ABSTRACT
BackgroundOn 23rd March 2020, the UK ‘stay at home’ order heralded the first national lockdown, lasting 7-weeks. Dramatic reductions of paediatric attendances/admissions were noted nationally and internationally, with concerns surrounding diagnosis which may be missing from secondary care.We conducted a systematic review on 9th January 2021, searching PubMed for ‘COVID’, AND ‘lockdown’, AND ‘paediatric’ OR ‘children’, AND ‘attendance’ OR ‘admission’, in all languages using MESH terms. This identified n=41 primary articles exploring paediatric healthcare usage during a lockdown period. These covered Europe, Brazil, USA, Canada, Iran, and India. 44% examined ED settings only;49% reported on admissions for a single disease or specialty;only 2 examined all inpatients.No previous study has explored the changing patterns of diagnoses amongst all paediatric inpatients during a lockdown period, compared to historical years.ObjectivesTo establish the changing patterns of ED attendance and inpatient diagnoses across two Oxfordshire hospitals during the first COVID-19 lockdown in 2020, compared to five historical years (2015–2019).MethodsWe retrospectively reviewed anonymised electronic records for all ED attendances and inpatients aged 0–15 years, across two Oxfordshire hospitals providing secondary and tertiary care services. Discharge ICD-10 coding were analysed to identify significant differences in lockdown inpatient diagnoses, compared to a matched 7-weeks in 2015–2019 (Mann-Whitney U test, admissions-per-week).ResultsDuring the first 2020 lockdown period, 2,843 diagnoses were associated with 1,416 admissions (mean 4.81 diagnoses/patient), compared with 12,458 admissions and 19,946 diagnoses across matched dates 2015–2019 (2.97 diagnoses/patient). Lockdown ED attendances (n=4030) and admissions (n=1416) were reduced by 56.8% and 59.4%, respectively, compared to 2015–2019 (mean n=7446.8 and n=2491.6, respectively). Proportions of admissions from ED and patients’ subsequent length of stay were similar across all years. Reductions in hospital admissions were highest in 1–5-year-old (age <1 =48.4%, 1–5 =67.2%, 6–10 =53.3% and 11–15 years =48.9%).We categorised diagnostic codes significantly reduced during lockdown (’missing’) compared to 2015–2019: 80% were infectious diseases or their sequelae;non-specific pains/aches/malaise (11%) and accidental injury/poisonings (9%) accounted for the remaining 20%. Categories with increased diagnoses (24% of lockdown diagnoses) were ‘related to pandemic screening’, ‘incidental finding/co-morbidity’ and ‘other diagnoses’. We also found significantly greater numbers of neoplasms (benign and malignant) diagnosed during lockdown (p=0.0123).ConclusionsPandemic measures and messaging are altering paediatric disease presentation. Our study confirms large reductions in paediatric ED attendances and inpatient admissions during the first national lockdown, raising concerns of vulnerable children ‘lost’ to secondary care.Our assessment of ‘missing’ paediatric diagnoses uses internationally comparable ICD-10 codes. We therefore postulate that the 80% of infection-related diagnoses ‘missing’ during the lockdown period are driven by a combination of stringent infection-control measures, parents/carers management of mild/self-limiting disease at home, and/or increased anxiety surrounding hospital attendance. As 20% were non-specific or accidental injuries, we remain concerned about significant disease with late presentations or patients with safeguarding concerns who may not be brought to hospital, amongst these patients.Prospective studies are necessary to establish whether parents/carers are adequately supported, have adequate contact with health professionals and feel empowered to use referral pathways for hospital review.
ABSTRACT
The study aims to identify 'missing' diagnoses amongst paediatric admissions during the UK's first national lockdown, compared with the previous 5 years. A retrospective observational cohort study of all children (0-15 years) attending for urgent care across Oxfordshire, during the first UK lockdown in 2020, compared to matched dates in 2015-2019, across two paediatric hospitals providing secondary care, including one with tertiary services. Our outcome measures were changes in numbers of patients attending and inpatient diagnoses (using ICD-10 classification) during the first 2020 lockdown, compared with the previous 5 years, were used. We found that total Emergency Department (ED) attendances (n = 4030) and hospital admissions (n = 1416) during the first UK lockdown were reduced by 56.8% and 59.4%, respectively, compared to 2015-2019 (5-year means n = 7446.8 and n = 2491.6, respectively). Proportions of patients admitted from ED and length of stay were similar across 2015-2020. ICD-10 diagnoses in lockdown of 2020 (n = 2843) versus matched 2015-2019 dates (n = 19,946) demonstrated significantly greater neoplasm diagnoses (p = 0.0123). Of diagnoses 'missing' in lockdown, 80% were categorised as infectious diseases or their sequelae and 20% were non-specific pains/aches/malaise and accidental injury/poisonings.Conclusions: Pandemic public health measures significantly altered paediatric presentations. Oxfordshire hospitals had a 58% reduction in ED attendances/inpatient admissions, with 'missing' diagnoses predominantly infection-related illnesses. These are likely driven by a combination of the following: (1) public health infection control measures successfully reducing disease transmission, (2) parents/carers keeping mild/self-limiting disease at home, and (3) pandemic-related healthcare anxieties. Prospective studies are needed to ensure referral pathways identify vulnerable children, those with social concerns, and avoid delayed presentation. What is Known: ⢠Significant reductions of paediatric ED attendances and inpatient admissions are reported globally, throughout national and regional lockdowns for COVID-19. ⢠Previous studies (supplemental table 5) examined only ED diagnoses or specific inpatient diagnoses during lockdown periods, demonstrating reductions of infectious diseases, accidents/injuries, and safeguarding referrals. What is New: ⢠Using ICD-10 coding, robustly controlling for five historical years and adopting a hypothesis-independent analysis, demonstrating 80% of 'missing' inpatient diagnoses during national COVID-19 lockdown were infectious diseases or its sequelae, the remainder being non-specific aches/pains/malaise and accidental injuries/poisonings. ⢠Greater numbers of neoplasms and other specific diagnoses were detected during lockdown, including greater documentation of co-morbidities and incidental findings.