Changing admission patterns in paediatric emergency departments during the COVID-19 pandemic

Incidence of mental health diagnoses during the COVID-19 pandemic: a multinational network study

AIMS

Population-wide restrictions during the COVID-19 pandemic may create barriers to mental health diagnosis. This study aims to examine changes in the number of incident cases and the incidence rates of mental health diagnoses during the COVID-19 pandemic.

METHODS

By using electronic health records from France, Germany, Italy, South Korea and the UK and claims data from the US, this study conducted interrupted time-series analyses to compare the monthly incident cases and the incidence of depressive disorders, anxiety disorders, alcohol misuse or dependence, substance misuse or dependence, bipolar disorders, personality disorders and psychoses diagnoses before (January 2017 to February 2020) and after (April 2020 to the latest available date of each database [up to November 2021]) the introduction of COVID-related restrictions.

RESULTS

A total of 629,712,954 individuals were enrolled across nine databases. Following the introduction of restrictions, an immediate decline was observed in the number of incident cases of all mental health diagnoses in the US (rate ratios (RRs) ranged from 0.005 to 0.677) and in the incidence of all conditions in France, Germany, Italy and the US (RRs ranged from 0.002 to 0.422). In the UK, significant reductions were only observed in common mental illnesses. The number of incident cases and the incidence began to return to or exceed pre-pandemic levels in most countries from mid-2020 through 2021.

CONCLUSIONS

Healthcare providers should be prepared to deliver service adaptations to mitigate burdens directly or indirectly caused by delays in the diagnosis and treatment of mental health conditions.

Impact of adapting paediatric intensive care units for adult care during the COVID-19 pandemic: a scoping review

OBJECTIVES

The objectives were to categorise the evidence, map out the existing studies and explore what was known about the organisation of paediatric intensive care units (PICUs) during the first 18 months of the COVID-19 pandemic. Additionally, this review set out to identify any knowledge gaps in the literature and recommend areas for future research.

DESIGN

Scoping review.

METHODS

This study used Arksey and O'Malley's six-stage scoping review framework. A comprehensive search was conducted using the following databases, CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE and grey literature search engines. A search strategy with predefined inclusion criteria was used to uncover relevant research in this area. Screening and data collection were done in duplicate.

RESULTS

47 631 articles were obtained through searching. However, only 25 articles met the inclusion criteria and were included in the analysis. Three dominant themes emerged from the literature: (1) the reorganisation of space for managing increased capacity; (2) increased staffing and support; and (3) the resulting challenges.

CONCLUSION

COVID-19 has strained institutional resources across the globe. To relieve the burden on intensive care units (ICUs), some PICUs adjusted their units to care for critically ill adults, with other PICUs making significant changes, including the redeployment of staff to adult ICUs to provide extra care for adults. Overall, PICUs were collectively well equipped to care for adult patients, with care enhanced by implementing elements of holistic, family-centred PICU practices. The pandemic fostered a collaborative approach among PICU teams and wider hospital communities. However, specific healthcare guidelines had to be created to safely care for adult patients.

Impact of a double catastrophe, war and COVID-19, on health service utilization of a tertiary care hospital in Tigray: an interrupted time-series study

BACKGROUND

In developing nations with fragile healthcare systems, the effect of war is likely to be much worse than it would be in more developed countries. The presence of COVID-19 will also likely exacerbate the war's impact. This study set out to determine the effect of armed conflict and the COVID-19 pandemic on health service utilization at Ayder Comprehensive Specialized Hospital, in the Tigray region of Ethiopia.

METHODS

An interrupted time-series study design was used to analyze patient visits over forty-eight consecutive months (from July 2017 to June 2021) at inpatient, outpatient, and emergency departments. Data were analyzed using segmented regression analysis with a defined outcome of level and trend changes in the number of patient visits. In addition, negative binomial regression analysis was also used to estimate the impact of both COVID-19 and the war on patient flow.

RESULTS

There were 59,935 admissions, 876,533 outpatient visits, and 127,872 emergency room visits. The effect of COVID-19 was seen as soon as the Tigray regional government imposed comprehensive restrictions. Immediately after COVID-19 appeared, all the service areas exhibited a significant monthly drop in visits; [-35.6% (95% CI: -48.2%, -23.1%)] for inpatient, [-60.6% (95% CI: -71.6%, -49.5%)] for outpatient, and [-44.1% (95% CI: -59.5%, -28.7%)] for emergency department visits. The impact of the war became apparent after a lag time of one month. Controlling the effects of time and COVID-19, the war led to a significant fall in inpatient visits [-44.3% (95% CI: -67.2%, -21.5%)], outpatients [-52.1% (95% CI: -82.7%, -21.5%)], and emergency-room attendances [-45.0% (95% CI: -74.8%, -15.2%)]. An upward trend in outpatient flow was observed after the war [1,219.4 (95% CI: 326.1, 2,112.8)].

CONCLUSIONS

The present study has clearly indicated that the war and COVID-19 have led to a large reduction in admissions, outpatient attendance, and emergency department visits. The evidence from this study suggests that due to this double catastrophe, thousands of patients could not gain access to healthcare, with probable negative consequences. Governments and organizations should implement measures to buttress the healthcare system to maintain pre-war status of service.

The COVID-19 pandemic and healthcare utilization in Iran: evidence from an interrupted time series analysis

BACKGROUND

This study aimed to examine the effect of the coronavirus disease 2019 (COVID-19) outbreak on the hospitalization rate, emergency department (ED) visits, and outpatient clinic visits in western Iran.

METHODS

We collected data on the monthly hospitalization rate, rate of patients referred to the ED, and rate of patients referred to outpatient clinics for a period of 40 months (23 months before and 17 months after the COVID-19 outbreak in Iran) from all 7 public hospitals in the city of Kermanshah. An interrupted time series analysis was conducted to examine the impact of COVID-19 on the outcome variables in this study.

RESULTS

A statistically significant decrease of 38.11 hospitalizations per 10,000 population (95% confidence interval [CI], 24.93-51.29) was observed in the first month of the COVID-19 outbreak. The corresponding reductions in ED visits and outpatient visits per 10,000 population were 191.65 (95% CI, 166.63-216.66) and 168.57 (95% CI, 126.41-210.73), respectively. After the initial reduction, significant monthly increases in the hospitalization rate (an increase of 1.81 per 10,000 population), ED visits (an increase of 2.16 per 10,000 population), and outpatient clinic visits (an increase of 5.77 per 10,000 population) were observed during the COVID-19 pandemic.

CONCLUSION

Our study showed that the utilization of outpatient and inpatient services in hospitals and clinics significantly declined after the COVID-19 outbreak, and use of these services did not return to pre-outbreak levels as of June 2021.

Care seeking for under-five children and vaccine perceptions during the first two waves of the COVID-19 pandemic in Lagos State, Nigeria: a qualitative exploratory study

OBJECTIVE

To explore healthcare seeking practices for children and the context-specific direct and indirect effects of public health interventions during the first two waves of COVID-19 in Lagos State, Nigeria. We also explored decision-making around vaccine acceptance at the start of COVID-19 vaccine roll-out in Nigeria.

DESIGN, SETTING AND PARTICIPANTS

A qualitative explorative study involving 19 semistructured interviews with healthcare providers from public and private primary health facilities and 32 interviews with caregivers of under-five children in Lagos from December 2020 to March 2021. Participants were purposively selected from healthcare facilities to include community health workers, nurses and doctors, and interviews were conducted in quiet locations at facilities. A data-driven reflexive thematic analysis according to Braun and Clark was conducted.

FINDINGS

Two themes were developed: appropriating COVID-19 in belief systems, and ambiguity about COVID-19 preventive measures. The interpretation of COVID-19 ranged from fearful to considering it as a 'scam' or 'falsification from the government'. Underlying distrust in government fuelled COVID-19 misperceptions. Care seeking for children under five was affected, as facilities were seen as contagious places for COVID-19. Caregivers resorted to alternative care and self-management of childhood illnesses. COVID-19 vaccine hesitancy was a major concern among healthcare providers compared with community members at the time of vaccine roll-out in Lagos, Nigeria. Indirect impacts of COVID-19 lockdown included diminished household income, worsening food insecurity, mental health challenges for caregivers and reduced clinic visits for immunisation.

