key: cord-328601-gi6rr2np authors: Degiorgio, Sophie; Grech, Neil; Dimech, Yana Marie; Xuereb, John; Grech, Victor title: COVID-19 related acute decline in paediatric admissions in Malta, a population-based study date: 2020-11-12 journal: Early Hum Dev DOI: 10.1016/j.earlhumdev.2020.105251 sha: doc_id: 328601 cord_uid: gi6rr2np Background The COVID-19 pandemic has decimated non-pandemic hospital admissions worldwide. This population-based study was carried out in order to ascertain whether there were any differences in numbers or characteristics of acute paediatric medical admissions during the first wave of COVID-19 in Malta compared with the corresponding 2019 period. Methods Data was collected from Malta's only acute general hospital using health records and computer databases including iSoft Clinical Manager (ICM) and Electronic Case Summaries (ECS). Data was collected for 1/3–9/5/2019 (control period) and the corresponding 2020 period (study period). Results Acute paediatric medical admissions dropped by 63.5%. Neonates increased by 5.25% (p = 0.001). An increase in child abuse/social paediatric cases (p < 0.001) was noted. Data analysed after school closure revealed a significant drop in the number of communicable (infectious) disease admissions (p < 0.001). There was also a negative correlation between daily paediatric admissions and active COVID-19 cases in Malta (p = 0.005). No significant delay in the presentation of patients was noted and no increased admissions to the NPICU was recorded. Conclusion Our findings demonstrate a decrease in paediatric illnesses due to school closures, possibly exacerbated by fear of contracting COVID-19 in hospital environments. Public health measures to alleviate guardians' concerns are important to decrease further potential avoidable consequences from the ongoing pandemic. COVID-19 commenced in China in December 2019, quickly spreading rapidly globally (1) . The World Health Organization (WHO) declared COVID-19 a pandemic global emergency on the 11 th March 2020 (2) . The first case of COVID-19 in Malta was a paediatric case and it was reported on the 7 th Match 2020 (3) . Several public health measures were implemented to limit the spread of COVID-19. Travel bans and mandatory self-quarantine was introduced upon return from high-risk countries, until eventually all flights were limited to repatriation services. On the 12 th March 2020, childcare centres, schools, elderly homes were closed. Malta declared a state of national emergency on the 1 st April 2020 (3) . Although various studies have shown that children represent a minority of the population affected by the COVID-19 pandemic, they are the primary focus of every paediatricians' work (4) . Malta has one general hospital and the only changes to paediatric services were structural ones, made to accommodate isolation of patients with potentially COVID-19 illness. (5) Paediatric emergency services remained functional at full capacity amid the pandemic. Despite minimal changes to the department and the continuation of a well-functioning paediatric service, it was noted that fewer patients were presenting to hospital and being admitted. This had been reported in several centres in Italy and the United Kingdom (UK) (6, 7) . This population-based study was carried out in order to determine whether there were any significant differences in acute paediatric admissions during the first wave of the COVID-19 pandemic in Malta compared to the same period in the previous year. Apart from categorising diagnoses according to the system involved, admissions were also divided into 2 groups: communicable and non-communicable. A sub-cohort of cases were considered in these two categories following the closure of schools and nurseries (13 th March 2020). A communicable disease was considered as an infection which may be contracted from interaction with other children and this includes respiratory illnesses, meningitis, hand and mouth foot disease, and gastroenteritis and so on. Chi-squared test was used for comparison of all categorical data. Unpaired T-tests were used for comparison of non-categorical data. Pearson's correlation was used to determine whether a significant correlations. Statistical analysis was performed using bespoke Microsoft Excel spreadsheets and a p value of less than 0.05 was deemed a statistically significant result. Journal Pre-proof The total number of acute paediatric medical admissions between 1 st March and 9 th May 2019 was 729 compared to 266 in the corresponding 2020 period, a 63.5% drop. The difference in presentation between male and female gender was not statistically significant (Table 1) . A significantly higher percentage of neonates (aged 0 to 28 days) presented in 2020 ( There was a significant difference in the percentage of children admitted with respiratory and allergy pathologies. 