Compared to the previous two years, this study showed a significant decline in the number of pediatric ED visits during the COVID-19 outbreak and national lockdown, with a substantial increase in the relative rate of hospitalizations. The reduction in ED visits was more prominent for low-acuity diseases (scored as green codes) than for higher triage scores (yellow and red codes).
In recent years, an overcrowding of ED was reported in several countries, and one-fifth of children under 5 years-old had at least one ED access(17). According to a recent Italian report, non-urgent visits (namely, white and green codes) accounted for 27.6% of all ED users and 58.2% of total pediatric attendance episodes(18). The decrease in the number of visits observed in our ED during the COVID period was probably due to the restrictive measures. In Italy, schools and sports activities have been closed since 1 March, 2020, so it appears reasonable that acute infections resulted less frequent than usual among children. The drop in the incidence of acute infections might appear in contrast with the increased number of patient visits normally observed during seasonal influenza epidemics(19,20), but currently few cases of COVID-19 among children have been reported(21). As of 27 April, there were almost 200.000 confirmed cases of SARS-CoV-2 infection in Italy, but only 1.2% of all patients were children(4,22). SARS-CoV-2 affects children less commonly and less severely in comparison to adults (23). Overall, 2.846 Italian children and adolescents below 18 years of age were diagnosed with COVID-19: no death was reported, and 119 out of 2846 cases (4.2%) were hospitalized (21).
In our study, a higher proportion of white codes were recorded during the COVID period in comparison to the same time-interval in the two previous years (Sp19 and Sp18) and to winter periods. During the COVID outbreak, outpatient clinics were suspended, therefore all minor procedures, such as daily renewal of burns dressing or removals of stiches, took place in the Pediatric ED. On the other hand, a relative reduction of the proportion of green codes and a contemporary increase of the yellow codes was reported in comparison to all control periods. This could be explained in part by the fact that viral infections (mainly respiratory and gastrointestinal) usually affecting children during winter and early spring seasons(24) decreased due to social distancing, while the number of accesses of children with chronic or underlying disease did not significantly change. However, this trend was observed in comparison to summer periods too, when schools are similarly closed and there are fewer people circulating in urban areas. Therefore, the closure of scholar and recreational activities may not be the only reason for this finding. In 2011, Brousseau et al. conducted a survey on parents’ and PCPs’ perspectives on the correct utilization of pediatric ED services(12). Parents reported to feel anxious about their children, and they did not consider non-urgent ED visits a violation of the use of healthcare system, as the ED offered firsthand evaluations within the time-frame they desired (12). However, the rapid local and international spread and the ability of this novel Coronovirus to infect a large number of hospital workers generated fears regarding the potential nosocomial transmission of this contagious disease(25,26). Citizens are likely to be more afraid than before to visit healthcare facilities due to the risk of contracting COVID-19, and the use of alternative strategies (e.g., telephone consultation) might have increased. Similarly, during the 2003 SARS outbreak, significant decreases in visits and length of hospital stay in a Canadian pediatric ED were reported(27). This decrease in patient volume together with the government's decision to suspend non-urgent healthcare services encouraged the use of telephone consultation to address mild issues(27).
Incidence of pediatric red codes was not significantly affected during the COVID-19 pandemic. This may be in contrast with a recent case series of 12 children who received delayed hospital care as reported by an Italian Pediatric Hospital Research Network(13). Half of them were admitted to an Intensive Care Unit and four died, and in all cases parents reported avoiding accessing hospital because of fear of infection with SARS-CoV-2(13). This was a preliminary report and no direct comparisons with previous years were available, nor delay in access to care for severely ill children was systematically monitored, therefore it appears speculative to generalize these results. However, concerns have been raised also from reports on adult patients. Recently, a significant increase in mortality due to acute coronary syndrome was observed during the lockdown period, and this was not fully explained by SARS-CoV-2 infection alone(15). This observation raises the question of whether the clinical outcome of some of these patients may have been different if they had sought medical attention earlier.
Discharge diagnosis were significantly different among studied periods, in particular a relative increase in the proportion of children presenting with traumatic injuries (including accidental ingestions, burns, foreign body aspiration and bone fractures) was observed during the COVID outbreak. This finding appears in contrast with preliminary data on adult patients, showing a significant reduction in injury-related admissions(28). However, since outdoor activities have been banned from the beginning of the quarantine, children have been forced at home. Domestic accidents represent one of the most frequent causes of morbidity in children under 14 years old, and nearly half of them typically happen during play time(29).
A slightly higher proportion of children with mental health disorders were diagnosed in the pediatric ED during the COVID period. The forced quarantine may worsen existing mental health problems and lead to more cases among children and adolescents because of the unique combination of the public health crisis, social isolation, and economic recession(30). In particular, school closures may be especially disruptive for mental health services of some adolescents with lower family income, who were likely to receive mental health services exclusively from school settings(31).
The rate of hospitalizations also significantly increased, but different patterns of admission diagnosis were demonstrated only in comparison to spring and winter periods, probably due to the lower number of patients with infectious diseases, as previously discussed.
Our study has several limitations. It was a single-centre retrospective analysis, and therefore the generalizability of these findings may be limited to comparable institutions. Moreover, we could not evaluate the possible role of factors influencing people’s perceptions and utilization of healthcare facilities, such as family’s structure and socioeconomic status, scholarship, distance between the child’s house and the ED. However, despite the retrospective design, data were collected prospectively in a standardized way, with detailed clinical and epidemiological information for each patient from hospital software.
In conclusion, during the national lockdown period, our pediatric ED experienced significantly reduced volumes of children presenting with low-acuity problems. This decrease in the number of visits may be due either to a reduction in the incidence of acute infectious diseases and to the fear of the potential nosocomial transmission of COVID-19. However, even if parents may be more afraid to access healthcare facilities, red codes were not likely to be affected and urgent conditions were evaluated as usual. This study not only provides information for future SARS-related public health preparedness policies, it may also provide a foundation for research into strategies other than emergency services to address non-urgent pediatric medical issues.