals with temperature measurements in households with multiple members between October 2019 and October 2022 who opted into data sharing.

Main Outcomes and Measures

Proportion of household transmissions with a pediatric index case and changes in transmissions during school breaks were assessed using app and thermometer data.

Results

A total of 862 577 individuals from 320 073 households with multiple participants (462 000 female [53.6%] and 463 368 adults [53.7%]) were included. The number of febrile episodes forecast new COVID-19 cases. Within-household transmission was inferred in 54 506 (15.4%) febrile episodes and increased from the fourth pandemic period, March to July 2021 (3263 of 32 294 [10.1%]) to the Omicron BA.1/BA.2 wave (16 516 of 94 316 [17.5%]; P < .001). Among 38 787 transmissions in 166 170 households with adults and children, a median (IQR) 70.4% (61.4%-77.6%) had a pediatric index case; proportions fluctuated weekly from 36.9% to 84.6%. A pediatric index case was 0.6 to 0.8 times less frequent during typical school breaks. The winter break decrease was from 68.4% (95% CI, 57.1%-77.8%) to 41.7% (95% CI, 34.3%-49.5%) at the end of 2020 (P < .001). At the beginning of 2022, it dropped from 80.3% (95% CI, 75.1%-84.6%) to 54.5% (95% CI, 51.3%-57.7%) (P < .001). During summer breaks, rates dropped from 81.4% (95% CI, 74.0%-87.1%) to 62.5% (95% CI, 56.3%-68.3%) by August 2021 (P = .02) and from 83.8% (95% CI, 79.2%-87.5) to 62.8% (95% CI, 57.1%-68.1%) by July 2022 (P < .001). These patterns persisted over 2 school years.

Conclusions and Relevance

In this cohort study using participatory surveillance to measure within-household transmission at a national scale, we discerned an important role for children in the spread of viral infection within households during the COVID-19 pandemic, heightened when schools were in session, supporting a role for school attendance in COVID-19 spread.

Assessing the Gap in Adolescent Emergency Care Training for Emergency Medicine Residents: A Systematic Review

Over 1.5 million U.S. adolescents rely on emergency services for the majority of their healthcare, with increasing presentations (particularly for mental health complaints) during the coronavirus disease 2019 (COVID-19) pandemic. However, a majority of physicians practicing emergency medicine report feeling unprepared to care for adolescent patients. In turn, adolescent patients often report feeling uncomfortable or unsafe when attempting to access emergency care. Despite this deficiency, the extent to which adolescent medicine is addressed during emergency residency medical training remains unclear. Our objective in this systematic review was to identify any existing, publicly available curriculum targeted to teach adolescent emergency care during emergency medicine residency. We conducted a keyword search within the Medline Ovid, Embase, Web of Science, and Cochrane databases to identify relevant literature published between the years of 1968 and 2021; publications meeting inclusion criteria were then analyzed for content. Despite an extensive review of the existing literature, we identified no systematized curriculum and only seven individual papers describing educational efforts to promote competency in adolescent care among emergency medicine residents. Of the resources available, none provide instruction on the management of multiple adolescent presentations, nor common conditions that should be included in a more comprehensive general emergency residency curriculum. No standardized curricula exist for the instruction of relevant adolescent care in an emergency medicine residency. We conclude that the available education for emergency medicine residents is lacking in the area of adolescent care and future work is needed to identify specific competencies to target with further intervention.

Parental Attitude, Knowledge, and Practices Regarding the Usage of Antibiotics for Upper Respiratory Tract Infections in Children During the COVID-19 Pandemic

BACKGROUND

The COVID-19 pandemic has raised knowledge of the proper antibiotic dosage for treating childhood upper respiratory tract infections (URTIs). In order to ensure proper antibiotic usage and prevent the establishment of illnesses that is antibiotic-resistant during the COVID-19 pandemic, parental attitudes, knowledge, and behaviour surrounding antibiotic use for URTIs in children are essential. The goal of this study was to find out the parental attitude, knowledge, and practices regarding the usage of antibiotics for URTIs in children during the COVID-19 epidemic.

