Risks to children and young people during covid-19 pandemicBMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m1669 (Published 28 April 2020) Cite this as: BMJ 2020;369:m1669
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Dr Fisayo , 30 April has pointed out something others have missed. Thank you Dr Fisayo.
Using Covid-19 as an excuse, the Govt has sneaked through the use of a Statutory Instrument, legal provisions which have nothing to do with Corvid.
Of course political success depends upon intellectual dishonesty. I also realise that with a majority of 80, the government has little to fear .
But surely, surely, the journalists are still alive and well?
Competing interests: A commoner, wondering how many irrelevant laws are being foisted on us in the name of Covid.
I have read the article and the responses. I have also read Dr Noel Thomas’s response to another but related subject - the children being damaged by war.
There is a common thread: our government, besides the governments of other “developed governments” are concerned only with speedy acquisition of MONEY. And when they spend money (for development, as they call it) it is with the aim of making more money.
Turning to the children and young people whose lives are being affected by Covid-19,: they will mostly live. But what kind of lives?
There is not the slightest sign of the governments, national and local moving their fingers to help. Certainly, the government is jumping with alacrity to help BIG BUSINESS.
Where is the help for young mothers, mothers of adolescents, for adolescents, for young adults?
Competing interests: No competing interests
As frontline paediatricians advocating for the rights and safeguarding of children, we applaud Dr Green’s editorial (1) and call upon the government to shift the focus to children and the collateral damage they have suffered as a result of the pandemic in terms of their health and well-being.
Information regarding the pandemic has not been communicated in a child and youth friendly manner. New Zealand and Norway have both held press conferences for children only, whereas our government has never done this since the pandemic broke (2,3).
As a collective we share concerns around the vulnerability of our children and young people. We worry for the children at home, hidden from society and some living with the perpetrator of their abuse. Their voices and cries cannot be heard.
Calls to Childline have dramatically increased (4) and domestic violence arrests are up by 25% (5) but by contrast, our child protection referrals are down. Teachers, social workers, health visitors, community midwives – all partners in safeguarding - have had their interaction with children and young people reduced.
As paediatricians on the frontline, we have seen an overall decline in attendances to the emergency department (ED) but witnessed families and young people coming to ED for issues that would have been absorbed by community and safeguarding teams: babies exhibiting poor weight gain who may have been picked up via our community services pre-Covid-19; distressed mothers bringing their constantly crying babies who may have avoided medical attention with the presence of extended family to support; parents presenting late with their septic babies, fearful to come to hospital due to the virus.
We worry for the mental health of young people who we are seeing attending ED in crisis with nowhere to turn. Their triggers are varied (6) but isolation has certainly played a part (7). Having previously been warned of the dangers of spending too much time in cyberspace, children and young people are now spending a vast amount of time online for education and socialisation and the risks are very real (8). Meanwhile their lives are on hold, impacting both emotional resilience and mental wellbeing.
Protecting children is everyone’s responsibility and never have those words been more meaningful. We must all act now to give children a voice: not just the professionals to whom this role would ordinarily be given, but their local communities. By empowering neighbours, delivery drivers, supermarket workers and those who now may be the only ones seeing our young, through education, they may speak up and report any concerns to the NSPCC or Children’s social care.
We call upon Government to direct resources to enable community workers from health, education and social care to visit homes and connect with children at risk. We also need a strategy to safely bring all children back to school.
We call upon Government to move quickly and decisively to try and repair the harm suffered by young, vulnerable people during this pandemic. Failure to do so will come at a price too high.
Where is the voice of the child in weighing the cost of this pandemic? These children need a voice.
1. Green P. Risks to children and young people during covid-19 pandemic BMJ 2020; 369 :m1669. https://www.bmj.com/content/369/bmj.m1669?fbclid=IwAR0ouFiLolxwtE5m1h-3R...
2. Young, E. 'It’s okay to be scared’: Norway PM holds children-only COVID-19 press conference’. SBS News. 2020 March 17.. https://www.sbs.com.au/news/it-s-okay-to-be-scared-norway-pm-holds-child...
3. Ainge Roy, E. Jacinda Ardern holds special coronavirus press conference for children, The Guardian. 2020 March 19. https://www.theguardian.com/world/2020/mar/19/jacinda-ardern-holds-speci...
