Presentations of children to emergency departments across Europe and the COVID-19 pandemic: A multinational observational study
Authors: Nijman Ruud G. , Honeyford Kate , Farrugia Ruth , Rose Katy , Bognar Zsolt , Buonsenso Danilo , Da Dalt Liviana , De Tisham , Maconochie Ian K. , Parri Niccolo , Roland Damian , Alfven Tobias , Aupiais Camille , Barrett Michael , Basmaci Romain , Borensztajn Dorine , Castanhinha Susana , Vasilico Corinne , Durnin Sheena , Fitzpatrick Paddy , Fodor Laszlo , Gomez Borja , Greber-Platzer Susanne , Guedj Romain , Hartshorn Stuart , Hey Florian , Jankauskaite Lina , Kohlfuerst Daniela , Kolnik Mojca , Lyttle Mark D. , Mação Patrícia , Mascarenhas Maria Inês , Messahel Shrouk , Özkan Esra Akyüz , Pučuka Zanda , Reis Sofia , Rybak Alexis , Ryd Rinder Malin , Teksam Ozlem , Turan Caner , Thors Valtýr Stefánsson , Velasco Roberto , Bressan Silvia , Moll Henriette A. , Oostenbrink Rianne , Titomanlio Luigi ,   in association with the REPEM network (Research in European Pediatric Emergency Medicine) as part of the EPISODES study group
Published: August 2022

Background
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.