Front. Pediatr. Frontiers in Pediatrics Front. Pediatr. 2296-2360 Frontiers Media S.A. 10.3389/fped.2022.874045 Pediatrics Systematic Review Consequences of Social Distancing Measures During the COVID-19 Pandemic First Wave on the Epidemiology of Children Admitted to Pediatric Emergency Departments and Pediatric Intensive Care Units: A Systematic Review Levy Michael 1 2 Lestrade Victor 1 Said Carla 3 Jouvet Philippe 1 Kawaguchi Atsushi 1 4 * 1Department of Pediatrics, Centre Hospitalier Universitaire Sainte-Justine, Pediatric Critical Care, University of Montreal, Montréal, QC, Canada 2Pediatric Intensive Care Unit, Centre Hospitalier Universitaire Robert-Debré, Assistance Publique Hôpitaux de Paris, Université de Paris, Paris, France 3School of Medicine, University of Paris Saclay, Paris, France 4Department of Intensive Care Medicine, Pediatric Critical Care Medicine, Tokyo Women's Medical University, Tokyo, Japan

Edited by: Brenda M. Morrow, University of Cape Town, South Africa

Reviewed by: Madhusudan Samprathi, All India Institute of Medical Sciences, India; Tanil Kendirli, Ankara University, Turkey; Shu-Ling Chong, KK Women's and Children's Hospital, Singapore

 *Correspondence: Atsushi Kawaguchi atsushi@ualberta.ca

This article was submitted to Autism, a section of the journal Frontiers in Pediatrics

 03 06 2022 2022 10 874045 11 02 2022 28 04 2022 Copyright © 2022 Levy, Lestrade, Said, Jouvet and Kawaguchi. 2022 Levy, Lestrade, Said, Jouvet and Kawaguchi

This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

 Objectives

To synthesize knowledge describing the impact of social distancing measures (SDM) during the first wave of the COVID-19 pandemic on acute illness in children by focusing on the admission to pediatric emergency departments (PED) and pediatric intensive care units (PICU).

 Methods

We searched Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register, EPOC Register, MEDLINE, Evidence-Based Medicine Reviews, EMBASE, WHO database on COVID-19, Cochrane Resources on COVID-19, Oxford COVID-19 Evidence Service, Google Scholar for literature on COVID-19 including pre-print engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 in December 2020. We did not apply study design filtering. The primary outcomes of interest were the global incidence of admission to PICU and PED, disease etiologies, and elective/emergency surgeries, compared to the historical cohort in each studied region, country, or hospital.

 Results

We identified 6,660 records and eighty-seven articles met our inclusion criteria. All the studies were with before and after study design compared with the historical data, with an overall high risk of bias. The median daily PED admissions decreased to 65% in 39 included studies and a 54% reduction in PICU admission in eight studies. A significant decline was reported in acute respiratory illness and LRTI in five studies with a median decrease of 63%. We did not find a consistent trend in the incidence of poisoning, but there was an increasing trend in burns, DKA, and a downward trend in trauma and unplanned surgeries.

 Conclusions

SDMs in the first wave of the COVID-19 pandemic reduced the global incidence of pediatric acute illnesses. However, some disease groups, such as burns and DKA, showed a tendency to increase and its severity of illness at hospital presentation. Continual effort and research into the subject should be essential for us to better understand the effects of this new phenomenon of SDMs to protect the well-being of children.

 Systematic Review Registration

Clinicaltrials.gov, identifier: CRD42020221215.

 social distancing measures school closure lockdown pediatrics emergency care pediatric intensive care unit (PICU) SARS-CoV-2 pandemic (COVID-19) Introduction

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-Cov-2) and its pandemic have severely affected the healthcare system worldwide as well as our social lives. Studies have demonstrated that children with COVID-19 are responding differently from the elderly population with less severity of illness requiring less emergency and critical care resources (1–4). Preventing transmission particularly to the elderly population and slowing the rate of infections in the community to maintain the healthcare system resulted mainly in social distancing measures (SDMs) including school closures (SCs), which came from the experience of the influenza epidemic and other previous pandemics, particularly during the first wave of this pandemic (5–7). Hospitals have also taken specific measures to decrease their activity in the prevision of an increase in COVID-19 admissions and workforce shortage (8). Both SDMs and hospital measures have come with many trade-offs that have impacted acute illness of children requiring Pediatric Emergency Department (PED) or Pediatric Intensive Care Unit (PICU) admission. After the first wave, various countries and regions have reported their results and insights into the consequences of their respective SDMs. This review aims to synthesize knowledge describing the impact of the SDMs together with other various measures of the first wave of the pandemic, defined in each country by the pandemic outbreak until the specific peak and secondary decline, on acute illness requiring hospital admission in children by focusing on PED and PICU admissions as well as on the main type of acute illness or injury in children.

 Methods

In this review, we followed the methodology for data collection and analysis in the Cochrane Handbook for Systematic Reviews of Interventions (9). The study protocol was registered in the PROSPERO database (registration number: CRD42020221215).

Eligibility Criteria Participants

We included pediatric patients including neonates, infants and children/adolescents regardless of gender, countries, regions, and ethnic groups.

 Intervention

The impacts of the “pandemic” itself, and other medical and social measures such as social distancing measures (e.g., school closure or mandatory mask-wearing) and hospital-based clinical measures such as postponing planned surgery or restricting the planned surgery related to the COVID-19 pandemic first wave in 2020.

 Comparators

The historical cohort in each studied region, country, or hospital.

 Outcomes

The global incidence of admission to PED and PICU.

Incidence of PED admission of children with i) acute respiratory illness including respiratory illness, bronchiolitis and asthma, ii) viral infections, iii) injuries including trauma, burns and poisoning, iii) diabetic ketoacidosis (DKA), and iiii) unplanned surgery.

Incidence of elective/emergency surgeries like neurosurgery and cardiac surgery.

These categories of illness were chosen according to the usual epidemiology of children admitted to PED and to PICU and included diseases that had consensual definitions.

 Search Sources

Studies were identified from journal literature and conference proceedings via systematic searches of bibliographic databases including the Cochrane Library (Cochrane Database of Systematic Reviews, Cochrane Controlled Trials Register and the EPOC Register), MEDLINE, Evidence-Based Medicine Reviews (OVID) and Embase. On top of those databases, WHO database on COVID-19, Cochrane Resources on COVID-19, Oxford COVID-19 Evidence Service, Google Scholar for literature on COVID-19 including pre-print engines such as medRxiv, bioRxiv, Litcovid and SSRN for unpublished studies on COVID-19 were searched. Electronic databases were explored for all studies published articles before December 8, 2020, using the search terms addressed in Appendix 1.

 Study Selection

To be included in the review, studies needed to compare the number of admissions for the main selected diseases within two time periods: during the COVID-19 pandemic first wave period of SDM, as compared to the previous year(s), or to the period just before. Only articles in the English language were included.

Following the removal of duplicate studies, two authors (AK and ML) independently assessed the eligibility of the studies using Rayyan (https://rayyan.qcri.org/welcome). Studies were selected as being potentially relevant by screening the titles and abstracts. A third reviewer (VL) assessed all the titles and abstracts that remained in disagreement between the two investigators. We obtained the full text of the article for review when a decision cannot be made by screening the title and the abstract. The two review authors retrieved the full texts of all potentially relevant articles and independently assessed their eligibility by filling out eligibility forms designed by the specified inclusion criteria.

 Data Extraction and Quality Assessment

Data from the eligible studies were extracted by two investigators using a prespecified data extraction form to record demographic data (including age, country/region), study details (aims/study question, country of origin, methods/study designs), and study outcomes.

Study quality and risk of bias was undertaken according to the Johanna Briggs Institute appraisal tool for analytical cross-sectionals studies (10). However, we did not include the assessment results of the study quality and risk of bias for each included study because all the corresponding studies were with before and after the design of the study with historical cohorts, indicating a high risk of bias without exceptions.

 Data Syntheses and Analyses

Data regarding incidence in all the included studies were expressed in mean daily admissions during each study period (Period of social distancing measures = SDM period versus control period). The comparison was made using the percentage of change between the SDM period and the control periods. Median differences and interquartile ranges [IQR] were calculated for each outcome. For all the variables expressed in absolute numbers and percentages (i.e., hospital admission following PED attendance, very urgent triage codes (including patients that either required immediate resuscitation or had life-threatening conditions that required prompt evaluation by the emergency team) and PICU admissions), effects of the study period on these outcomes were reported using odds ratios (OR) and 95% confidence interval (CI) estimates.

 Results

We identified 6,660 records through a systematic database search (Figure 1). We removed 52 duplicates, and the titles and abstracts of the remaining 6,608 records were screened for eligibility. We identified 139 potentially eligible articles for the full-text review. After independent assessment by the two investigators, 87 articles met our inclusion criteria and presented actionable data. All the studies were included in this review and were with before and after design with historical cohorts as expected, indicating a high risk of bias without exceptions.

Study Flow Diagram.

 Countries and Regions

Of the 87 included studies (Table 1), three were international studies. Reports from 26 different countries were identified. To be specific, 15 (17%) were, respectively from the USA and Italy, 13 (15%) from the UK, 4 (5%) from Australia, 3 (3%), respectively from China, France, Ireland, and Spain, 2 (2%), respectively from Brazil, Finland, Germany, India, Japan, New-Zealand, and Turkey. The remaining studies were from Argentina, Cameroon, Canada, Indonesia, Iran, Israel, Malta, Morocco, Scotland, Slovenia, and South Africa (n = 1 in each country).

