key: cord-0711250-wry4czwl
authors: Lewit, Ruth A.; Kotagal, Meera; Duron, Vincent P.; Falcone, Richard A.; Fortenberry, Logan C.; Greene, H. Michelle; Leonard, Julie C.; Makoroff, Kathi; Midura, Devin; Moody, Suzanne; Ramaiah, Veena; Gosain, Ankush; Slidell, Mark B.
title: Association of Economic Recession and Social Distancing with Pediatric Non-Accidental Trauma During COVID-19
date: 2022-02-24
journal: J Surg Res
DOI: 10.1016/j.jss.2022.02.038
sha: 88e899be55e5889b1e688927709078e62393925f
doc_id: 711250
cord_uid: wry4czwl

BACKGROUND/OBJECTIVES: There has been concern that the incidence of non-accidental trauma (NAT) cases in children would rise during the COVID-19 pandemic due to the combination of social isolation and economic depression. Our goal was to evaluate NAT incidence and severity during the pandemic across multiple US cities. METHODS: Multi-institutional, retrospective cohort study comparing NAT rates in children <18 years old during the COVID-19 pandemic (March-August 2020) with recent historical data (January 2015-February 2020) and during a previous economic recession (January 2007-December 2011) at level 1 Pediatric Trauma Centers. Comparisons were made to local and national macroeconomic indicators. RESULTS: Overall rates of NAT during March-August 2020 did not increase compared to historical data (p=0.8). Severity of injuries did not increase during the pandemic as measured by Glasgow Coma Score (GCS) (p=0.97) or mortality (p=0.7), but ISS slightly decreased (p=0.018). Racial differences between time periods were seen, with increased proportions of NAT occurring in African-Americans during the pandemic (p<0.001). NAT rates over time had low correlation (r=0.32) with historical averages, suggesting a difference from previous years. Older children (≥3y) had increased NAT rates during the pandemic. Overall NAT rates had low inverse correlation with unemployment (r=-0.37) and moderate inverse correlation with the stock market (r=-0.6). Significant variation between sites were observed. CONCLUSIONS: Overall NAT rates in children did not increase during the COVID-19 pandemic, but rates were highly variable by site and increases were seen in African-Americans and older children. Further studies are warranted to explore local influences on NAT rates.

Drs. Gosain and Slidell conceptualized and designed the study, designed the data collection instruments, coordinated, and supervised data collection across sites, drafted the manuscript and critically reviewed and revised the manuscript for intellectual content.

Drs. Duron, Falcone, Greene, Leonard, Makoroff, Midura, Ramaiah, Mr. Fortenberry and Ms. Moody acquired data, and critically reviewed and revised the manuscript for intellectual content.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

J o u r n a l P r e -p r o o f Abstract Background/Objectives: There has been concern that the incidence of non-accidental trauma (NAT) cases in children would rise during the COVID-19 pandemic due to the combination of social isolation and economic depression. Our goal was to evaluate NAT incidence and severity during the pandemic across multiple US cities.

Methods: Multi-institutional, retrospective cohort study comparing NAT rates in children <18 years old during the COVID-19 pandemic (March-August 2020) with recent historical data (January 2015-February 2020) and during a previous economic recession (January 2007-December 2011) at level 1 Pediatric Trauma Centers. Comparisons were made to local and national macroeconomic indicators.

Overall rates of NAT during March-August 2020 did not increase compared to historical data (p=0.8). Severity of injuries did not increase during the pandemic as measured by Glasgow Coma Score (GCS) (p=0.97) or mortality (p=0.7), but ISS slightly decreased (p=0.018). Racial differences between time periods were seen, with increased proportions of NAT occurring in African-Americans during the pandemic (p<0.001). NAT rates over time had low correlation (r=0.32) with historical averages, suggesting a difference from previous years. Older children (≥3y) had increased NAT rates during the pandemic. Overall NAT rates had low inverse correlation with unemployment (r=-0.37) and moderate inverse correlation with the stock market (r=-0.6). Significant variation between sites were observed.

