Use of Acute Mental Health Care in U.S. Children's Hospitals Before and After Statewide COVID-19 School Closure Orders.

Objective: This study aimed to examine changes in child emergency department (ED) discharges and hospitalizations for primary general medical (GM) and primary psychiatric disorders; prevalence of psychiatric disorders among acute care encounters; and change in acute mental health (MH) care encounters by disorder type and, within these categories, by child sociodemographic characteristics before and after statewide COVID-19­related school closure orders. Methods: This retrospective, cross-sectional cohort study used the Pediatric Health Information System database to assess percent changes in ED discharges and hospitalizations (N=2,658,474 total encounters) among children ages 3­17 years in 44 U.S. children's hospitals in 2020 compared with 2019, by using matched data for 36- and 12-calendar-week intervals. Results: Decline in MH ED discharges accounted for about half of the decline in ED discharges and hospitalizations for primary GM disorders (−24.8% vs. −49.1%), and MH hospitalizations declined 3.4 times less (−8.0% vs. −26.8%) in 2020. Suicide attempt or self-injury and depressive disorders accounted for >50% of acute MH care encounters before and after the statewide school closures. The increase in both ED discharges and hospitalizations for suicide attempt or self-injury was 5.1 percentage points (p<0.001). By fall 2020, MH hospitalizations for suicide attempt or self-injury rose by 41.7%, with a 43.8% and 49.2% rise among adolescents and girls, respectively. Conclusions: Suicide or self-injury and depressive disorders drove acute MH care encounters in 44 U.S. children's hospitals after COVID-19­related school closures. Research is needed to identify continuing risk indicators (e.g., sociodemographic characteristics, psychiatric disorder types, and social determinants of health) of acute child MH care.

Patient attendance at a pediatric emergency referral hospital in an area with low COVID-19 incidence.

The purpose of this study was to clarify the effects of individual infection control measures and physical distancing on pediatric medical care in a local prefecture in Japan, where the incidence of coronavirus disease (COVID-19) in pediatric patients was extremely low. We extracted data from hospital records on the number of outpatients, inpatients, infectious disease consultations, and consultations for representative pediatric diseases. We compared attendance in 2017-2019, before the COVID-19 pandemic, with 2020, when COVID-19 spread to Japan. There were no COVID-19 patients in the pediatric department during the study period. The total number outpatient visits decreased by 24.4%, and the number of hospital admissions, excluding neonatal care unit admissions, decreased by approximately 35%. There was a marked reduction in the number of hospitalizations for infectious diseases such as influenza (-74.8%) and respiratory syncytial virus infection (-93.5%), and the number of hospitalizations for bronchitis/pneumonia, Kawasaki disease, and bronchial asthma decreased. In contrast, the number of clinical psychological interventions and cases reported to the child guidance center increased. In the context of pandemic infectious diseases, it is important to control the spread of problematic infectious diseases by individual infection control measures and physical distancing. However, it is necessary to maintain social life as much as possible for the mental health and physical development of children.

SARS-CoV-2 vaccination for adolescents and young adult patients treated at a specialist pediatric oncology unit.

This brief report describes the SARS-CoV-2 vaccination program at our pediatric oncology unit. Adopting Italian regulations, patients treated for cancer within the previous 6 months were offered vaccination with the Pfizer-BioNtech vaccine if aged ≥16 years, and with the Pfizer-BioNtech or Moderna vaccine if aged ≥18 years. From March 24 to April 28, 2021, 80/89 adolescent and young adult patients enrolled were vaccinated, while nine refused the vaccine due to fear of side effects, disbelief regarding the pandemic, or lack of trust in the scientific community. The refusal rate in our cohort was lower than in the Italian general population.

Analysis of pediatric emergency department patient volume trends during the COVID-19 pandemic.

ABSTRACT: During the early period of the COVID-19 pandemic there was a substantial decrease in pediatric emergency department (PED) visitation. The intent of this study is to report PED utilization during the COVID-19 pandemic in an urban pediatric referral center located close to the epicenter in the northeastern US.A retrospective analysis of medical records of patients visiting the PED at Robert Wood Johnson University Hospital (RWJUH) was performed. Data included: daily census, admission rate, Emergency Severity Index, and ICD-10 diagnosis codes for the period of February through July, 2018 to 2020.By the week of March 26th, visits had decreased by 70% compared to the average of the previous 2 years. This census nadir lasted for 6 weeks. At 5 weeks postnadir the average daily census recovered to levels 40% lower than prior year norms and remained at that level during subsequent months. The greatest decreases were seen in low-acuity visits. Visits for behavioral health and fractures decreased by approximately 50% and 70%, respectively, but recovered to prior year norms by June and July of 2020. Visits for asthma exacerbation decreased by as much as 87% and remained at record lows for the remainder of the study period.A substantial and persistent decrease in PED visitation was experienced during the COVID-19 pandemic. Whereas visits for behavioral health and fractures have recovered to prior year norms, visits for asthma exacerbation remain at record lows. Further research is needed to ascertain the causes of these changes, including patient perceptions of the PED.