Included studies.

References Countries (level of income)* Multicenter study Number of patients included Age of cohort Settings Type of admission Method used SDM period Comparison period
Akuaake et al. (11) South Africa (MIC) No 9,982 Children <13 yrs. ED ED Before-after March 27 to April 30, 2020 February 21 to March 26, 2020
March 27 to April 30, 2019
March 27 to April 30, 2018
Angoulvant et al. (12) France (HIC) Yes 871,543 Children ED n = 6 ED Time-series analysis March 17 to April 19, 2020 February 15 to March 16, 2020
Araujo et al. (13) Brazil (MIC) Yes 8,654 Children PICU n = 15 PICU, bronchiolitis, asthma Interrupted time-series method March 1 to May 31, 2020 March 1 to May 31, 2020 March 1 to May 31, 2017-19
Bastemur E UK (HIC) No 136 Children transportation team DKA Before after March 1 to July 31, 2020 March 1 to July 31, 2015-19
Baxter et al. (14) UK (HIC) No 329 Children ED Trauma Before after March 24 to May 10, 2020 March 24, 2020, to May 10, 2019
Bram et al. (15) USA (HIC) No 1,745 Children ED + Clinic + virtual Trauma Before after March 15 to April 15, 2020 March 15 to April 15, 2018-19
Bressan et al. (16) Italy (HIC) No 3,713 Children > 1 yr. ED Trauma, Burn, Poisoning Before after March 8 to April 20, 2020 March 8 to April 20, 2019
Britton et al. (17) Australia (HIC) No NA Children ED Bronchiolitis, RSV Time-series analysis April 1 to June 30, 2020 Jan 1, 2015, to March 30, 2020
Chavasse et al. (17) UK (HIC) No NA Children 1–17 yrs. ED Asthma Before after Week 12 to 19, 2020 Week 12 to 19 2017-19
Week 8 to 11, 2020
Chelo et al. (18) Cameroon (MIC) No 33,363 Children HA ED Time-series analysis March 1 to May 31, 2020 March 1 to May 31, 2016–19
Christey et al. (19) New Zealand (HIC) No 83 Children <14 yrs. + adults ED Trauma Before after March 26 to April 8, 2020 March 5 to March 18, 2020
Ciofi degli Atti et al. (20) Italy (HIC) No 18,825 Children ED ED, Trauma Before after March 11 to April 20, 2020 January 1 to February 19, 2020
February 20 to March 10, 2020
Claudet e tal. (21) France (HIC) No 3,137 Children ED ED, Trauma Before after March 17 to April 19, 2020 March 17 to April 19, 2017-19
Clavenna et al. (22) Italy (HIC) No 7,092 Children ED ED Before after January 1 to March 31, 2020 Feb 23 to March 31, 2020 January 1 to March 31, 2019 January to Feb 23, 2020
February 24 to March 31, 2020 January 1 to Feb 23, 2020
D'asta F UK (HIC) No 10,063 Children ED ED, Burn Before after March 23 to April 30, 2020 March 23 to April 30, 2019
Dann et al. (23) Ireland (HIC) No 21,766 Children ED ED, injury and poisoning, surgical, respiratory illnesses Before after March 1 to April 30, 2020 March 1 to April 30, 2019
Davico et al. Italy (HIC) Yes 15,523 Children <14 ED n = 2 ED, seizures Before after January 6 to April 19, 2020 January 7 to April 21, 2019
(24) yrs. January 6 to February 23, 2020 January 7 to February 24, 2019
February 24 to April 19, 2020 February 25 to April 21 2019
Dean et al. (25) USA (HIC) No 210,358 Children ED ED Time series analysis December 31, 2019, to May 14, 2020 December 31, to May 14, 2015-19
Degiorgio et al. (26) Malta (HIC) No 995 Children <15 yrs. ED Medical ED, respiratory illnesses Before after March 1 to May 9, 2020 March 1 to May 9, 2019
Dhillon et al. (27) India (MIC) No 74 Children 0-12 yrs. ED Trauma Before after March 25 to May 3, 2020 March 25 to May 3, 2019
May 4 to May 31, 2020 May 4 to May 31, 2019
Dopfer et al. (28) Germany (HIC) No 5,424 Children ED ED Before after January 1 to April 19, 2020 January 1 to April 19, 2019
Dyson et al. (29) UK (HIC) No 146 Children Neurosurgery admission Neurosurgery admission Before after March 23 to May 3, 2020 March 25 to May 5, 2019
Ferrero et al. (30) Argentina (MIC) No Children 0–18 yrs. ED ED Before after January 1 to May 31, 2020 January 1 to May 31, 2019
Fisher et al. (31) USA (HIC) Yes 1,346 Children ED n=3 Appendicitis Before after March 1 to May 7, 2020 January 1, 2014, to June 1, 2019
Friedrich et al. (32) Brazil (MIC) Yes 167,870 Children 0–1 yr. ED / National database n = NA Bronchiolitis Times series analysis March 1 to June 30, 2020 March 1 to June 30, 2016-2019
Gerall et al. (33) USA (HIC) No 89 Children Surgery Appendicitis Before after March 1 to May 31, 2020 March 1, 2019, to May 31, 2019
Giamberti et al. (34) Italy (HIC) Yes Children Cardiac surgery n = 14 Cardiac surgery Before after March 9 to May 4, 2020 March 9 to May 4, 2019
Goldman et al. (35) Canada (HIC) Yes 88,368 Children 0–16 yrs. ED n = 18 ED Before after March 17 to April 30, 2020 March 17 to April 30, 2019
December 1, 2019, to January 27, 2020
January 28, 2020, to March 16, 2020
Graciano et al. (24) USA (HIC) No 1,487 Children PICU PICU, bronchiolitis, asthma Before after March 1 to May 31, 2020 March 1 to May 31, 2015-2019
Gunadi et al. (36) Indonesia (MIC) No 152 Children Surgery Pediatric surgery Before after March 1 to May 31 2020 March 1, 2019 – February 29, 2020
Hampton et al. (37) UK (HIC) No 5,165 Children + adults ED ED, trauma Before after March 24 to April 7, 2020 March 24 to April 7, 2019 March 10 to March 23, 2020
Hartnett et al. (38) USA (HIC) Yes >1,600,000 Children 0–14 yrs. + adults ED n = 3552 ED Before after March 29 to April 25, 2020 March 31 to April 27, 2019
Hughes et al. (39) UK (HIC) Yes 8,915 Children 0-14 yrs. + adults ED n = 109 ED Before after March 12 to April 26, 2020 March 14 to April 28, 2019
Iozzi et al. (40) Italy (HIC) No 2,956 Children ED ED, trauma Before after March 10 to May 3, 2020 March 10 to May 3, 2019
Izba et al. (24) UK/USA (HIC) Yes NA Children 0–16 yrs. ED n = 2 ED Before after January 1 to May 20, 2020 January 1 to May, 2019
Weeks 1–12, 2020 Weeks 1–12, 2019
Weeks 13–20, 2020 Weeks 13–20, 2019
Kamrath et al. (31) Germany (HIC) Yes 1,491 Children ED n = 217 DKA Before after March 13 to May 13, 2020 March 13 to May 13, 2018–19
Rose et al. (41) UK (HIC) No 4,690 Children 0–16 yrs. ED ED, head trauma Before after March 21 to April 26, 2020 March 21 to April 26, 2019
Kishimoto et al. (14) Japan (HIC) Yes 75,053 Children 0-15 yrs. HA n = 210 Appendicitis, influenza Interrupted time series analysis March 1 to June 30, 2020 July 1, 2018, to February 29, 2020
Korun et al. (42) Turkey (MIC) No 696 Children Cardiac surgery Cardiac surgery Before after March 11 to May 11, 2020 March 11, 2019, to March 10, 2020
Krivec et al. (43) Slovenia (HIC) No 27 Children HA Asthma Before after March 16 to April 20, 2020 March 16 to April 20, 2017–19
Kruchevsky et al. (44) Israel (HIC) No 8,291 Children + adults ED ED, Burn, Trauma Before after March 14 to April 20, 2020 March 14 to April 20, 2017–19
Kuitunen et al. (24) Finland (HIC) Yes 1,174 Children ED n=2 ED Before after March 16 to April 12, 2020 February 17 to March 15, 2020
Kvasnovsky et al. (45) USA (HIC) No 205 Children Surgery Appendicitis Before after March 31 to May 3, 2020 March 31 to May 3, 2017–2019
Lalarukh et al. (46) UK (HIC) No NA Children <18 yrs. ED ED Before after March 1 to May 31, 2020 March 1 to May 31, 2019
Lawrence et al. (47) Australia (HIC) No 43 Children <18 yrs. ED ED, DKA Before after March 1 to May 31, 2020 March 1 to May 31, 2015-19
Lee et al. (48) USA/Singapore/Australia/France (HIC) Yes NA Children ED n = 5 ED, PICU Time series analysis December 1, 2017, to August 10, 2020
Lee-Archer et al. (49) Australia (HIC) No 105 Children Surgery Appendicitis Before after March 16 to May 5, 2020 March 16 to May 5, 2019
Lv et al. (24) China (MIC) Yes 194 Children + adults ED n = 11 Fractures Before after January 20, to February 19, 2020 January 31 to March 2, 2019
Mann et al. (50) UK (HIC) No 147 Children ED Burns Before after March 23 to May 31, 2020 March 23 to May 31, 2019
Manzoni et al. (48) Italy (HIC) Yes 1,654 Children ED n = 2 ED, Trauma, Urgent surgery Before after March 1 to April 30, 2020 March 1 to April 30, 2019
Matthay et al. (51) USA (HIC) No 20,129 C+A Children <15 yrs. + adults ED Trauma Interrupted time-series analysis March 17 to June 30, 2020 January 1, 2015, to March 17, 2020
McDonnell et al. (52) Ireland (HIC) Yes 61,317 Children ED n = 5 ED Before after February 29 to March 12, 2020 February 29 to March 12, 2018–19
March 13 to March 27, 2020 March 13 to March 27, 2018–19
March 28 to May 17, 2020 March 28 to May 17, 2018–19
Mekaoui et al. (53) Morocco (MIC) No 5,342 Children <16 yrs. ED ED Before after March 16 to April 15, 2020 March 16 to April 15, 2019
Memeo et al. (54) Italy (HIC) Yes 1,380 Children 0-17 yrs. Trauma ED n = 2 Trauma Before after February 23 to April 15, 2020 February 23 to April 15, 2019
Molina Gutiérrez et al. (55) Spain (HIC) No 6,493 Children <18 yrs. ED ED, trauma, poisoning Before after March 14 to April 17, 2020 March 14 to April 17, 2019
Montalva et al. (49) France (HIC) No 108 Children Surgery Appendicitis Before after January 20 to March 16, 2020 March 17 to May 11, 2020
Nabian et al. (56) Iran (MIC) No 877 Children <18 yrs. Trauma ED Trauma Before after March 1 to April 15, 2020 March 1 to April 15, 2018-19
Nelson et al. (57) USA (HIC) No 94 Children Surgery Testicular torsion Before after March 1 to May 31, 2020 January 1, 2018, to February 29, 2020
Nolen et al. (58) USA (HIC) No NA Children <3 yrs. ED RSV, ARI Time series analysis January 1 to May 31, 2020 January 1 to May 31, 2009-19
Nourazari et al. (59) USA (HIC) Yes 501,369 Children + adults ED n = 12 ED Before after January 1 to August 9, 2020 January 1 to September 9, 2019
Okonkwo et al. (60) UK (HIC) No 3,826 Children Surgery emergency surgery Before after March 23 to May 25, 2020 March 23 to May 25, 2019
Palladino et al. (61) Italy (HIC) No 57 Children 4–14 years ED ED, seizures Before after March 9 to May 4, 2020 March 9 to May 4, 2019
Park et al. (62) UK (HIC) No 39 Children + adults ED Trauma Before after March 17 to April 15, 2020 March 17 to April 15, 2019
Peiro-Garcia et al. (63) Spain (HIC) No NA Children Orthopedic surgery Orthopedic surgery & Trauma Before after March 14 to April 14, 2020 March 14 to April 14, 2018–19
Pines et al. (64) USA (HIC) Yes 383,033 Children + adults ED n = 144 ED, asthma, influenzae, viral infection, DKA, Appendicitis, Intussepstion, testicular torsion Before after March 13 to June 30, 2020 March 13 to June 30, 2019
Place (65) USA (HIC) No 160 Children <18 yrs. ED Appendicitis Before after March 16 to June 7, 2020 March 16 to June 7, 2019
Qasim et al. (66) USA (HIC) Yes 336 Children + adults ED n = 2 Trauma Before after March 9 to April 19, 2020 March 9 to April 19, 2019
Raitio et al. (67) Finland (HIC) Yes 1,755 Children Surgery n = 5 Trauma Before after March 1 to May 31, 2020 March 1 to May 31, 2017–19
Raman et al. (68) India (MIC) No 1,070 Children ED ED, PICU Before after April 1 to July 31, 2020 April 1 to July 31, 2019
Pediatric Surgery Trainee Research Network UK (HIC) Yes 87 Children Surgery n = 10 Pyloric stenosis Before after March 23 to May 31, 2020 March 23 to May 31, 2019
Scaramuzza A Italy (HIC) Yes 3,912 Children <15 yrs. ED n = 2 ED Before after February 20 to March 30, 2020 February 20 to March 30, 2019
Bun et al. (43) Japan (HIC) Yes 10,481 Children <15 yrs. ED n = 67 Asthma Interrupted time-series analysis July 1, 2019, to June 30, 2020 July 1, 2018, to June 30, 2019
Sheridan et al. (69) Ireland (HIC) No 423 Children ED Trauma Before after March 13 to April 13, 2020 March 13 to April 13, 2009–19
Sherman et al. (70) USA (HIC) No 224 Children + adults ED Trauma Before after March 20 to May 14, 2020 March 20 to May 14, 2017–19
Shi et al. (42) China (MIC) Yes 4,877 Children Cardiac surgery n = 13 Cardiac surgery Before after January 23 to April 8, 2020 January 23 to April 8, 2018–19
Smarrazzo A Italy (HIC) No Children ED ED Before after March 1 to May 31, 2020 March 1 to May 31, 2019
Sperotto et al. (71) Italy (HIC) Yes 1,001 Children PICU n = 4 PICU, Seizures, Surgical, Trauma, Respiratory lower tract Before after February 24 to April 20, 2020 December 30, 2019, to February 24, 2020
February 24 to April 20, 2019
Williams et al. (72) Scotland (HIC) Yes ED 462,437 Children 0–14 yrs. ED n=NA, PICU n = 2 ED, PICU, Surgical ED, Bronchiolitis, Asthma, Seizures Before after March 23 to August 9, 2020 March 23 to August 9, 2016–19
PICU 413 February 2 to August 9, 2020 February 2 to August 9, 2016–19
March 23 to June 30, 2020 March 23 to June 30, 2016–19
Trenholme et al. (17) New Zealand (HIC) No 5,248 Children <2 yrs. Hospital LRTI, RSV, Influenza A, B, Rhinovirus/enterovirus, adenovirus Interrupted time-series analysis March 1 to August 31, 2020 March 1 to August 31, 2015–019
Turgut et al. (73) Turkey (MIC) No 2,216 Children <16 yrs. Hospital Orthopedic surgery & Trauma Before-after March 16 to May 22, 2020 March 16 to May 22, 2018 & 2019
Valitutti et al. (74) Italy (HIC) Yes 38,501 Children ED n = 2 ED, trauma, burn, seizure Before-after March 1 to May 31, 2020 March 1 to May 31, 2019
Vásquez-Hoyos (58) Colombia, Bolivia, Chile, Uruguay (MIC) Yes 3,041 Children <18 yrs. PICU PICU, LRTI, bronchiolitis, RSV, influenza Before-after January 1 to August 31, 2020 January 1 to August 31, 2018-19
Velayos et al. (75) Spain (HIC) No 66 Children <18 yrs. Surgery Appendicitis Before-after January 1 to March 14, 2020 March 15 to April 30, 2020
Vierucci et al. (76) Italy (HIC) No 1,418 Children ED ED, LRTI, Trauma, Febrile Seizure, Appendicitis Before-after March 9 to May 31, 2020 January 1 to March 8, 2020
March 1 to May 31, 2020 January 1 to February 29, 2019
Wei et al. (3) China (MIC) No 4,527 Children Surgery Urgent surgery Before after January 23 to May 21, 2020 January 23 to May 21, 2019
Wong et al. (67) Australia (HIC) No 621 Children Orthopedics ED Trauma Before after March 16 to April 26, 2020 March 18 to April 28, 2019
Zampieri et al. (77) Italy (HIC) No 95 Children Surgery Appendicitis Before-after March 1 to April 30, 2020 March 1 to April 30, 2011-19