4. Morgan, T. Coronavirus: Child abuse calls to NSPCC up 20% since lockdown. BBC News. 2020 April 30. https://www.bbc.co.uk/news/uk-wales-52473453?intlink_from_url=https://ww...
5. Kelly, J & Morgan, T. Coronavirus: Domestic abuse calls up 25% since lockdown, charity says. BBC News. 2020 April 6. https://www.bbc.co.uk/news/uk-52157620
6. Gombert-Waldron, K. Children and stress, what’s worrying them most, Children’s Commissioner. 2020 May 20. https://www.childrenscommissioner.gov.uk/2020/05/20/children-and-stress-...
7. Young Minds. Coronavirus having major impact on young people with mental health needs – new survey. 2020 March 30. https://youngminds.org.uk/about-us/media-centre/press-releases/coronavir...
8. Girlguiding. Girlguiding research briefing: Early findings on the impact of Covid-19 on girls and young women. 2020 May. https://www.girlguiding.org.uk/globalassets/docs-and-resources/research-...
Competing interests: No competing interests
Risks to children during the pandemic: some essential epidemiology for parents, clinicians and policymakers
Difficult decisions are being made worldwide variably about how best to protect children from the direct and indirect consequences of COVID-19. The different policies of European countries in relation to children returning to school are an example of confusing variability.
Peter Green warns of the dangers of scarring a whole generation given our systems of child protection have been severely curtailed during the pandemic. Given multiple unknowns, we think caution from parents and carers is natural, not least because we need to understand the implications of the rare inflammatory syndrome reported in recent weeks. However, caution in the form of shielding is not itself risk free and children cannot be kept at home if we want them to thrive.
To help provide some context for parents, teachers, clinicians and policymakers grappling with this, we examined age-specific mortality data which shows that deaths from COVID-19 fortunately remain infrequent in children and young people. Across the USA, England, Italy, Germany, Spain, France and Korea there were 43 deaths from COVID-19 in 0-19 year olds (total population 135,691,226) in the three months to 12 May 2020 [4–6]. In this period, in these countries, we estimated from published Global Burden of Disease data that we would expect more than 36,000 deaths from all causes in this age group, including over 3,000 from unintentional injury and 891 from lower respiratory tract infection including influenza . COVID-19, by this measure, was responsible for an estimated 0.117% of deaths of 0-19 year old in these three months. Results are similar for each country. We provide a data table including deaths by age-categories, and by country online (https://tinyurl.com/child-covid) and welcome feedback on this.
Given these data, we think the medical community should be upfront with parents, carers, teachers, clinicians and decision-makers that the direct impact of COVID-19 on children is currently small in comparison with other risks that children confront, and that the main reason we are keeping children at home is to protect adults. This conclusion may change as the pandemic evolves, and the epidemiology of COVID-19 in children should be closely monitored.
1 Connolly K, Willsher K. European schools get ready to reopen despite concern about pupils spreading Covid-19. The Guardian. 2020.https://www.theguardian.com/world/2020/may/01/children-as-likely-to-spre... (accessed 13 May 2020).
2 Green P. Risks to children and young people during covid-19 pandemic. BMJ 2020;369. doi:10.1136/bmj.m1669
3 Mahase E. Covid-19: concerns grow over inflammatory syndrome emerging in children. BMJ 2020;369. doi:10.1136/bmj.m1710
4 National Institute for Demographic Studies (INED) (distributor). The demography of deaths by COVID-19 (2020) Extract from: https://dc-covid.site.ined.fr/fr/ (Accessed 13 May 2020).
5 Centers for Disease Control and Prevention: National Center for Health Statistics. Provisional Death Counts for Coronavirus Disease (COVID-19). 2020.https://www.cdc.gov/nchs/nvss/vsrr/covid19/index.htm (accessed 13 May 2020).
6 NHS England. COVID-19 Daily Deaths. www.england.nhs.uk/statistics/statistical-work-areas/covid-19-daily-deaths/ (accessed 13 May 2020).
7 Global Burden of Disease Study 2017 (GBD 2017) Data Resources | GHDx. http://ghdx.healthdata.org/gbd-2017 (accessed 13 May 2020).
Competing interests: No competing interests
The COVID-19 crisis so far seems to be less intruding for children’s physical condition and it affects older people disproportionately. Much effort must be spent to control COVID-19 in this older age group and improve their living conditions, including quality of care. But this first impression is misleading. Once mortality and morbidity caused by COVID-19 are controlled in Western countries, the current state of primary health care for children also requires a forward view to improve the primary health care of the youngest generation.