CONCLUSION

The first wave of the COVID-19 pandemic in Lagos was associated with reductions in care seeking for children, clinic attendance for childhood immunisations and household income. Strengthening health and social support systems with context-specific interventions and correcting misinformation is crucial to building adaptive capacity for response to future pandemics.

TRIAL REGISTRATION NUMBER

ACTRN12621001071819.

Reshaping care in the aftermath of the pandemic. Implications for cardiology health systems

In the last two years, the COVID-19 pandemic has undeniably changed everyday life and significantly reshaped the healthcare systems. Besides the direct effect on daily care leading to significant excess mortality, several collateral damages have been observed during the pandemic. The impact of the pandemic led to staff shortages, disrupted education, worse healthcare professional well-being, and a lack of proper clinical training and research. In this review we highlight the results of these important changes and how can the healthcare systems can adapt to prevent unprecedented events in case of future catastrophes.

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

OBJECTIVE

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

SETTING

Systematic review.

DESIGN

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

PATIENTS

Children under 18 years.

INTERVENTIONS

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

MAIN OUTCOME MEASURES

Changes in paediatric emergency care utilisation.

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION NUMBER

CRD42021242808.

Clinical and Forensic Aspects of the Management of Child Abuse: The Experience of the Paediatric Emergency Department in Novara, North-West Italy

BACKGROUND

Child abuse is an endemic phenomenon that refers to any form of violence aimed at children and adolescents. The Emergency Room is often the entry point to healthcare for the abused child.

METHODS

This is a cross-sectional study including minors, aged 0-18 years, of all genders, who experienced any form of violence examined at the Paediatric Emergency Department of the 'Maggiore della Carità' Hospital in Novara (North-West Italy) between 1 January 2017 to 31 December 2021. Data were extrapolated by looking at the diagnosis at discharge. A comparison of the different variables collected was made between the pre-COVID-19 period and the COVID era.

RESULTS

120 minors presented to the paediatric emergency room seeking help for violence. The average age was 10 years, 55% of the victims were male and 75% of them were Italian. In the pre-COVID period, the number of presentations for abuse was 62, while in the COVID period it was 58 with an increase of peer violence (from 38.71% to 62.07%) and with a statistically significant impact of the pandemic on the phenomenon (p-value < 0.00001). In general, peer violence accounts for 50% of the cases reviewed and resulted in fewer reports to the judicial authority and requests for forensic advice.

CONCLUSION

The SARS-CoV-2-related pandemic has had an impact on total emergency room admissions and the types of abuse perpetrated.

Comparison of outcomes in emergency department revisiting patients before and after coronavirus disease 2019 epidemic

BACKGROUND AND IMPORTANCE

The outbreak of COVID-19 challenged the global health system and specifically impacted the emergency departments (EDs). Studying the quality indicators of ED care under COVID-19 has been a necessary task, and ED revisits have been used as an indicator to monitor ED performance.

OBJECTIVES

The study investigated whether discrepancies existed among ED revisiting cases before and after COVID-19 and whether the COVID-19 epidemic was a predictor of poor outcomes of ED revisits.

DESIGN

Retrospective study.

SETTINGS AND PARTICIPANTS

We used electronic health records data from a tertiary medical center. Data of patients with 72-h ED revisit after the COVID-19 epidemic were collected from February 2020 to June 2020 and compared with those of patients before COVID-19, from February 2019 to June 2019.

OUTCOME MEASURES AND ANALYSIS

The investigated outcomes included hospital admission, ICU admission, out-of-hospital cardiac arrest, and subsequent inhospital mortality. Univariate and multivariate logistic regression models were used to identify independent predictors of 72-h ED revisit outcomes.

MAIN RESULTS

In total, 1786 patients were enrolled in our study - 765 in the COVID group and 1021 in the non-COVID group. Compared with the non-COVID group, patients in the COVID group were younger (53.9 vs. 56.1 years old; P = 0.002) and more often female (66.1% vs. 47.3%; P < 0.001) and had less escalation of triage level (11.6% vs. 15.0%; P = 0.041). The hospital admission and inhospital mortality rates in the COVID and non-COVID groups were 33.9% vs. 32.0% and 2.7% vs. 1.5%, respectively. In the logistic regression model, the COVID-19 period was significantly associated with inhospital mortality (adjusted odds ratio, 2.289; 95% confidence interval, 1.059-4.948; P = 0.035).

CONCLUSION

Patients with 72-h ED revisits showed distinct demographic and clinical patterns before and after the COVID-19 epidemic; the COVID-19 period was an independent predictor of increased inhospital mortality.

The year 2021 in COVID-19 pandemic in children

In this article, the developments in the field of COVID-19 pandemic published in the Italian Journal of Pediatrics in 2021 are reflected. We describe progresses in SARS-CoV-2 transmission route, clinical presentation, diagnosis, treatment, and access to health care facilities in children. They led to substantial changes in the clinical approach.

COVID-19 and diabetes in children

This review describes the impact of coronavirus disease 2019 (COVID-19) in children and adolescents, investigating changes in diabetes presentation during the COVID-19 pandemic, possible links between severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection and diabetes, and mechanisms of pancreatic β-cell destruction. Although glycemic control in individuals with already known diabetes mellitus did not worsen during the pandemic, there was a worrying increase in diabetic ketoacidosis in children with new-onset diabetes, probably due to containment measures and delayed access to emergency departments. Moreover, new evidence suggests that SARS-CoV-2 has the capacity to directly and indirectly induce pancreatic β-cell destruction, and the risk of newly diagnosed diabetes after COVID-19 increased in both children and adults. While long-term studies continue to follow children with SARS-CoV-2 infection, this review discusses available findings on the relationship between COVID-19 and diabetes. It is important to emphasize the need to maintain close links between families of children with chronic conditions and their pediatricians, as well as to promote early access to healthcare services, in order to reduce dangerous delays in diabetes diagnosis and prevent diabetic ketoacidosis.

Stress hyperglycemia, Diabetes mellitus and COVID-19 infection: The impact on newly diagnosed type 1 diabetes

Several recent studies have documented an increased incidence of newly diagnosed type 1 Diabetes (T1D) cases in children and adolescents during the COVID-19 pandemic and a more severe presentation at diabetes onset. In this descriptive study, we present the experience of the Diabetes Centre of the Division of Endocrinology, Diabetes, and Metabolism of the First Department of Pediatrics of the National and Kapodistrian University of Athens Medical School at “Aghia Sophia” Children’s Hospital in Athens, Greece, concerning new cases of T1D diagnosis during the COVID-19 pandemic (March 2020- December 2021). Patients who had already been diagnosed with T1D and needed hospitalization due to poor control during the pandemic have been excluded from this study. Eighty- three children and adolescents with a mean age of 8,5 ± 4.02 years were admitted to the hospital due to newly diagnosed T1D during this 22 months’ period in comparison to 34 new cases in the previous year. All patients admitted during the pandemic with a new diagnosis of T1D, presented in their majority with DKA (Ph: 7.2) representing an increase of new severe cases in comparison to previous years (Ph 7.2 versus 7.3, p value: 0.021, in the previous year), [p-value: 0.027]. 49 cases presented with DKA, of which 24 were characterized moderate and 14 severe DKA (28.9% and 16,9%, respectively), while 5 patients newly diagnosed, needed to be admitted to the ICU to recover from severe acidosis. Whether a previous COVID- 19 infection could have been the triggering factor is not supported by the SARS-Cov2 specific antibodies analysis in our cohort of patients. As far as HbA1c is concerned there was no statistically significant difference between the pre COVID-19 year and the years of the pandemic (11.6% versus 11.9%, p- value: 0.461). Triglycerides values were significantly higher in patients with new onset T1D during COVID-19 years compared to those before the pandemic (p value= 0.032). Additionally, there is a statistically significant correlation between Ph and Triglycerides for the whole period 2020-2021 (p-value&lt;0.001), while this correlation is not significant for the year 2019. More large- scale studies are required to confirm these observations.

Impact of COVID-19 on outpatient appointments in children and young people in England: an observational study

OBJECTIVES

To describe the impact of the COVID-19 pandemic on outpatient appointments for children and young people.

SETTING

All National Health Service (public) hospitals in England.

PARTICIPANTS

All people in England aged <25 years.

OUTCOME MEASURES

Outpatient department attendance numbers, rates and modes (face to face vs telephone) by age group, sex and socioeconomic deprivation.