METHODOLOGY

This cross-sectional was conducted in the Department of Paediatric Medicine, Central Hospital, Ganesh Nagar, New Delhi, India from September 2022 to February 2023. The study analysed a total of 500. All the children had URTIs. A structured questionnaire was randomly distributed among parents. Socio-demographic information like gender, age, occupation, monthly family income, and age of the children were noted at the time of enrollment. Outcomes were recorded in terms of responses to questions regarding attitude, knowledge, and practices regarding the use of antibiotics for URTIs in children during the COVID-19 epidemic.  Results: Of a total of 500 parents, 380 (76.0%) were male. The mean age was 39.9±8.3 years while 280 (56.0%) participants were aged between 31 to 45 years. Relatively older age (p<0.0001) and occupational status as unemployed (p<0.0001) were found to have a significant association with response to "virus being the cause of COVID-19". Females (p=0.0004) and increasing age (p<0.0001) were found to have significant associations with incorrect responses to "antibiotics are essential for managing the symptoms in children with COVID-19". Incorrect responses to "without the use of antibiotics, children usually suffer from greater periods of sickness" were associated with females and increasing age (p<0.0001). Incorrect responses to "not using antibiotics will prove beneficial for the children suffering from COVID-19" were significantly associated with female gender (p=0.0016) and increasing age (p<0.0001). The incorrect responses to "how often are antibiotics being prescribed to the COVID-19 children" was significantly linked with females and relatively older age (p<0.0001).

CONCLUSIONS

Parental attitude, knowledge, and practices regarding the usage of antibiotics for URTIs in children during the COVID-19 epidemic showed variations. Parental attitude, knowledge, and practices were associated with gender, age, and socio-economic status.

Initial emergency department vital signs may predict PICU admission in pediatric patients presenting with asthma exacerbation

OBJECTIVE

Severe asthma exacerbations account for a large share of asthma morbidity, mortality, and costs. Here, we aim to identify early predictive factors associated with pediatric intensive care unit (PICU) admission.

METHODS

We performed a retrospective observational study of 5,185 emergency department (ED) encounters at a large children's hospital, including 86 (1.7%) resulting in PICU admission between 10/1/2015 and 8/7/2018 with ICD9/ICD10 codes for "asthma," "bronchospasm," or "wheezing." Vital signs and demographic information were obtained from electronic health record data and analyzed for each encounter. Predictive factors were identified using adjusted regression models, and our primary outcome was PICU admission.

RESULTS

Higher mean heart rates (HRs) and respiratory rates (RRs), and lower SpO2 within the first hour of ED presentation were independently associated with PICU admission. Odds of PICU admission increased 70% for each 10 beats/min higher HR, 125% for each 10 breaths/min higher RR, and 34% for each 5% lower SpO2. A binary predictive index using 1-h vitals yielded OR 13.4 (95% CI 8.1-22.1) for PICU admission, area under receiver operator characteristic (AUROC) curve 0.84 and overall accuracy of 80.1%. Results were largely unchanged (AUROC 0.84-0.88) after adjusting for surrogates of asthma severity and initial ED management. In combination with a secondary standardized clinical asthma distress score, positive predictive value increased by sevenfold (6.1%-46%).

CONCLUSIONS

A predictive index using HR, RR, and SpO2 within the first hour of ED presentation accurately predicted PICU admission in this cohort. Automated vital signs trend analysis may help identify vulnerable patients quickly upon presentation.

Parental help-seeking behaviour for, and care of, a sick or injured child during the COVID-19 pandemic: a European online survey

BACKGROUND

Globally, the COVID-19 pandemic had a huge impact on patients and healthcare systems. A decline in paediatric visits to healthcare settings was observed, which might have been due to lower incidence of injury and infectious illness, changes in healthcare services and parental concern. The aim of our study was to examine parental experiences of help-seeking for, and care of, a sick or injured child during COVID-19 lockdown periods in five European countries with different healthcare systems in place.

METHODS

An online survey for parents with a child with any kind or illness of injury during COVID-19 lockdowns was circulated through social media in five European countries: Italy, Spain, Sweden, the Netherlands, and the United Kingdom. Parents living in one of these countries with self-identification of a sick or injured child during COVID-19 lockdown periods were eligible to fill in the survey. Descriptive statistics were used for the level of restrictions per country, children's characteristics, family characteristics and reported help-seeking behaviour of parents prior to the lockdown and their real experience during the lockdown. The free text data was subjected to thematic analysis.

RESULTS

The survey was fully completed by 598 parents, ranging from 50 to 198 parents per country, during varying lockdown periods from March 2020 until May 2022. Parents who completed the survey were not deterred from seeking medical help for their sick or injured child during the COVID-19 pandemic. This finding was comparable in five European countries with different healthcare systems in place. Thematic analysis identified three main areas: parental experiences of access to healthcare, changes in parents' help-seeking behaviours for a sick or injured child during lockdowns, and the impact of caring for a sick or injured child during the lockdowns. Parents reported limited access to non-urgent care services and were anxious about either their child or themselves catching COVID-19.

