Social distancing measures, defined as closures of schools and public places, physical distancing, and cancellation of mass gatherings,1 were implemented to reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) during the coronavirus disease 2019 (COVID-19) pandemic. Although children have been relatively spared from severe SARS-CoV-2 infections requiring hospitalization,2,3 it remains unknown if social distancing measures are related to pediatric inpatient use for conditions caused by other respiratory viruses. To address this knowledge gap, we examined the effect of the COVID-19 pandemic and social distancing measures on pediatric hospitalizations at a freestanding children’s hospital.
Methods
We analyzed electronic medical record data from a freestanding children’s hospital to compare hospitalizations during 5 weeks in March and April 2020 (COVID-19 cohort), corresponding with the initiation of social distancing measures in Massachusetts,4 and the comparable 2016–2019 weeks (pre–COVID-19 cohort). We included children hospitalized on medicine services (excluding surgery, neurology, and cardiology) during the selected weeks and recorded demographic characteristics. We conducted descriptive statistics and compared overall median hospitalizations per week between the COVID-19 and pre–COVID-19 cohorts using the Wilcoxon rank test.
A priori, we selected 3 diagnoses (asthma, bronchiolitis, and pneumonia) that are viral-associated and may be related to social distancing measures. We also selected 3 diagnoses (cellulitis, gastroesophageal reflux disease, and urinary tract infection) that should not be associated with social distancing measures. We used the Wilcoxon rank test to compare median weekly admissions for these 6 conditions between the COVID-19 and pre–COVID-19 cohorts.
Results
Our sample included 339 hospitalizations in the COVID-19 cohort and 3292 hospitalizations in the 4-year pre–COVID-19 cohort (average 823 per year in 2016–2019). There were no significant differences in patient sex, age, insurance type, or length of stay between these cohorts. Median overall hospitalizations per week were significantly lower in the COVID-19 cohort (64 per week) compared with the pre–COVID-19 cohort (166 per week; P < .001; Fig 1).
Boxplot of weekly pediatric hospitalizations by year. Boxplots depict the medians and interquartile ranges (IQRs) of weekly hospitalizations. Whiskers are 1.5 times the IQR.
Boxplot of weekly pediatric hospitalizations by year. Boxplots depict the medians and interquartile ranges (IQRs) of weekly hospitalizations. Whiskers are 1.5 times the IQR.
Three diagnoses had fewer median hospitalizations per week in the COVID-19 cohort compared with the pre–COVID-19 cohort: asthma (3 vs 8.5; P = .014), bronchiolitis (1 vs 7; P = .008), and pneumonia (2 vs 6.5; P = .064). We found no significant difference in median hospitalizations per week for cellulitis, gastroesophageal reflux disease, or urinary tract infection (Fig 2).
Boxplot of weekly pediatric hospitalizations per diagnosis in 2016–2019 compared to 2020. Boxplots are the medians and interquartile ranges (IQRs) of weekly hospitalizations per diagnosis. Whiskers are 1.5 times the IQR. Dots are outliers. GERD, gastroesophageal reflux disease; UTI, urinary tract infection.
Boxplot of weekly pediatric hospitalizations per diagnosis in 2016–2019 compared to 2020. Boxplots are the medians and interquartile ranges (IQRs) of weekly hospitalizations per diagnosis. Whiskers are 1.5 times the IQR. Dots are outliers. GERD, gastroesophageal reflux disease; UTI, urinary tract infection.
Discussion
On the basis of an analysis of hospitalizations at a children’s hospital, we found a significant reduction in overall hospitalizations during the initial SARS-CoV-2 outbreak compared to the same calendar period in the 4 previous years. We also found significant reductions in bronchiolitis and asthma hospitalizations and a nonstatistically significant reduction in pneumonia hospitalizations, all viral-associated conditions that may be affected by social distancing measures. By contrast, there was no change in hospitalizations in the examined conditions that are not known to be associated with viral infections.
Although pediatric hospitalizations have been declining over the past decade, the observed acute decrease in pediatric hospitalizations during the initial wave of COVID-19 cases in our area was larger than the previously documented year-over-year decline.5,6 The reasons for and implications of this decline may be numerous. Social distancing measures have been associated with a decline in both the prevalence of viral illnesses1 and outpatient visits for common pediatric infectious diseases.7 This study demonstrates that these measures may also be associated with a decline in bronchiolitis and asthma hospitalizations. This finding could have implications for mitigation strategies during surges of COVID-19 or other pandemics or as a strategy to ease the burden on hospitals at capacity during winter months. Additionally, the noted decline in hospitalizations has been paralleled by a decline in pediatric vaccination rates8 and hospitalizations for non–COVID-19-related conditions in adults.9,10 These declines have raised concerns that patients are delaying necessary care during the COVID-19 pandemic. By contrast, the present results revealed no statistically significant decline in hospitalizations for acute medical conditions not associated with viral infections.
