A Silver Lining in a Dark Cloud? Pandemic Hospitalizations in Children With Medical Complexity

The impact of the coronavirus 2019 disease (COVID-19) pandemic on children with medical complexity (CMC) has been substantial. Although severe COVID-19 illness is relatively rare among children and youth, many CMC are at a comparatively increased risk.¹  Perhaps of even greater concern has been the indirect impacts of the pandemic on the well-being of CMCs, including barriers to accessing care, social supports, and education, as well as the consequences of caregiver illness and caregiver stress on the health of these children.^2,3  Nevertheless, there have been some reports that at least one aspect of CMC health may have improved over the course of the pandemic, their risk of acute care hospitalization. Data from early in the pandemic suggested dramatic declines in hospitalization risk among children,⁴  including those that are healthy and those with chronic conditions. A large, more recent study from the UK reported substantial declines in hospitalizations for children, including those with preexisting comorbidities, with the most significant reductions in respiratory conditions, such as influenza and bronchiolitis.⁵  To date there have been few reports that specifically described changes in acute care utilization by CMC during the pandemic. Understanding the changes in this population are essential since they are such frequent users of inpatient services and are at substantially higher risk of poor outcomes during hospitalization.^6–8 

The paper by Markham et al⁹  in this edition of Hospital Pediatrics provides some important insights into the patterns of acute care use among CMC during the pandemic. This multicenter cross-sectional study reviewed admission trends in 49 US children’s hospitals using the Pediatric Health Information System (PHIS) database. The authors used a commonly used algorithm for ascertaining CMC with health administrative data, Feudtner’s complex chronic conditions (CCCs)¹⁰  and compared utilization during the first year of the pandemic with that in the 3 years prior. The study reported that children with a CCC had a 19.5% decline in admissions during COVID-19, beginning right at the onset of the pandemic in March 2020, reaching a rapid nadir 1 month later, but still not returning to pre-COVID levels by March 2021. The decline in admissions was particularly notable for respiratory diagnoses, such as pneumonia and bronchiolitis (44.7% to 57.7% decline). Despite the marked drop in admissions, other indicators of hospitalization disease burden for CMC, including length of stay and ICU days, were not substantially different.

Why did CMC require fewer hospitalizations during the first year of the pandemic? The authors offer 2 plausible explanations. Pandemic measures to control the spread of COVID-19, such as social distancing, masking, and school closures likely also limited the spread of other respiratory viruses. Declines in activity of influenza and respiratory syncytial virus (RSV) have been well described during the pandemic.¹¹  Such viruses are known to lead to substantial morbidity and mortality among CMC. For example, RSV has the highest mortality risk among CMC, including those with cardiac conditions, chronic lung disease, neurologic impairment, and genetic disorders.^12–15 

Another explanation could be that many families may have simply delayed or forgone care in hospitals during the first year of the pandemic. This phenomenon has been described by other researchers during the pandemic among the CMC population.^16,17  Limitations inherent to the study design make it challenging to untangle these and other potential explanatory factors. Administrative data cannot determine whether an admission is related to changes in health behaviors, decreased community supports, or an exacerbation of their underlying medical condition. Additionally, the PHIS database does not contain data on community hospital admissions, and some families may have received care in such hospitals that may be closer to their homes. It is also not known what the patterns of ambulatory care were among the CMC in the study, including access to telemedicine that may have provided support to families.

It is important to highlight that this study was conducted during the first year of the pandemic (until March 2021). A key question emerging from this work is whether the decreased admissions noted during the early phase of the pandemic continued in subsequent periods as public health measures varied over time. It is also uncertain whether the patterns observed will continue. While public health measures may have reduced the risk of other respiratory infections during the COVID-19 pandemic, there is concern that with relaxation of such measures, susceptible individuals may be at risk from substantial outbreaks in the future.¹¹  It will be important to continue to track hospitalization metrics over time to better understand how these factors may affect CMC.

And what about lessons for future pandemics or even seasonal surges of endemic viral infections? While the full scope of restrictions that existed in the worst phases of the pandemic, such as school closures and social isolation, have caused harms to CMC and their families,¹⁸  there may be important benefits to continue to protect them with some measures at times when they are most vulnerable. Is some of the decline in admissions, particularly those admissions due to viral respiratory infections, preventable with some public health measures? If so, is there a role for the use of masking, social distancing, and/or hand-washing campaigns around vulnerable CMC during periods of high rates of community transmission of viral respiratory infections? Or perhaps can increased use of telemedicine protect them from acquiring infections in health care settings during periods of viral surges? All of these questions will likely require rigorous evaluative methods, such as cluster randomized trials to answer.

Markham et al have provided us with important preliminary data that suggests that hospitalization of CMC has declined substantially during the pandemic, a potential silver lining in the dark cloud of the pandemic. Future research is essential to better understand this observation to optimize CMC health and well-being.