How did the number of children presenting to EDs across Europe during the first phase of the COVID-19 pandemic compare with the 2 previous years?

By Dr. Liji Thomas, MDAug 31 2022Reviewed by Danielle Ellis, B.Sc.

The coronavirus disease 2019 (COVID-19) pandemic, caused by the explosive spread of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), almost paralyzed the world. Healthcare did not escape this effect, with emergency department (ED) visits showing a steep decline as the fear of contracting the infection grew.

Background

A recent study reported on the occurrence of this decrease in ED visits among children with acute illness or injury, using an observational design across several countries. The aim was to define this phenomenon as well as to attempt to identify the risk factors and effects.

Introduction

As sanitary cordons, contact tracing, and quarantine and isolation measures, were put into operation to stem the pace of transmission of the virus during its earliest catastrophic phase. Accordingly, hospitals and other medical facilities often cancel or postpone elective or non-urgent visits and procedures.

Concerns were raised as to how this might affect morbidity and mortality due to less serious but more chronic illnesses. It was feared that patients might present later and at a more serious stage of illness due to the restrictions in force. Some sporadic evidence suggested that diabetic ketoacidosis (DKA) was presenting more commonly among children at the ED, as well as intussusception and other acute illnesses, seemingly bearing out this fear.

In the absence of a large, multicenter study, the current study, published in the journal PLoS Medicine, sought to examine how pandemic-related lockdowns impacted ED visits among children in 16 European countries. As part of the “Epidemiology, severity and outcomes of children presenting to emergency departments across Europe during the SARS-CoV-2 pandemic” (EPISODES) study, it covered a period between January 2018 and May 2020, comparing the incidence and type of pediatric ED visits with those in the two years immediately preceding this period. 

The study was designed to be a retrospective observational study, using routine clinical data from 38 centers.

What did the study show?

The findings of the current study revealed a general and widespread reduction in ED visits and hospital admissions across all the study sites and all pediatric age groups. The fall was proportional to the severity of the pandemic in terms of COVID-19 prevalence in the region of interest and the stringency of containment measures implemented. In fact, when four or more measures were in force, the numbers plummeted by almost 90% compared to regions with no containment measures.

At worst, only 5% of ED visits compared to preceding years was recorded, at one site, while at best, the number was down by 46%. Overall, ED attendance was sustained at half the predicted levels, or more, in France, Sweden, Ireland, Iceland, Latvia, and the Netherlands.

Hospitals that catered only to children showed lower reductions in ED visits, with those serving both adult and pediatric patients showing 3.5-fold lower numbers of patients compared to the former. Urban hospitals also showed the same trend compared to urban-rural hospitals.

When visits were categorized by cause, the most affected were infectious disease visits, which remained significantly lower throughout the study period. This included tonsillitis, otitis media, gastrointestinal infections, and lower respiratory tract infections (LRTIs). Common minor injuries in children, including those to the head and breaks in the radius, were decreased as well.

Contrary to common perception, there was no increase in DKA, intussusception, or testicular torsion, even when COVID-19 prevalence was high, in absolute numbers. Mental health issues were less commonly observed but increased from the end of March, along with minor injuries, though not minor childhood illnesses.

ED visits were more than twice as high in regions with lower prevalence, and infants were relatively more likely to be brought in than the next oldest age groups, in some sites at least. That is, children aged 1-2 years registered a 14% decrease in ED presentations, vs. 20% and 30% in those between 2-5 years and children above this age but below 18, respectively. However, these differences were less marked than those between countries.

Pediatric intensive care admissions were also affected, showing a fall of 30%, but less than general admissions. When the urgency of triage was used as a sorting criterion, the number of patients assigned to lower urgency triage was reduced the most, though numbers in emergent and very urgent triage categories were also halved.

Conclusions

The study reflected a reduced pediatric attendance at EDs throughout Europe during the period of the first lockdown related to the COVID-19 pandemic. This fall partially spared seriously ill or injured children, though the numbers of such cases presenting at the ED fell relative to pre-pandemic levels. Less urgent cases, such as minor injuries and common infections, showed the greatest and most sustained reduction.

The reasons could be many, including a tendency not to seek care by the parents, changes in healthcare access, and the reduced spread of respiratory pathogens due to infection control measures.

“The findings suggest that the introduction of infection prevention measures can decrease the burden of acute childhood illnesses and injuries.” The absence of unsupervised interactions between children, reduced air pollution, and better compliance with medication, could all have contributed to a lower incidence of infections as well as potentially dangerous activities, accounting for the lower number of such cases.  

Interestingly, illnesses such as mental health crises or diabetic ketoacidosis made up a larger proportion of ED visits among children. This could have led to a wrong assumption that these events were occurring at a higher rate than was the case. Conversely, it could be driven by the greater focus on mental health issues during the pandemic.

Moreover, urgent intervention continued to be required in the same number of cases, making it mandatory to maintain surgical teams for emergency surgery even during such health crises.

Our study informs how pediatric emergency medicine can prepare for future pandemics, taking into account that different infectious diseases outbreaks can affect children differently, and illustrates the potential of electronic health records to monitor trends in urgent and emergency care for children.”