*LIC, low-income country; MIC, middle-income country; HIC, High-income country.

 Study Settings and Data Sources

Among all the included studies, 59 were studies performed in PEDs, five in PICUs, 17 used institutional surgical databases (including three studies on congenital heart disease and one on neurosurgery), and three used a hospital-based administrative database.

 Impact on Pediatric Emergency and Intensive Care Unit Admission Admissions to Pediatric Emergency Department

We included 39 studies from 19 countries including 15 multicenter studies (11, 12, 16, 18, 20–26, 28, 30, 35, 37–41, 44, 46–48, 52, 53, 55, 59, 61, 64, 65, 68, 72, 74, 76, 78–82) (Supplementary Table 1). All the included studies found a decrease in daily PED admissions during the SDM period with a median reduction of 65% [IQR: 52–72%] compared to historical cohorts. When focusing on studies including the largest number of patients (i.e., more than 200 mean daily admissions in the control period) (12, 20, 24, 35, 64, 65, 74), the reduction in PED attendance ranged from 38 to 77%.

Of these studies, 15 presented data on hospital admission following PED attendance (22, 23, 28, 35, 41, 52, 53, 55, 65, 68, 72, 74, 76, 79, 80) (Supplementary Table 2). Overall, during the SDM period, we observed a significant increase in the proportion of patients admitted to the hospital after PED visits with median ORs ranging from 1.12 to 3.51 (n = 13/15).

