The COVID-19 pandemic have had a significant impact on healthcare systems worldwide.
From March 9th to May 3rd, 2020, the Italian Ministry of Health recommended avoiding direct access to the ED in case of fever and/or respiratory symptoms, giving priority to home care or phone consultation for patients with mild or moderate disease [10].
COVID-19 pandemic resulted in a substantial decline of pediatric ED visits and hospitalizations. During March 1–27, 2020, ED visits decreased markedly (∆%: -73 to -88) at 5 Italian pediatric EDs when compared with the same periods in 2019 and 2018 [4]. Similarly to other Authors [7, 11, 12], we observed a marked decrease (∆%: -46.5) in the total number of pediatric ED visits during the first semester of the year 2020, compared to the same period of 2019. The decrease was more relevant when the lockdown period was compared to both the corresponding time period of 2019 (∆%: -78.0), and to the pre-lockdown period (∆%: -79.0).
The lowest number of ED visits in May 2019 might be due to the beginning of the warm season, even though, after May, there is a slight increase in the number of ED visits, consistent with the spread of some viruses (e.g., enteroviruses) in this season. Conversely, in the year 2020, the temporal trend of ED visits showed a marked reduction occurring as early as March–April months, and a slight and gradual increase during May–June. The lowest number of ED visits in April 2020 is consistent with the effect of the lockdown measures, which started one month before.
At the triage assessment, we did not find an increase in urgent triage codes, as previously reported [7, 12, 13]: the percentage of white codes decreased (15.4% vs 20.4%; p < 0.0001) and, unexpectedly, green codes increased (76% vs 70.3%; p < 0.0001) during the lockdown months when compared to January–February 2020. Parents seemed to be not discouraged despite national recommendations.
The age of patient ED visits was found to change during the study periods. A higher percentage of visits in children aged < 2 years and a lower in children aged 2–5 years were observed during the first semester of 2020, as proved by other Authors [12, 14]. Unlike the multicentre study by Matera et al. [13], we found no differences for patients older than 11 years. However, unlike other Authors [15], no increased frequency of patients < 2 years was observed after the beginning of the lockdown period.
In line with the study by Vierucci et al. [15], our data showed a progressive decrease of visits for acute respiratory disease from the pre-lockdown period to the post-lockdown period. Moreover, the acute respiratory disease frequency was found to be significantly reduced in both the lockdown and post-lockdown periods when compared to the same periods in 2019, as previously reported [7, 11, 13,14,15,16,17]. In general, the warm season (from June to September) is associated with a decrease of acute respiratory diseases, as found in this study during May–June 2019.
In line with literature, the percentage of children with trauma [7, 12,13,14,15], acute surgical problem, intoxication [12, 16], and neuropsychiatric disease [7, 13, 15, 16], was found to be significantly higher in March–April 2020 compared to both March–April 2019 and to January–February 2020.
The lockdown may have contributed to a reduction in community infections, road accidents, and respiratory and cardiovascular diseases due to the interruption of schools and sports activities, the reduction of road traffic and the improvement of air quality [18]. However, social isolation might have exposed children to other risks such as intoxication, neuropsychiatric disorders [11], and trauma [12, 17].
In our study, the hospital admission rate was significantly higher during the lockdown period (with a peak of 19.3%) when compared with that of the same 2019 period; this is consistent with the results of Cozzi G et al. [7], and suggests that children in urgent need of medical care and hospitalization arrived at the pediatric ED despite the lockdown.
Some Authors reported a delayed access to the ED during the lockdown period, resulting in diagnostic and therapeutic delays, and sometimes in fatal outcomes. This could be attributed to the reduced availability of resources [4] and/or to the propensity of caregivers to avoid ED because of fear of infection [4, 19]. The delayed access to healthcare can be especially detrimental to children with special needs, who are at higher risk of severe illness. In the UK and Ireland, Lynn et al. [9] showed that the most common delayed ED presentations were sepsis, diabetes mellitus, and malignancies. On the other hand, the extreme reduction of ED visits (e.g., the inappropriate ones) allowed a better healthcare organization [15].
The main limitations of this study are its retrospective design, the inclusion of only two centres, and the time period considered. The observational, retrospective study design implies that unrecognized factors may have influenced our results. Moreover, the recruited hospitals provide care to a large proportion of pediatric patients in the North and South of Sardinia, but the remaining Sardinian pediatric population was not investigated in this study.
Finally, the division of the observational period into 3 bimesters do not exactly reflect the Italian lockdown period, potentially leading to a mild underestimation of the “lockdown effect”.