Analysis: a new study has found that children are now attending emergency departments with much different health problems than before
By Emma Nicholson, Thérèse McDonnell, Eilish McAuliffe and Ciara Conlon, UCD
It is now well established that children are less likely to suffer the effects of Covid-19 infection, but children's healthcare in Ireland has experienced unprecedented change since the start of the pandemic. Like many hospitals around the world, paediatric emergency departments in Ireland have reconfigured how they deliver care in response to the risks and constraints of the pandemic.
The profile of illnesses presenting at these departments has also changed since March 2020. Researchers at the UCD Centre for Interdisciplinary Research, Education and Innovation in Health Systems have been examining these changes, and the reasons for them. The team extracted anonymised data from participating hospitals over the first 12 months of the pandemic, carried out a national survey of parents and conducted interviews with staff working at paediatric emergency departments. This built a comprehensive picture of the experience of paediatric emergency care in Ireland during the period under review.
At the outset, paediatric emergency departments were quieter, with fewer children attending for emergency care. In fact, analysis found that paediatric attendance dropped by 46% between March and May 2020 compared to the same period in 2019.
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From RTÉ Radio 1's News At One, Dr Ciara Martin, Consultant & Paediatric Executive Lead at Children's Health Ireland on the re-opening of the children's hospital in Tallaght in September 2020
The change in living conditions due to the restrictions imposed in response to the pandemic explained much of this decrease. Children remained home from school and childcare, with little or no opportunity to interact with other children, therefore common infectious or viral diseases were not circulating. Injuries also reduced due to restrictions on mobility and the cancellation of sports and other physical activities. Parental hesitancy to attend healthcare services may also have played a role in this reduction.
A survey of over 1,000 parents in June 2020 revealed that 22% of the 34% of parents who stated they needed to access healthcare for their children during the initial lockdown decided against doing so. Many parents feared contracting Covid-19 in healthcare settings and many also believed that these services were extremely busy, contrary to the actual experience at paediatric emergency departments during this time.
Some parents explained that their decision not to access needed healthcare was due to not wanting to burden what they understood to be a health service under severe strain. Some also believed that public health guidance advised against attending hospitals.
"9, 8-year-olds who shouldn't really be anxious about things like this, but come with severe anxiety and panic attacks"
Clinicians working in EDs who were interviewed described their experience of delayed presentations, with one stating "there was definitely a sense that we were seeing sicker children". They felt that some children were presenting with more progressed or critical illnesses, such as diabetes ketoacidosis, malignancies, pneumonia, and meningitis, and the treatment of these illnesses would have been less severe had they presented earlier.
As the pandemic continued into the summer months of 2020, the number of Covid cases reduced, restrictions initially eased and the number of children attending emergency departments began to slowly rise. However, children were coming in with health problems that were different from those seen in pre-Covid times.
Concerns began to be raised about the mental toll of the pandemic on children. Staff working in emergency departments over the late summer period highlighted what they were witnessing: "I think the main group that has been struggling hugely here has been kind of teens really, early teens". Cases of younger children presenting with anxiety and panic attacks were also highlighted: "9, 8-year-olds who shouldn't really be anxious about things like this but come with severe anxiety and panic attacks".
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From RTÉ Radio 1 in May 2020, Dr Carol Blackburn, Consultant in Paediatric Emergency Medicine at Children's Health Ireland at Crumlin Hospital, on increased attendance at the hospital
A closer look at the profile of attendances at the EDs at Children's Health Ireland hospitals in Dublin, which treat children aged under 16, found that attendance for mental health reasons, such as eating disorders or self-harm over the summer months, was 52% higher than the prior year. This increased attendance persisted through to the end of the year, with the number of mental health visits from September to December 46% above 2019 levels. Some children attending for mental health reasons told clinicians they were unable to access Child and Adolescent Mental Health Services (CAMHS), which clinicians felt left some children "falling through the net".
Staff at EDs expressed concern about other vulnerable groups potentially impacted by the pandemic. For example, fewer children with chronic conditions were seen during the early stages of the pandemic and some may not have received much needed timely care. One clinician felt these children were trying to "stay away with their co-morbidities".
Staff were also concerned that the closure of schools and other community services removed a safety net for children at risk of child protection issues such as neglect or abuse. "Some kids that we are getting because the school isn't picking up on certain little things that should be addressed". This highlights the importance of accessible healthcare and other support services in the community, and the role EDs play when these services cannot be accessed.
From RTÉ One's Six One News, 60% of parents say children's mental health affected by pandemic
Emergency departments had to rapidly change how they delivered care due to the pandemic. Staff began to wear PPE, which created communication challenges when interacting with children and their colleagues. More space, more staff and more resources were required, something the health system was already lacking, as one clinician put it "It just laid bare the deficiencies and inefficiencies that were already there".
While ED staff responded to the challenge and seized the opportunity to improve, clinicians described the uncertainty and anxiety they felt, particularly at the start of the pandemic. Staff also described how they could no longer socially interact, chat over coffee or lunch with colleagues, often a means to de-stress during a busy shift in pre-pandemic times.
Access to mental health services is critical for many children
Through analysing trends in attendance, gathering feedback from parents and those working on the frontline delivering emergency care to sick children, this research aids our understanding of how the pandemic is impacting our children. Presentations to emergency departments reflect the wider healthcare needs of the population, providing policymakers and healthcare service providers with timely signals.
Clear, concise and uncomplicated public health messaging is imperative to ensure that children continue to receive appropriate healthcare as the pandemic continues to impact our daily lives. In particular, access to mental health services is critical for many children, and these services must be supported to provide timely care to ensure the long-term impact of Covid-19 on children is minimised as society recovers from this extraordinary time. Furthermore, the impact on staff working in emergency departments should not be ignored, and their wellbeing must be protected as the pandemic continues.
The CUPID Covid-19 project is funded by the Health Research Board, and the research team are collaborating with Children's Health Ireland in Dublin and both Cork and Limerick University Hospitals. The authors acknowledge the participation of Dr Michael Barrett (CHI Crumlin), Dr. Conor Hensey (CHI Temple St) and Prof Fergal Cummins (University Hospital Limerick) as co-Investigators on this project.
Dr. Emma Nicholson is a Research Fellow at the School of Nursing, Midwifery and Health Systems at UCD. She is an Irish Research Council awardee. Dr. Thérèse McDonnell is a Postdoctoral Researcher at the School of Nursing, Midwifery and Health Systems at UCD. She is an Irish Research Council awardee. Prof. Eilish McAuliffe is a Professor of Health Systems at the School of Nursing, Midwifery and Health Systems at UCD. She is an Irish Research Council awardee. Ciara Conlon is a research assistant at the School of Nursing, Midwifery and Health Systems at UCD.
The views expressed here are those of the author and do not represent or reflect the views of RTÉ