Ten studies looked at the proportions of very-urgent triage code on the presentation at PEDs (11, 22, 23, 25, 35, 41, 53, 59, 72, 74) but results were not consistent (Supplementary Table 3). In particular, compared with the same period in previous years, four studies found a significant increase in the proportion of very-urgent triage code (35, 41, 59, 74) whereas others found no difference (11, 22, 23, 53, 72) or even a decrease (25). However, when comparing to the period just before the SDM period, three studies found a significant increase in these urgent PED admissions (11, 22, 35).

 Pediatric Intensive Care Unit Admissions

We included eight studies with data regarding PICU admission (13, 26, 48, 58, 71, 81–83) with two international studies and six studies, respectively from Brazil, India, Italy, Malta, Scotland, and the USA including data from a total of 51 PICUs. All the studies found a reduction in daily PICU attendances with a median reduction of 54% [IQR: 48–65%] compared with controlled periods (Table 2). Two large multicenter studies from South America including 15 and 22 PICUs found, respectively a decrease of 53% of all the PICU admissions (13) and 83% of respiratory PICU admissions (58). Only one out of all the 51 study sites included in these studies from France found an increase of 2% in the mean number of daily admissions (48). Of note, one study from India found an overall decrease of PICU admissions of 26% in the SDM period but a significantly higher proportion of patients admitted to PICU after PED attendance (20%) compared with the control period (9, 6%) (OR: 2.35, 95%CI: 1.61–3.42) (81).

PICU Admissions.

Study Study periods Comparison (absolute reduction or OR (IQR)
SDM period Control period Mean daily admission
References Country & region Setting Period Number of patients Age of cohort Period Number of patients Age of cohort SDM period Control period
Araujo et al. (13) Brazil PICU n = 15 March 1 to May 31, 2020 1181 4.3 (+/-6.9) March 1 to May 31, 2017–2019 7,473 NA 12.98 27.37 −53%
March 1 to May 31, 2019 2,564 2.5 (+/-3.7) 2019 28.18 −54%
March 1 to May 31, 2018 2,599 2.6 (+/-6.7) 2018 28.56 −55%
March 1 to May 31, 2017 2,310 2.8 (+/-3.8) 2017 25.38 −49%
Degiorgio Malta PICU n = 1 March 1 to May 9, 2020 3 NA March 1–May 9, 2019 8 NA 0.04 0.12 −63%
Graciano AL USA PICU n = 1 March 1 to 31 May, 2020 101 NA March 1 to 31 May, 2019 195 NA 1.11 2.14 −48%
March 1 to 31 May, 2018 275 3.02 −63%
March 1 to 31 May, 2017 309 3.40 −67%
March 1 to 31 May, 2016 299 3.29 −66%
March 1 to 31 May, 2015 308 3.38 −67%
Lee L USA/Singapore/Australia/France ED n = 5 Singapore, May 4, 2020 NA NA Singapore, March 15, 2020 NA NA NA NA −38 %
Paris, May 4, 2020 Paris, March 15, 2020 NA NA NA +2%
Boston, May 4, 2020 Boston, March 15, 2020 NA NA NA −12 %
Seattle, May 4, 2020 Seattle, March 15, 2020 NA NA NA −36 %
Melbourne, May 4, 2020 Melbourne, March 15, 2020 NA NA NA −34 %
Raman et al. (68) India ED n = 1 April 1 to July 31, 2020 280 NA April 1 to July 31, 2019 790 NA 0.46 0.63 −26%
56/280 (20%) 76/790 (9.6%) 2.35 (1.61, 3.42), p <0.001
Sperotto et al. (71) Italy PICU n = 4 February 24 to April 20, 2020 166 NA December 30, 2019, to February 24, 2020 277 NA 2.96 4.95 −40%
February 24 to April 20, 2019 259 4.71 −36%
Williams e tal. (72) Scotland PICU n = 2 March 23 to June 30, 2020 413 total NA March 23 to June 30, 2016-2019 413 total NA 413 total NA 0.52 (0.37–0.70), p <0.001
Vásquez-Hoyos P Colombia, Bolivia, Chile, Uruguay PICU 22 January 1 to August 31, 2020 234 NA January 1 to August 31, 2018–2019 2,807 NA 0.96 5.80 −83%

OR, Odds Ratio.

 Impacts on Each Etiology of Illness Respiratory Illness Acute Respiratory Illness

Seven studies presented data regarding acute respiratory illnesses including 5 focusing on lower respiratory tract infections (LRTI) (17, 23, 26, 58, 76, 83, 84) reported from Malta, Ireland, Italy, New Zealand and four South American countries (Colombia, Bolivia, Chile, and Uruguay) (Supplementary Table 4). There was a significant decline reported in acute respiratory illness and LRTI in the five studies, all of which examined data in the PED (17, 23, 26, 76, 84) during the SDM period compared with the control periods (median decrease of 63% [50–80%]). A study from the US found that the proportion of admissions related to respiratory illness was 3.6% of all the PED admissions during the SDM period compared with 22.8% during the same period during the 10 previous years (p < 0.001) (84). The two studies performed in PICU also found a marked reduction in PICU admissions due to LRTI during the SDM period (52 and 83%) (58, 83).

 Bronchiolitis

Seven studies presented data regarding acute bronchiolitis admissions (13, 23, 32, 58, 71, 82, 85) from Brazil, Australia, Ireland, USA, Scotland and four South American countries (Colombia, Bolivia, Chile, and Uruguay) (Supplementary Table 5). Three studies were performed in PEDs and found a significant reduction in hospital admissions during the SDM period ranging from 34 to 85% (23, 32, 85). The other studies looked at the data in PICU and found a similar significant reduction in children requiring critical care admission for acute bronchiolitis with a median decrease of 73% [69–78%] (13, 58, 71, 82).

 Asthma

Seven studies presented data regarding pediatric asthma admissions (13, 43, 65, 71, 86, 87) in Brazil, the USA, the UK, Slovenia, Japan, and Scotland. Four studies performed in PED found a decrease in admissions due to asthma from 32 to 90% (43, 65, 86, 87) and two studies performed in PICUs found similar findings with a decrease of 58 to 100% (13, 82) (Supplementary Table 6).

 Viral Infections

Seven studies (14, 17, 23, 32, 58, 65, 84) showed data regarding viral infections in Australia, Ireland, Japan, USA, New Zealand, and four South American countries (Colombia, Bolivia, Chile, and Uruguay) (Supplementary Table 7), found a significant decrease in the number of admissions due to viral infection (23, 65).

Four studies (17, 32, 58, 84) included data on RSV infections requiring PED or PICU admission during the SDM period, all of which presented a significant reduction in the incidence of presentation with RSV infections in PED (17, 32, 84) as well as in PICU (58). Similarly, PED and PICU presentations for Influenza infection reduced dramatically during the SDM period in three studies (17, 58, 65) and more mildly in a Japanese study (14). On the contrary, a study performed in New Zealand found that hospitalizations for Adenovirus or Rhinovirus/Enterovirus infections during the SDM period stayed at a similar level to the previous years (17).

 Injuries (Trauma, Burns and Poisoning) Trauma

We included 32 studies with data regarding trauma admissions to PED (n = 29) (15, 16, 19–21, 23, 27, 29, 37, 40, 41, 44, 51, 52, 54, 56, 59, 62, 63, 65–67, 69, 70, 73, 74, 76, 88, 89), PICU (n = 2) (82, 83), and a study specifically looking at neurosurgery for head trauma in children (n = 1) (50) (Supplementary Table 8). Of the studies in the PED, 93% of the studies (27/29) found a significant decline in admissions linked to trauma with SDMs (median reduction of 48% [35–63%]). On the contrary, 7% (2/29) reported an increase in trauma admission (16, 40, 50).

The two studies including data from patients admitted to PICU found a decrease of trauma admissions from 17 to 61% (82, 83) during the SDM period.

 Burns

We included five studies with data regarding burns (16, 44, 74, 78, 90) respectively from the UK, Italy, and Israel (Supplementary Table 9). Four studies (44, 74, 78, 90) reported a decrease in the number of burns presenting to the PED (from 22 to 66%); while one found a slight increase in the number of burns (16) during the SDM period. However, the severity of burns at the time of hospital presentation was higher for the SDM cohorts compared to the historical (44, 78, 90). A study from the UK (78) reported that more patients presented with burns with greater total body surface area (TBSA); 50% of the patients with >5% TBSA burns in the COVID-19 pandemic compared with 5% in the control period. The study in Israel reported that the majority of burns were scalded during the SDM period; while, during previous years, causes of burns were more diverse, including scald, contact, fire, sun, and chemical injuries (44).

 Poisoning

We included three studies with data regarding poisoning (16, 23, 59) respectively from Italy, Ireland, and Spain (Supplementary Table 10). Two of them (16, 23) did not find a significant change in the number of PED presentations for poisoning; while one found a 76% decrease in the number of hospital admissions (59). One study differentiated accidental from deliberate poisoning (23) with no differences found in both series. An Italian study found an increased incidence ratio for hospitalization in intoxicated children during the SDM period (9.0 (0.5 to 167.2), p = 0.14).

