Discussion
Children have been relatively spared from the direct health impacts of the COVID-19 pandemic, but there has been significant concern about the indirect effects on their health and well-being.15 A drop in primary and secondary care attendances at the start of lockdown, and reports of delayed presentation of serious illness, prompted the National Health Service and The Royal College of Paediatrics and Child Health to remind patients to seek medical care when required.16–18 Therefore, it is important to use large-scale data to quantify the impact of the pandemic and the periods of national lockdown on the presentations of children to healthcare providers. By analysing integrated primary and secondary care data on children across NWL from January 2015 to January 2021 we were able to identify changes in patterns of presentation and utilisation of healthcare and changes in severity of illness.
We found that primary care consultations, ED attendances and emergency hospital admissions were substantially below 5-year averages during periods of lockdown. The proportion of consultations taking place in primary care changed very little from prepandemic levels. Attendances due to infections fell the most during lockdowns, while injuries and poisonings were lowest in schoolchildren (5–16 years) when schools were shut between March and June 2020.
Numbers of admissions >48 hours decreased to a lesser extent. This is consistent with a study of 23 paediatric EDs in North-Western Italy: low priority admissions decreased almost twice as much as critical presentations. The authors suggested that non-pharmaceutical interventions (NPIs) and fear of infection lowered non-urgent use of ED facilities but that this reticence was overcome by recognition of children with urgent symptoms, especially in those with significant comorbidities.19 The higher than expected admissions>48 hours observed in the >11–16 years group between July and September 2020 may be partly explained by the pandemic’s impact on mental health.20 Increases have been recorded in behavioural and attentional difficulties, eating disorders, depression and anxiety.21 22 In England, the first lockdown period was not associated with excess mortality in children.23
Multiple factors are likely to have contributed to the observed changes in healthcare utilisation and hospital admissions. These may include changing behaviours of parents and carers, changes in the availability of different routes for healthcare consultation, and changes in disease incidence.24 At the same time, use of information technology for health expanded greatly: virtual consultations (telemedicine) rose from 15%–20% prior to the pandemic to 50%–60%, calls to the NHS 111 helpline (and the 999 emergency services number) rose by over 143 000 calls during March 2020 (a 12.2% increase on the previous year), and use of the online 111 app averaged over half a million users every day during the same month.25
The NPIs put in place to control COVID-19 may have attenuated the normal seasonal increases in transmission of respiratory viral diseases,26–28 and contributing to lower numbers of admissions for infectious diseases in general.29 While NPIs reduce the stress on healthcare systems in the short-term, exposure to many common pathogens leads to acquisition immunity, and limited exposure may increase the susceptible population and hence size of future epidemics.30 31 Yet, the observed impact of NPIs can inform future policy making when considering the use of, sometimes simple to introduce, NPIs to reduce the burden of acute childhood illness, balancing the advantages of doing so against the potential harms and impact on broader child health.
We observed reductions in injury admissions during the first lockdown which returned to seasonal averages when schools partially reopened in June 2020. Other studies suggesting a fivefold rise in the number of domestic accidents32 and increases in child abuse and neglect leading to large increases in head trauma, and increased calls to child support lines.33–35
This study has several limitations inherent from the methodology and nature of the data available. First, our data represent a multicultural, urban population of a major metropolitan city with widely ranging levels of wealth and deprivation, and these might not be reflective of other geographical areas (online supplemental figure 5) for comparative child health profiles for London vs England). A small number of NWL general practices are not part of the WSIC network and hence children registered with these practices would not be part of our database. However; as of June 2019, WSIC collects the data of 365 participating general practices accounting for 95% of the total NWL population.12 Children who are not registered with any general practice would also not be included. Our approach of analysing ICD-coding groups did not account for more subtle epidemiological changes within these overarching coding groups. For example, studies reported relative unchanged ED attendance rates for urinary tract infections,3 5 and changes in the number of admissions for relatively infrequent safeguarding related injuries will have gone unnoticed. Likewise, our study would have benefited from more detailed information on mental health issues to verify the reported rise of mental health issues in primary and secondary care elsewhere.36 37 We were not able to reliably differentiate between face-to-face and virtual appointments in primary care, nor to assess comorbidities or vaccination status.
In conclusion, mandated lockdowns and NPIs were associated with a reduction in primary and secondary healthcare usage for children in NWL. These decreases were seen directly after these measures were instigated indicating that their rapid deployment reduced the burden on the health system. NPIs against COVID-19 also reduced consultations and admissions for other infections. Using a database compiled of both primary and secondary care data provided a ‘whole system’ view showing that the net effect of the pandemic on acute non-COVID-19 childhood illness and injury in NWL was not the feared increase, but actually a substantial reduction.