Number and timing of primary cleft lip and palate repair surgeries in England: whole nation study of electronic health records before and during the COVID-19 pandemic.

OBJECTIVE: To quantify differences in number and timing of first primary cleft lip and palate (CLP) repair procedures during the first year of the COVID-19 pandemic (1 April 2020 to 31 March 2021; 2020/2021) compared with the preceding year (1 April 2019 to 31 March 2020; 2019/2021). DESIGN: National observational study of administrative hospital data. SETTING: National Health Service hospitals in England. STUDY POPULATION: Children <5 years undergoing primary repair for an orofacial cleft Population Consensus and Surveys Classification of Interventions and Procedures-fourth revisions (OPCS-4) codes F031, F291). MAIN EXPOSURE: Procedure date (2020/2021 vs 2019/2020). MAIN OUTCOMES: Numbers and timing (age in months) of first primary CLP procedures. RESULTS: 1716 CLP primary repair procedures were included in the analysis. In 2020/2021, 774 CLP procedures were carried out compared with 942 in 2019/2020, a reduction of 17.8% (95% CI 9.5% to 25.4%). The reduction varied over time in 2020/2021, with no surgeries at all during the first 2 months (April and May 2020). Compared with 2019/2020, first primary lip repair procedures performed in 2020/2021 were delayed by 1.6 months on average (95% CI 0.9 to 2.2 months). Delays in primary palate repairs were smaller on average but varied across the nine geographical regions. CONCLUSION: There were significant reductions in the number and delays in timing of first primary CLP repair procedures in England during the first year of the pandemic, which may affect long-term outcomes.

Reductions in hospital care among clinically vulnerable children aged 0-4 years during the COVID-19 pandemic.

OBJECTIVE: To quantify reductions in hospital care for clinically vulnerable children during the COVID-19 pandemic. DESIGN: Birth cohort. SETTING: National Health Service hospitals in England. STUDY POPULATION: All children aged <5 years with a birth recorded in hospital administrative data (January 2010-March 2021). MAIN EXPOSURE: Clinical vulnerability defined by a chronic health condition, preterm birth (<37 weeks' gestation) or low birth weight (<2500 g). MAIN OUTCOMES: Reductions in care defined by predicted hospital contact rates for 2020, estimated from 2015 to 2019, minus observed rates per 1000 child years during the first year of the pandemic (March 2020-2021). RESULTS: Of 3 813 465 children, 17.7% (one in six) were clinically vulnerable (9.5% born preterm or low birth weight, 10.3% had a chronic condition). Reductions in hospital care during the pandemic were much higher for clinically vulnerable children than peers: respectively, outpatient attendances (314 vs 73 per 1000 child years), planned admissions (55 vs 10) and unplanned admissions (105 vs 79). Clinically vulnerable children accounted for 50.1% of the reduction in outpatient attendances, 55.0% in planned admissions and 32.8% in unplanned hospital admissions. During the pandemic, weekly rates of planned care returned to prepandemic levels for infants with chronic conditions but not older children. Reductions in care differed by ethnic group and level of deprivation. Virtual outpatient attendances increased from 3.2% to 24.8% during the pandemic. CONCLUSION: One in six clinically vulnerable children accounted for one-third to one half of the reduction in hospital care during the pandemic.

Changes in adolescents' planned hospital care during the COVID-19 pandemic: analysis of linked administrative data.

OBJECTIVE: To describe changes in planned hospital care during the pandemic for vulnerable adolescents receiving children's social care (CSC) services or special educational needs (SEN) support, relative to their peers. DESIGN: Observational cohort in the Education and Child Health Insights from Linked Data database (linked de-identified administrative health, education and social care records of all children in England). STUDY POPULATION: All secondary school pupils in years 7-11 in academic year 2019/2020 (N=3 030 235). MAIN EXPOSURE: Receiving SEN support or CSC services. MAIN OUTCOMES: Changes in outpatient attendances and planned hospital admissions during the first 9 months of the pandemic (23 March-31 December 2020), estimated by comparing predicted with observed numbers and rates per 1000 child-years. RESULTS: A fifth of pupils (20.5%) received some form of statutory support: 14.2% received SEN support only, 3.6% received CSC services only and 2.7% received both. Decreases in planned hospital care were greater for these vulnerable adolescents than their peers: -290 vs -225 per 1000 child-years for outpatient attendances and -36 vs -16 per 1000 child-years for planned admissions. Overall, 21% of adolescents who were vulnerable disproportionately bore 25% of the decrease in outpatient attendances and 37% of the decrease in planned hospital admissions. Vulnerable adolescents were less likely than their peers to have face-to-face outpatient care. CONCLUSION: These findings indicate that socially vulnerable groups of children have high health needs, which may need to be prioritised to ensure equitable provision, including for catch-up of planned care postpandemic.