 Diabetic Ketoacidosis

We found 4 studies with data regarding diabetic ketoacidosis (DKA) (31, 47, 65, 91) each from the UK, Germany, Australia, and the USA (Supplementary Table 11). Three of them found an overall increase in the referral of DKA to ED compared with previous years (93 to 264% increase). These studies also found an increase in admission of severe DKA; and the initial pH, bicarbonate and glucose levels at hospital presentations were significantly worse in the SDM group compared to the historical cohort (31, 47).

 Surgery Unplanned Surgery

A total of 20 studies met the inclusion criteria looking at unplanned surgeries, in Australia, China, France, Indonesia, Ireland, Italy, Japan, Scotland, the UK, and the USA (14, 23, 33, 36, 45, 49, 52, 57, 60, 65, 66, 68, 75–77, 82, 83, 92–95) (Supplementary Table 12). These examined data on PED/PICU admissions for acute surgical conditions, appendicitis, intussusception, testicular torsion, and pyloric stenosis as well as data on emergency surgeries performed.

Regarding studies including data on acute surgical disease, two studies found a decrease in the number of admission for acute surgical disease to PED and PICU from 9 to 40% although non-significant in the PICU (23, 83). Regarding the number of emergency surgeries performed for acute conditions, most studies found a decrease from 25 to 70% in the SDM period (77, 92, 93).

Four studies found an increase in the number of admissions with acute appendicitis during the SDM period ranging from 18 to 64% (33, 36, 45, 68). Two studies also addressed the significant increase in the proportion of perforated appendicitis (33, 68). On the contrary, three studies found a decrease in the number of admissions for appendicitis from 16 to 71% (49, 65, 76).

In addition, two studies found an increase in the number of testicular torsions (60, 65), one study found an increase in the number of pyloric stenosis (94) and one study found a decrease in the number of intussusception (65) during the SDM period compared with control periods.

 Neurosurgery and Cardiac Surgery

Three studies reported the data of incidence of cardiac surgery for congenital heart disease during the SDM period in China, Italy, and Turkey (34, 42, 96). All three found a decrease in mean daily cases of cardiac surgery performed during the SDM period with a reduction of 52 to 88%.

Regarding studies on pediatric neurosurgery, only one study was included (50). The study reported an increase in the number of hospital admission in a pediatric neurosurgical unit during the SDM period by 14.7%.

 Discussions

Since the beginning of the COVID-19 pandemic, especially during the first wave, several modes of SDMs have been issued in most countries and regions, including school closures and restrictions on children's social activities (97). The COVID-19 pandemic was the first global pandemic in modern society with such a great impact on contemporary medical infrastructures. Therefore, facing the threat to healthcare systems capacities, SDMs were widely imposed worldwide as emergency measures and their consequences on other diseases than COVID-19 had never been described. Since then, the effects of SDM on the epidemiological dynamics of patients have been examined in various countries and regions. This systematic review summarized these studies and integrated the knowledge on the effect of SDM on acute illness in children to prepare for potential future pandemic threats during which the question of implementing SDM might arise again.

We found that SDMs in both developed and developing countries brought down the incidence of PED visits while the severity of illness at the time of the visit increased. Regarding the number of PED visits, this phenomenon might have occurred due to the decrease of morbidity or due to the avoidance of hospital visits associated with the current pandemic. The increased severity of patients might have resulted from the fact that parents tended to wait to present to the PED when their children got sick instead of immediate visits. Public communication and outreach are warranted to encourage parents/guardians to seek appropriate medical attention for emergencies of their children (28).

Likewise, a decrease in PICU admissions was also observed in almost all the reports. These results suggested that the reduction of the incidence of seasonal viral infections, and the resulting decline in the number of patients with respiratory diseases, one of the most common causes of admission to PICU, were the possible major factors behind. There was nearly a 50% decrease in general in the number of PICU admissions, and this can be important preliminary information for securing hospital beds in the event of a future pandemic or disaster, for instance, as a consequence of SDMs. These results have been confirmed by other studies published more recently (98–100).

In this study, we also compiled information on poisoning, trauma, and burns. Despite the isolation of children at home and its associated consequences both on mental health and on the access to potential accidental poisons, none of the included studies found a significant increase in accidental or deliberate poisoning. However, with the repetition of SDMs and the duration of the pandemic, the mental health of children and teenagers was strongly impacted and many studies were published since then reporting an increased incidence of mental health disorder during the COVID-19 pandemic (101, 102) but this does not seem to result in intentional poisoning increase (103).

As for burns, the number of cases decreased, but the severity at the time of consultation increased. It was encouraging that pandemic with SDMs did not translate into an increase of pediatric burn; however, parents might have chosen to seek advice from other services such as local pharmacies to avoid visits to the PED, which might explain the severity of burn at a hospital visit. The causes were more likely to be scald which might be explained by the increase in time spent at home. As for traumatic injuries, there was a general downward trend, and we believe that this was largely due to the eviction from school and the drop-in outdoor activities of kids.

DKA tended to increase, as well as the severity of the disease at the time of the hospital visit. We could assume that anxiety about presenting to the hospital led to a delay in diagnosis or receiving treatment before getting a critical condition. There has also been speculation that COVID-19 infection itself could trigger the development of DKA via direct damage to pancreatic beta cells, which might increase its actual incidence (104).

Lastly, regarding surgeries, the incidence of acute appendicitis requiring surgical intervention also increased during the SDM period, and the rate of perforated cases was reported to have risen. This might also be a result of the fact that the patients refrained from seeking medical attention until the last minute of the condition. On the contrary, the number of planned surgeries decreased significantly due to the organizational changes in the SDMs. Since a large proportion of pediatric surgical conditions, including congenital heart disease, cannot be performed on a standby basis, this might have had a significant impact on subsequent patient outcomes.

This study had limitations. First, different policies and timings of implementation must have been taken by the countries or regions in SDMs (105) although the measures were overall more strict (including national lockdowns) and similar during the first wave than during subsequent ones. For example, during the first wave, regulations and their compelling force differed from province to province and country to country. For example, in Canada, regulations for wearing masks in schools and indoors were established relatively quickly, but outdoor measures were delayed in some provinces. In some countries, such as Japan, there were no governmental regulations with strong compelling force issued as Canada, but only regulations based on a request basis to the public. Second, the magnitude of the wave of the pandemic varied from country to country, and the size of the effect of SDM itself may have been affected by this. Furthermore, since the seasons are different in the northern and southern hemispheres during the first wave, the impact of SDM on infection, respiratory diseases, and social activities may have been different in each country. Lastly, the historical cohorts to be compared in each study could be heterogeneous, and we believe that we should be cautious in evaluating them.

In conclusion, this review found that acute pediatric hospital care was significantly affected by the first wave of the COVID-19 pandemic and related SDMs in a wide range of ways. Overall admissions to PED and PICU significantly decreased. Some diseases, such as infectious diseases, decreased, while others increased in incidence and severity such as DKA. The continual effort and research in the field should be essential for us to better comprehend the effects of this new phenomenon of SDMs, to aim at minimizing possible collateral damage caused by such delays in emergency healthcare utilization, which eventually leads to protecting the well-being of children. These lessons we learned here should count for options for structuring SDMs if needed in response to future local outbreaks or pandemics in our modern society, especially given the potential harm of SDM on children's well-being (106).

 Data Availability Statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author/s.

 Author Contributions

AK and ML conceptualized, designed the review and carried out a systematic review and subsequent analysis, drafted the initial manuscript (method and result part), revised the initial manuscript, and approved the final manuscript as submitted. AK also constructed a search formula and searched. VL assessed all the titles and abstracts that remained in disagreement between the two investigators AK and ML. CS performed the statistical analyses. VL, CS, and PJ reviewed and revised the manuscript, and approved the final version as submitted. All authors contributed to the article and approved the submitted version.

 Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Publisher's Note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fped.2022.874045/full#supplementary-material