RESULTS

Compared with the average for January 2017 to December 2019, there was a 3.8 million appointment shortfall (23.5%) for the under-25 population in England between March 2020 and February 2021, despite a total rise in phone appointments of 2.6 million during that time. This was true for each age group, sex and deprivation fifth, but there were smaller decreases in face to face and total appointments for babies under 1 year. For all ages combined, around one in six first and one in four follow-up appointments were by phone in the most recent period. The proportion of appointments attended was high, at over 95% for telephone and over 90% for face-to-face appointments for all ages.

CONCLUSIONS

COVID-19 led to a dramatic fall in total outpatient appointments and a large rise in the proportion of those appointments conducted by telephone. The impact that this has had on patient outcomes is still unknown. The differential impact of COVID-19 on outpatient activity in different sociodemographic groups may also inform design of paediatric outpatient services in the post-COVID period.

The impact of the SARS COV-2 pandemic on pediatric accesses in ED: A Healthcare Emergency Information System analysis

Background

The Emergency Department (ED) services play a fundamental role in managing the accesses of potential Sars-Cov-2 cases. The aim of this study is to evaluate the impact of the SARS COV-2 pandemic on pediatric accesses in Emergency Department of Lazio Region.

Methods

The population includes all pediatric accesses (0–17 years) in the ED of Lazio Region during 2019 and 2020. Accesses were characterized by age, week and calendar period. Four periods were defined: pre-lockdown, lockdown, post-lockdown and the second wave. The trend of ED accesses (total or for specific cause) in 2020 (by period and week) were compared to them occurred in 2019. ED visits have been described by absolute frequency and percentage variation. Percentage variation of adult was also reported to compare the trend in adult and young population. The Chi-square test was used to compare characteristics of admissions in 2019 and 2020.

Results

There is a large decrease of pediatric accesses in 2020 compared to 2019 (-47%), especially for younger age-classes (1–2 years: -52.5% and 3–5 years: -50.5%). Pediatric visits to ED in 2020 decreased following the same trend of adults, but more drastically (-47% vs -30%). ED accesses for suspected COVID-19 pneumonia trend show different characteristics between children and adults: in adults there is an increase in 2020, especially during the 2nd wave period (+321%), in children there is a decrease starting from the lockdown period to the achievement of the lowest level in December 2020 (-98%).

Conclusions

This descriptive study has identified a decrease of total pediatric accesses in ED in 2020 compared to 2019 and a different trend of accesses by adult and young population especially by cause. The monitoring of paediatric accesses could be a useful tool to analyse the trend of COVID-19 pandemic in Italy and to reprogramming of the healthcare offer according to criteria of clinical and organizational appropriateness.

Changes in pediatric emergency department visits during a COVID-19 lockdown period: an exhaustive single-center analysis

Background

In many countries, the restrictions related to the first period of lockdown during the coronavirus disease 2019 (COVID-19) pandemic led to widespread changes in health service usage in general and in emergency departments in particular. However, no comprehensive evaluation of changes has been published to date. The objective of the present study was to determine the precise impact of the 2020 lockdown on admissions to a pediatric emergency department (PED) compared to the same periods in 2018 and 2019.

Methods

This retrospective, observational study included all patients under the age of 183 months (15.25 years) admitted to our French university hospital's PED during the period from March 17 to May 11 in the years 2018, 2019, and 2020. The primary outcome was the change in PED admissions in 2020 compared to 2018 and 2019. The secondary outcomes were notably changes in the primary discharge diagnoses, the discharge destination, and unwarranted visits.

Results

A total of 10,479 PED visits were identified, of which 10,295 were analyzed. In 2020, the number of PED visits fell by 61% and 63% vs. 2018 and 2019, respectively. Although the number of discharges to other hospital departments decreased by 52% and 49%, the proportion of these discharges increased: 18% of 1579 in 2020 vs. 13% of 4232 in 2018 and of 4484 in 2019 (p<0.01). Discharge from the PED to the intensive care unit was significantly more frequent in 2020 (p<0.05). Unwarranted visits were significantly lower in 2020 (19%) as compared to 2018 (22%) and 2019 (24%). Surgical and injury-related discharge diagnoses increased by 6% in 2020 (p<0.001), with a significant rise in trauma and foreign-body injuries (p<0.05). With regard to disease-related discharge diagnoses, we observed a significant rise in mental, behavioral, and social issues (p<0.01). Conversely, there was a significant (p<0.01) drop in diagnoses of acute infectious diseases in 2020 compared with 2018 and 2019.

Conclusion

Lockdown was associated with a massive reduction in the number of PED visits, a significant change in primary discharge diagnoses, and a decrease in the proportion of unwarranted PED visits compared to the previous 2 years. This should encourage public health researchers to examine how to alleviate the burden of unnecessary PED visits.

Effect of COVID-19 pandemic on presentation and referral patterns of newly diagnosed children with type 1 diabetes in a developing country

OBJECTIVES

The global spread of coronavirus disease 2019 (COVID-19), had a great impact on patients worldwide, including those with chronic diseases. We aim to study the effect of COVID-19 pandemic on presentation patterns of patients with type 1 diabetes (T1D) in Jordan, as an example a developing country with limited resources.

METHODS

Medical charts were reviewed for patients presented with new-onset T1D to Jordan University hospital during the first year of pandemic and the preceding year. Categorical data were compared using Pearson Chi-Square and Fisher's exact test. Continuous data were compared using the Independent Sample t-Test.

RESULTS

A total of 137 children were diagnosed with T1D during the study period, with 60.6% of those children were diagnosed in the pre-pandemic year compared to 39.4% during the first year of pandemic, p-value=0.013. Percentage of patients diagnosed with DKA as first presentation of T1D during the pre-pandemic year was 34.9% compared to 51.9% during the pandemic year, p-value=0.049. Significant differences in family monthly income (p-value=0.006) and paternal education level (p-value=0.036) were found between children with DKA and those without DKA in the pre-pandemic year, but they were not significant during the pandemic year.

CONCLUSIONS

The unprecedented COVID-19 pandemic had affected presentation pattern of newly diagnosed T1D patients, manifested by lower number of children diagnosed with T1D and higher percentage of DKA as first presentation compared to the preceding year. Health care services should be at utmost preparedness for possible future waves and other pandemics.

Reductions in hospital care among clinically vulnerable children aged 0-4 years during the COVID-19 pandemic

OBJECTIVE

To quantify reductions in hospital care for clinically vulnerable children during the COVID-19 pandemic.

DESIGN

Birth cohort.

SETTING

National Health Service hospitals in England.

STUDY POPULATION

All children aged <5 years with a birth recorded in hospital administrative data (January 2010-March 2021).

MAIN EXPOSURE

Clinical vulnerability defined by a chronic health condition, preterm birth (<37 weeks' gestation) or low birth weight (<2500 g).

MAIN OUTCOMES

Reductions in care defined by predicted hospital contact rates for 2020, estimated from 2015 to 2019, minus observed rates per 1000 child years during the first year of the pandemic (March 2020-2021).

RESULTS

Of 3 813 465 children, 17.7% (one in six) were clinically vulnerable (9.5% born preterm or low birth weight, 10.3% had a chronic condition). Reductions in hospital care during the pandemic were much higher for clinically vulnerable children than peers: respectively, outpatient attendances (314 vs 73 per 1000 child years), planned admissions (55 vs 10) and unplanned admissions (105 vs 79). Clinically vulnerable children accounted for 50.1% of the reduction in outpatient attendances, 55.0% in planned admissions and 32.8% in unplanned hospital admissions. During the pandemic, weekly rates of planned care returned to prepandemic levels for infants with chronic conditions but not older children. Reductions in care differed by ethnic group and level of deprivation. Virtual outpatient attendances increased from 3.2% to 24.8% during the pandemic.

CONCLUSION

One in six clinically vulnerable children accounted for one-third to one half of the reduction in hospital care during the pandemic.

Consequences of Social Distancing Measures During the COVID-19 Pandemic First Wave on the Epidemiology of Children Admitted to Pediatric Emergency Departments and Pediatric Intensive Care Units: A Systematic Review

Objectives

To synthesize knowledge describing the impact of social distancing measures (SDM) during the first wave of the COVID-19 pandemic on acute illness in children by focusing on the admission to pediatric emergency departments (PED) and pediatric intensive care units (PICU).

