Collateral Damage: Delayed Diagnoses in Kids During COVID-19

Diabetes was by far the most common delayed pediatric presentation in emergency care during the COVID-19 pandemic, according to a snapshot survey of nearly 2500 pediatricians in the UK and Ireland.

There were also nine deaths where delayed presentation was considered a contributing factor, resulting mainly from sepsis and malignancy.

By comparison, over the same 2-week period of the survey there were three child deaths from COVID-19 directly, according to senior study author Shamez Ladhani, MRCPCH, PhD, chair of the British Paediatric Surveillance Unit (BPSU), Royal College of Paediatrics and Child Health, London, UK.

"The unintended consequences of COVID are far greater, in children, than the disease itself. The way we are trying to prevent this is causing more harm than the disease," he lamented.

One third of senior UK pediatric specialists who responded to the survey reported dealing with so-called emergency delayed presentations in children who they would normally have expected to present much earlier.

After diabetes, the most commonly reported delayed diagnoses were sepsis and child protection issues. Cancer also featured prominently.

"We've found that there is great concern that children are not accessing healthcare as they should during lockdown and after," Ladhani stressed to Medscape Medical News.

"Our emergency departments saw a 50% reduction during the peak, and now it is still 40% less than expected. The problem is improving but it remains."

The survey findings were recently published online in Archives of Disease in Childhood, by first author Richard M. Lynn, MSc, of the Institute of Child Health, Department of Epidemiology and Public Health, University College London Research, UK, and colleagues.

New Diabetes Cases Presented Very Late During Lockdown

Over the 2-week reporting period (in mid-April 2020), type 1 diabetes was the most frequently reported delayed diagnosis, with 44 cases overall, 23 of which involved diabetic ketoacidosis.

"If you talk to the diabetes specialists, they tell us that generally, most cases of new diabetes arrive late because it has very nonspecific symptoms," Ladhani explained.

However, he added, "Pediatricians on the frontline know what to expect with diabetes. Those children who would have come in late prior to the pandemic are now arriving very late. Those consultants surveyed were not junior doctors but consultant pediatricians with many years of experience."

In a recent article looking at pediatric delayed presentations, published in the Lancet, one patient with diabetes entered intensive care, and the BPSU report recorded one death possibly associated with diabetes, Ladhani pointed out.

"Pediatricians are worried that children are coming in late. We need to raise awareness that parents need to access healthcare and this message needs to go out now," he said.

"We can't wait until a second wave. It has to be now because A&E [accident and emergency] attendance is still 40% [lower than]...expected."

BPSU Survey Covers Over 90% of Pediatricians in UK and Ireland

After numerous anecdotal reports of delayed presentations in the UK and abroad, the snapshot survey was conducted as part of routine monthly reports where pediatricians are asked to document any cases of rare conditions seen.

"We had heard stories of delayed presentations, but we wanted to know was this a real problem or just anecdotal?" Ladhani said.

The regular BPSU survey covers over 90% of UK and Ireland-based pediatric consultants (numbering 4075). On the back of this established communication, the BPSU decided to gauge the extent of delayed presentations during the peak weeks of the COVID-19 pandemic.

Over the next 7 days, 2433 pediatricians, representing 60% of BPSU participants, responded.

"This response rate in 7 days highlights the importance given to the survey by pediatricians...and the widespread professional concern about delayed presentations," write the authors.

Participants were asked whether they had seen any children during the previous 14 days who, in their opinion, presented later than they would have expected prior to the COVID-19 pandemic.

"There's no one definition for this but these senior clinicians know when something is unusual," said Ladhani.

Emergency department attendances were compared with figures for the same period last year.

Overall, a total of 32% of 752 pediatricians working in emergency departments and pediatric assessment units reported witnessing delayed presentations, with 57 (8%) reporting at least three patients with delayed presentation.

"It was clear that those doctors on the frontline were seeing a lot of delayed presentations. Also, neonatologists reported women arriving late for labor, and community physicians said they just weren't witnessing child protection cases anymore," added Ladhani.

Other issues included early discharges following births because of COVID-19 concerns, before feeding had been established, prompting return visits due to feeding problems and dehydration.

The top five delayed diagnoses were diabetes (n = 44), sepsis (n = 21), child protection (n = 14), malignancy (n = 8), and appendicitis (n = 6). There were 10 delayed perinatal presentations.

Of the nine deaths, for which delayed presentation was considered to play a role, three were due to sepsis, three were due to new malignancy diagnoses, one was due to new diagnosis of metabolic disease, and two did not have the cause reported.

The delays in presentation are likely to have been influenced by the UK government's message to 'Stay at Home' during the strict lockdown period, which perhaps was sometimes interpreted too literally, Ladhani suggested.

"It was the right message socially, but not medically."

Russell Viner, MB, PhD, president of the Royal College of Paediatrics and Child Health, said in a statement: "The impact for children is what we call 'collateral damage', including long absences from school and delays or interruptions to vital services."

"We know that parents adhered very strongly to the 'Stay at Home' [message] and we need to say clearly that this doesn't apply if your child is very sick."

"Should we experience a second wave or regional outbreaks, it is vital that we get the message out to parents that we want to see unwell children at the earliest possible stage," Viner cautioned.

Arch Dis Child. Published online June 25, 2020. Letter

Ladhani has reported no relevant financial relationships.

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