An Interrupted Time-Series Analysis of Pediatric Emergency Department Visits During the Coronavirus Disease 2019 Pandemic.

OBJECTIVE: The objective of this study was to estimate the impact of the coronavirus disease 2019 pandemic on pediatric emergency department (PED) visits after declaration of stay-at-home orders within British Columbia, Canada, and the change in cases by acuity and age for 6 months during the pandemic. METHODS: Retrospective data on PED visits at British Columbia Children's Hospital were collected between December 1, 2019, and August 31, 2020, and for 2 previous years. An interrupted time-series analysis was performed to estimate the difference in daily visits after stay-at-home orders on March 17, 2020, as well as before and after. Further analysis was performed to estimate the drop and recovery of admission and visits by age and acuity. RESULTS: After adjustment for year and seasonality, we documented a drop in the expected number of daily visits of 83 (95% confidence interval [CI], 78-89) after stay-at-home orders. Thereafter, daily visits increased by 12.9 (95% CI, 11.3-14.4) every month. Probability of admission adjusted for seasonality and acuity increased 6.9% (95% CI, 4.9%-9.0%) after stay-at-home orders and decreased in the odds of -0.7% (95% CI, -1% to -0.4%) monthly thereafter. CONCLUSIONS: The coronavirus disease 2019 pandemic has had a dramatic and lasting impact on the number of PED visits, with contracted rates 6 months into the pandemic. Further increase in acuity-adjusted rate of admissions after stay at home orders suggests that individuals may be delaying arrival to the emergency department. Further assessment is needed to determine if patients are seeking care through other venues or not seeking care altogether.

Safety Events in Children's Hospitals During the COVID-19 Pandemic.

BACKGROUND AND OBJECTIVES: The coronavirus disease 2019 (COVID-19) pandemic has impacted hospitals, potentially affecting quality and safety. Our objective was to compare pediatric hospitalization safety events during the pandemic versus previous years. METHODS: In this retrospective cohort study of hospitalizations in the Pediatric Health Information System, we compared Pediatric Quality Indicator (PDI) rates from March 15 to May 31, 2017-2019 (pre-COVID-19), with those from March 15 to May 31, 2020 (during COVID-19). Generalized linear mixed-effects models with adjustment for patient characteristics (eg, diagnosis, clinical severity) were used. RESULTS: There were 399 113 discharges pre-COVID-19 and 88 140 during COVID-19. Unadjusted PDI rates were higher during versus pre-COVID-19 for overall PDIs (6.39 vs 5.05; P < .001). In adjusted analyses, odds of postoperative sepsis were higher during COVID-19 versus pre-COVID-19 (adjusted odds ratio 1.28 [95% confidence interval 1.04-1.56]). The remainder of the PDIs did not have increased adjusted odds during compared with pre-COVID-19. CONCLUSIONS: Postoperative sepsis rates increased among children hospitalized during COVID-19. Efforts are needed to improve safety of postoperative care for hospitalized children.

The ongoing indirect effect of the COVID-19 pandemic on a pediatric emergency department.

INTRODUCTION: The SARS-CoV-2 coronavirus pandemic may cause significant morbidity and mortality in adults, yet severe cases are rare among children. The indirect impact of the pandemic on health care delivery in general and pediatric emergency department (PED) visits in particular has been widely reported. AIMS: To assess the impact of the pandemic and the social restrictions imposed in its wake on PED visits and hospitalization rates in our Israeli medical center. We also sought to track these data in relation to the variation in pandemic severity and social restrictions over time. A comparison of this data with that of the adult emergency department was also performed. METHODS: Data for this study were drawn from the Shaare Zedek Medical Center (SZMC), Jerusalem, Israel computerized databank. The daily number of PED and adult ER visits as well as hospitalizations resulting from these visits during the months January-July during the years 2018, 2019, 2020 were recorded. We compared the risk ratio for hospitalization in 2019 and 2020, as well as the incidence rate ratio. RESULTS: During March and April there was a decrease in PED visits from 4,588 visits in 2019 to 2,527 visits in 2020 (ratio = .551, 95%CI [.52,.58]. Despite the drop in PED visits, the rate of hospitalizations rose with respect to 2019 (Risk Ratio = 1.31, p < .001, 95%CI [1.17,1.47]). Similar but more moderate trends were seen in the adult ED. From May-July 2020, after the lockdown was lifted, PED visits remained 30% below the same time period from 2018 and 2019, while the hospitalization rate returned to its pre-pandemic level. CONCLUSIONS: A significant drop in PED visits is seen to extend well beyond the peak of the pandemic and the lockdown period. This highlights the potential risk of children with serious emergencies becoming casualties of the pandemic by their not being brought to medical attention. Efforts should be made to raise public awareness among parents and other caretakers of children regarding this matter.