Despite the expected economic shortfalls foreseen in the coming years, we must guarantee prolongation of effective primary health care systems available for children and adolescents. But we also need to thrive for the improvements recommended in the EU financed Models of Child Health Care Appraised (MOCHA) research project, www.childhealthservicemodels.eu .
So far, the mechanism of viral resistance for COVID-19 in children and young people is unknown. We probably do not need to be concerned about direct effects on their physical health, however, we do need to be concerned about their social and psychological condition caused by the COVID-19 crisis. It can be expected that children and especially those from disadvantaged families, will bear the health consequences of the crisis the world has fallen in.
Children from low income and migrant populations witness a disproportionate high morbidity and mortality among family members afflicted by COVID-19 . They will also disprortionately experience the health consequences of the economic crisis and associated austerity, already significant . Moreover, there are signs the lockdown affects the mental health of children and adolescents. The number of children who are victim of abuse, or witness of abuse and domestic violence, is expected to rise. The confinement through measures such as staying at home, not seeing friends and avoiding physical contact will also cause stress in children and adolescents.
There are also early signs that vaccination rates are dropping, and a parallel likelihood that children are not being presented early enough for lesser health problems or developmental delays – either because services are currently restricted, or because of concern at taking children to heavily protected settings . The combination of focussing service redesign onto adult services, and the growing backlog of preventive and early diagnosis needs, bring a new double jeopardy to health services for children.
Yet the pre-pandemic baseline is itself deficient. We bring to readers’ attention a selection of the worrying issues the MOCHA research project brought to light. They need attention from primary care professionals and policy makers, especially in current circumstances with low budgets, making it even more desperate to bring about child health care systems’ change.
1. The immunization rate of children already gradually dropped in many European countries last years. The current children’s underuse of primary care due to COVID-19 will further influence this decline in the current cohorts ready to be immunized. This backlog has to be repaired as soon as possible putting primary care facilities for an enormous task to continue its immunization program. Hopefully vaccine hesitant parents have now become more aware of the viral threat and need for immunization of their child. COVID-19 underlines the need for EU countries to work together to align immunization programs and communicate about the importance of immunization. We have seen the impact of ‘fake news’ on the immunization rates, which we will have to continue to countervail. A uniform message should be brought to the public, based on science and supported by (social) media expertise: vaccination is the main tool and the safest way to prevent communicable diseases. At the same time, delivery systems should be better tuned to the needs of busy parents with employment as well as varied caring commitments, and to their concerns about indivuidual health issues [5,6].
2. Primary health care systems should secure a free access to mental health care for young people having experienced abuse or COVID-19 stress. They as ever should have access to child friendly units that can provide comprehensive care in a neutral empathetic climate and secure confidentiality when requested. It is currently unclear in which contexts and settings confidential access should be guaranteed to adolescents. Discussions and agreement in the EU on access with and without parental consent is needed.
3. Professionals in primary care and school health services should be trained in mental health consequences of COVID-19. They should be skilled to identify adolescents who need psychological support or treatment, and to respond or refer adequately .
4. The MOCHA research project concluded that availability of data on health indicators for children and adolescents is poor and data are often incomparable between EU countries. Improved data collection and registration systems are needed that provide health care professionals at all levels with information and feedback. Such data systems are essential to monitor and compare the health and social consequences of the COVID-19 crisis for young people (Rigby et al, 2020). They also enable the evaluation of measures taken to control COVID-19 in EU-countries and anticipate future developments.
Primary health care systems’ improvements and data availability are unconditional to achieving a demonstrable healthy population of well-developed and happy children and adolescents, especially in low-income groups. This must be evident from figures on immunization rates, children’s psychosocial health and quality of care. We are aware of the enormous challenges our economic and health care systems face but claim attention to the care for the youngest generation – the adverse legacy of the Covid-19 pandemic will be further deepened if the health of the emergent next generation is also compromised. Therefore we must not forget to invest in the care for this future generation who can contribute to avoid such crisis as we are in now.