CONCLUSION

This insight into parental perspectives of help-seeking behaviour and care for a sick or injured child during COVID-19 lockdowns could inform future strategies to improve access to healthcare, and to provide parents with adequate information concerning when and where to seek help and support during pandemics.

Ingestion of Illicit Substances by Young Children Before and During the COVID-19 Pandemic

Importance

Information about the trend in illicit substance ingestions among young children during the pandemic is limited.

Objectives

To assess immediate and sustained changes in overall illicit substance ingestion rates among children younger than 6 years before and during the COVID-19 pandemic and to examine changes by substance type (amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids) while controlling for differing statewide medicinal and recreational cannabis legalization policies.

Design, Setting, and Participants

Retrospective cross-sectional study using an interrupted time series at 46 tertiary care children's hospitals within the Pediatric Health Information System (PHIS). Participants were children younger than 6 years who presented to a PHIS hospital for an illicit substance(s) ingestion between January 1, 2017, and December 31, 2021. Data were analyzed in February 2023.

Exposure

Absence or presence of the COVID-19 pandemic.

Main Outcome(s) and Measure(s)

The primary outcome was the monthly rate of encounters for illicit substance ingestions among children younger than 6 years defined by International Statistical Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code(s) for poisoning by amphetamines, benzodiazepines, cannabis, cocaine, ethanol, and opioids. The secondary outcomes were the monthly rate of encounters for individual substances.

Results

Among 7659 children presenting with ingestions, the mean (SD) age was 2.2 (1.3) years and 5825 (76.0%) were Medicaid insured/self-pay. There was a 25.6% (95% CI, 13.2%-39.4%) immediate increase in overall ingestions at the onset of the pandemic compared with the prepandemic period, which was attributed to cannabis, opioid, and ethanol ingestions. There was a 1.8% (95% CI, 1.1%-2.4%) sustained monthly relative increase compared with prepandemic trends in overall ingestions which was due to opioids. There was no association between medicinal or recreational cannabis legalization and the rate of cannabis ingestion encounters.

Conclusions and Relevance

In this study of illicit substance ingestions in young children before and during the COVID-19 pandemic, there was an immediate and sustained increase in illicit substance ingestions during the pandemic. Additional studies are needed to contextualize these findings in the setting of pandemic-related stress and to identify interventions to prevent ingestions in face of such stress, such as improved parental mental health and substance treatment services, accessible childcare, and increased substance storage education.

Trends in pediatric nonprescription analgesic/antipyretic exposures during the COVID-19 pandemic

OBJECTIVE

To examine pediatric exposure trends involving selected nonprescription analgesics/antipyretics, before and during the COVID-19 pandemic.

METHODS

Using descriptive and interrupted time-series analyses, we assessed monthly United States poison center data involving pediatric (<18 years) exposures to nonprescription paracetamol (acetaminophen), ibuprofen, acetylsalicylic acid, and naproxen before (January 2015-February 2020) and during (March 2020-April 2021) the pandemic. Statins and proton pump inhibitors (prescription or nonprescription) served as controls.

RESULTS

Most nonprescription analgesic/antipyretic exposures (75-90%) were single-substance; unintentional exposures typically involved children <6 years (84-92%), while intentional exposures involved females (82-85%) and adolescents, 13-17 years (91-93%). Unintentional exposures among children <6 years, declined for all four analgesics/antipyretics immediately after the World Health Organization declared COVID-19 a pandemic (March 11, 2020), but most significantly for ibuprofen (30-39%). Most intentional exposures were classified as suspected suicide. Intentional exposures were relatively low and stable among males. Intentional exposures in females declined immediately after the pandemic was announced but subsequently increased to pre-pandemic levels for acetylsalicylic acid and naproxen and above pre-pandemic levels for paracetamol and ibuprofen. For paracetamol, female intentional exposures increased from 513 average monthly cases in the pre-pandemic to 641 average monthly cases during the pandemic; and reached 888 cases by the end of the study period in April 2021. While for ibuprofen, average monthly cases rose from 194 in the pre-pandemic, to 223 during the pandemic; and reached 352 cases in April 2021. Patterns were similar among females 6-12 and 13-17 years.

CONCLUSION

Nonprescription analgesic/antipyretic unintentional exposure cases declined among young children, while intentional exposure cases increased among females, 6-17 years, during the pandemic. Findings highlight the importance of safely storing medications and being alert to signs that adolescents may be in need of mental health support services; caregivers should seek medical care or call poison control centers for any suspected poisoning event.