Methods

We searched Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, EPOC Register, MEDLINE, Evidence-Based Medicine Reviews, EMBASE, WHO database on COVID-19, Cochrane Resources on COVID-19, Oxford COVID-19 Evidence Service, Google Scholar for literature on COVID-19 including pre-print engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 in December 2020. We did not apply study design filtering. The primary outcomes of interest were the global incidence of admission to PICU and PED, disease etiologies, and elective/emergency surgeries, compared to the historical cohort in each studied region, country, or hospital.

Results

We identified 6,660 records and eighty-seven articles met our inclusion criteria. All the studies were with before and after study design compared with the historical data, with an overall high risk of bias. The median daily PED admissions decreased to 65% in 39 included studies and a 54% reduction in PICU admission in eight studies. A significant decline was reported in acute respiratory illness and LRTI in five studies with a median decrease of 63%. We did not find a consistent trend in the incidence of poisoning, but there was an increasing trend in burns, DKA, and a downward trend in trauma and unplanned surgeries.

Conclusions

SDMs in the first wave of the COVID-19 pandemic reduced the global incidence of pediatric acute illnesses. However, some disease groups, such as burns and DKA, showed a tendency to increase and its severity of illness at hospital presentation. Continual effort and research into the subject should be essential for us to better understand the effects of this new phenomenon of SDMs to protect the well-being of children.

Systematic Review Registration

Clinicaltrials.gov, identifier: CRD42020221215.

Organisation of care in paediatric intensive care units during the first 18 months of the COVID-19 pandemic: a scoping review protocol

INTRODUCTION

The emergence of COVID-19 has had a significant impact on hospital services, particularly care delivered to those in intensive care units (ICUs) and paediatric ICUs (PICUs) across the world. Although much has been written about healthcare delivery and the healthcare setting since COVID-19 began, to the authors' knowledge, this is the first scoping review to investigate the organisation of care and changes implemented in PICUs during the COVID-19 pandemic. The aim is to conduct a scoping review of the literature to map out the existing studies about care delivery in PICUs during the COVID-19 pandemic and the changes made to the organisation of care in these units during the first 18 months of the pandemic. This review will also identify gaps in current knowledge in this area.

METHODS AND ANALYSIS

This study will be guided by the Joanna Briggs Institute's methodology for scoping reviews, using Arksey and O'Malley's six-stage scoping review framework: (1) identifying the research question; (2) identifying relevant studies; (3) selecting the studies; (4) data charting; (5) collating, summarising and reporting results; and (6) consulting with experts. A comprehensive search will be conducted using the following databases: CINAHL Complete; MEDLINE; PsycINFO; PsycARTICLES and EMBASE. A search strategy with predefined inclusion and exclusion criteria will be used to uncover relevant research in this area. This study will include quantitative, qualitative and mixed research methods studies published in English from 2019 to May 2021.

ETHICS AND DISSEMINATION

Ethical approval is not required for this scoping review. The results from this study will be disseminated through conferences and in peer-reviewed academic journals for those working in the healthcare arena.

DKA and new-onset type 1 diabetes in Brazilian children and adolescents during the COVID-19 pandemic

We assess the severity and frequency of diabetic ketoacidosis (DKA) in new-onset type 1 diabetes mellitus (T1D) patients and in patients with previous diagnosis of T1D in a referral Brazilian university hospital in the first five months of the COVID-19 pandemic. We also compare the data with data from pre-pandemic periods. Forty-three new-onset T1D patients were diagnosed between April and August of the years 2017, 2018, 2019, and 2020. During the COVID-19 pandemic, the number of new-onset T1D was over twice the number of new-onset T1D in the same period in the three previous years. All the 43 patients survived and are now on outpatient follow-up. We also compared the characteristics of the T1D patients hospitalized between April and August of the years 2017, 2018, and 2019 (32 hospitalizations) to the characteristics of the T1D patients hospitalized between April and August/2020 (35 hospitalizations; 1 patient was hospitalized twice in this period). Fourteen of the 34 patients admitted during the pandemic presented with COVID-19-related symptoms (any respiratory symptom, fever, nausea, vomiting, and diarrhea), but only one had positive SARS-CoV-2 RT-PCR test. Samples from 32 out of these 34 patients were assayed for SARS-CoV-2 antibodies, and four patients were positive for total antibodies (IgM and IgG). In agreement with recent reports from European countries, we observed increased frequency of DKA and severe DKA in new-onset and previously diagnosed T1D children and adolescents in a large referral public hospital in Brazil in the first five months of the COVID-19 pandemic. The reasons for this outcome might have been fear of SARS-CoV-2 infection in emergency settings, the more limited availability of primary healthcare, and the lack of school personnel's attention toward children's general well-being.

Peculiar characteristics of new-onset Type 1 Diabetes during COVID-19 pandemic

Background

The COVID-19 pandemic period is having a strong impact on the management of diabetes as well as other chronic diseases as shown by the most severe clinical presentation at onset. The aim of this study was to evaluate the severity of diabetic ketoacidosis (DKA) in youth with newly diagnosed type 1 diabetes in “Santissima Annunziata Hospital” (Chieti, Italy) during COVID-19 pandemic in comparison to the five previous years.

Methods

A retrospective population-based incidence study was performed. Data were obtained from hospital records of 172 patients with new onset type 1 diabetes divided into two groups according to the diagnosis: Group I, between January 2015 and February 2020; Group II, between March 2020 and April 2021. Data regarding anthropometric, socio-economic and laboratory test were analyzed. DKA (pH < 7.30) and different severity of the disease (severe pH < 7.10; moderate pH < 7.20, mild pH < 7.30) were evaluated. A Spearman correlation between pH values and the main variables of interest was performed.

Results

DKA frequency was increased by 19 percentage in Group II compared to Group I (55% vs 36%; P = 0.03) with a significant increased risk of severe DKA cases compared to the previous five years (severe DKA 22.5% vs. 8.4%, P = 0.01). pH values were significantly related with HbA1c, blood glucose and c-peptide values in all groups. In addition, in Group II but not in Group I, pH values correlated with Triglycerides and TG/HDL cholesterol ratio.

Conclusions

During COVID-19 pandemic the risk of more severe clinical presentation of type 1 diabetes at onset is increased. The correlation with lipid profile might suppose an additional effect of lifestyle changes beside the delay in the diagnosis. Modifications of health care system need to be implemented during this peculiar situation in order to avoid such a relevant complication at onset.

Ketoacidosis in new-onset type 1 diabetes: did the severity increase during the COVID-19 pandemic?

OBJECTIVES

Since the beginning of the COVID-19 pandemic, there has been a consistent decrease in the number of admissions to the emergency department, leading to a delay in the diagnosis of several pathologies. The time from onset of symptoms to the diagnosis of Type 1 diabetes is highly variable. This treatment delay can lead to the appearance of ketoacidosis.

METHODS

Retrospective study of inaugural Type 1 diabetes cases, from March 2016 to March 2021. The pandemic group was considered between March 2020 to March 2021, and the remaining period was considered as pre-pandemic. Clinical variables were analysed: duration of symptoms, weight loss and value of ketonemia and glycated haemoglobin on admission. The mean differences were considered statistically significant at p<0.05.

RESULTS

103 inaugural episodes of Type 1 diabetes were registered. The pandemic group had a lower mean age when compared to pre-pandemic group, and 51.7% of the episodes had ketoacidosis with a higher relative risk of ketoacidosis and severe ketoacidosis, when compared the pandemic with pre-pandemic group, there was a longer symptom evolution time (34 vs. 20 days), greater weight loss occurred (9.5% vs. 6.3%), the pH and HCO₃ ^- values were lower (7.30 vs. 7.36 and 16.43 vs. 20.71 mmol/L respectively) and ketonemia was higher (5.9 vs. 2.3 mmol/L).

CONCLUSIONS

The COVID-19 pandemic caused a delay in the diagnosis of Type 1 diabetes, greater length of disease, greater weight loss, higher ketonemia and lower pH and HCO₃ ^-. There was greater ketoacidosis relative risk in pandemic group when compared to pre-pandemic group.