Paul L. Kocken PhD, research on behaviour change and policy at Erasmus School of Social and Behavioural Sciences, Erasmus University Rotterdam, the Netherland, firstname.lastname@example.org
Danielle E.M.C. Jansen PhD, chair section Child and Adolescent Public Health, EUPHA, Research on organization of care for children and adolescents at Department of Health Sciences, University Medical Center Groningen, the Netherlands, email@example.com
Daniela Luzi, research on models based on clinical standards and quality indicators at National Research Council Institute for Research on Population and Social Policies IRPPS, Italy, firstname.lastname@example.org
Prof dr Michael Rigby, Emeritus Professor of Health Information Strategy at the School of Social, Political and Global Studies and School of Primary, Community and Social Care, Keele University, United Kingdom, Visiting Professor, Section of Paediatrics, Imperial College London, for the duration of the MOCHA project, email@example.com
1. Blair M, Rigby M, Alexander D (eds). Issues and Opportunities in Primary Health Care for Children in Europe: The Final Summarised Results of the Models of Child Health Appraised (MOCHA) Project. Emerald, Bingley, 2019. doi/book/10.1108/9781789733518. Open Access at https://www.emerald.com/insight/content/doi/10.1108/978-1-78973-351-8201...
2. ICNARC report on COVID-19 in critical care. Intensive Care National Audit & Research Center, London, 2020. https://www.icnarc.org/Our-Audit/Audits/Cmp/Reports (accessed May 15 2020)
3. Rigby MJ. Potentially over 3 million children in EU Europe believed not to be receiving needed medical and dental treatment—and parents' reasons why. Child Care Health Dev 2020;1–7. https://doi.org/10.1111/cch. 12757
4. Lazzerini M, Barbi E, Apicella A, Marchetti F, Cardinale F, Trobia G. Lancet Child Adolesc Health 2020, https://doi.org/10.1016/S2352-4642(20)30108-5
5. Expert Panel on Effective Ways of Investing in Health. Programmes and Health Systems in The European Union; Brussels, 2018 (available at https://ec.europa.eu/health/expert_panel/sites/expertpanel/files/020_vac...)
6. Bedford H, Attwell K, Danchin M, Marshall H, Corben P, Leask J. Vaccine hesitancy, refusal and access barriers: The need for clarity in terminology; Vaccine 2018;36:6556–6558. https://doi.org/10.1016/j.vaccine.2017.08.004
7. Michaud PA, Visser V, Vervoort JPM, Kocken PL, Reijneveld SA, Jansen DEMC. Availability and accessibility of mental health services for adolescents: national recommendations and services in E.U. European Journal of Public Health, accepted
8. Rigby MJ, Deshpande S, Blair M. Child health research and planning in Europe disadvantaged by major gaps and disparities in published statistics; European Journal of Public Health, 2020, doi: https://doi.org/10.1093/eurpub/ckaa052
Competing interests: No competing interests
We read with interest the Editorial by Peter Green about the risks to children and young people in the UK during the COVID-19 pandemic . The article is published around the same time when there is an increasing confirmed case of COVID-19 in children and young people in Bangladesh. The first three patients were reported on March 08, 2020, and as of May 05, 2020, there were 10,929 confirmed cases of COVID-19, including 183 deaths . Of all COVID-19 cases, approximately 3%, 8%, and 26% were aged under 10 years, 11-20 years and 21-30 years, respectively . Apart from the risk of being exposed to the infection, these children and young people are at higher risk of adverse health outcomes including obesity, neglect and abuse by parents, and thus more prone to increased mental health and chronic health issues such as obesity.
To prevent the rapid outbreak of the pandemic, the Government of Bangladesh first decided to close all educational institutions on March 16, and all other economic sectors (except some emergency services) on March 26, with strict enforcement to stay at home . The present situation amid COVID-19 has led the children and young people into a sedentary lifestyle, idleness, and physical inactivity which may increase the incidence of obesity, and other chronic diseases such as diabetes mellitus, cardiovascular diseases, and some types of cancers . The lack of social contact, loss of income of parents, continuous media coverage, and anxiety of uncertainty related to COVID-19 pandemic may have adverse psychological effectsleading to post-traumatic stress disorder (PTSD) [5-6]. Family violence can also rise during restrictions because of an economic crisis which will increase the risk of child abuse . They can also be highly addicted to social media, pornography websites, and video games; and long-term closure of educational institutes may adversely affect their learning. The Government of Bangladesh has adopted to telecast educational programs for primary and high school students through Television, which is appreciated. However, this might lead to extra pressure on students from low-income families who do not own a medium to connect to those programs.
