Study examines pediatric emergency department attendance trends during the first COVID-19 wave in Europe

In a recent study posted to the medRxiv* pre-print server, researchers investigated the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and the adoption of preventive measures in the pediatric emergency department (ED) attendances in Europe.

Background

Studies have reported a low incidence of severe coronavirus disease 2019 (COVID-19) in children with low corresponding pediatric ED attendances. Additionally, preventive measures such as wearing face masks, staying indoors, and preventing public gatherings further reduce pediatric ED attendances.

However, concerns have been raised about the probable delay in pediatric visits to health facilities due to difficulties in access, health provision changes, and fear of viral exposure. Additionally, reports have linked disorders such as intussusception and diabetic ketoacidosis with COVID-19. However, the validity of such associations is questionable.

About the study

In the present study, researchers compared the pediatric ED attendance during the initial COVID-19 wave with that of the previous two years in Europe. This retrospective study was a part of the EPISODES (Epidemiology, severity, and outcomes of children presenting to emergency departments across Europe during the SARS-CoV-2 pandemic) study.

Data were extracted for 10 domains from electronic patient records of the pediatric population attending 38 ED among 16 European nations between January 1, 2018, and May 17, 2020. The ED sites were selected from the Pediatric Emergency Research in the United Kingdom and Ireland (PERUKI) and the Research in European Pediatric Medicine (REPEM) networks.

The domains were as follows: time of ED attendance, patient characteristics, arrival modes and referral modes, triage urgency, presenting issue, vital signs, diagnosis, ED diagnostics, ED treatment, hospitalization, and length of stay in ED and hospitals.

Triage urgency was classified as follows: very urgent/emergent/level 1 and 2, level 3/urgent/, and non-urgent/standard/level 4 and 5 to enable uniform coding among the ED. COVID-19 severity was based on the triage classification, hospitalizations, pediatric intensive care unit (PICU) admissions, or deaths in ED.

COVID-19 preventive measures were introduced during the same period and to a similar extent across the European nations. The predicted and observed numbers of ED attendances were estimated. Poisson models and incidence rate ratios (IRR) were used for the analysis.

Results

The number of pediatric ED attendances ranged from 4961 (NL001, 2019) to 295,787 (TUR003, 2019). Most sites were tertiary care academic hospitals with specialized pediatric ED except for three.

At all sites, reductions were observed in pediatric ED attendances, high triage urgencies, and hospitalizations across all ages (larger reduction above 12 months age) during Spring 2020. The smallest and largest reductions were observed in SWE001 and AUS001, respectively, from the end of March 2020. The observed ED attendances were 50% higher than the predicted attendances at ED sites in France, Ireland, Sweden, Latvia, Netherlands, and Iceland. However, there was substantial overlapping among the sites when 95% confidence interval values were taken into consideration.

The ED attendances were greater in countries with lower SARS-CoV-2 prevalence (IRR 2.6) and children aged above one year. The IRRs for the 1-2 years, 2-4 years, 5-11years and 12-16 years age groups were 0.9, 0.8, 0.7, and 0.7, respectively. The impact of COVID-19 on PICU admissions (IRR 1.3) was lower than that on general admissions. Overall, the observed hospital and PICU admissions were lower than the predicted admissions. Additionally, there was no increase in the observed ED mortality compared to the predicted mortality.

The urgent triage and very urgent triage IRRs were 1.1 and 1.5, respectively. The lower triage urgencies were reduced considerably. This indicates that children with severe COVID-19 had more ED attendances than those with mild infection or injuries. Additionally, the sustained, as well as the greatest reductions were observed for communicable infections, particularly for otitis media, tonsillitis, lower respiratory tract infections (LRTI), and gastrointestinal disorders.

There was no increase in absolute counts for diagnoses such as intussusception, testicular torsion, and diabetic ketoacidosis. Contrastingly, the ED attendance increased post-March end for radius fractures, minor head injuries, and frequency of mental health issues. Overall, the reductions in ED attendances for infections were significantly larger than that for trauma or surgical presentations.

A positive and inverse association was observed between the COVID-19 measures and pediatric ED attendances. More COVID-19 measures resulted in lower ED attendances.

Conclusion

To summarize, pediatric ED attendances reduced across all ages in Europe during the first COVID-19 wave. This reduction was inversely proportional to the adoption of preventive measures and SARS-CoV-2 prevalence. While the reduction was greatest and sustained for communicable infections, children with severe COVID-19 attended the ED more frequently than the ones with mild infections or injuries.

*Important notice

medRxiv publishes preliminary scientific reports that are not peer-reviewed and, therefore, should not be regarded as conclusive, guide clinical practice/health-related behavior, or treated as established information.

Written by

Pooja Toshniwal Paharia

Dr. based clinical-radiological diagnosis and management of oral lesions and conditions and associated maxillofacial disorders.