COVID-19 in two children with new-onset diabetes: case reports

Delayed diagnosis, low socioeconomic status and infection have been associated with diabetic ketoacidosis (DKA) at type 1 diabetes mellitus presentation. A teenager from a low socioeconomic status family, with longstanding weight loss, polyphagia, polyuria, vomiting and abdominal pain, attended the emergency department, also complaining of anosmia and odynophagia. He was diagnosed with COVID-19 and new-onset DKA. The second child had 2 weeks of diabetes symptoms and was admitted with new-onset mild DKA. SARS-CoV-2 RT-PCR test was positive, although asymptomatic. Persistent hyperglycaemia with high insulin requirements was a common feature to both patients. Both cases support that SARS-CoV-2 may have an association with rapidly increasing insulin daily needs. In case one, not only fear of COVID-19 delayed hospital attendance but also the setting of a low socioeconomic status family appears to have enhanced the risk for late diagnosis and challenging disease management.

Acute Care Visits for Eating Disorders Among Children and Adolescents After the Onset of the COVID-19 Pandemic

PURPOSE

Anecdotal reports suggest a significant increase in acute presentations of eating disorders among children and adolescents. Our objective was to compare the rates of emergency department visits and hospitalizations for pediatric eating disorders before and during the first 10 months of the COVID-19 pandemic.

METHODS

Using linked health administrative databases, we conducted a population-based repeated cross-sectional study of emergency department visits and hospitalizations for eating disorders among all children and adolescents aged 3-17 years, residing in Ontario, Canada. We defined the pre-COVID period from January 1, 2017, to February 29, 2020, and the post-COVID period from March 1, 2020, to December 26, 2020. Poisson generalized estimating equations were used to model 3-year pre-COVID trends to predict expected post-COVID trends and estimate the relative change from expected rates.

RESULTS

In our population of almost 2.5 million children and adolescents, acute care visits for eating disorders increased immediately after the onset of the pandemic, reaching a 4-week peak annualized rate of 34.6 (emergency department visits) and 43.2 per 100,000 population (hospitalizations) in October 2020. Overall, we observed a 66% (adjusted relative rate: 1.66, 95% confidence interval: 1.41-1.96) and 37% (adjusted relative rate: 1.37, 95% confidence interval: 1.25-1.50) increase in risk for emergency department visit and hospitalization, respectively.

CONCLUSIONS

Acute care visits for pediatric eating disorders increased significantly in Ontario after the onset of COVID-19 pandemic and remained well above expected levels during the first 10 months of the pandemic. Further research is needed to understand the social and neurobiological mechanisms underlying the observed changes in health system utilization.

Trends in the Incidence of New-Onset Anorexia Nervosa and Atypical Anorexia Nervosa Among Youth During the COVID-19 Pandemic in Canada

IMPORTANCE

The COVID-19 pandemic has had considerable mental health consequences for children and adolescents, including the exacerbation of previously diagnosed eating disorders. Whether the pandemic is a factor associated with the concomitant increase in new-onset anorexia nervosa or atypical anorexia nervosa remains unknown.

OBJECTIVE

To assess the incidence and severity of newly diagnosed anorexia nervosa or atypical anorexia nervosa in a national sample of youth before and during the first wave of the COVID-19 pandemic.

DESIGN, SETTING, AND PARTICIPANTS

This repeated cross-sectional study analyzed new eating disorder assessments that were conducted at 6 pediatric tertiary-care hospitals in Canada between January 1, 2015, and November 30, 2020. Patients aged 9 to 18 years with a new anorexia nervosa or atypical anorexia nervosa diagnosis at the index assessment were included.

EXPOSURES

COVID-19-associated public health confinement measures during the first wave of the pandemic (March 1 to November 30, 2020).

MAIN OUTCOMES AND MEASURES

Primary outcomes were the incidence and hospitalization rates within 7 days of de novo anorexia nervosa or atypical anorexia nervosa diagnosis. Event rate trends during the first wave were compared with trends in the 5-year prepandemic period (January 1, 2015, to February 28, 2020) using an interrupted time series with linear regression models. Demographic and clinical variables were compared using a χ2 test for categorical data and t tests for continuous data.

RESULTS

Overall, 1883 children and adolescents with newly diagnosed anorexia nervosa or atypical anorexia nervosa (median [IQR] age, 15.9 [13.8-16.9] years; 1713 female patients [91.0%]) were included. Prepandemic anorexia nervosa or atypical anorexia nervosa diagnoses were stable over time (mean [SD], 24.5 [1.6] cases per month; β coefficient, 0.043; P = .33). New diagnoses increased during the first wave of the pandemic to a mean (SD) of 40.6 (20.1) cases per month with a steep upward trend (β coefficient, 5.97; P < .001). Similarly, hospitalizations for newly diagnosed patients increased from a mean (SD) of 7.5 (2.8) to 20.0 (9.8) cases per month, with a significant increase in linear trend (β coefficient, -0.008 vs 3.23; P < .001). These trends were more pronounced in Canadian provinces with higher rates of COVID-19 infections. Markers of disease severity were worse among patients who were diagnosed during the first wave rather than before the pandemic, including more rapid progression (mean [SD], 7.0 [4.2] months vs 9.8 [7.4] months; P < .001), greater mean (SD) weight loss (19.2% [9.4%] vs 17.5% [9.6%]; P = .01), and more profound bradycardia (mean [SD] heart rate, 57 [15.8] beats per minute vs 63 [15.9] beats per minute; P < .001).

CONCLUSIONS AND RELEVANCE

This cross-sectional study found a higher number of new diagnoses of and hospitalizations for anorexia nervosa or atypical anorexia nervosa in children and adolescents during the first wave of the COVID-19 pandemic in Canada. Research is needed to better understand the drivers and prognosis for these patients and to prepare for their mental health needs in the event of future pandemics or prolonged social isolation.

The Impact of Strict Public Health Restrictions on Pediatric Critical Illness

OBJECTIVES

To characterize the impact of public health interventions on the volume and characteristics of admissions to the PICU.

DESIGN

Multicenter retrospective cohort study.

SETTING

Six U.S. referral PICUs during February 15, 2020-May 14, 2020, compared with the same months during 2017-2019 (baseline).

PATIENTS

PICU admissions excluding admissions for illnesses due to severe acute respiratory syndrome coronavirus 2 and readmissions during the same hospitalization.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Primary outcome was admission volumes during the period of stay-at-home orders (March 15, 2020-May 14, 2020) compared with baseline. Secondary outcomes were hospitalization characteristics including advanced support (e.g., invasive mechanical ventilation), PICU and hospital lengths of stay, and mortality. We used generalized linear mixed modeling to compare patient and admission characteristics during the stay-at-home orders period to baseline. We evaluated 7,960 admissions including 1,327 during March 15, 2020-May 14, 2020. Daily admissions and patients days were lower during the period of stay-at-home orders compared with baseline: median admissions 21 (interquartile range, 17-25) versus 36 (interquartile range, 30-42) (p < 0.001) and median patient days 93.0 (interquartile range, 55.9-136.7) versus 143.6 (interquartile range, 108.5-189.2) (p < 0.001). Admissions during the period of stay-at-home orders were less common in young children and for respiratory and infectious illnesses and more common for poisonings, endocrinopathies and for children with race/ethnicity categorized as other/unspecified. There were no differences in hospitalization characteristics except fewer patients received noninvasive ventilation during the period of stay-at-home orders.

CONCLUSIONS

Reductions in PICU admissions suggest that much of pediatric critical illness in younger children and for respiratory and infectious illnesses may be preventable through targeted public health strategies.

Pediatric emergency department visits during the COVID-19 pandemic: a large retrospective population-based study

BACKGROUND

COVID-19 pandemic has stretched healthcare system capacities worldwide and deterred people from seeking medical support at Emergency Departments (ED). Nevertheless, population-based studies examining the consequences on children are lacking.

METHODS

All ED visits from 2019 to 2020 in Veneto, Italy (4.9 million residents) were collected. Anonymized records of pediatric (≤14 years) ED visits included patient characteristics, arrival mode, triage code, clinical presentation, and discharge mode. Year-on-year variation of the main ED visit characteristics, and descriptive trends throughout the study period have been examined.

RESULTS

Overall, 425,875 ED presentations were collected, 279,481 in 2019, and 146,394 in 2020 (- 48%), with a peak (- 79%) in March-April (first pandemic wave), and a second peak (below - 60%) in November-December (second pandemic wave). Burn or trauma, and fever were the two most common clinical presentations. Visits for nonurgent conditions underwent the strongest reduction during both pandemic waves, while urgent conditions reduced less sharply. ED arrival by ambulance was more common in 2020 (4.5%) than 2019 (3.5%), with a higher proportion of red triage codes (0.5%, and 0.4% respectively), and hospitalizations following ED discharge (9.1%, and 5.9% respectively).