Socioeconomically disadvantaged people are at a higher risk for poor physical and mental health in Bangladesh. About 9.2% of people in Bangladesh live in extreme poverty (daily income below $1.90) . The economic shutdown due to COVID-19 pandemic threatens millions of people. The prevalence of undernutrition among Bangladeshi children is relatively higher compared to other developing countries , which can rise due to the food crisis. The children of extremely low-income families often involve in the diverse workforce like the construction sector, agriculture, garment industry, waste-picking, transportation, among others for a little amount of money. Child labour is common in both rural and urban areas in Bangladesh, with almost 1.2 million children aged between 5 and 14 engaged in the workforce . These child labourers cannot earn to support their family.
Moreover, many children in Bangladesh are homeless and live on the street and in rail stations, making them more vulnerable to infection. However, the child labourer and street children are already abused as well as neglected, and COVID-19 might have a severe impact on their daily life, physical and mental health. Furthermore, the youth unemployment rate in Bangladesh was 12% in 2018 . Also, many young people will lose their job due to COVID-19. The unemployed young people are also at higher risk for engaging in different crimes, drug addiction and mental disorders.
Children and young people in Bangladeshi are concerned about adverse emotional and physical outcome due to COVID-19. Community-based programs and strategies are needed to reduce the risk of adverse outcome among them, especially in those who live with poverty, engage in the labour force and are currently unemployed.
1. Green P. Risks to children and young people during covid-19 pandemic. BMJ 2020;369:m1669. https://doi.org/10.1136/bmj.m1669.
2. Institute of Epidemiology, Disease Control and Research (IEDCR). Covid-19 Status Bangladesh. https://www.iedcr.gov.bd/. Accessed on: May 05, 2020.
3. World Heath Organization. Covid-19 situation report no. 04. Available at: https://www.who.int/docs/default-source/searo/bangladesh/covid-19-who-ba.... (Accessed on: May 05, 2020).
4. Chakravarthy MV, Joyner MJ, Booth FW. An obligation for primary care physicians to prescribe physical activity to sedentary patients to reduce the risk of chronic health conditions. Mayo Clinic Proceedings 2002;77:165-173. https://doi.org/10.4065/77.2.165.
5. Douglas M, Katikireddi SV, Taulbut M, McKee M, McCartney G. Mitigating the wider health effects of covid-19 pandemic response. BMJ 2020;369:m1557. https://doi.org/10.1136/bmj.m1557.
6. Chiolero A. Covid-19: a digital epidemic. BMJ 2020;368;m764. https://doi.org/10.1136/bmj.m764.
7. Asian Development Bank. Basic Statistics 2020. Avaiable at: https://www.adb.org/countries/bangladesh/poverty. Accessed on: May 05, 2020.
8. Rahman MS, Rahman MA, Maniruzzaman M, Howlader MH. Prevalence of undernutrition in Bangladeshi children. Journal of Biosocial Science 2019:1-14. https://doi.org/10.1017/S0021932019000683.
9. International Labour Organization. Child Labour in Bangladesh. Available at: https://www.ilo.org/dhaka/Areasofwork/child-labour/lang--en/index.htm.
Accessed on: May 05, 2020.
10. Bangladesh Youth Unemployment Rate 1991-2020. Avaiable at: https://www.macrotrends.net/countries/BGD/bangladesh/youth-unemployment-.... Accessed on: May 05, 2020.
Competing interests: No competing interests
It was with great interest that I read the timely editorial by Peter Green on the heightened risk of child abuse and neglect during the COVID-19 pandemic (1), particularly in areas where a lockdown or curfew has been imposed. There is already enough evidence to suggest that this is the case in several countries, and that it is accompanied by a heightened risk of spousal abuse, which can further compromise the care and well-being of children (2).
Successful approaches to the prevention and management of this grave problem depend crucially on the use of an appropriate theoretical framework that would permit both a realistic appraisal of risk and the development of effective protective and therapeutic strategies. In this case, the perspective of John Bowlby, founder of attachment theory, on the topic of violence in the family is worth recalling (3). Seen from this viewpoint, perpetrators of violence against their own children have often themselves been exposed to threats of violence and abandonment, if not actual violence itself, during childhood. These vulnerabilities lead to an insecure attachment style, characterized by mistrust, anger, anxiety, and difficulty in generating helpful responses when their own child is distressed.