Overall NAT rates in children did not increase during the COVID-19 pandemic, but rates were

There have been concerns that social distancing measures and subsequent social isolation during the SARS-CoV-2 (COVID-19) pandemic may lead to increased rates of child physical abuse, also known as non-accidental trauma (NAT). Increased rates of NAT have been observed during previous economic downturns, including the 2008-2009 Great Recession, which brought increased rates of abusive head trauma. 1, 2 In addition to increases in absolute numbers, the severity of NAT increased during that recession, 2 and several studies have linked child abuse with mortgage delinquency and unemployment. 3, 4 The economic recession and high unemployment rates observed during the COVID-19 pandemic are concerning for possible increases in NAT. Unfortunately, along with the recession came shelter-in-place guidelines, school closures and other social distancing measures. Thus there has been intense speculation that the incidence in NAT cases would rise during the pandemic due to the dual impact of social isolation and economic depression. 5, 6 An increase in intimate partner violence was reported early in the pandemic, with some suggesting this was secondary to stay-at-home policies. 7, 8 Additionally, some early studies found increases in child abuse during COVID-19, while others noted a decrease in the number of NAT cases seen compared to previous years. [9] [10] [11] [12] [13] [14] This study sought to evaluate changes in NAT incidence and severity during the COVID-19 pandemic across multiple diverse US cities. Our a priori hypothesis was that an initial drop in NAT incidence would be seen at the onset of the pandemic while lockdown measures were in place, with a subsequent rise in numbers and severity as these measures were relaxed and the effects of social distancing and economic depression become more visible. Children <18 years old with injuries suspected to be due to NAT seen in the emergency room or inpatient were included in the study. Our primary study period was March-August 2020. The primary outcome measure of this study was the rate of suspected NAT during the COVID-19 pandemic. Rates of NAT are expressed as the number of suspected NAT patients per trauma admissions over the specified time periods. Secondary outcomes included association of suspected NAT with macroeconomic indicators, as well as the severity of NAT and mortality rates during the study periods.

Economic indicators used in this study included monthly national and local (e.g, citylevel) unemployment rates, obtained from the U.S. Bureau of Labor Statistics, 15 ,16 as well as Dow Jones Industrial Average (DJIA) historical data. 17 The daily closing value of the DJIA was averaged to create a monthly closing average. For this study, the COVID pandemic in the U.S. was defined as starting in March 2020. Data were also compared by age groups: infants under 1

year of age (<1), children between the ages 1-2 years (1-2), and children three years and older (≥3).

Chi-square and Kruskal-Wallis tests were used for categorical data and Mann-Whitney 

Across all the time periods and sites included in this study, 3,598 patients were identified as suspected NAT. Overall demographics and demographics by site are seen in Table 1 . The majority of patients were male (60%), predominantly White (47%), publicly insured (61%), had a median age of 9 months, a median GCS of 15 and a median ISS of 9. Overall mortality was 5.4%. Statistically significant differences were seen between sites in race, insurance type, and age. Statistically significant, but clinically insignificant, differences were seen between sites in GCS and ISS. There was no difference in mortality between sites.

Demographics were compared between time periods: March-August 2020 versus historical data from January 2015-February 2020 [ Table 2 ]. The rate of NAT relative to all trauma admissions from January 2015-February 2020 was 5.54%; the rate of NAT during the COVID-19 pandemic from March-August 2020 was 5.42% (p=0.8). Significant differences were seen in race between time periods (36% White and 49% African-American during the pandemic vs 52% White and 40% African-American historically, p<0.001). No differences in ISS, GCS or mortality rates were seen during the pandemic versus historical data.

Monthly NAT rates expressed as cases per trauma admission were plotted. In Recession; however, there was no correlation between those NAT rates and unemployment (r=0.07) or DJIA (r=0.008).

In Figure 1b , NAT rates by month are seen for the pandemic period, as well as historical average rates from 2015-2019, national unemployment rates and DJIA closing monthly averages for 2020. NAT rates had low correlation with the historic average NAT rate (r=0.32) and are seen outside the interquartile range from the historical data in February, March, May and July 2020. There was an increase in NAT seen in February (8.98% vs 6.37%, p=0.23), followed by a drop in March (4.76% vs 6.76%, p=0.20), and then increases in May (5.35% vs 3.93%, p=0.28) and July (5.90% vs 4.47%, p=0.35). None of these changes were statistically significant. NAT rates during the pandemic had low inverse correlation with 2020 unemployment rates (r=-0.37) and moderate inverse correlation with DJIA (r=-0.60).

To understand variability between sites, site level data (organized geographically from West to East) and overall data are presented [ Memphis' pandemic NAT rates did not correlate with the historical average NAT rate (r=0.013), indicating a significant difference during the pandemic compared to previous years.