CONCLUSION

Since the beginning of the COVID-19 pandemic, pediatric ED presentations underwent a steeper reduction than that observed for adults. Lockdown and fear of contagion in hospital-based services likely deterred parents from seeking medical support for their children. Given COVID-19 could become endemic, it is imperative that public health experts guarantee unhindered access to medical support for urgent, and less urgent health conditions, while minimizing infectious disease risks, to prevent children from suffering direct and indirect consequences of the pandemic.

Evaluation of changes in pediatric healthcare activity during the Covid-19 state of alarm in the Canary Islands

OBJECTIVE

During the SARS-CoV-2 state of alarm (SoA), a 30-70% reduction was observed in the number of visits to Pediatric Emergency Departments (ED), as well as frequent delay in diagnosis or difficulty accessing healthcare services. Here we evaluate modifications observed in pediatric healthcare activity during the SoA.

STUDY DESIGN

Descriptive retrospective observational study of the hospital pediatric activity.

METHOD

We compared the use of pediatric healthcare services during the SoA (March 11th - June 25th, 2020) versus the use during the equivalent periods of years 2018 and 2019, in the "Complejo Hospitalario Universitario Insular Materno Infantil de Canarias" (Mother and Child University Hospital of the Canary Islands).

RESULTS

The number of patients visiting the pediatric ED decreased by 66.75% on average (95%CI: -65.6; - 67.7; p < 0.001), with a peak reduction (70.4%; 95%CI: -69.0; -71.7; p < 0.001) during the lockdown. We observed an increase in the number of cases of psychiatric disorders, foreign body ingestions and intoxications, as well as a decrease in respiratory conditions. Hospital admissions decreased by 45.5% (95%CI: - 38.9; -51.3; p < 0.001), while the ratio and duration of hospital stay increased. A proportion of 3.95% of admitted patients experienced complications caused by delayed visit to the ED.

CONCLUSIONS

The study shows that more patient education campaigns are needed to improve the efficiency of emergency services. It is important to reinforce the message that adequate healthcare service management is necessary.

Changing Admission Patterns in Pediatric Emergency Departments during the COVID-19 Pandemic in Italy Were Due to Reductions in Inappropriate Accesses

During the initial phase of the national lockdown, we found that there were sharp decreases in admissions to two pediatric emergency departments (EDs) in northern Italy (Cremona and Novara). Here we present a detailed analysis of these admission patterns and types of admissions over a longer timeframe. ED admissions data were anonymously extracted from the departmental management software. Admissions data from 2019 and 2020 were analyzed and compared separately for each ED and combined. There was a 73.2% decrease in total admissions compared with the same period in 2019. With respect to admission diagnoses, there was a significant (p < 0.001) drop in infectious (-51%), respiratory (-25.5%), and nervous systems diseases (-50%) and injuries and poisoning (-17%) but not endocrine, metabolic, neoplastic, circulatory, or musculoskeletal diseases. White codes (patients with minor injuries for whom ED medical care is not required) significantly decreased by 56.3% (p < 0.001). Even if the COVID-19 pandemic represented an enormous healthcare burden in Italy, especially during the first months of the pandemic (late February to May), the workload of pediatric EDs was significantly reduced, especially for unnecessary accesses (white codes).

Care of Pediatric Patients with Diabetes During the Coronavirus Disease 2019 (COVID-19) Pandemic

This article summarizes clinical observations and management strategies in pediatric type 1 diabetes (T1D) during the coronavirus disease 2019 (COVID-19) pandemic. Despite initial fears that children with diabetes would, similar to adults with diabetes, be at risk for severe COVID-19, most pediatric patients with a history of T1D who developed COVID-19 had mild disease or were asymptomatic similar to their peers without diabetes. The article also summarizes the use of telemedicine to provide ongoing care for pediatric patients with T1D during the COVID-19 pandemic. Finally, the article highlights important lessons learned about management of pediatric diabetes during the COVID-19 pandemic.

Delayed access to care and late presentations in children during the COVID-19 pandemic New Zealand-wide lockdown: A New Zealand Paediatric Surveillance Unit study

AIM

Describe paediatricians' experience of adverse health outcomes for children during the New Zealand-wide level 4 lockdown in response to the COVID-19 pandemic.

METHODS

Weekly national survey of paediatricians with an open-ended questionnaire.

RESULTS

During the 6-week study survey period, the New Zealand Paediatric Surveillance Unit received 33 reports about 55 instances where paediatricians believed care may have been compromised, about half (56%) relating to infants aged from birth to 6 weeks. Compromised care was for acute presentations in 75%, acute complications of a chronic illness in 14%, with 11% for chronic conditions. Paediatricians reported the outcome as moderately severe (short-term morbidity, increased length of stay, higher level of care) in 38 cases (69%) and in a further 4 (7%) as severe (potential to be life-threatening or result in permanent disability).

CONCLUSION

Despite clear messaging, hospital avoidance and reduced access to primary and secondary care were associated with significant potential harm for children in New Zealand during a strict lockdown, with newborn infants disproportionately affected. During the implementation of interventions to eliminate community transmission of COVID-19, New Zealand paediatricians note the importance of face-to-face post-natal visits for newborns and primary care services for children with acute illness, to avoid preventable harm.

Effects of Relaxed Lockdown on Pediatric ER Visits during SARS-CoV-2 Pandemic in Italy

Previously, we demonstrated an 81% reduction in pediatric Emergency Room (ER) visits in Italy during the strict lockdown due to the SARS-CoV-2 pandemic. Since May 2020, lockdown measures were relaxed until 6 November 2020, when a strict lockdown was patchily reintroduced. Our aim was to evaluate the impact of the relaxed lockdown on pediatric ER visits in Italy. We performed a retrospective multicenter study involving 14 Italian pediatric ERs. We compared total ER visits from 24 September 2020 to 6 November 2020 with those during the corresponding timeframe in 2019. We evaluated 17 ER specific diagnoses grouped in air communicable and non-air communicable diseases. We recognized four different triage categories: white, green, yellow and red. In 2020 total ER visits were reduced by 51% compared to 2019 (16,088 vs. 32,568, respectively). The decrease in air communicable diseases was significantly higher if compared to non-air communicable diseases (-64% vs. -42%, respectively). ER visits in each triage category decreased in 2020 compared to 2019, but in percentage, white and red codes remained stable, while yellow codes slightly increased and green codes slightly decreased. Our results suggest that preventive measures drastically reduced the circulation of air communicable diseases even during the reopening of social activities but to a lesser extent with regard to the strict lockdown period (March-May 2020).

Type 1 diabetes onset in Lombardy region, Italy, during the COVID-19 pandemic: The double-wave occurrence

BACKGROUND

The Italian Lombardy region has been the epicenter of COVID-19 since February 2020. This study analyses the epidemiology of pediatric type 1 diabetes (T1D) onset during the first two pandemic waves and three previous years.

METHODS

All the 13 pediatric diabetes centers in Lombardy prospectively evaluated charts of children at T1D onset (0-17 years), during year 2020. After calculating the annual incidence, the data were compared with those of the 3 previous years, using generalized linear models, adjusted for age and sex. Monthly T1D new onsets and diabetic ketoacidosis (DKA) were investigated yearly from 2017 to 2020. Data were extracted from outpatients charts of the pediatric diabetes centers and from the database of the national institute of statistics.

FINDINGS

The estimated incidence proportion of T1D was 16/100·000 in 2020, compared to 14, 11 and 12 in 2019, 2018 and 2017, respectively. When adjusting for age and gender, the incidence was significantly lower in 2018 and 2017 compared to 2020 (adjusted incidence ratio: 0.73 and 0.77 respectively, with 95% CI: 0.63 to 0.84, and 0.67 to 0.83; p = 0·002 and p = 0·01), but no difference was found between the years 2020 and 2019. A reduction trend in the percentage of T1D diagnosis during the first wave (March-April) over the total year diagnoses was observed compared to previous years (11·7% in 2020, 17·7% in 2019, 14·1% in 2018 and 14·4% 2017). No difference was observed during the second wave (October-December) (32·8% in 2020, 33·8% in 2019, 34% in 2018, 30·7% in 2017). The proportion of DKA over the total T1D diagnoses during the second wave had higher trend than the first one (41·7% vs 33·3%), while severe DKA over the total DKA appeared higher during the first wave (60% vs 37·1%).