This attachment system can be activated by external threats or environmental dangers (4), which would include not only the COVID-19 pandemic but the privations and restrictions necessitated in order to contain it (5). This leads to maladaptive emotional responses, such as anxiety and anger, the effects of which are exacerbated by social isolation and a lack of support (3), as well as by socioeconomic deprivation (6).
Furthermore, perceived threats or dangers - such as a disease outbreak, quarantine or lockdown - can also activate the child's own innate attachment response, leading to behaviours such as increased clinging to parents and irritability. Such behaviours have already been documented in young children (aged 3-6 years) during the COVID-19 lockdown (7). The result is a vicious circle, in which an anxious child's increased demand for attention evokes an angry and violent response from a vulnerable parent, which in turn evokes further "undesirable" behaviours from the parent's point of view - thus perpetuating the cycle of violence.
Following this model, an effective response to the problem of child abuse and neglect during the COVID-19 outbreak requires a multifaceted approach. First, environmental factors that evoke insecure attachment responses should be controlled or minimized where possible. This would require the identification and provision of material and psychological assistance to vulnerable families; ensuring the continuity of social bonds and contacts in communities without compromising infection control; the dissemination of accurate information to minimize paranoia and panic at the broader social level; and, finally, communicating effectively with children who may have an inaccurate understanding of the sudden changes taking place around them (8). Second, more direct intervention in specific cases could include volunteer-based befriending and parent training programmes, under the supervision of a medical or social work professional (2). These may be delivered using remote communication if direct contact is imprudent, and will need to be adapted to the parenting practices and patterns of specific cultures (9).
It is hoped that such knowledge of such a perspective will be helpful to therapists as well as to those involved in planning and implementing health and social policies during this crisis, in order to protect the well-being of children, particularly their psychological health (2, 4).
1. Green P. Risks to children and young people during covid-19 pandemic. BMJ [Internet]. 2020;369. Available from: https://www.bmj.com/content/369/bmj.m1669
2. Usher K, Bhullar N, Durkin J, Gyamfi N, Jackson. Family violence and COVID-19: increased vulnerability and reduced options for support. Int J Ment Health Nurs 2020 Apr 20. [Online ahead of print.] https://doi.org/10.1111/inm.12735.
3. Bowlby J. Violence in the family. In: Bowlby J, A Secure Base: Parent-Child Attachment and Healthy Human Development. London; Routledge, 1988.
4. Bowlby J. Attachment and loss. Vol. 1: attachment. London; Hogarth Press, 1969
5. van Gelder N, Peterman A, Potts A et al. COVID-19: reducing the risk of infection might increase the risk of intimate partner violence. EClinicalMedicine 2020 Apr 2. [Online ahead of print.] https://doi.org/10.1016/j.eclinm.2020.100348
6. Stansfeld S, Head J, Bartley M, Fonagy P. Social position, early deprivation and the development of attachment. Soc Psychiatry Psychiatr Epidemiol 2008; 43: 516-26. https://doi.org/10.1007/s00127-008-0330-4
7. Jiao WY, Wang LN, Liu J et al. Behavioral and emotional disorders in children during the COVID-19 epidemic. J Pediatr 2020 Mar 13. [Online ahead of print.] https://doi.org/10.1016/j.jpeds.2020.03.013
8. Dalton L, Rapa E, Stein A. Protecting the psychological health of children through effective communication about COVID-19. Lancet Child Adolesc 2020; 4: 346-347. https://doi.org/10.1016/S2352-4642(20)30097-3.
9. Keller H: Universality claim of attachment theory: children’s socioemotional development across cultures. PNAS 2018; 115: 11414-11419. https://doi.org/10.1073/pnas.1720325115
Competing interests: No competing interests
The safeguarding of children and young people during the COVID-19 pandemic has rightly become a topic of concern (1).
Unfortunately, it appears unlikely that this government will change direction with regard for its concern for child health. A new statutory instrument, which relaxes an array of safeguards for children, was laid on 23/04/2020 (2). It came into force just one day later, thus bypassing the conventional 21-day grace period in Parliament.
Some changes to the legislation allow for practical workarounds in light of social distancing. Yet others seem to have little to do with the pandemic itself. For example, contained in the new statutory instrument is an amendment to the Residential Family Centres Regulations (3) which weakens provisions for the health and welfare of residents. Before, the law stated that the registered person (the centre’s manager) “[must] ensure… proper provision” for children’s health. Now, it only directs that they “use reasonable endeavours” (2).