Epidemiological and clinical profile between influenza A and B virus in Costa Rican children.

OBJECTIVE: We aimed to evaluate the clinical and epidemiological behavior of influenza type A versus type B and analyze if there was any correlation or differences between the characteristics of both groups. METHODS: An observational, retrospective, descriptive, and population-based study based of children who were hospitalized at the only national pediatric hospital of Costa Rica from January 1, 2010 to December 31, 2018 and had a confirmed influenza virus infection. RESULTS: 336 patients were analyzed. Mean age was 35,6 ± 36,7 months (3,0 ± 3,1 years). The only significant variables at 25% in relation to influenza type A or B virus were: sex, month of diagnosis, fever, vomiting, cough, use of antibiotics and admission to the PICU. The hospitalization rate at our hospital increased between the months of October to December, with a higher percentage of cases in November and December, which reveals that the "real peak" in our population begins between 3 to 4 months after the end of the vaccination campaign. Patients with influenza A virus had a 2.5 times greater risk of being admitted to the PICU. Mortality rate was 0.6% and 0% among influenza A and B children, respectively. CONCLUSIONS: Variables in which a causality was found with type A or B virus were: admission to the PICU, month of diagnosis, and cough. However, influenza B clinical behavior continues to be unpredictable.

Prevalence of IgG antibodies against SARS-CoV-2 among healthcare workers in a tertiary pediatric hospital in Poland.

Data on the prevalence of the SARS-CoV-2 antibody in healthcare workers (HCWs) is scarce, especially in pediatric settings. The purpose of this study was to evaluate SARS-CoV-2 IgG-positivity among HCWs of a tertiary pediatric hospital. In addition, follow-up of the serological response in the subgroup of seropositive HCWs was analysed, to gain some insight on the persistence of IgG antibodies to SARS-CoV-2. We performed a retrospective analysis of voluntary SARS-CoV-2 IgG testing, which was made available free of charge to HCWs of the Children's Memorial Health Institute in Warsaw (Poland). Plasma samples were collected between July 1 and August 9, 2020, and tested using the Abbott SARS-CoV-2 IgG assay. Of 2,282 eligible participants, 1,879 (82.3%) HCWs volunteered to undergo testing. Sixteen HCWs tested positive for SARS-CoV-2 IgG, corresponding to a seroprevalence of 0.85%. Among seropositive HCWs, three HCWs had confirmed COVID-19. Nine (56.3%) of the seropositive HCWs reported neither symptoms nor unprotected contact with confirmed SARS-CoV-2 cases in the previous months. A decline in the IgG index was observed at a median time of 86.5 days (range:84‒128 days) after symptom onset or RT-PCR testing. Further studies are necessary to elucidate the duration of persistence of anti-SARS-CoV-2 antibodies, as well as the correlation between seropositivity and protective immunity against reinfection. Regardless of the persistence of antibodies and their protective properties, such low prevalence indicates that this population is vulnerable to a second wave of the COVID-19 pandemic.

Visitor Guidelines in US Children's Hospitals During COVID-19.

OBJECTIVES: To examine visitor guidelines among children's hospitals in the United States in response to the coronavirus 2019 (COVID-19) pandemic. METHODS: A retrospective assessment of visitor guidelines in 239 children's hospitals in the United States. RESULTS: In this study, we present an analysis of 239 children's hospital visitor guidelines posted to hospitals' Web sites during 1 week in June 2020. Of the 239 hospitals, only 28 did not have posted guidelines for review. The guidelines were analyzed and grouped by how the guidelines were updated in response to COVID-19. Parental visitation was restricted to 1 parent in 116 of the posted guidelines (49%). There were no obvious similarities among guidelines associated with their geographical (eg, state or local) location. As of February 2021, 33 of 55 (60%) randomly selected hospitals had not changed their visitor policy since our initial review. CONCLUSIONS: The COVID-19 pandemic triggered changes in publicly reported visitor guidelines across the majority of children's hospitals. With our findings, we suggest wide variation in policies and practices in how guidelines were updated. More work is needed to understand how to optimize public safety and preserve family-centered care and parental authority in times of crisis.