 References Ouldali N Yang DD Madhi F Levy M Gaschignard J Craiu I . Factors associated with severe SARS-CoV-2 infection. Pediatrics. (2021) 147:e2020023432. 10.1542/peds.2020-02343233323493 Liu W Zhang Q Chen J Xiang R Song H Shu S . Detection of Covid-19 in children in early January 2020 in Wuhan, China. N Engl J Med. (2020) 382:1370–1. 10.1056/NEJMc200371732163697 Wei M Yuan J Liu Y Fu T Yu X Zhang ZJ. Novel Coronavirus infection in hospitalized infants under 1 year of age in China. JAMA. (2020) 323:1313–4. 10.1001/jama.2020.213132058570 Xia W Shao J Guo Y Peng X Li Z Hu D. Clinical and CT features in pediatric patients with COVID-19 infection: different points from adults. Pediatr Pulmonol. (2020) 55:1169–74. 10.1002/ppul.2471832134205 Litvinova M Liu QH Kulikov ES Ajelli M. Reactive school closure weakens the network of social interactions and reduces the spread of influenza. Proc Natl Acad Sci USA. (2019) 116:13174–81. 10.1073/pnas.182129811631209042 Ryu S Ali ST Cowling BJ Lau EHY. Effects of School Holidays on Seasonal Influenza in South Korea, 2014–2016. J Infect Dis. (2020) 222:832–5. 10.1093/infdis/jiaa17932277239 Jackson C Mangtani P Hawker J Olowokure B Vynnycky E. The effects of school closures on influenza outbreaks and pandemics: systematic review of simulation studies. PLoS ONE. (2014) 9:e97297. 10.1371/journal.pone.009729724830407 Ehrlich H McKenney M Elkbuli A. Strategic planning and recommendations for healthcare workers during the COVID-19 pandemic. Am J Emerg Med. (2020) 38:1446–7. 10.1016/j.ajem.2020.03.05732273142 Higgins JPT Thomas J Chandler J Cumpston M Li T Page MJ Welch VA. Cochrane Handbook for Systematic Reviews of Interventions version 6.1 (updated September 2020). Cochrane, 2020. Available online at: www.training.cochrane.org/handbook (accessed February 3, 2021). Munn Z Barker TH Moola S Tufanaru C Stern C McArthur A . Methodological quality of case series studies: an introduction to the JBI critical appraisal tool. JBI Evid Synth. (2020) 18:2127–33. 10.11124/JBISRIR-D-19-0009933038125 Akuaake LM Hendrikse C Spittal G Evans K Van Hoving DJ. Cross-sectional study of paediatric case mix presenting to an emergency centre in Cape Town, South Africa, during COVID-19. BMJ Paediatrics Open. (2020) 4:e000801. 10.1136/bmjpo-2020-00080134192174 Angoulvant F Ouldali N Yang DD Filser M Gajdos V Rybak A . COVID-19 pandemic: impact caused by school closure and national lockdown on pediatric visits and admissions for viral and non-viral infections, a time series analysis. Clin Infect Dis. (2021) 72:319–22. 10.1093/cid/ciaa71033501967 Araujo OR Almeida CG Lima-Setta F Prata-Barbosa A Colleti Junior J. The impact of the novel coronavirus on Brazilian PICUs. Pediatr Crit Care Med. (2020) 21:1059–63. 10.1097/PCC.000000000000258332925566 Kishimoto K Bun S Shin J Takada D Morishita T Kunisawa S . Early impact of school closure and social distancing for COVID-19 on the number of inpatients with childhood non-COVID-19 acute infections in Japan. Eur J Pediatr. (2021) 180:2871–8. 10.1007/s00431-021-04043-w33791861 Baxter I Hancock G Clark M Hampton M Fishlock A Widnall J . Paediatric orthopaedics in lockdown: a study on the effect of the SARS-Cov-2 pandemic on acute paediatric orthopaedics and trauma. Bone Jt Open. (2020) 1:424–30. 10.1302/2633-1462.17.BJO-2020-0086.R133215134 Bressan S Gallo E Tirelli F Gregori D Da Dalt L. Lockdown: more domestic accidents than COVID-19 in children. Arch Dis Child. (2021) 106:e3. 10.1136/archdischild-2020-31954732487724 Trenholme A Webb R Lawrence S Arrol S Taylor S Ameratunga S . COVID-19 and infant hospitalizations for seasonal respiratory virus infections, New Zealand, 2020. Emerg Infect Dis. (2021) 27:641–3. 10.3201/eid2702.20404133263515 Chelo D Mekone Nkwelle I Nguefack F Mbassi Awa HD Enyama D Nguefack S . Decrease in hospitalizations and increase in deaths during the Covid-19 epidemic in a pediatric hospital, Yaounde-Cameroon and prediction for the coming months. Fetal Pediatr Pathol. (2021) 40:18–31. 10.1080/15513815.2020.183166433078968 Bram JT Johnson MA Magee LC Mehta NN Fazal FZ Baldwin KD . Where have all the fractures gone? The epidemiology of pediatric fractures during the COVID-19 pandemic. J Pediatr Orthop. (2020) 40:373–9. 10.1097/BPO.000000000000160032433260 Ciofi Degli Atti ML Campana A Muda AO Concato C Rav L Ricotta L . Facing SARS-CoV-2 pandemic at a COVID-19 regional children's hospital in Italy. Pediatr Infect Dis J. (2020) 39:e221–5. 10.1097/INF.000000000000281132639459 Claudet I. March, -Tonel C, Ricco L, HouzRicco L, C-H, Lang T, Br-H, C. During the COVID-19 quarantine, home has been more harmful than the virus for children! Pediatr Emerg Care. (2020) 36:e538–40. 10.1097/PEC.000000000000220532868552 Clavenna A Nardelli S Sala D Fontana M Biondi A Bonati M. Impact of COVID-19 on the pattern of access to a pediatric emergency department in the Lombardy region, Italy. Pediatr Emerg Care. (2020) 36:e597–8. 10.1097/PEC.000000000000223232826641 Dann L Fitzsimons J Gorman KM Hourihane J Okafor I. Disappearing act: COVID-19 and pediatric emergency department attendances. Arch Dis Child. (2020) 105:810–1. 10.1136/archdischild-2020-31965432518141 Davico C Marcotulli D Lux C Calderoni D Terrinoni A Di Santo F . Where have the children with epilepsy gone? An observational study of seizure-related accesses to emergency department at the time of COVID-19. Seizure. (2020) 83:38–40. 10.1016/j.seizure.2020.09.02533080483 Dean P Zhang Y Frey M Shah A Edmunds K Boyd S . The impact of public health interventions on critical illness in the pediatric emergency department during the SARS-CoV-2 pandemic. J Am Coll Emerg Physicians Open. (2020) 1:1542–51. 10.1002/emp2.1222032838393 Degiorgio S Grech S Dimech Y Xuereb J Grech V. COVID-19 related acute decline in paediatric admissions in Malta, a population-based study. Early Hum Dev. (2020) 12:105251. 10.1016/j.earlhumdev.2020.10525133293107 Christey G Amey J Campbell A Smith A. Variation in volumes and characteristics of trauma patients admitted to a level one trauma centre during national level 4 lockdown for COVID-19 in New Zealand. N Z Med J. (2020) 133:81–8.32325471 Dopfer C Wetzke M Zychlinsky Scharff A Mueller F Dressler F Baumann U . COVID-19 related reduction in pediatric emergency healthcare utilization - a concerning trend. BMC Pediatr. (2020) 20:427. 10.1186/s12887-020-02303-632894080 Wong FL Antoniou G Williams N Cundy PJ. Disruption of paediatric orthopaedic hospital services due to the COVID-19 pandemic in a region with minimal COVID-19 illness. J Child Orthop. (2020) 14:245–51. 10.1302/1863-2548.14.20014032874355 Ferrero F Ossorio MF Torres FA Debaisi G. Impact of the COVID-19 pandemic in the paediatric emergency department attendances in Argentina. Arch Dis Child. (2021) 106:e5. 10.1136/archdischild-2020-31983332554509 Kamrath C MC Mth CK Biester T Rohrer TR Warncke K . Ketoacidosis in children and adolescents with newly diagnosed type 1 diabetes during the COVID-19 pandemic in Germany. JAMA. (2020) 324:801n Ge10.1001/jama.2020.1344532702751 Britton PN Hu N Saravanos G Shrapnel J Davis J Snelling T . COVID-19 public health measures and respiratory syncytial virus. Lancet Child Adolesc Health. (2020) 4:e42–3. 10.1016/S2352-4642(20)30307-234347190 Fisher JC Tomita SS Ginsburg HB Gordon A Walker D Kuenzler KA. Increase in pediatric perforated appendicitis in the New York City metropolitan region at the epicenter of the COVID-19 outbreak. Ann Surg. (2021) 273:410VID-10.1097/SLA.000000000000442632976285 Shi G Huang J Pi M Chen X Li X Ding Y Zhang H National National Association of Pediatric Cardiology and Cardiac Surgery Working Group. Impact of early COVID-19 pandemic on pediatric cardiac surgery in China. J Thoracic Cardiovasc Surg. (2020) 161:1605–14. 10.1016/j.jtcvs.2020.11.07433419537 Goldman RD Grafstein E Barclay N Irvine MA Portales-Casamar E. Paediatric patients seen in 18 emergency departments during the COVID-19 pandemic. Emerg Med J. (2020) 37:773–7. 10.1136/emermed-2020-21027333127743 Gerall CD DeFazio JR Kahan AM Fan W Fallon EM Middlesworth W . Delayed presentation and sub-optimal outcomes of pediatric patients with acute appendicitis during the COVID-19 pandemic. J Pediatr Surg. (2021) 56:905Surgr10.1016/j.jpedsurg.2020.10.00833220973 Hampton M Clark M Baxter I Stevens R Flatt E Murray J . The effects of a UK lockdown on orthopaedic trauma admissions and surgical cases: a multi-centre comparative study. Bone Jt Open. (2020) 1:137–43. 