Our study aimed to explore the impact of a strict lockdown policy on attendance of patients to an urban PED, in one of the first areas of COVID-19 outbreak in Europe. Indeed, COVID-19 outbreak in 2020 had a marked impact on volume and characteristics of visits in our PED in Verona. Mean daily PED accesses dropped to one third of those registered in the same period in 2019, with reduced percentage of white codes and a slight increase of green codes, while yellow and red codes did not vary. Of note, “accidents” were the most frequent cause for PED visits during COVID-19, overcoming the “infections and fever” category, which had ranked first in the previous year. As another important finding, we observed a marked increase of PED visits for minor neonatal conditions, which nearly tripled in percentage if compared to 2019. Hospitalization rate slightly increased during COVID-19 period, while admissions to the PICU remained at 10% in both epochs.
After COVID-19 became pandemic, a drastic decrease in number of patients presenting to adult EDs was noticed.  Similar data were recently highlighted also for children  and are confirmed by our study, that reported a drop of PED visits by 67% during the “COVID-19 period”, if compared to the same period in 2019. This dramatic change was clearly linked to the pandemic, as in two previous months (January and February 2020) the number of PED visits was equivalent to the previous winter season.
As for classification at triage, white, green and yellow codes showed a marked reduction in terms of absolute numbers during the COVID-19 period. However, the overall drop of PED visits was mainly due to a large decrease in children with less urgent problems, e.g. those classified as white codes, which decreased from 45 to 35%, while percentage of green codes slightly increased. We may argue that parents of children with minor problems (white codes) were more reluctant of taking them to the hospital, given the risk of contagion. Furthermore, access to hospital for non-urgent problems was discouraged by restriction on private and public transport, which limited travels for urgent reasons and essential services only. Instead, reassuringly, the proportion of children presenting to our PED with urgent or emergent conditions (yellow or red codes), was nearly the same in the two epochs.
Unexpectedly, accidents were the first reason for accessing our PED during the COVID-19 period. Specifically, we found a marked increase in injuries, burns or wounds, mimicking the rise of traumatic events typically observed in children during summer or holidays seasons. This finding suggests that home remains a frequent place for accidents in children. 
In line with a recent finding in a large paediatric population , we observed a marked reduction of children presenting to our PED with infections or fever (from 49–28%). Possibly, avoidance of social interactions, school closure, suspension of all non-essential services and sport activities, may have limited the spread of other viral infections usually seen in previous winter seasons. [5, 9]
Nonetheless, infections and fever ranked as the second most represented category in our PED during the COVID-19 period. Several studies suggest that infectious diseases are the main cause for PED visits all over the year, and signs and symptoms like fever, cough, respiratory distress, vomiting and diarrhoea are frequently found in the paediatric population. [10–12] Indeed, the population had become quickly aware that respiratory symptoms and fever could be warning signs for possible COVID-19, thus prompting caregivers to seek PED consultation for their children, despite the opposite recommendation by the national health service to stay at home and the low involvement of the paediatric age. [13–16] Conversely, PED visits for gastroenteritis showed a significantly fall in the COVID-19 period, probably because gastrointestinal symptoms were not known yet as a possible manifestation of COVID-19 by caregivers, particularly in the first weeks of the outbreak.
PED visits for headache, abdominal and musculoskeletal pain significantly decreased during COVID-19. These data may be partly related to the frequent functional etiologic cause of these symptoms, more frequently observed during school attendance. [10, 17]
As a novel information, during the COVID-19 period we observed a much larger proportion of otherwise healthy newborns, who were brought to our PED for minor neonatal conditions, such as breastfeeding or umbilical care related problems. This somewhat surprising data may be primarily explained by the restricted access to primary care services. Forced home isolation may also have limited the possibility for inexperienced parents to seek advice from relatives and friends, raising anxiety and worries about the best management for their infant. The need for help on routine care of their baby may have offset parents’ fear of contagion, prompting them to reach out the PED despite the limitations imposed by the lockdown. This data should be carefully taken into account should another lockdown had to be re-instituted. Indeed, neonates are a vulnerable population, that in a COVID-19 context could be exposed inappropriately to a higher risk of infection while visiting the PED. Furthermore, inappropriate access to PED for minor neonatal issues may pose an unnecessary burden to healthcare providers and the hospital system, as well as a higher risk of contagion also for other family members. More efficient territorial services should be made easily available for the neonatal population in the future, to limit incongruous access of these fragile subjects to the PED.
Finally, in terms of outcome we observed a moderate although significant increase of hospitalization rate during the COVID-19 period. This may be coherent with the marked reduction of white codes in 2020, suggesting the population visiting our PED was generally sicker during COVID-19, thus requiring hospital care more frequently. However, as percentage of yellow and red codes were not different, and the need for PICU admission did not change in 2019 and 2020, we speculate that the risk of delayed access to PED during the COVID-19 period was negligible in our population, differently from that reported in other studies. [4, 18]
This study has some limitations. First, the retrospective study design and the relatively small sample size do not allow to draw robust conclusions. Second, it is a single centre study, thus it may not fully reflect the diversity of care provided in other paediatric emergency departments, in Italy and other countries. Nonetheless, it provides information on the characteristics of more than one thousand PED visits in a third-level urban centre, during the early phase of a unique situation, such as that caused by the COVID-19 pandemic. These data may be useful for comparing figures from other PEDs, as well as for guidance in adapting healthcare policies for possible future outbreaks.
In conclusion, our data point out the abrupt reduction and reveal some distinct characteristics of PED visits in Verona during the COVID-19 pandemic, if compared with the same period in 2019.
The strict and prolonged national lockdown policy had a strong impact on volume and features of patients accessing our PED, with a marked reduction in percentage of white codes. Of note, one third of visits was accident-related, emphasizing the need of implementing strategies to raise public awareness of child safety at home, particularly during a mandatory stay-at-home policy. We report an unexpected marked increase of PED visits for minor neonatal conditions, which nearly tripled in percentage if compared to 2019. This finding highlights the need for primary care services to be more efficient and easily available, should another lockdown had to be re-established, to reduce unnecessary PED visits and the inherent risk of contagion for these infants and their family members. Hospitalization rate slightly increased during COVID-19 period, while admission rate to the PICU remained equal in the two epochs, suggesting an overall judicious use of hospital resources despite the inevitable pressure PED healthcare providers had to face during the pandemic.