Trends in hospital admissions for clinically vulnerable infants in England during the COVID-19 lockdown

BackgroundOne in four infants have a hospital admission in their first year of life, of which 75% are unplanned. Clinically vulnerable infants have more planned and unplanned hospital contacts than other infants. They are therefore likely to have been disproportionately affected by restricted access to hospitals during the COVID-19 pandemic.ObjectivesTo compare trends in planned and unplanned hospital contacts among clinically vulnerable and other infants before and during the COVID-19 pandemic.MethodsWe included infants born between September 2016 and March 2020 in Hospital Episode Statistics (HES).We defined clinically vulnerable infants by (i) long-term health conditions (chronic conditions or congenital anomalies), or (ii) adverse birth outcomes (low birth weight <2500g or preterm birth <37 weeks of gestation). We included characteristics and diagnoses recorded at birth, during subsequent hospital admissions, or as a cause of death.We described rates of planned and unplanned hospital admissions (excluding the birth admission) between January 2017 and March 2020 for infants with and without vulnerability.ResultsOf 2,184,114 infants in the study, 9.1% had a long-term health condition (6.8% had a chronic condition;3.8% had a congenital anomaly), 9.3% had an adverse birth outcome (6.1% were low birth weight and 6.7% were preterm), and 16.4% had one or more.Between January 2017 and March 2020, an average of 0.12% of the infants had a planned and 0.69% had an unplanned admission each week. Infants with a long-term health condition were at a higher risk for hospital admissions with 16 times (RR: 15.38 (11.16–21.74)) as many weekly planned and over four times (RR: 4.56 (4.00–5.20)) as many weekly unplanned admissions as infants without these conditions. This was similar for infants with an adverse birth outcome who had twice as many weekly planned (RR: 2.36 (1.86–3.02)) and unplanned (RR: 1.75 (1.59–1.93)) admissions as infants without.Both weekly planned and unplanned hospital admissions started to fall two weeks before the first lockdown on March 23, 2020 for infants compared with the same period (averaged over 2017 and 2019);unplanned admissions fell more steeply. The reduction was greater for clinically vulnerable infants: there was a ten-fold decrease in planned admissions and a four-fold decrease in unplanned admissions for infants with long-term health conditions compared to those without. There was a three-fold reduction in planned admissions and a two-fold reduction in unplanned admissions for infants with an adverse birth outcome compared to those without.ConclusionsThe impact of the COVID-19 pandemic was greatest for unplanned admissions in infants with long-term health conditions. This may be due to restricted access to hospitals, fear of COVID-19 infection, lower rates of other infections, closer monitoring by carers at home, or deferred presentations. Reductions in planned admissions could reflect postponement of elective procedures. Further research is needed to establish the unmet needs that will result from the pandemic. Prioritisation of interventions to address unmet clinical need during lockdown should focus on clinically vulnerable infants.

The education and child health insights from linked data (ECHILD) database: a newly linked, de-identified health-education data resource

BackgroundThe COVID-19 pandemic has raised concerns about long-term harms to children’s health and education and re-emphasised how strongly interconnected these domains are in childhood and adolescence. It has also highlighted the need to maximise the utility of administrative datasets (which reflect service provision for the whole population) as an evidence base for policy and practice. To date, technical and governance barriers have limited the potential for wide-scale analyses across health and education. Here, we report linking Hospital Episode Statistics (HES) to the National Pupil Database (NPD), which includes important information on children’s functional health and wellbeing, such as attainment in national exams, special educational needs (SEN) support and absence rates. This newly linked health-education database can generate evidence for paediatricians, policymakers and the public on, for example, educational outcomes for children with rare or common health conditions or how SEN support in schools might improve health outcomes.ObjectivesCreate a de-identified, linked HES-NPD database for all children and young people in England aged 0–24 years who were born on or after 01/09/1995 (the Education and Child Health Insights from Linked Data (ECHILD) Database)Assess linkage quality in the ECHILD DatabaseMethodsTo create the ECHILD Database, NHS Digital applied multi-step rules-based algorithms to longitudinal records of names, date of birth, gender and postcodes extracted from HES and NPD (to separate them from health- and education-related information). This produced a bridging file of pseudonymised IDs to link extracts of de-identified NPD and HES data (the ECHILD Database). If data linkage is biased (for example, less accurate for ethnic minority groups), then subsequent analyses could underestimate health needs and further entrench disadvantage. We evaluated linkage quality for three academic cohorts born 1st September to 31st August in 1996/7, 1999/00 and 2004/5. Permissions to create the ECHILD Database are described at: https://www.ucl.ac.uk/child-health/echildResultsIn total, the newly-created ECHILD Database includes de-identified, linked HES-NPD records for approximately 14.7 million individuals. It currently covers a 25-year period (01/09/1995 to 31/03/2020) and will be updated with more recent data as it is available. Our initial assessments indicate high linkage rates, particularly for more recent cohorts. Of pupils born in 2004/05, 99% linked to a HES record and, overall, 96% of pupils linked (1,609,670/1,674,899). Ethnic minority pupils and those living in more deprived areas were less likely to link;however, differences in linked and unlinked pupil characteristics were moderate to small. Throughout childhood, two-thirds of children had at least one admission to hospital (excluding being born in hospital).ConclusionsThe ECHILD Database enables large-scale, longitudinal research exploring interrelationships between health and education. For example, we are exploring how gestational age at birth relates to attainment and SEN. These results will be useful for policymakers and service providers for estimating future need for SEN support in schools based on the population’s birth characteristics. As more recent data becomes available, the ECHILD Database represents a unique opportunity to explore the impact of recent disruptions to health services on health and educational outcomes for children and young people during and after the COVID-19 pandemic.