346 (47.5%) paediatric cases were admitted in 2019 with a respiratory illness, compared to 84 (31.6%) cases in 2020 (p=<0.001) ( Table 1 ). There was also a higher percentage of child abuse or social paediatric cases in 2020 (3.5% vs 0.14% in 2019, p=<0.001). Furthermore, on dividing all admissions into communicable (infectious) and non-communicable (non-infectious) cases following school closures, a significant difference was noted between the study and control period. Significantly more communicable cases presented and required admission in 2019 (421, 70.3%) compared to 2020 (68, 42.2%) (p=<0.001) ( Table 1) . There were no significant differences in the past medical history of the admitted paediatric cases, between the average length of stay or the time of onset of symptoms to hospital presentation, in the number of discharges against medical advice, follow-ups given and in the number of patients needing Intensive Care Unit (ITU) or Neonatal Paediatric Intensive Care (NPICU) during admission (Tables 2 and 3 ). The percentage of chest x-rays performed either on presentation or during admission was noted to be significantly higher in the control cohort (2019, 48.4% vs 2020, 30.8% [p=<0.001]) ( Table 3) . There was a significant negative correlation between daily acute paediatric medical admissions and the number of active COVID-19 cases in Malta (p=0.005) ( Table 4 ). Discussion COVID-19 typically affects children mildly as an acute respiratory infection with fever, cough, sore throat and sneezing (8, 9) . Children are commonly exposed to non-COVID-19 strains of coronavirus, and emerging studies suggest that this may provide some cross-protection against COVID-19 (9). Although the paediatric population demographic is least impacted by COVID-19, there are concerns regarding the witnessed reduction of paediatric admissions. In Northern Italy, a 76% decrease in the number of paediatric patients admitted to the Emergency Department (ED) was seen over a forty-day observation period (6). Similar results were described within the paediatric ED of a trauma centre in the UK (7). The reasons for this drop may be multifactorial. Firstly, fear of the COVID 19 pandemic was potentially a strong contributor. Secondarily, a sharp decline in common seasonal viral infections seems to have played a major role among the paediatric population. Schools, childcare centres, and nurseries closed their doors on the 13 th of March 2020 in Malta after the 9 th case of COVID-19 was detected. According to the United National Educational, Science and Cultural Organization, 194 countries had implemented school closure by the 1 st of April 2020, in an effort to limit transmission and control the COVID-19 pandemic (10). The closure of schools together with social distancing measures and isolation within the community seems to have limited child-to-child transmission of the usual common communicable diseases, which frequently lead to acute respiratory illness and hospital admissions (6, 11) . Furthermore, substantial air quality improvement during the lockdown was reported in certain studies which may have led to a drop in asthma exacerbations (12) . Apart from reduced paediatric admissions, a delay in presentation of paediatric cases to hospitals was also noted. An Italian study showed 12 cases of delayed access to healthcare, across five hospitals. Upon questioning, parents admitted avoiding hospital contact due to fear of contracting COVID-19 (13) . Similar concerns were recorded in the UK, with detrimental implications of delayed presentations to critically ill children (14) . Amongst the disruption caused by COVID-19 within the paediatric population, neonatologists expressed concerns regarding early hospital discharges after birth due to COVID-19. The main issues highlighted included the lack of sufficient time to establish proper feeding. Apart from the neonatologist specialists, community paediatricians expressed concern in view of a fall in referral rates for child protection (7, 15) . The decline in paediatric admissions is of particular concern with regard to vulnerable patients who may not be seeking medical care, including neonates, oncology patients and those with mental health illness (16) . The pandemic has caused a cultural shift within families with parents isolating themselves indoors with their children. Parental stress has increased due to factors including family isolation, growing unemployment and the pandemic itself (17, 18) . This rise in parental stress inevitably leads to an increase in child abuse and neglect (19) , and indeed, this was found in our study. COVID-19 has impacted the paediatric service provided in many centres across the world, interrupting the important support and treatment that the paediatric population requires. As a result, the Royal College of Paediatrics and Child Health (RCPCH) has issued guidelines which aim to provide information regarding safeguarding and treating vulnerable neonates and children. The College stressed that all professionals who are involved in the care of children must continue to base their judgements on the best interest of the child (20) (21) (22) . Protocols have similarly been implemented in Malta within the local paediatric department, which has not suspended any of its services throughout the pandemic. The current global emergency may offer a unique opportunity for us to re-assess how we deliver healthcare to the paediatric population and allows us to introduce innovative ways of care as eventually return to the pre-COVID-19 state (23). The authors have no conflict of interest to declare. This study has demonstrated a significant drop in paediatric admissions in Malta between 2019 and 2020, which negatively correlated with Malta's first wave of COVID-19 cases. There was significant drop in respiratory and communicable cases, and an increase in child abuse and paediatric social cases in 2020. These findings can be partially explained by the closure of schools, with less child-to-child contact and more time in isolation at home. Another contributing factor to reduced admissions is the fear of COVID-19 itself among hospital environments which may have kept parents and guardians away from hospitals. 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