Plummeting A&E Attendances Show Children 'Made Invisible' by COVID Measures

Rachel Pugh

Disclosures

November 27, 2020

As the UK’s only paediatric public health consultant based in an emergency department (ED), Professor Rachel Isba was in a frontline position to see the number of children and young people attending North Manchester General Hospital plummet when COVID-19 struck. It raised big questions.

Prof Rachel Isba

The desire to quantify the extraordinary decrease in numbers she and other colleagues observed coming through the front door at North Manchester General spawned a transatlantic study in collaboration with Royal Manchester Children’s Hospital (RMCH, the largest paediatric hospital in the UK, and Yale New Haven Children’s Hospital in the US (YNHCH).  Results revealed not only around a 25-30% drop in attendances at both sites, but that youngsters were also up to 60% more likely to be admitted than at the same time last year.

This has raised important questions for both Prof Isba and fellow researchers about whether children and young people attending hospital during the pandemic are more unwell than before COVID broke out, and what has governed their behaviour.

Prof Isba, whose time is shared between her clinical work at North Manchester General Hospital and that as associate dean for engagement for Lancaster University’s Faculty of Health and Medicine, is passionate about the welfare of children and young people, with a particular clinical and research focus on vaccinations and dental health.

This fact-finding study, published in Pediatric Emergency Care, has increased the concerns of Prof Isba and collaborating colleagues that children and young people have suffered disproportionately as a result of the pandemic and some COVID control measures. She is also disappointed at what she sees as the Government’s neglect of children in its pandemic plans.

She spoke to Medscape UK about her experience of trying to quantify the impact of COVID on children during lockdown.

Q&A

What prompted the research and why was it set up with Yale New Haven Children’s Hospital, US?

When the pandemic was declared, it was 'all hands on deck' and it quickly became apparent to us all at North Manchester that we were seeing much smaller numbers of children coming to ED than usual. We counted them from March to the end of April and wrote a letter in the Archives of Disease in Childhood.  Other European countries seemed to have the same picture. Since the US had a completely different healthcare system and had handled the pandemic differently I wondered whether their experience would also follow ours. As a visiting scholar at Yale, I enquired from a colleague and found that they were seeing a similar drop in numbers. We decided to use simple count data to look at the number of children attending the respective EDs (comparing weeks 1 to 20 in both 2019 and 2020) and also to measure how likely they were to be admitted. The latter was a proxy measure for how poorly the youngsters were.

Were you surprised by the results? Will there be a follow up?

The results were staggering. We had different numbers of children, different hospitals, different parts of the world and different healthcare systems, but the patterns displayed in the UK and the US were pretty much identical. Attendance numbers for each PED (paediatric emergency department) decreased in 2020 compared with 2019 (RMCH, 29.2%; YNHCH, 24.8%). Odds of admission were significantly higher after lockdown than in 2019—RMCH (odds ratio, 1.26; 95% confidence interval, 1.08–1.46) and YNHCH (odds ratio, 1.60; 95% confidence interval, 1.31–1.98).

Smaller numbers were coming, so fewer children were getting admitted but the ones who were coming were more likely be admitted. What was so striking was that you could have just swapped the labels around on the graph. I was completely blown away by how similar the data appeared.

I’m now interested in looking at the same figures across the 12 months of 2020.

Can you give some idea of how much more poorly the children admitted were during COVID?

It is difficult to say. Our children were more likely to be admitted but it was not the remit of this research to look at details of why. Other research elsewhere in the UK is looking into that question. The feeling around the country is that some children have been coming in later. On the adult side that is certainly anecdotally the case.

Why might parents have been delaying taking children to hospital? 

It’s probably down to a few reasons. Early on in the pandemic, no one knew that children were not going to be made as ill by the virus as adults. Parents were scared of the virus, they were justifiably scared of going to hospital and they did not understand what services were open. There were a lot of mixed messages in the media.

The other side of the story is that many people now know how to wash their hands properly which was not the case before. So, for example, a lot of children did not attend because they were not infected with the normal diarrhoea and viruses we see. People were also not mixing as much. This accounts for some of the drop off in attendances.

Some diseases will continue regardless of COVID. The worrying cases are those - like brain tumours - which really should have been going to ED and weren’t. We have not managed to quantify that yet.

What might be missed since the pandemic started that might be picked up during a ‘normal’ PED visit?

Two big things. The mental health of children and young people has been well flagged up now. But there is emerging evidence that a huge number of safeguarding problems have been missed, because during the pandemic children have become invisible. If they are not going to school and they are not going to clubs or to the hospital then no one picks up that they have unexplained bruising, or something else which would suggest there is a concern. Schools, hospitals, and GPs pick up a lot of safeguarding concerns. The number of referrals for child protection have dropped since the pandemic started because for a long time when schools were closed nobody could see these kids.

Children are (by comparison with adults) relatively unaffected by the virus itself, but disproportionately affected by the unintended consequences and equality issues. It’s better now that they are back at school.

What other impacts on child health have you observed in your frontline work during COVID-19?

No-one has really been going to the dentist for routine care and data is mixed about whether people have been going for their vaccinations. It looks as if more people may have missed out on their MMR, and we were not in a particularly good place with that anyway before the pandemic. In autumn 2019, the UK lost its WHO measles-free status, indicating that the UK had circulating measles virus and inadequate vaccination coverage levels (via MMR) to prevent spread within populations. My worry is that we will get a measles outbreak whilst recovering from the pandemic.

What would you like to come out of your study?

A message needs to be clarified for parents and carers who think their child is really poorly, about when they should take them to hospital. This was clearly absent in March when some days we saw single figures, whereas at the same time in 2019 we were seeing four or five times as many a day. Some of the cases genuinely needed hospital care, but others would have been better managed elsewhere in the system. We can’t go back to the way it was before the pandemic.

Has COVID made people think differently? 

It has taught us how to get things done quickly and some of that will stay because it’s definitely for the better.

The biggest lesson should be that someone needs to look at children and how they are faring during the pandemic. The pandemic made them invisible, so they have been overlooked. You would struggle to find any metric applied to children and young people that has not got worse during the pandemic, but because they are rarely dying from COVID they are being forgotten, and the resources channelled into adult services.

The Royal College of Paediatrics and Child Health have been brilliant, but the whole uproar about free school meals for ‘at risk’ children during the pandemic shone a light on the fact that the kids are being disproportionately damaged. The fact that the Government voted against feeding them during the holidays is simply horrendous.

Our children are going to have to live with the fall-out from COVID for far longer than the rest of us.

Pediatric Emergency Care: November 2020 - Volume 36 - Issue 11 - p 551-553. doi: 10.1097/PEC.0000000000002260. Abstract.

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