I agree that the full impact of the COVID-19 lockdown on children and young people will continue to unfurl over the months and years ahead. As paediatricians we constantly battle to have the voices of children heard in hard pressed hospital trusts and other environments. But out of the fire our services must rise like phoenixes as we have the opportunity to redesign systems available to better enrich and support children.
One commonly recognised 'benefit' of the pandemic has been the dramatically reduced number of admissions to children's wards. This is not unique to the UK and was previously noted in both China and Italy primarily reassuring us that COVID-19 as an acute infection in children is dramatically different from adults. [1,2] However, the reduction in hospital attendances has not just been the lack of COVID infections but also a reduction on other expected acute presentations. In our paediatric respiratory service, we have seen hospital attendances of children with acute asthma/wheeze fall, almost overnight, from 3-5 children per day to 1-2 children per week since the lockdown. Overall attendance with asthma/ wheeze are approximately 95% lower than average for this time of year. Initially we feared that this represented families being too scared to attend hospitals but over eight weeks the situation hasn't changed, our asthma nurses are not overwhelmed with calls from worried parents of unwell children and our telephone outpatient reviews find most children in reportedly rude health.
So why has this change occurred? Sub-optimal adherence to prescribed controller therapy is a common factor in poor asthma control. It is possible that patients have become more assiduous in their adherence to treatment regimens driven by fear and public service broadcasts. This is difficult to assess objectively. Poor air quality is a recognised trigger for acute respiratory disease. The lockdown has produced substantial reductions in use of motor vehicles and air travel which should have resulted in improvement in air quality. Surprisingly air quality indices, including average daily PM10 and Nitrogen dioxide, measured in the locality of our hospital do not seem to show significant changes which could account for the reduction. [3] Other potential risk factors for asthma as highlighted in the editorial including 'toxic stress', 'poor quality and overcrowded housing' and reduced organised exercise seem to have manifested into acute attacks. [4]
The most significant change for the majority of children has been the closure of schools and distancing from their friends. For those who have been attending school during the lockdown, they are in smaller, socially distanced classes. Historically, hospital attendances with acute asthma decrease during school vacations but not to the same extent as seen in March 2020, presumably because in ‘normal’ times children continue to socialise outside their immediate family. It would therefore seem plausible that the transmission of other respiratory viruses has been halted by the unique measures put in place for the lockdown.
Asthma morbidity and mortality of children in the UK has been highlighted as a problem in recent years in comparison to our European neighbours. As we start to rebuild our society from the pandemic, we should learn from these unusual circumstances to see if other institutional factors can be improved to reduce non-COVID morbidity. Whilst the importance and benefits of school and education are undeniable, we should perhaps reflect on the environments that we put our children into and the impact that this may have on their health and in particular asthma. Whether it be the size and state of the school buildings, overcrowded classrooms with 30 children or the expectations of hand hygiene, all of which may impact on the spread of viruses. Looking forwards, it will be interesting to see how rapidly acute asthma presentations recur as schools re-open, particularly during the next winter viral season.
Children will be affected by COVID-19 for much of their lives educationally, financially and emotionally. As paediatricians we need to ensure that they benefit from any lessons learned through this unique time. Maybe one opportunity for our education policy makers is to review potential harms caused by current education system.
1. Clinical characteristics of COVID-19 in children compared with adults in Shandong Province, China. Du, W. Yu, J. Wang, H. et al. Infection 2020 https;//doi.org/10.1007/s15010-020-01427-2
2. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lazzerini, M. Barbi, E. Apicella, A. et al. Lancet Child Adolesc Health 2020; https://doi.org/10/1016/S2352-4642(20)30108-5
3. https://www.londonair.org.uk
4. Children are being sidelined by covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2061
Competing interests:
No competing interests
02 June 2020
Richard J Chavasse
Consultant Respiratory Paediatrician
St. George's University Hospitals NHS Foundation Trust
Rapid Response:
Re: Children are being sidelined by covid-19
Dear Editor,
I agree that the full impact of the COVID-19 lockdown on children and young people will continue to unfurl over the months and years ahead. As paediatricians we constantly battle to have the voices of children heard in hard pressed hospital trusts and other environments. But out of the fire our services must rise like phoenixes as we have the opportunity to redesign systems available to better enrich and support children.