The COVID-19 Pandemic and Changes in Healthcare Utilization for Pediatric Respiratory and Nonrespiratory Illnesses in the United States.

The impact of COVID-19 public health interventions on pediatric illnesses nationwide is unknown. We performed a multicenter, cross-sectional study of encounters at 44 children's hospitals in the United States to assess changes in healthcare utilization during the pandemic. The COVID-19 pandemic was associated with substantial reductions in encounters for respiratory diseases; these large reductions were consistent across illness subgroups. Although encounters for nonrespiratory diseases decreased as well, reductions were more modest and varied by age. Encounters for respiratory diseases among adolescents declined to a lesser degree and returned to previous levels faster compared with those of younger children. Further study is needed to determine the contributions of decreased illness and changes in care-seeking behavior to this observed reduction.

Impact of COVID-19 on procedure volume at a tertiary pediatric hospital.

INTRODUCTION: In March 2020, the COVID-19 pandemic threatened to overwhelm entire healthcare systems. Here we characterize changes in surgical volumes at a regional tertiary pediatric hospital during the early phase of the COVID-19 pandemic. METHODS: Data on all procedures performed during the state-wide ban on elective procedures (March 19th, 2020 to May 18th, 2020) that required anesthesia involvement were collected retrospectively and compared to the same time period in 2019. RESULTS: A total of 5785 procedures were performed: 4005 (69%) in 2019, and 1780 (31%) in 2020, representing a 55% decrease in total cases. The percentage decrease was disproportionate across surgical services. Add-on cases increased from 23% to 39%, and outpatient procedures decreased from 60% to 27%. DISCUSSION: The ban on elective procedures during the COVID-19 pandemic resulted in a significant decrease in the volume of procedures performed at a tertiary pediatric hospital that differed among surgical services.

Virtual care in the pediatric emergency department: a new way of doing business?

OBJECTIVES: To understand the feasibility, utilization rate, and satisfaction of the first Virtual Pediatric ED (V-PED) in Canada. METHODS: We conducted a prospective cohort study examining the feasibility and impact of virtual care as an adjunct to in-person emergency care at a tertiary pediatric hospital from May to July 2020. Children (< 18 years) from Ontario and Quebec seeking V-PED care were included. A secure, encrypted, video platform within the hospital's electronic medical record was used. Caregivers self-determined appropriateness of V-PED using a standardized online triage questionnaire to request their appointment. The V-PED is directly launched from the patient's chart and the family joins the portal via hyperlink. Outcome measures included the number of V-PED visits, hospital admission rates, and caregiver satisfaction using a 10-item voluntary post-visit online survey. RESULTS: A total of 1036 V-PED visits were seen of which 176 (17.0%) were referred for further in-person ED assessment, and 8 (0.8%) required hospital admission. Of the 107 completing patient experience surveys (10% response), most respondents (69%) endorsed they "very likely" or "definitely" would have presented in-person to the ED if V-PED were unavailable. Overall satisfaction was rated as excellent (9 or 10 out of 10) in 87% of respondents. CONCLUSION: Our novel V-PED is feasible, has high caregiver satisfaction, and can reduce the burden of in-person ED visits. Future work must ensure the safety of emergency virtual care and examine how to increase capacity and integrate V-PED within traditional emergency medicine.