Another example is the amendment to The Children’s Homes (England) Regulations 2015 (4). Here, the duty to maintain adequate conditions in Children’s Homes, specifically that children’s care “is delivered by a person who— (i) has the experience, knowledge and skills to deliver that care; and (ii) is under the supervision of a person who is appropriately skilled and qualified to supervise that care”, is relaxed (2,4). Since the instrument’s passing, children in Children’s Homes only have the right to receive care from a suitably qualified person “as far as reasonably practicable” (2).
Moreover, some of the changes contained in the instrument have been proposed before, only to be withdrawn after considerable public outcry (5,6).
Safeguarding has significant implications for children’s health outcomes (7), and so it is troubling that, instead of bolstering children’s protections, the government appears to be undermining them.
It is no surprise, then, that this instrument has drawn considerable criticism from Article 39, a children’s rights charity (6). They note an apparent lack of consideration for the UK’s obligations under the UN Convention on the Rights of the Child. Relatedly, the UK ranks low (170/181) on the Kid’s Rights Index (8), which comprises an assessment of the rights to education, life, health, and protection, as well as an enabling environment for child rights.
In lieu of a portal (9), I fear this pandemic may instead be an opportunity for the government to pursue ideological goals with little scrutiny. This has been the case for other European governments (10,11). Children and young people, especially children in institutional settings, must have their needs met and their concerns heard. After all, it is children and young people who will have to live with the devastating effects of this pandemic. Yet, as the government has signalled, it is precisely this group being made more vulnerable in an already precarious time.
1. Green P. Risks to children and young people during covid-19 pandemic. BMJ [Internet]. 2020;369. Available from: https://www.bmj.com/content/369/bmj.m1669
2. UK Government. The Adoption and Children (Coronavirus)(Amendment) Regulations 2020 [Internet]. 2020. Available from: https://www.legislation.gov.uk/uksi/2020/445/made/data.pdf
3. UK Government. The Residential Family Centres Regulations [Internet]. 2002. Available from: http://www.legislation.gov.uk/uksi/2002/3213/pdfs/uksi_20023213_en.pdf
4. UK Government. The Children’s Homes (England) Regulations 2015 [Internet]. 2015. Available from: care is delivered by a person who—%0A%0A(i)has the experience, knowledge and skills to deliver that care; and%0A%0A(ii)is under the supervision of a person who is appropriately skilled and qualified to supervise that care
5. Walker P. Greening drops plans to allow councils to opt out of child protection laws. The Guardian [Internet]. 2017 Mar 3; Available from: https://www.theguardian.com/society/2017/mar/03/greening-drops-plans-to-...
6. Article 39. Ministers use COVID-19 to destroy children’s safeguards [Internet]. 2020 [cited 2020 Apr 30]. Available from: https://article39.org.uk/2020/04/23/ministers-use-covid-19-to-destroy-ch...
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Competing interests: No competing interests
Re: Risks to children and young people during covid-19 pandemic: The Reverse Titanic phenomenon: “Women and children last” – the implications of the COVID-19 pandemic and health system shock on reproductive, perinatal, and paediatric health
The COVID-19 pandemic has led to abrupt changes in health service delivery, from face-to-face to largely virtual interactions, to protect those vulnerable to the virus (beneficial) and reacting to staff shortages (potentially harmful). This dislocation of care is exacerbated by social distancing requirements. For the elderly and adults with significant co-morbidities, this is clearly evidence-based, but may result in deleterious delays in care seeking by those with acute health events (e.g., myocardial infarction and stroke). For young women and children who usually experience mild symptoms of COVID-19, these changes in service delivery may have gone too far, jeopardising non-COVID-19 related health.
When the Titanic suffered an abrupt and catastrophic maritime shock, the safety and survival of women and children were prioritised, however this health system shock may have resulted in an inadvertent reverse Titanic phenomenon. There has been increasing concern about the impact on pregnant women and children, as voiced by the UK Secretary of State for Health and professional groups such as the Royal Colleges of Midwifery (RCM), Obstetrics and Gynaecology (RCOG), Paediatrics and Child Health (RCPCH), and General practice (RCGP) .
