Paediatric presentations to Christchurch Hospital Emergency Department during COVID‐19 lockdown – Bothara – – Journal of Paediatrics and Child Health

What this paper adds

COVID‐19, caused by the novel coronavirus SARS‐CoV‐2, has rapidly become a world‐wide threat to travel, commerce and health. This virus is believed to have originated in Wuhan, China, and is highly infectious.¹ Children of all ages appear susceptible to COVID‐19; however, the clinical manifestation of the virus appears to be less severe for children compared to adults, with better prognosis and lower mortality.^2–4

On 28 February 2020, New Zealand reported its first case of COVID‐19. Over the next 3 weeks, there was a steady increase of cases. On 19th of March, indoor gatherings were limited to 100 people and the country’s borders were closed. People were instructed to stay home, while schools and other educational facilities were instructed to close from 24 March. On 25 March, New Zealand moved into Alert Level 4 ‘Lockdown’.⁵ This included limiting domestic travel, cancelling all public gatherings, closing public venues, educational facilities and all non‐essential businesses. Supermarkets, pharmacies, clinics, petrol stations and lifeline utilities remained open with COVID‐19 precautions. People were instructed to stay at home in their ‘bubble’, supplies were rationed and health services re‐prioritised.⁶

These measures had a significant impact on the health system. Non‐essential operations and outpatient appointments were postponed, while face‐to‐face primary care consultations were reduced by 70%.^7–9 For the paediatric population, this included New Zealand’s community‐based child health service (Plunket) closing all clinics, playgrounds, parenting groups and toy libraries, and shifting home visits by nurses to online phone and video calls.¹⁰

Previous infectious disease outbreaks have caused a reduction in total emergency presentations. A 33% decrease in total emergency presentations and 45% decrease in non‐trauma presentations by the <18‐year‐old group was reported during the SARS outbreak in Taiwan in 2005.¹¹ A 2006 Toronto‐based study showed a 21% decline in total ED visits, with a 69% reduction in ED visits for infant and toddlers.¹² Likewise, during the 2015 MERS outbreak, a South Korean‐based study by Paek et al. showed paediatric ED visits declined by up to 42.3%. This was significantly greater than the decrease in presentations by adults.¹³

To date there is limited literature regarding changes to emergency department paediatric presentations and characteristics during the COVID‐19 outbreak. This project aims to quantify and describe the change in paediatric presentations to Christchurch Hospital Emergency Department, New Zealand, during the COVID‐10 lockdown period.

Methods

Results

A total of 2084 paediatric patients presented to the emergency department during the study period. Of these, 1415 were during the 33‐day pre‐lockdown period and 669 were during the 33‐day lockdown period. This is an overall reduction in paediatric presentations by 53%, which was greater than the 10% and 15% reduction observed in 2019 and 2018, respectively (P < 0.00001) (Table 1). Non‐paediatric presentations reduced by only 34% during the lockdown period in 2020 (Table 2).

Overall, a total of 15 410 patients presented to the emergency department during the study period: 9460 during the 33‐day pre‐lockdown period and 5950 during the 33‐day lockdown period. This is an overall reduction in presentations by 37%, which was greater than the 10% and 7% reduction observed in 2019 and 2018, respectively (Table 1).

Discussion

Total paediatric emergency presentations dropped by 53% at Christchurch Hospital Emergency Department during lockdown. This decrease is consistent with previous infectious disease outbreaks and similar reductions have been reported elsewhere during COVID‐19.^{11–13, 17, 18} The reduction in paediatric emergency presentations has several possible explanations. The implementation of restrictions to reduce the transmission of COVID‐19 in the community may have prevented the usual transmission and incidence of several other infectious diseases among the paediatric population. The closure of kindergartens and schools may partially explain the significant reduction in respiratory‐related paediatric emergency presentations reported in this study.

The anxiety and uncertainty associated with the COVID‐19 pandemic may have influenced presentations to clinics and hospitals for concern of contracting coronavirus.¹⁹ This may have encouraged patients and their caregivers to stay home with illnesses that they would otherwise present to the emergency department for. This is a concern as it may represent a group with delayed presentation and therefore more serious illness such as cancer, endocrine disorders (e.g. diabetes) and surgical conditions (e.g. appendicitis).¹⁹ Lazzerini et al. postulate that fear may be a reason children and their caregivers are not presenting to emergency departments; however, this study is based on a small number of case reports and it is worth noting that the cause of decreased presentations may be multifactorial and not simply attributable to fear.¹⁹

Injury was the most common cause of paediatric emergency presentations in this study. The reduction in the total number of injury‐related paediatric presentations may be partially explained by restrictions on outdoors activities and closure of schools. Christey et al. report a similar reduction in injury‐related emergency presentations during the first 2 weeks of lockdown among those aged 0–14 years in Waikato, New Zealand.²⁰ Hamill and Sawyer report total trauma admissions were at a 5‐year low at Starship Children’s Hospital, New Zealand’s only specialist paediatric hospital. Of the trauma admissions during lockdown, 72% occurred at home compared to an average of 32% in previous years. The proportion of bicycle‐related trauma increased to a 5‐year high of 19% compared to an average of 3.6% in previous years.²¹

Prior to COVID‐19, Māori and Pacific Peoples already faced inadequate and inequitable access to health‐care services compared to New Zealand Europeans.²² This study found that the proportion of paediatrics presentations by New Zealand Europeans increased, but presentations by Pacific peoples decreased. This discrepancy may be due to a difference in accessibility to health care, which may have been exacerbated by the COVID‐19 pandemic. The closure of public transport services may have made it more difficult to reach general practice clinics, and subsequently reduced referrals and presentations to ED. There was no significant change in New Zealand Māori presentations. This raises the question of whether there are other factors specific to the Pacific population, which resulted in decreased emergency presentation during COVID‐19. Vulnerable groups such as Māori and Pacific Peoples in New Zealand already face inequities in health‐care provision and this gap may be widened during pandemics.^{23, 24}

Despite an overall reduction in total numbers across all age groups, there was an increase in the proportion of <1‐year‐old presentations during the lockdown period. Similar increase in presentations of these vulnerable populations was found in Australia.²⁵ This may be influenced by increased parental anxiety, disruption to social supports and change in community‐based child health services. Parental concern about issues such as fever and feeding problems may have increased emergency department attendances, which otherwise may have been addressed by community‐based services. The proportion of presentations for those aged 11–15 years decreased significantly compared to other age groups. This may relate to increased parental supervision and limitation of outdoor activities resulting in fewer injuries.

There is concern that the COVID‐19 pandemic may worsen child mental health due to the associated anxiety and uncertainty, social isolation and economic recession.²³ Although the numbers are small in this study, the increase in self‐harm presentations and decrease in suicidal ideation presentations during the lockdown period may represent a shift from a contemplative to an action phase. Patients may have been discouraged from attending unless a non‐discretionary concern such as physical injury had occurred. This suggests that there may be children needing mental health care but not seeking it.

Conclusion

This study has identified a significant reduction in paediatric presentations to a tertiary emergency department in New Zealand during the national Alert Level 4 Lockdown for COVID‐19. The proportional increase in the <1‐year‐old group may be suggestive of a greater need for community‐based child health services during the COVID‐19 pandemic. Mental health support services may also need to adapt and expand to provide adequate psychological support for children during this crisis. Recognising the needs of these vulnerable groups will be critical during the ongoing COVID‐19 pandemic in addition to informing response plans for similar events in the future.

Ethical Approval

This study has been granted ethical approval under the ‘Minimal Risk Health Research’ University of Otago Human Ethics Application HD20/049.