10.1302/2633-1462.15.BJO-2020-0028.R133241224 Hartnett KP Kite-Powell A DeVies J Coletta MA Boehmer TK Adjemian J . Impact of the COVID-19 pandemic on emergency department visits - United States, January 1, 2019-May 30, 2020. MMWR Morb Mortal Wkly Rep. (2020) 69699–704. 10.15585/mmwr.mm6923e132525856 Hughes HE Hughes TC Morbey R Challen K Oliver I Smith GE . Emergency department use during COVID-19 as described by syndromic surveillance. Emerg Med J. (2020) 37:600–4. 10.1136/emermed-2020-20998032948621 Iozzi L Brambilla I Foiadelli T Marseglia GL Cipr IG. Paediatric emergency department visits fell by more than 70% during the COVID-19 lockdown in Northern Italy. Acta Paediatr. (2020) 109:2137–8. 10.1111/apa.1545832623774 Rose K Zyl KV Cotton R Wallace S Cleugh F. Paediatric attendances and acuity in the emergency department during the COVID-19 pandemic. medRxiv. (2020) 2020:8666. 10.1101/2020.08.05.2016866633127743 Korun O Yurdakök O Arslan A Çiçek M Selçuk A Kiliç Y . The impact of COVID-19 pandemic on congenital heart surgery practice: An alarming change in demographics. J Card Surg. (2020) 35:2908–12. 10.1111/jocs.1491432789953 Krivec U Kofol Seliger A Tursic J. COVID-19 lockdown dropped the rate of paediatric asthma admissions. Arch Dis Child. (2020) 105:809–10. 10.1136/archdischild-2020-31952232444452 Kruchevsky D Arraf M Levanon S Capucha T Ramon Y Ullmann Y. Trends in burn injuries in Northern Israel during the COVID-19 lockdown. J Burn Care Res. (2021) 42:135–40. 10.1093/jbcr/iraa15432969466 Kvasnovsky CL Shi Y Rich BS Glick RD Soffer SZ Lipskar AM . Limiting hospital resources for acute appendicitis in children: lessons learned from the US epicenter of the COVID-19 pandemic. J Pediatr Surg. (2021) 56:900Surg10.1016/j.jpedsurg.2020.06.02432620267 Lalarukh ARJDS. 468 Presentation of vulnerable children in Finland during earla. Emerg Med J : EMJ. (2020) 37:852–52. Lawrence C Seckold R Smart C King BR Howley P Feltrin R . Increased paediatric presentations of severe diabetic ketoacidosis in an Australian tertiary centre during the COVID-19 pandemic. Diabet Med. (2021) 38:e14417. 10.1111/dme.1441733020999 Lee L Mannix R Guedj R Chong SL Sunwoo S Woodward T . Paediatric ED utilisation in the early phase of the COVID-19 pandemic. Emerg Med J. (2021) 38:100–2. 10.1136/emermed-2020-21012433273041 Lee-Archer P Blackall S Campbell H Boyd D Patel B McBride C. Increased incidence of complicated appendicitis during the COVID-19 pandemic. J Paediatr Child Health. (2020) 56:1313–313:0iatr C1111/jpc.1505832830891 Dyson EW Craven CL Tisdall MM James GA. The impact of social distancing on pediatric neurosurgical emergency referrals during the COVID-19 pandemic: a prospective observational cohort study. Childs Nerv Syst. (2020) 36:1821–3. 10.1007/s00381-020-04783-432621006 Lv H Zhang Q Yin Y Zhu Y Wang J Hou Z . Epidemiologic characteristics of traumatic fractures during the outbreak of coronavirus disease 2019 (COVID-19) in China: A retrospective & comparative multi-center study. Injury. (2020) 51:1698–704. 10.1016/j.injury.2020.06.02232563519 Manzoni P Militello MA Fiorica L Cappiello AR Manzionna M. Impact of COVID-19 epidemics in pediatric morbidity and utilization of hospital pediatric services in Italy. Acta Paediatr. (2021) 110:1369–70. 10.1111/apa.1543533309793 McDonnell T Nicholson E Conlon C Barrett M Cummins F Hensey C . Assessing the impact of COVID-19 public health stages on paediatric emergency attendance. Int J Environ Res Public Health. (2020) 17:6719. 10.3390/ijerph1718671932942698 Matthay ZA Kornblith AE Matthay EC Sedaghati M Peterson S Boeck M . The distance study: determining the impact of social distancing on trauma epidemiology during the COVID-19 epidemic-an interrupted time-series analysis. J Trauma Acute Care Surg. (2021) 90:700–7. 10.1097/TA.000000000000304433252457 Mekaoui N Razine R Bassat Q Benjelloun BS Karboubi L. The effect of COVID-19 on paediatric emergencies and admissions in Morocco: cannot see the forest for the trees? J Trop Pediatr. (2021) 67:fmaa046. 10.1093/tropej/fmaa04632744305 Memeo A Priano D Caldarini C Trezza P Laquidara M Montanari L R elli P. How the pandemic spread of COVID-19 affected children's traumatology in Italy: changes of numbers, anatomical locations, and severity. Minerva Pediatr. (2020) 10.23736/S0026-4946.20.05910-133016683 Montalva L Haffreingue A Ali L Clariot S Julien-Marsollier F Ghoneimi AE . The role of a pediatric tertiary care center in avoiding collateral damage for children with acute appendicitis during the COVID-19 outbreak. Pediatr Surg Int. (2020) 36:1397–397:0r Surg I1007/s00383-020-04759-033070203 Vásquez-Hoyos P Diaz-Rubio F Monteverde-Fern N Jaramillo-Bustamante JC Carvajal C Serra A . Reduced PICU respiratory admissions during COVID-19. Arch Dis Child. (2020) 106:808–11. 10.1136/archdischild-2020-32046933028512 Molina Gutiérrez M Ruiz Domínguez JA Bueno Barriocanal M de Miguel Lavisier B López López R Martín Sánchez J . Impact of the COVID-19 pandemic on emergency department: Early findings from a hospital in Madrid. An Pediatr. (2020) 93:313–22. 10.1016/j.anpede.2020.06.00233020734 Nelson CP Kurtz MP Logvinenko T Venna A McNamara ER. Timing and outcomes of testicular torsion during the COVID-19 crisis. J Pediatr Urol. (2020) 16:841. 10.1016/j.jpurol.2020.10.02133223456 Nourazari S Davis SR Granovsky R Austin R Straff DJ Joseph JW . Decreased hospital admissions through emergency departments during the COVID-19 pandemic. Am J Emerg Med. (2021) 42:203–10. 10.1016/j.ajem.2020.11.02933279331 Nabian MH Vosoughi F Najafi F Khabiri SS Nafisi M Veisi J . Epidemiological pattern of pediatric trauma in COVID-19 outbreak: data from a tertiary trauma center in Iran. Injury. (2020) 51:2811–5. 10.1016/j.injury.2020.09.01532958345 Park C Sug K Nathwani D Bhattacharya R Sarraf KM. Impact of the COVID-19 pandemic on orthopedic trauma workload in a London level 1 trauma center: the golden month. Acta Orthop. (2020) 91:556–61. 10.1080/17453674.2020.178362132573331 Palladino F Merolla E Solimeno M de Leva MF Lenta S Di Mita O . Is Covid-19 lockdown related to an increase of accesses for seizures in the emergency department? An observational analysis of a paediatric cohort in the Southern Italy. Neurol Sci. (2020) 41:3475–83. 10.1007/s10072-020-04824-533095368 Pines JM Zocchi MS Black BS Carlson JN Celedon P Moghtaderi A . Characterizing pediatric emergency department visits during the COVID-19 pandemic. Am J Emerg Med. (2021) 41:201–4. 10.1016/j.ajem.2020.11.03733257144 Peiro-Garcia A Corominas L Coelho A DeSena-DeCabo L Torner-Rubies F Fontecha CG. How the COVID-19 pandemic is affecting paediatric orthopaedics practice: a preliminary report. J Child Orthop. (2020) 14:154–60. 10.1302/1863-2548.14.20009932582381 Qasim Z Sjoholm LO Volgraf J Sailes S Nance ML Perks DH . Trauma center activity and surge response during the early phase of the COVID-19 pandemic-the Philadelphia story. J Trauma Acute Care Surg. (2020) 89:821–8. 10.1097/TA.000000000000285932618967 Place R Lee J Howell J. Rate of Pediatric Appendiceal perforation at a children's hospital during the COVID-19 pandemic compared with the previous year. JAMA Netw Open. (2020) 3:e2027948. 10.1001/jamanetworkopen.2020.2794833275149 Raitio A Ahonen M Jääskelä M Jalkanen J Luoto TT Haara M . Reduced number of pediatric orthopedic trauma requiring operative treatment during COVID-19 restrictions: a nationwide cohort study. Scand J Surg. (2021) 110:254–7. 10.1177/145749692096801433100133 Sheridan GA Nagle M Russell S Varghese S O'Loughlin PF Boran S . Pediatric trauma and the COVID-19 pandemic: a 12-year comparison in a level-1 trauma center. HSS J. (2020) 16:92–6. 10.1007/s11420-020-09807-y33041725 Graciano AL Bhutta AT Custer JW. Reduction in paediatric intensive care admissions during COVID-19 lockdown in Maryland, USA. BMJ Paediatr Open. (2020) 4:e000876. 10.1136/bmjpo-2020-00087633173836 Scaramuzza A Tagliaferri F Bonetti L Soliani M Morotti F Bellone S . Changing admission patterns in paediatric emergency departments during the COVID-19 pandemic. Arch Dis Child. (2020) 105:704–6. 10.1136/archdischild-2020-31939732461213 Turgut A Arli H Altundag Ü Hancioglu S Egeli E Kalenderer Ö. Effect of COVID-19 pandemic on the fracture demographics: Data from a tertiary care hospital in Turkey. Acta Orthop Traumatol Turc. (2020) 54:355–63. 