Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study

  1. Ruud G. Nijman
  2. Kate Honeyford
  3. Ruth Farrugia
  4. Katy Rose
  5. Zsolt Bognar
  6. Danilo Buonsenso
  7. Liviana Da Dalt
  8. Tisham De
  9. Ian K. Maconochie
  10. Niccolo Parri
  11. Damian Roland
  12. Tobias Alfven
  13. Camille Aupiais
  14. Michael Barrett
  15. Romain Basmaci
  16. Dorine Borensztajn
  17. Susana Castanhinha
  18. Corinne Vasilico
  19. Sheena Durnin
  20. Paddy Fitzpatrick
  21. Laszlo Fodor
  22. Borja Gomez
  23. Susanne Greber-Platzer
  24. Romain Guedj
  25. Stuart Hartshorn
  26. Florian Hey
  27. Lina Jankauskaite
  28. Daniela Kohlfuerst
  29. Mojca Kolnik
  30. Mark D. Lyttle
  31. Patrícia Mação
  32. Maria Inês Mascarenhas
  33. Shrouk Messahel
  34. Esra Akyüz Özkan
  35. Zanda Pučuka
  36. Sofia Reis
  37. Alexis Rybak
  38. Malin Ryd Rinder
  39. Ozlem Teksam
  40. Caner Turan
  41. Valtýr Stefánsson Thors
  42. Roberto Velasco
  43. Silvia Bressan
  44. Henriette A. Moll
  45. Rianne Oostenbrink
  46. Luigi Titomanlio
  47. in association with the REPEM network (Research in European Pediatric Emergency Medicine) as part of the EPISODES study group

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Abstract

During the initial phase of the Coronavirus Disease 2019 (COVID-19) pandemic, reduced numbers of acutely ill or injured children presented to emergency departments (EDs). Concerns were raised about the potential for delayed and more severe presentations and an increase in diagnoses such as diabetic ketoacidosis and mental health issues. This multinational observational study aimed to study the number of children presenting to EDs across Europe during the early COVID-19 pandemic and factors influencing this and to investigate changes in severity of illness and diagnoses.

Methods and findings

Routine health data were extracted retrospectively from electronic patient records of children aged 18 years and under, presenting to 38 EDs in 16 European countries for the period January 2018 to May 2020, using predefined and standardized data domains. Observed and predicted numbers of ED attendances were calculated for the period February 2020 to May 2020. Poisson models and incidence rate ratios (IRRs), using predicted counts for each site as offset to adjust for case-mix differences, were used to compare age groups, diagnoses, and outcomes.

Reductions in pediatric ED attendances, hospital admissions, and high triage urgencies were seen in all participating sites. ED attendances were relatively higher in countries with lower SARS-CoV-2 prevalence (IRR 2.26, 95% CI 1.90 to 2.70, p < 0.001) and in children aged <12 months (12 to <24 months IRR 0.86, 95% CI 0.84 to 0.89; 2 to <5 years IRR 0.80, 95% CI 0.78 to 0.82; 5 to <12 years IRR 0.68, 95% CI 0.67 to 0.70; 12 to 18 years IRR 0.72, 95% CI 0.70 to 0.74; versus age <12 months as reference group, p < 0.001). The lowering of pediatric intensive care admissions was not as great as that of general admissions (IRR 1.30, 95% CI 1.16 to 1.45, p < 0.001). Lower triage urgencies were reduced more than higher triage urgencies (urgent triage IRR 1.10, 95% CI 1.08 to 1.12; emergent and very urgent triage IRR 1.53, 95% CI 1.49 to 1.57; versus nonurgent triage category, p < 0.001). Reductions were highest and sustained throughout the study period for children with communicable infectious diseases. The main limitation was the retrospective nature of the study, using routine clinical data from a wide range of European hospitals and health systems.

Conclusions

Reductions in ED attendances were seen across Europe during the first COVID-19 lockdown period. More severely ill children continued to attend hospital more frequently compared to those with minor injuries and illnesses, although absolute numbers fell.

Trial registration

ISRCTN91495258 https://www.isrctn.com/ISRCTN91495258 .

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  1. Version published to 10.1371/journal.pmed.1003974
  2. ScreenIT

    SciScore for 10.1101/2022.03.25.22272926: (What is this?)

    Please note, not all rigor criteria are appropriate for all manuscripts.

    Table 1: Rigor

    EthicsIRB: Ethics: Following initial approval by the UK Health Research Authority, all participating sites obtained approval from their national/local institutional review boards
    Consent: The need for individual patient informed consent was waived.
    Sex as a biological variablenot detected.
    Randomizationnot detected.
    Blindingnot detected.
    Power Analysisnot detected.

    Table 2: Resources

    Software and Algorithms
    SentencesResources
    Aggregated, standardized data were uploaded using the REDCap online platform (S2 File).
    REDCap
    suggested: (REDCap, RRID:SCR_003445)

    Results from OddPub: Thank you for sharing your data.

    Results from LimitationRecognizer: We detected the following sentences addressing limitations in the study:
    Strengths and limitations: Our study presents multinational data enabling the comparison between infection prevention measures, national SARS-CoV-2 prevalenceand the impact on acute illness and injuries in children between European countries. Most participating sites were tertiary institutions, with dedicated pediatric emergency medicine teams, with potential implications for the generalisability of our findings. At present, no standardized data extraction system for pediatric urgent and emergency care exists between European countries; and the EPISODES study is the first to navigate the difficulties of dealing with different data systems, data availabilityand varying coding practices. Hence, also limited by the time restrictions caused by the COVID-19 pandemic, some sites were not able to provide data for all domains, and two sites (NL002, HUN002) were only able to provide data for part of the study duration. Limitations of electronic health records to describe patients’ diagnoses are well known. [71] Participating study sites had unique coding systems, and we urged all study teams to be consistent in transforming local data to fit the study clinical report form. Although most diagnoses linked to SARS-CoV-2 in children were included in the pre-defined clinical report form, other diagnoses might be of interest in future studies. Of note, coding for children with Multi Inflammatory Syndrome in Children (MIS-C) proved unreliable, with no unique diagnostic codes available for th...

    Results from TrialIdentifier: We found the following clinical trial numbers in your paper:

    IdentifierStatusTitle
    ISRCTN91495258NANA

    Results from Barzooka: We did not find any issues relating to the usage of bar graphs.

    Results from JetFighter: We did not find any issues relating to colormaps.

    Results from rtransparent:
    • Thank you for including a conflict of interest statement. Authors are encouraged to include this statement when submitting to a journal.
    • Thank you for including a funding statement. Authors are encouraged to include this statement when submitting to a journal.
    • No protocol registration statement was detected.

    Results from scite Reference Check: We found no unreliable references.

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  3. Version published to 10.1101/2022.03.25.22272926v1 on medRxiv