INTERPRETATION

The study suggests an increase in the incidence of pediatric T1D in Lombardy throughout the past five years. Pandemic waves may have affected the clinical presentation at onset.

FUNDING

None.

Impact of COVID-19 on a paediatric emergency service

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

Foreign body ingestion during the COVID-19 pandemic: a retrospective single centre review

Introduction

During the COVID-19 pandemic in 2020, there were many changes in the provision of healthcare as well as home and educational environments for children. We noted an apparent increase in the number of children presenting with ingested foreign bodies and due to the potential impact of injury from this, further investigated this phenomenon.

Method

Using a prospective electronic record, data were retrospectively collected for patients referred to our institution with foreign body ingestion from March 2020 to September 2020 and compared with the same period the year prior as a control.

Results

During the 6-month pandemic period of review, it was observed that 2.5 times more children were referred with foreign body ingestion (n=25) in comparison to the control period (n=10). There was also a significant increase in the proportion of button battery and magnet ingestions during the COVID-19 pandemic (p 0.04).

Conclusion

These findings raise concerns of both increased frequency of foreign body ingestion during the COVID-19 pandemic and the nature of ingested foreign bodies linked with significant morbidity. This may relate to the disruption of home and work environments and carries implications for ongoing restrictions. Further awareness of the danger of foreign body ingestion, especially batteries and magnets, is necessary (project ID: 2956).

The COVID-19 pandemic dramatically reduced admissions of children with and without chronic conditions to general paediatric wards

Aim

We examined the impact of the COVID‐19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted.

Methods

Israel declared COVID‐19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID‐19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre‐existing conditions, with 638 children hospitalised during the same period in 2019.

Results

The mean number of daily hospitalisations during the COVID‐19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID‐19. There was a significant decrease in the number of patients admitted with infectious (74%) and non‐infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre‐existing medical conditions.

Conclusion

The Israeli COVID‐19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.

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

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

The ongoing indirect effect of the COVID-19 pandemic on a pediatric emergency department

Introduction

The SARS-CoV-2 coronavirus pandemic may cause significant morbidity and mortality in adults, yet severe cases are rare among children. The indirect impact of the pandemic on health care delivery in general and pediatric emergency department (PED) visits in particular has been widely reported.

Aims

To assess the impact of the pandemic and the social restrictions imposed in its wake on PED visits and hospitalization rates in our Israeli medical center. We also sought to track these data in relation to the variation in pandemic severity and social restrictions over time. A comparison of this data with that of the adult emergency department was also performed.

Methods

Data for this study were drawn from the Shaare Zedek Medical Center (SZMC), Jerusalem, Israel computerized databank. The daily number of PED and adult ER visits as well as hospitalizations resulting from these visits during the months January-July during the years 2018, 2019, 2020 were recorded. We compared the risk ratio for hospitalization in 2019 and 2020, as well as the incidence rate ratio.

Results

During March and April there was a decrease in PED visits from 4,588 visits in 2019 to 2,527 visits in 2020 (ratio = .551, 95%CI [.52,.58]. Despite the drop in PED visits, the rate of hospitalizations rose with respect to 2019 (Risk Ratio = 1.31, p < .001, 95%CI [1.17,1.47]). Similar but more moderate trends were seen in the adult ED. From May-July 2020, after the lockdown was lifted, PED visits remained 30% below the same time period from 2018 and 2019, while the hospitalization rate returned to its pre-pandemic level.

Conclusions

A significant drop in PED visits is seen to extend well beyond the peak of the pandemic and the lockdown period. This highlights the potential risk of children with serious emergencies becoming casualties of the pandemic by their not being brought to medical attention. Efforts should be made to raise public awareness among parents and other caretakers of children regarding this matter.

Neonatal and Pediatric Emergency Room Visits in a Tertiary Center during the COVID-19 Pandemic in Italy

The COVID-19 pandemic is affecting healthcare services worldwide. We investigated the impact of a strict lockdown policy on the characteristics of neonatal and pediatric attendances to our pediatric emergency department (PED). The clinical features of PED visits in March-April 2020 (COVID-19) and March-April 2019 (non-COVID-19) were analyzed. During the COVID-19 lockdown period, visits reduced by 67%, from 3159 to 1039. Neonatal access decreased from 78 to 59, mainly due to fewer pathological conditions, with a complete disappearance of respiratory infections. On the other hand, minor neonatal clinical conditions rose from 44 (56.4%) to 48 (81.4%), mostly due to feeding-related issues. Communicable diseases, particularly respiratory infections and gastroenteritis, dropped from 1552 (49.1%) to 288 (27.7%). Accident-related visits also decreased during COVID-19, from 535 (16.9%) to 309 (29.7%), becoming the most common cause of PED access. Hospital admissions reduced from 266 to 109, while PICU (pediatric intensive care unit) admissions decreased from 27 to 11, with a comparable rate of 10.1% in both periods. The lockdown due to COVID-19 had a substantial impact on our PED visits, which markedly decreased, mainly due to fewer respiratory infections. Unexpectedly, neonatal visits for minor conditions did not decline, but rather slightly increased. Among the children admitted to the PICU, none had respiratory disease.

COVID-19 and complicated bacterial pneumonia in children

We read with great interest the recent publication by Steinfortet al. [1] outlining the profound reduction in influenza infections in Australia as a result of social distancing during the COVID-19 pandemic. Similar dramatic effects of social distancing on paediatric hospital activity have been reported, with reduced hospital admissions, presentations for respiratory conditions and detection of other viruses [2–6]. However, the impact of the pandemic on bacterial respiratory infections has not been well characterised. The Australian state of Victoria (population 6.7 million) has experienced a prolonged period of social restrictions (“lockdown”) since March 2020. This period spanned the southern hemisphere autumn to spring, the usual peak period for bacterial respiratory infections.

Social distancing measures instituted due to #SARSCoV2 have dramatically reduced paediatric thoracic empyema cases in Australiahttps://bit.ly/3akG98M

Pediatric admissions to emergency departments of North-Western Italy during COVID-19 pandemic: A retrospective observational study

Background

COVID-19 pandemic caused huge decrease of pediatric admissions to Emergency Department (ED), arising concerns about possible delays in diagnosis and treatment of severe disorders.

Methods

Impact of COVID-19 on Pediatric Emergency Room (ICOPER) was a retrospective multicentre observational study including 23 Italian EDs.

All the children <18 years admitted, between March 9th and May 3rd 2020 stratified by age, priority code, cause of admission and outcome have been included and compared to those admitted in the same period of 2019.

Our objectives were to assess the characteristics of pediatric admissions to EDs since COVID-19 outbreak until the end of lockdown, and to describe the features of critical children.

Findings

16,426 children were admitted in 2020, compared to 55,643 in 2019 (-70·48%). Higher reduction was reported in hospitals without Pediatric Intensive Care Unit (PICU) (-73·38%) than in those with PICU (-64·08%) (P<0·0001). Admissions with low priority decreased more than critical ones (-82·77% vs. 44·17% respectively; P<0·0001). Reduction of discharged patients was observed both in hospitals with (-66·50%) and without PICU (-74·65%) (P<0·0001). No difference in the duration of symptoms before admission was reported between 2019 and 2020, with the majority of children accessing within 24 h (55·08% vs. 57·28% respectively; P = 0·2344).

Interpretation

Admissions with low priority decreased significantly more than those with high priority; we suppose that the fear of being infected in hospital maybe overcame the concerns of caregivers. Compared to 2019, no significant referral delay by caregivers was reported. Our data suggest the need of adaptation of EDs and primary care services to different needs of children during COVID-9 pandemic.

Impact of COVID-19 pandemic on utilisation of healthcare services: a systematic review

OBJECTIVES

To determine the extent and nature of changes in utilisation of healthcare services during COVID-19 pandemic.

DESIGN

Systematic review.

ELIGIBILITY

Eligible studies compared utilisation of services during COVID-19 pandemic to at least one comparable period in prior years. Services included visits, admissions, diagnostics and therapeutics. Studies were excluded if from single centres or studied only patients with COVID-19.

DATA SOURCES

PubMed, Embase, Cochrane COVID-19 Study Register and preprints were searched, without language restrictions, until 10 August, using detailed searches with key concepts including COVID-19, health services and impact.