RéSUMé: OBJECTIFS: Comprendre la faisabilité, le taux d'utilisation et la satisfaction du premier service d'urgence pédiatrique virtuel (V-PED) au Canada. MéTHODES: Nous avons mené une étude de cohorte prospective examinant la faisabilité et l'impact des soins virtuels comme complément aux soins d'urgence en personne dans un hôpital pédiatrique tertiaire de mai à juillet 2020. Les enfants (< 18 ans) de l'Ontario et du Québec cherchant à bénéficier d'une prise en charge par la V-PED ont été inclus. Une plateforme vidéo sécurisée et cryptée a été utilisée dans le dossier médical électronique de l'hôpital. Les soignants ont autodéterminé la pertinence du V-PED à l'aide d'un questionnaire de triage en ligne normalisé pour demander leur rendez-vous. Le V-PED est directement lancé à partir du dossier du patient et la famille rejoint le portail via un lien hypertexte. Les mesures des résultats comprenaient le nombre de visites de V-PED, les taux d'admission à l'hôpital et la satisfaction des soignants à l'aide d'une enquête en ligne volontaire en 10 points après la visite. RéSULTATS: Au total, 1036 visites de DEP-V ont été effectuées, dont 176 (17,0 %) ont fait l'objet d'une évaluation approfondie en personne aux urgences, et 8 (0,8 %) ont nécessité une hospitalisation. Sur les 107 répondants aux enquêtes sur l'expérience des patients (10 % de réponses), la plupart (69 %) ont déclaré qu'ils se seraient "très probablement" ou "certainement" présentés en personne aux urgences si la V-PED n'était pas disponible. La satisfaction globale a été jugée excellente (9 ou 10 sur 10) par 87 % des répondants. CONCLUSION: Notre nouveau V-PED est réalisable, donne une grande satisfaction aux soignants et peut réduire le fardeau des visites en personne aux urgences. Les travaux futurs doivent garantir la sécurité des soins virtuels d'urgence et examiner comment augmenter la capacité et intégrer la V-PED dans la médecine d'urgence traditionnelle.

Organizational aspects of pediatric anesthesia and surgery between two waves of Covid-19.

BACKGROUND: The initial wave of the Covid-19 pandemic has hit Italy, and Lombardy in particular, with violence, forcing to reshape all hospitals' activities; this happened even in pediatric hospitals, although the young population seemed initially spared from the disease. "Vittore Buzzi" Children's Hospital, which is a pediatric/maternal hospital located in Milan (Lombardy Region), had to stop elective procedures-with the exception of urgent/emergent ones-between February and May 2020 to leave space and resources to adults' care. We describe the challenges of reshaping the hospital's identity and structure, and restarting pediatric surgery and anesthesia, from May on, in the most hit area of the world, with the purpose to avoid and contain infections. Both patients and caregivers admitted to hospital have been tested for Sars-CoV-2 in every case. METHODS: Observational cohort study via review of clinical charts of patients undergoing surgery between 16th May and 30th September 2020, together with SARS-CoV -2 RT-PCR testing outcomes, and comparison to same period surgeries in 2019. RESULTS: An increase of approximately 70% in pediatric surgeries (OR 1.68 [1.33-2.13], P < .001) and a higher increase in the number of surgeries were reported (OR 1.75 (1.43-2.15), P < .001). Considering only urgent procedures, a significant difference in the distribution of the type of surgery was observed (Chi-squared P-value < .001). Sars-CoV-2-positive patients have been 0.8% of total number; 14% of these was discovered through caregiver's positivity. CONCLUSION: We describe our pathway for safe pediatric surgery and anesthesia and the importance of testing both patient and caregiver.

Cross-sectional prevalence of SARS-CoV-2 antibodies in healthcare workers in paediatric facilities in eight countries.

BACKGROUND: Healthcare workers (HCWs) have been disproportionately affected by coronavirus disease 2019 (COVID-19), which may be driven, in part, by nosocomial exposure. If HCW exposure is predominantly nosocomial, HCWs in paediatric facilities, where few patients are admitted with COVID-19, may lack antibodies to severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and be at increased risk during the current resurgence. AIM: To compare the seroprevalence of SARS-CoV-2 amongst HCWs in paediatric facilities in seven European countries and South Africa (N=8). METHODS: All categories of paediatric HCWs were invited to participate in the study, irrespective of previous symptoms. A single blood sample was taken and data about previous symptoms were documented. Serum was shipped to a central laboratory in London where SARS-CoV-2 immunoglobulin G was measured. FINDINGS: In total, 4114 HCWs were recruited between 1st May and mid-July 2020. The range of seroprevalence was 0-16.93%. The highest seroprevalence was found in London (16.93%), followed by Cape Town, South Africa (10.36%). There were no positive HCWs in the Austrian, Estonian and Latvian cohorts; 2/300 [0.66%, 95% confidence interval (CI) 0.18-2.4] HCWs tested positive in Lithuania; 1/124 (0.81%, 95% CI 0.14-4.3) HCWs tested positive in Romania; and 1/76 (1.3%, 95% CI 0.23-7.0) HCWs tested positive in Greece. CONCLUSION: Overall seroprevalence amongst paediatric HCWs is similar to their national populations and linked to the national COVID-19 burden. Staff working in paediatric facilities in low-burden countries have very low seroprevalence rates and thus are likely to be susceptible to COVID-19. Their susceptibility to infection may affect their ability to provide care in the face of increasing cases of COVID-19, and this highlights the need for appropriate preventative strategies in paediatric healthcare settings.