To reduce infection risks to pregnant women and respond to staff shortages, the RCOG’s regularly updated national guidance has advised reconfiguration of antenatal services towards virtual appointments for women with both low- and high-risk pregnancies, and reduced ultrasound services and community visits . The UK Government has cautioned that pregnant women may be at higher risk of severe COVID-19-related illness and should be especially compliant with social distancing . Similar guidance from the RCPCH covers: COVID-19 preparations, occupational health, 'shielding' advice for vulnerable children and young people, safeguarding and child protection, and services normally delivered in acute/emergency, neonatal and community settings .
What are the measured and potential implications of these changes in behaviour?
Previous Coronavirus epidemics (e.g., SARS, MERS) were probably associated with additional maternal and perinatal risks . A meta-analysis of maternal and perinatal adverse outcomes related to COVID-19 has observed that while the risk of preterm birth and Caesarean delivery are increased, maternal and serious neonatal morbidity appear to be unaltered ; however, most of this evidence comes from China and the USA, with higher levels of intervention, especially Caesarean delivery, than the UK. Current screening measures are missing close to 90% of COVID-19 positive pregnant women, as this proportion are asymptomatic .
In the political sphere outside the UK, some politicians, known to be inclined to limit women’s reproductive choices, have used the pandemic as an excuse to reduce access to abortion services .
Social distancing is having both direct and indirect impacts on antenatal and paediatric care. As many as 50% of pregnant women will have a condition or complication that necessitates additional appointments or multidisciplinary care during pregnancy. Similarly, children with long-term and complex medical conditions need multidisciplinary care, and when acute exacerbations occur often require face-to-face consultations. Antenatal appointments that do not require measurement of fundal height, blood or urine tests, or scans; and non-urgent paediatric appointments can and should be provided virtually.
The World Health Organization recommendations for antenatal care state that the major auditable standard for a prenatal visit is the measurement of blood pressure . Despite a significant NHS investment in home blood pressure monitoring targeting pregnant women with known hypertension, the rapid shift to virtual care reduces face-to-face visits by two per pregnancy. Therefore, blood pressure measurement is missing from the care of most previously normotensive women. Most pregnancy hypertension arises at term, and without detection and appropriate clinical response, including normalising blood pressure , increases the risks associated with severe pregnancy hypertension . Individual units should identify clinicians capable of assessing and triaging risks of fetal growth disorders to assist with triaging of referrals; whether in person or remote. As individual units’ demands in each of the categories (moderate and high) will vary, units may need to make local decisions about risk factor prioritisation within and across categories.
For paediatrics, a system of triaging and providing virtual clinics is needed; integrated care can provide improved outcomes , and system transformations are underway in several areas .
Clinicians are reporting widespread and shared observation of reductions in hospital attendances by pregnant women to early pregnancy, day assessment, and triage units, with associated reductions in referrals for both maternal and fetal indications. This is likely to result in unintended negative effects of COVID-19 related to delayed presentation and resulting complications from early (e.g., ectopic pregnancy) to late (e.g., stillbirth) pregnancy.
Similarly, in child health, there are documented sharp declines in emergency department attendances for children with acute illnesses including potentially life-threatening conditions such as asthma and acute respiratory infections , and a growing concern by RCPCH and RCGP about reported falling vaccination rates and the potential for resurgent vaccine-preventable infections such as measles . We need to monitor the maternal, perinatal and child health consequences of the COVID-19 pandemic; the challenge will be discriminating between the direct (e.g., COVID-19 infection) and indirect (e.g., altered care seeking) causes.
Services should offer a combination of face-to-face and remote care, according to the woman’s and baby’s/child’s needs, while prioritising face-to-face visits for women and children with: (i) known psycho-social vulnerabilities; (ii) operative birth; (iii) prematurity/low birthweight; or (iv) other medical, neonatal, and childhood chronic conditions and complexities.
There is likely to be a COVID-19 legacy through changes in maternity and child health, and through the health system response to the shock caused by the pandemic. While the Titanic disaster resulted in significant improvements in maritime design, the COVID-19 pandemic has the potential to catalyse important, beneficial, and cost-effective health system improvements in the medium and long term. This acute phase of risks to reproductive, perinatal and child health must be acknowledged and measured. Health system responses must be monitored, and lessons learnt from innovations and challenges - both to improve future pandemic planning and health system performance during more stable times.
We have read and understood the BMJ Group policy on declaration of interests and declare the following interests: none.
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Competing interests: No competing interests