Delayed presentation to regular Dutch paediatric care in COVID-19 times: a national survey

We explored the collateral harm in Dutch children and adolescents during the COVID-19 pandemic from experience of paediatricians via an open question distributed via the website of the Dutch Paediatric Society. From the end of March till the first week of July, we received 51 reports of collateral harm involving mostly very young children with mainly acute physical problems but also social problems. In older children, several cases of diabetic ketoacidosis were reported. Our results show that delaying care can lead to seriously ill children, life-threatening situations and that in some cases it can even lead to death. If we want to avoid such a delay at a possible second peak of Corona, general care providers and paediatricians have to join forces and find new ways of working. Systematic data collection of collateral harm in children is needed to be able to intervene adequately.


ABSTRACT
We explored the collateral harm in Dutch children and adolescents during the COVID-19 pandemic from experience of paediatricians via an open question distributed via the website of the Dutch Paediatric Society. From the end of March till the first week of July, we received 51 reports of collateral harm involving mostly very young children with mainly acute physical problems but also social problems. In older children, several cases of diabetic ketoacidosis were reported. Our results show that delaying care can lead to seriously ill children, lifethreatening situations and that in some cases it can even lead to death. If we want to avoid such a delay at a possible second peak of Corona, general care providers and paediatricians have to join forces and find new ways of working. Systematic data collection of collateral harm in children is needed to be able to intervene adequately.
In their report on the consequences of the corona crisis for regular care, the Dutch Healthcare Authority showed that of all specialisms, paediatrics has experienced the largest decline in the number of urgent referrals in the first weeks of the COVID-19 crisis. In addition, paediatrics was the specialty that showed the least signs of a recovery in referrals (it even fell back slightly) while all other specialties showed a steady recovery from early April onwards. 1 The decrease in referrals might be explained by a reduced incidence of, for example, traffic and sports injuries as a result of social distancing and school closures. However, the decline might also indicate a delay in care and subsequently in collateral harm. Although some studies report on the consequences of delayed presentations to emergency departments, insight in the nature and severity of delayed presentation to regular paediatric care is missing. 2 3 Our objective was to explore the collateral harm in Dutch children and adolescents during the COVID-19 pandemic from the experience of paediatricians.

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Via the website of the Dutch Paediatric Society, we requested all 1400 paediatricians affiliated with the professional association (93% of all Dutch paediatricians) to report on collateral harm in children and adolescents, from 2 weeks since the initiation of the Dutch 'intelligent lockdown', 4 a lighter version of a full lockdown 5 (end of March) to the first week of July. The question was: 'We ask you to report if, in your opinion, a child was presented too late to acute, regular or chronic care due to parental or healthcare provider concerns about corona, and which resulted in unnecessary harm'.
The results of this inventory showed 51 reports (from 38 respondents divided over 31 hospitals) of collateral harm since the end of March. Although the majority of reports of harm were received in the first 4 weeks of the intelligent lockdown (n=27), there were still 24 reports in the months after, up to and including the second week of July. The reports came from all over the Netherlands, but most reports were received from the west and south-west of the Netherlands, the regions where the corona crisis was more severe and, in all likelihood, experienced the highest pressure on healthcare.
Most reports (54%) of collateral harm involved young children: neonates, infants and children aged 1-4 years (table 1). The symptoms with which the children were presented-too late-to the paediatrician varied widely, including mainly acute physical problems but also social problems. The delay in neonatal care was mainly related to hyperbilirubinaemia and weight-related problems (low birth weight and severe weight loss). Spread across multiple age groups, several children presented with diabetic ketoacidosis (table 2).
Although the results of this exploration among paediatricians shows an alarming situation, this is probably only the tip of the iceberg since it is an exploration in which the data were not collected systematically. Our results show that delaying care can lead to seriously ill children, life-threatening situations and that in some cases it can even lead to death. If we want to avoid such a delay in providing the right care at the right place by the right person, at a possible second peak of Corona, action must be taken in which general care providers and paediatricians have to join forces, in particular regarding triage. We need to find new ways of working for unusual times like this so that the delay in care is avoided at all times. Finally, there should be systematic data collection of collateral harm in children; this is the only way to clarify its causes so that targeted interventions can be made.
Contributors DJ drafted the initial manuscript. KI provided significant contributions to the data collection that led to this manuscript and critically reviewed and revised the manuscript. Both authors provided significant contributions to the data analysis and presentation used in this manuscript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; externally peer reviewed.
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