10.5152/j.aott.2020.2020932812872 Valitutti F Zenzeri L Mauro A Pacifico R Borrelli M Muzzica S . Effect of population lockdown on pediatric emergency room demands in the era of COVID-19. Front Pediatr. (2020) 8:521. 10.3389/fped.2020.0052133072657 Velayos M Muñoz-Serrano AJ Estefanía-Fernández K Sarmiento Caldas MC Moratilla Lapeña L López-Santamaría M . Influence of the coronavirus 2 (SARS-Cov-2) pandemic on acute appendicitis. An Pediatr. (2020) 93:118–22. 10.1016/j.anpede.2020.04.01032837965 Vierucci F Bacci C Mucaria C Dini F Federico G Maielli M . How COVID-19 pandemic changed children and adolescents use of the emergency department: the experience of a secondary care pediatric unit in central Italy. SN Compr Clin Med. (2020) 2:1959–69. 10.1007/s42399-020-00532-532984767 Wei Y Yu C Zhao TX Lin T Dawei HE Wu SD . The impact of the COVID-19 pandemic on pediatric operations: a retrospective study of Chinese children. Ital J Pediatr. (2020) 46:155. 10.1186/s13052-020-00915-333066803 D.0000 F, Choong J, Thomas C, Adamson J, Wilson Y, Wilson D, et al. Paediatric burns epidemiology during COVID-19 pandemic and demic and d on tBurns. (2020) 46:1471–2. 10.1016/j.burns.2020.06.02832680661 Isba R Edge R Auerbach M Cicero MX Jenner R Setzer E . COVID-19: transatlantic declines in pediatric emergency admissions. Pediatr Emerg Care. (2020) 36:551–3. 10.1097/PEC.000000000000226032925702 Kuitunen I Artama M MM Ma L Backman K Heiskanen-Kosma T Renko M. Effect of social distancing due to the COVID-19 pandemic on the incidence of viral respiratory tract infections in children in Finland during early 2020. Pediatr Infect Dis J. (2020) 39:e423–7. 10.1097/INF.000000000000284532773660 Raman R Madhusudan M. Impact of the COVID-19 Pandemic on admissions to the pediatric emergency department in a tertiary care hospital. Indian J Pediatr. (2021) 88:392. 10.1007/s12098-020-03562-y33146879 Williams T MacRae C Swann O Haseeb H Cunningham C Davies P . Indirect effects of the COVID-19 pandemic on paediatric health-care use and severe disease: a retrospective national cohort study. Arch Dis Child. (2021) 106:911Childects of1136/archdischild-2020-32100833451994 Sperotto F Wolfler A Biban P Montagnini L Ocagli H Comoretto R . Unplanned and medical admissions to pediatric intensive care units significantly decreased during COVID-19 outbreak in Northern Italy. Eur J Pediatr. (2021) 180:643–8. 10.1007/s00431-020-03832-z33070224 Nolen LD Seeman S Bruden D Klejka J Desnoyers C Tiesinga J . Impact of social distancing and travel restrictions on non-COVID-19 respiratory hospital admissions in young children in rural Alaska. Clin Infect Dis. (2021) 72:2196–8. 10.1093/cid/ciaa132832888007 Friedrich F Ongaratto R Scotta MC Veras TN Stein R Lumertz MS . Early Impact of social distancing in response to COVID-19 on hospitalizations for acute bronchiolitis in infants in Brazil. Clin Infect Dis. (2021) 72:2071–5. 10.1093/cid/ciaa145832986818 Chavasse R Almario A Christopher A Kappos A Shankar A. The indirect impact of COVID-19 on children with Asthma. Arch Bronconeumol. (2020) 56:768–9. 10.1016/j.arbres.2020.07.00335319591 Bun S Kishimoto K Shin J. -h, Takada D, Morishita T, Kunisawa S, Imanaka Y. Impact of the COVID-19 pandemic on infant and pediatric asthma: a multi-center survey using an administrative database in Japan. Allergol Int. (2021) 70:489–91. 10.1101/2020.11.29.20240374 Dhillon MS Kumar D Saini UC Bhayana H Gopinathan NR Aggarwal S. Changing pattern of orthopaedic trauma admissions during COVID-19 pandemic: experience at a tertiary trauma centre in India. Indian J Orthop. (2020) 54:1–6. 10.1007/s43465-020-00241-032873987 Sherman WF Khadra HS Kale NN Wu VJ Gladden PB Lee OC. How did the number and type of injuries in patients presenting to a regional level i trauma center change during the COVID-19 pandemic with a stay-at-home order? Clin Orthop Relat Res. (2021) 479:266–75. 10.1097/CORR.000000000000148433044313 Mann JA Patel N Bragg J. Rol, D. Did children “stay safe”? Evaluation of burns presentations to a children's emergency department during the period of COVID-19 school closures. Arch Dis Child. (2021) 106:e18. 10.1136/archdischild-2020-32001532883658 Basatemur E Jones A Peters M Ramnarayan P. Paediatric critical care referrals of children with diabetic ketoacidosis during the COVID-19 pandemic. Arch Dis Child. (2021) 106:e21. 10.1136/archdischild-2020-32047132938625 Gunadi Idham Y Paramita VMW Fauzi AR Dwihantoro A Makhmudi A. The Impact of COVID-19 pandemic on pediatric surgery practice: a cross-sectional study. Ann Med Surg. (2020) 59:96–100. 10.1016/j.amsu.2020.09.02032953094 Okonkwo INC Howie A Parry C Shelton CL Cobley S Craig R . The safety of paediatric surgery between COVID-19 surges: an observational study. Anaesthesia. (2020) 75:1605–605:0hesiay 1111/anae.1526432955100 Research Network PST Arthur F Harwood R Allin B Bethell GS Boam T . Lockdown during the COVID-19 pandemic: impact on infants with pyloric stenosis. Arch Dis Child. (2020) 106:e32. 10.1136/archdischild-2020-32054433262176 Zampieri N Cinquetti M Murri V Camoglio FS. Incidence of appendicitis during SARS-CoV-2 pandemic quarantine: report of a single area experience. Minerva Pediatr. (2020) 56. 10.23736/S0026-4946.20.05901-033016682 Giamberti A Varrica A Agati S Gargiulo G Luciani GB Marianeschi SM . Impact of the coronavirus disease 2019 (COVID-19) pandemic on the Italian congenital cardiac surgery system: a national survey. Eur J Cardiothorac Surg. (2020) 58:1254–60. 10.1093/ejcts/ezaa35233175141 Viner RM Russell SJ Croker H Packer J Ward J Stansfield C . School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health. (2020) 4:397–404. 10.1016/S2352-4642(20)30095-X32272089 Zee-Cheng JE McCluskey CK Klein MJ Scanlon MC Rotta AT Shein SL . Changes in pediatric ICU utilization and clinical trends during the coronavirus pandemic. Chest. (2021) 160:529–37. 10.1016/j.chest.2021.03.00433727033 Breinig S Mortamet G Brossier D Amadieu R Claudet I Javouhey E . Impact of the french national lockdown on admissions to 14 pediatric intensive care units during the 2020 COVID-19 pandemic-a retrospective multicenter study. Front Pediatr. (2021) 9:764583. 10.3389/fped.2021.76458334956977 Maddux AB Campbell K Woodruff AG LaVelle J Lutmer J Kennedy CE . The impact of strict public health restrictions on pediatric critical illness. Crit Care Med. (2021) 49:2033–41. 10.1097/CCM.000000000000520034259665 Chadi N Ryan NC Geoffroy MC. COVID-19 and the impacts on youth mental health: emerging evidence from longitudinal studies. Can J Public Health. (2022) 113:44–52. 10.17269/s41997-021-00567-835089589 Elharake JA Akbar F Malik AA Gilliam W Omer SB. Mental health impact of COVID-19 among children and college students: a systematic review. Child Psychiatry Hum Dev. (2022) 11:1–13. 10.1007/s10578-021-01297-135013847 Schultz BRE Hoffmann JA Clancy C Ramgopal S. Hospital encounters for pediatric ingestions before and during the COVID-19 pandemic. Clin Toxicol (Phila). (2022) 60:269–71. 10.1080/15563650.2021.192568733988077 Rubino F Amiel SA Zimmet P Alberti G Bornstein S Eckel RH . New-onset diabetes in Covid-19. N Engl J Med. (2020) 383:789–90. 10.1056/NEJMc201868832530585 Lane J Means AR Bardosh K Shapoval A Vio F Anderson C . Comparing COVID-19 physical distancing policies: results from a physical distancing intensity coding framework for Botswana, India, Jamaica, Mozambique, Namibia, Ukraine, and the United States. Global Health. (2021) 17:124. 10.1186/s12992-021-00770-934688295 Guen CGL Hentgen V Dubos F Kochert F Balençon Balençon M Levy C . French pediatric societies call for school to stay open amid the coronavirus disease 2019 pandemic. J Pediatr. (2021) 234:293–5. 10.1016/j.jpeds.2021.04.00133823187 Appendix 1

Each digital database was searched with the following search terms.

i) Population: “pediatrics”, “infant, newborn”, “child”, “adolescent”, “infant” and “newborn”.

ii) Exposures: “social distancing”, “measure”, “policy”, “regulation”, “quarantine”, “isolation”, “non-pharmacological interventions” combined with “COVID-19”, “Novel Coronavirus” or “SARS-COV2”.

iii) Outcomes: “Hospitalization”, “admission”, “incidence”, “occurrence”.

The search strategy used MeSH terms unless indicated otherwise.