However, NAT rates in Memphis had a negligible correlation with unemployment rates (r=-0.25). In contrast, Chicago's NAT rates had moderate inverse correlation with the historical average (r=-0.62), and high correlation with unemployment rates (r=0.76). Cincinnati saw no correlation between pandemic NAT rates and historical rates (r=0.07) but did experience a moderate inverse correlation with unemployment rates (r=-0.56). Columbus had moderate correlation between NAT rates and the historical average (r=0.62) and moderate inverse correlation with unemployment rates (r=-0.59). Lastly, New York NAT rates had high correlation with the historical average (r=0.71) and moderate inverse correlation with unemployment rates (r=-0.50).

NAT rates by age groups NAT rates were examined by age group [ Table 3 ]. Infancy (<1 year) was the most common age group with NAT (55%), followed by 1-2 years (26%), and then children ≥3 years (18%). NAT rates by age group did not differ from the historical averages (2015-2019) (<1 year: 51% vs 56%, p=0.5; 1-2 years: 29% vs 26%, p=0.6; ≥3 years: 20% vs 18%, p=0.6). Race, insurance type, ISS and GCS all differed significantly between age groups. ISS was significantly higher in those <1 year (median 9 vs 5, p<0.0001). Mortality was highest in the 1-2 years age group (7.4%), followed by those ≥3 years (6.5%) and lowest in infants <1 year (4.1%, p<0.0001). Statistically significant, but clinically insignificant, differences were seen in GCS between age groups. 9% vs 1.3%, p=0.7) . None of these changes were statistically significant. There was minimal deviation from the historic interquartile range seen in the 1-2 years age group. For children ages ≥3 years, rates were least correlated with the historical average, and spikes outside of the historical interquartile ranges were seen in April (2.0% vs 0.9%, p=0.17) and July (1.5% vs 1.1%, p=0.20), but these were not statistically significant.

The overall rates of NAT during March-August 2020, the height of the COVID-19 pandemic when social distancing guidelines were in place, did not increase compared to historical data nor did severity of injuries increase. Racial differences between time periods were seen, with higher proportions of NAT occurring in African-Americans during the pandemic.

NAT rates compared to historical averages demonstrated little correlation, suggesting that NAT rates during the pandemic differed from previous years. However, these did not reach statistical significance, nor did these trends support our hypothesis of an early decrease during social distancing followed by a subsequent rise. We did observe differences by age group, with older children (≥3 years) most affected during the pandemic. NAT rates in aggregate did not correlate with unemployment but had moderate inverse correlation with the DJIA. Importantly, there were J o u r n a l P r e -p r o o f variations between sites, suggesting that NAT rates may be more affected by local, rather than national, determinants.

This study highlights that regional differences are crucial to understanding the effects of the COVID-19 pandemic on NAT rates. Memphis' overall NAT cases increased, while trauma admissions were similar to previous years, leading to increased NAT rates. Meanwhile, Columbus and Chicago also saw more NAT cases, accompanied by proportional increases in trauma admissions, so NAT rates were not significantly changed. Conversely, Cincinnati observed fewer NAT cases during the study period. These findings are consistent with the available literature. Single center studies from Baltimore, Atlanta and Lubbock found increases in local NAT rates during the pandemic, 11, 12, 19 while studies from New York City, Dallas, and Los Angeles reported declines in local NAT cases. 9, 10, 20 This site-to-site variability highlights the importance of studying NAT epidemiology on multiple scales.

York found no significant increase in pediatric trauma admissions during the pandemic, 21 ,22 yet we observed numerous cities in the present study with increased trauma admissions. Several national studies examining NAT during COVID-19 have been published with conflicting results.

The Centers for Disease Control and Prevention found a decrease in NAT cases but increased rates of NAT when measured as a proportion of Emergency Department visits. 23 Several studies utilizing the Pediatric Health Information System found fewer NAT cases. 13, 14, 24 Another multicenter study from the Western Pediatric Surgery Research Consortium found no increases in NAT during the early months of the pandemic. 25 However, the COVID-19 pandemic affected each community differently, with varying state and city responses, social distancing guidelines and dates, local unemployment rates, etc. Our study focuses on and exemplifies that local trends J o u r n a l P r e -p r o o f may be more important when investigating NAT epidemiology, as many of these local trends are not apparent when data are aggregated on the national scale. The reason beyond these differences is likely multifactorial. One example of this is seen in cities with lower trauma admissions (like San Francisco and New York), that likely had more stringent social distancing guidelines in place with higher compliance, compared to higher rates of trauma seen in Columbus and Chicago. Racial demographics, such as cities like Memphis where there are larger African-American communities seeing increases in NAT rates, likely also contributed to the variations seen.