This study has several potential limitations. This is a single-center study, and the results may not be generalizable to other geographic regions. There were a small number of weekly hospitalizations for each diagnosis, which may have limited our power to detect differences.
Conclusions
At the onset of social distancing measures during the COVID-19 pandemic, we found a significant decline in both overall hospitalizations and hospitalizations for specific viral-associated conditions (bronchiolitis and asthma). Although these results require replication, social distancing measures may help reduce pediatric hospitalizations this winter when common seasonal viral illnesses increase in prevalence in conjunction with a forecasted increase in COVID-19 cases.
Dr Wilder conceptualized and designed the study, helped interpret the data, drafted the initial manuscript, and reviewed and revised the manuscript; Dr Parsons conceptualized and designed the study, conducted the data analyses, helped interpret the data, and critically revised the article for important intellectual content; Dr Growdon conceptualized the study, helped interpret the data, and critically revised the article for important intellectual content; Drs Toomey and Mansbach conceptualized and designed the study, coordinated and supervised data collection, helped interpret the data, and critically reviewed the manuscript for important intellectual content; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
Comments
RE: PEDIATRIC HOSPITALIZATIONS DURING THE COVID-19. ALL ALMOST SIMILAR UNDER THE SAME SKY .
Dear Sirs,
we read with interest the paper by Wilder et al. recently published as research brief on this journal (1). By a retrospective analysis of the electronic medical records at their pediatric hospital in Boston, they nicely describe the reduction of other viral-triggered respiratory diseases such as bronchiolitis, and pneumonia in children depending on a much likely indirect effect of social distancing for COVID-19 in March-April 2020. Albeit not a viral disease sensu stricto, asthma was appropriately included as well because it may be flared up by viral infections, and similar data have been highlighted also by other reports (2). Still, we are confident that for this disease a not negligible role might have also been played by better parental supervision on anti-asthma drug administration and less outdoor activities with allergen exposure during lockdowns (3). The authors also reported that few other disorders such as gastroesophageal reflux disease, urinary tract infection and cellulitis have passed unchanged through the first wave of COVID-19 epidemic.
Nevertheless, other social distancing scenarios may be quite diverse. In our setting, pediatric emergency departments (ED) are still strikingly uncongested and hospitalization rate has dropped for almost every disease. Compared to Wilder and colleagues’ data on hospitalization reduction (38.5%), in a recent paper involving two large Italian hospitals we showed an even higher reduction (48.2%) of inpatient hospital admissions in the trimester March-May 2020 vs. the same trimester of the previous year (4). Moreover, differently from their study, in our cohort we have encountered a significant reduction of all consultations for both infectious and non-infectious illnesses; similarly to other reports (5), we also highlighted an undeniable increase of more appropriate and clinically severe all-cause admissions. As regards frailty/chronic disease patients, ED admissions of these categories in our setting were overlapping in the two periods4.
Said that, based on their records, it would be interesting to possibly read few comments from the Authors on some other likely central aspects which clearly they did not mention as per study design1. In our opinion these should include the epidemics’ impact on disease severity of their hospital admissions, management of frailty/chronic disease patients, and appropriateness of ED accesses.
1) Wilder JL, Parsons CR, Growdon AS, et al. Pediatric Hospitalizations During the COVID-19 Pandemic. Pediatrics. 2020 Nov 3:e2020005983. doi: 10.1542/peds.2020-005983. Epub ahead of print.
2) Roland D, Harwood R, Bishop N, et al. Children’s emergency presentations during the COVID-19 pandemic. Lancet Child Adolesc Health. 2020; 4:e32–e33.
3) Papadopoulos NG, Custovic A, Deschildre A, et al. Impact of COVID-19 on Pediatric Asthma: Practice Adjustments and Disease Burden. J Allergy Clin Immunol Pract. 2020; 8:2592-2599.e3.
4) Valitutti F, Zenzeri L, Mauro A, et al. Effect of Population Lockdown on Pediatric Emergency Room Demands in the Era of COVID-19. Front Pediatr. 2020; 8:521.
5) Lazzerini M, Barbi E, Apicella A, et al. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lancet Child Health. 2020; 4:e10–1