DATA ANALYSIS

Risk of bias was assessed by adapting the Risk of Bias in Non-randomised Studies of Interventions tool, and a Cochrane Effective Practice and Organization of Care tool. Results were analysed using descriptive statistics, graphical figures and narrative synthesis.

OUTCOME MEASURES

Primary outcome was change in service utilisation between prepandemic and pandemic periods. Secondary outcome was the change in proportions of users of healthcare services with milder or more severe illness (eg, triage scores).

RESULTS

3097 unique references were identified, and 81 studies across 20 countries included, reporting on >11 million services prepandemic and 6.9 million during pandemic. For the primary outcome, there were 143 estimates of changes, with a median 37% reduction in services overall (IQR -51% to -20%), comprising median reductions for visits of 42% (-53% to -32%), admissions 28% (-40% to -17%), diagnostics 31% (-53% to -24%) and for therapeutics 30% (-57% to -19%). Among 35 studies reporting secondary outcomes, there were 60 estimates, with 27 (45%) reporting larger reductions in utilisation among people with a milder spectrum of illness, and 33 (55%) reporting no difference.

CONCLUSIONS

Healthcare utilisation decreased by about a third during the pandemic, with considerable variation, and with greater reductions among people with less severe illness. While addressing unmet need remains a priority, studies of health impacts of reductions may help health systems reduce unnecessary care in the postpandemic recovery.

PROSPERO REGISTRATION NUMBER

CRD42020203729.

Changing patterns of emergency paediatric presentations during the first wave of COVID-19: learning for the second wave from a UK tertiary emergency department

Background

The SARS-CoV-2 pandemic and initial public health response led to significant changes in health service delivery, access and utilisation. However, SARS-CoV-2 illness burden in children and young people (CYP) is low. To inform effective child public health interventions, we aimed to compare patterns of paediatric emergency department presentation during the initial pandemic response with a previous non-pandemic period.

Methods

Retrospective review of attendances (0-18 years) over the initial pandemic (2 March 2020-3 May 2020) compared with 2019. Outcome measures included number of attendances, referral source, presenting complaint, discharge diagnosis and disposal. Descriptive statistics with subgroup analysis by age/sex/ethnicity and pandemic time periods (pre-lockdown, lockdown weeks 1-3 and lockdown weeks 4-6) was performed.

Results

4417 attendances (57% illness and 43% injuries) occurred, compared with 8813 (57% illness and 43% injuries), a reduction of 50%, maximal in lockdown week 2 (-73%). Ranking of top three illness presentations changed across the pandemic weeks. Breathing difficulty dropped from first (300, 25%) to second (117, 21%) to third (59, 11%) (p<0.001). Abdominal pain rose from the third pre-lockdown (87, 7%) and lockdown weeks 1-3 (37, 7%) to second in weeks 4-6 (62, 12%; p=0.004). Fever ranked second (235, 19%) in pre-lockdown and first in weeks 1-3 (134, 24%) and weeks 4-6 (94, 18%; p=0.035).

Conclusions

Despite a 50% reduction, there was no significant change in acuity of illness. Rank of illness presentations changed, with abdominal pain ranking second and fever first, an important change from previous, which should prompt further research into causes. CYP-specific public health messaging and guidance for primary care are required in this second wave to ensure access to appropriate emergency services.

ECIEN-2020 study: the effect of COVID-19 on admissions for non-COVID-19 diseases

BACKGROUND

The pandemic caused by severe acute respiratory coronavirus 2 (SARS-CoV-2) has had great effects on health systems worldwide, not only in relation to coronavirus disease 2019 (COVID-19) cases but also affecting patients with other pathologies.

METHODS

ECIEN-2020 is an observational study conducted in a tertiary referral hospital in Navarra, Spain. It describes the effects of COVID-19 pandemic and the preventive measures adopted, in pediatric admissions for non-COVID-19 diseases. Admissions during March-June 2020 (first wave of the COVID-19 pandemic in Spain) are described and compared with the same quarter in 2019. A sub-analysis was performed delving into epidemiology. Patient characteristics (age, sex, past medical history), disease characteristics (symptoms, duration of symptoms, previous consultation in Primary Care Health Center), and admission characteristics (place and average stay) were analyzed.

RESULTS

A 33% reduction in the number of pediatric hospital admissions was observed, decreasing from 529 hospitalizations in 2019 to 353 in 2020 (P < 0.001). This highlights a 48% reduction in patients admitted for pulmonary diseases. There were no significant changes in average hospital-stay, percentage of intensive care unit admissions, or in admissions for other reasons. Percentage of patients admitted among those seen in the emergency department rose from 5.1% in 2019 to 10.9% in 2020, whereas the total number of consultations in the emergency department decreased by 68%.

CONCLUSION

The pandemic and the measures adopted due to SARS-CoV-2 have significantly decreased pediatric admissions for non-COVID-19 diseases, especially due to a reduction in the hospitalization for respiratory diseases.

The ongoing impact of COVID-19 on asthma and pediatric emergency health-seeking behavior in the Bronx, an epicenter

Background

The Bronx has the highest prevalence of asthma in the United States (US), and was also an early COVID-19 epicenter, making it a unique study location. Worldwide reports describe significant declines in pediatric emergency department (PED) visits during COVID-19. The ongoing impact of COVID-19 on all PED presentations, including asthma, at an early epicenter has not been studied beyond the pandemic peak and into the early phases of state re-opening.

Objectives

To compare PED health-seeking behaviors and clinical characteristics during the 2020 pandemic and subsequent initial New York State (NYS) phased re-opening to the same period in 2019.

Methods

Retrospective chart review of children <21 years utilizing the PED at a high-volume quaternary children's hospital in The Bronx, NY from March 15th 2020 – July 6th 2020 (pandemic cohort) and the same interval in 2019 (comparison cohort). Visits were assigned to pre-determined diagnostic categories. Demographic and clinical data were compared.

Results

19,981 visits were included. Visits declined by 66% during 2020. Proportions of asthma visits (2% vs. 7%, p < 0.0001) and minor medical problems (61% vs. 67%, p < 0.0001) had significant declines in the pandemic cohort, while major medical problems (13% vs. 8%, p < 0.0001), appendicitis (1% vs. 0.4%, p < 0.0001) and other surgical complaints (1% vs. 0.5%, p < 0.0001) had proportional increases in the pandemic cohort. No significant proportional changes were noted among psychosocial and trauma groups between the two cohorts.

Conclusion

The pandemic cohort experienced a substantial decrease in PED volume, but an increase in acuity and admission rates, which was sustained through the NYS phase-II re-opening. Despite being located in an asthma hub, the incidence of asthma-related PED visits declined appreciably in the pandemic cohort. Future studies examining the effects of indoor allergens in isolation on pediatric asthma are warranted.

The impact of COVID-19 lockdown on infectious diseases epidemiology: The experience of a tertiary Italian Pediatric Emergency Department

INTRODUCTION

The aim of this study was to describe the rate and types of community-acquired respiratory infections observed in a pediatric ED during the SARS-CoV-2 related lockdown in Italy and to compare data with the same period of previous year.

METHODS

A retrospective analysis of medical charts of patients arrived at the ED of Gaslini Children's Hospital from 10th March 2020 to 30th April 2019 and the same frame of 2020 were performed. We compared two groups by demographics, duration of fever before ED admission, triage code, number of patients hospitalized after ED evaluation. We calculated proportion and incidence rate for airborne infections, fever, and urinary tract infections (UTI), appendicitis, and gastroenteritis for control.

RESULTS

1362 children arrived at the ED during the lockdown compared to 5628 in the same period of 2019 (-75,8%). No difference was noticed (27.7% vs 28.4%) in the total amount of infectious episodes. A significant reduction in rate of incidence and proportion were observed for upper respiratory tract infections (21,4% vs 28%), otitis (2,6% vs 16,2%), streptococcal infections (0,5% vs 5,2%) and bronchiolitis (2,1% vs 5,7%). Conversely, FUO (27,8 vs 11,1%), infectious mononucleosis (2,6% vs 0,4%), UTI (7,4% vs 2,9%) and appendicitis (6,8% vs 1,1%) significantly increased. Median time from the onset of fever and arrival in ED was significantly lower in 2020 group.

CONCLUSION

Our results demonstrated a reduction in community-acquired respiratory infections during the lockdown for COVID-19. The increase in rate of FUO and febrile conditions, together with the short time from fever onset and ED visit could be related to the fear for a SARS-CoV-2 infection.