Macroeconomic indicators may not be appropriate measures to benchmark NAT. The existing literature surrounding the effects of unemployment on NAT is mixed. Some have reported no association between unemployment and child abuse, 4,27 while others suggested a relationship between male unemployment and abuse 28 and one found reduced rates of NAT during a time of increased unemployment. 3 Complex socioeconomic and sociodemographic factors make it difficult to isolate the impact of unemployment on NAT relative to other variables. It is interesting to note that NAT cases rose with unemployment rates during the Great Recession, however this was not mirrored during the rise in unemployment at the beginning of the COVID-19 pandemic. It is possible that economic stimulus efforts mitigated this effect. The first round of federal stimulus checks was distributed in April 2020, which may have lessened the impact of unemployment for many families. Previously, Kleven, et al. found that the earned income tax credit (which could increase household income) was associated with a reduction in abusive head trauma. 29 Additionally, it is possible that the benefits of the economic stimulus did not reach all cities or population groups equally, potentially contributing to variability in NAT incidence between cities. Using the stock market as an economic indicator is similarly fraught J o u r n a l P r e -p r o o f with limitations. When the DJIA dropped precipitously in February 2020, a sharp spike in the NAT rate was seen. However, it is possible that this spike is unrelated to the DJIA and instead correlated with the rising COVID-19 infections during that month. Based on our results, we cannot draw a causal relationship between these economic indicators and NAT rates.

The COVID-19 pandemic was more than an economic recession. School closures and social distancing guidelines may have also played a role in the rates of NAT. This may explain differences in NAT rates by age, which may be attributable to differences in typical caretakers for each of the age groups. Children three years and older are often in daycare or school, both of which were closed during the early pandemic. Older children were therefore spending most of the time at home in 2020 in contrast to previous years. This may account for why this age group was most affected, and explain the sharp spikes seen in this age group's NAT rates in April and again in July 2020. Household members are the most common perpetrators of child abuse, 30 which would support this line of reasoning.

This study has limitations. NAT rates were calculated using trauma admissions and therefore do not represent the complete population-based incidence of NAT. Cases of NAT were limited to trauma registries, so they may underrepresent the true number of NAT cases that presented to Child Services with minor injuries or cases that did not reach attention of mandated reporters. However, a recent study found child abuse investigations as a whole decreased substantially during COVID, which was attributed to school closures. 31 This may mitigate this major limitation of this study. Due to limitations in the electronic medical record coding and follow-up, they also represent suspected cases, rather than confirmed cases. Seasonal variations were not factored into this analysis. Differences by site may also affect our results; each site likely has slightly different criteria for trauma activations or admissions and specific signs or symptoms that trigger a NAT diagnosis. 32,33 However, individual site criteria were unchanged during the study period and should not cause time-related variation. Further, all sites included in this study were in urban centers; while each site has a catchment area that includes rural areas, these results may not be able to be extrapolated to rural areas. Additionally, some urban centers have multiple pediatric trauma centers that may not have been included in this study, which may skew some of the data presented. Furthermore, city-level unemployment rates were used and may not accurately represent each site's full patient catchment area. Patient poverty levels were not collected, which may have been a confounding variable. Lastly, we defined the pandemic as starting in March 2020; however, this may be an oversimplification of the timeline of the pandemic. In some regions cases of COVID-19 were seen earlier and voluntary self-isolation may have taken place before mandatory social distancing was instituted by local governments.

The overall rate of NAT in March-August 2020 did not increase compared to historical data and no difference in injury severity was observed. The economic recession and social distancing guidelines seen during the COVID-19 appear to have played minor roles in the observed trends. Important variations were seen between sites, suggesting differential impacts of the pandemic on individual communities and that additional local factors contributed to variability. This variation between sites highlights the complexity of understanding the true extent of NAT epidemiology to design prevention measures. NAT is a complex public health issue and remains a concern during the remainder of the COVID-19 pandemic and for future pandemics. 

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GCS-Glasgow Coma Score, ISS-Injury Severity Score a Insurance type was not available for this site. Missing data was not included in analysis