One commonly recognised 'benefit' of the pandemic has been the dramatically reduced number of admissions to children's wards. This is not unique to the UK and was previously noted in both China and Italy primarily reassuring us that COVID-19 as an acute infection in children is dramatically different from adults. [1,2] However, the reduction in hospital attendances has not just been the lack of COVID infections but also a reduction on other expected acute presentations. In our paediatric respiratory service, we have seen hospital attendances of children with acute asthma/wheeze fall, almost overnight, from 3-5 children per day to 1-2 children per week since the lockdown. Overall attendance with asthma/ wheeze are approximately 95% lower than average for this time of year. Initially we feared that this represented families being too scared to attend hospitals but over eight weeks the situation hasn't changed, our asthma nurses are not overwhelmed with calls from worried parents of unwell children and our telephone outpatient reviews find most children in reportedly rude health.
So why has this change occurred? Sub-optimal adherence to prescribed controller therapy is a common factor in poor asthma control. It is possible that patients have become more assiduous in their adherence to treatment regimens driven by fear and public service broadcasts. This is difficult to assess objectively. Poor air quality is a recognised trigger for acute respiratory disease. The lockdown has produced substantial reductions in use of motor vehicles and air travel which should have resulted in improvement in air quality. Surprisingly air quality indices, including average daily PM10 and Nitrogen dioxide, measured in the locality of our hospital do not seem to show significant changes which could account for the reduction. [3] Other potential risk factors for asthma as highlighted in the editorial including 'toxic stress', 'poor quality and overcrowded housing' and reduced organised exercise seem to have manifested into acute attacks. [4]
The most significant change for the majority of children has been the closure of schools and distancing from their friends. For those who have been attending school during the lockdown, they are in smaller, socially distanced classes. Historically, hospital attendances with acute asthma decrease during school vacations but not to the same extent as seen in March 2020, presumably because in ‘normal’ times children continue to socialise outside their immediate family. It would therefore seem plausible that the transmission of other respiratory viruses has been halted by the unique measures put in place for the lockdown.
Asthma morbidity and mortality of children in the UK has been highlighted as a problem in recent years in comparison to our European neighbours. As we start to rebuild our society from the pandemic, we should learn from these unusual circumstances to see if other institutional factors can be improved to reduce non-COVID morbidity. Whilst the importance and benefits of school and education are undeniable, we should perhaps reflect on the environments that we put our children into and the impact that this may have on their health and in particular asthma. Whether it be the size and state of the school buildings, overcrowded classrooms with 30 children or the expectations of hand hygiene, all of which may impact on the spread of viruses. Looking forwards, it will be interesting to see how rapidly acute asthma presentations recur as schools re-open, particularly during the next winter viral season.
Children will be affected by COVID-19 for much of their lives educationally, financially and emotionally. As paediatricians we need to ensure that they benefit from any lessons learned through this unique time. Maybe one opportunity for our education policy makers is to review potential harms caused by current education system.
1. Clinical characteristics of COVID-19 in children compared with adults in Shandong Province, China. Du, W. Yu, J. Wang, H. et al. Infection 2020 https;//doi.org/10.1007/s15010-020-01427-2
2. Delayed access or provision of care in Italy resulting from fear of COVID-19. Lazzerini, M. Barbi, E. Apicella, A. et al. Lancet Child Adolesc Health 2020; https://doi.org/10/1016/S2352-4642(20)30108-5
3. https://www.londonair.org.uk
4. Children are being sidelined by covid-19. BMJ 2020; 369 doi: https://doi.org/10.1136/bmj.m2061
Competing interests: No competing interests