Abstract and Introduction
Introduction
Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic.[1,2] CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0–17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non–COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents.
CDC assessed data from the National Syndromic Surveillance Program (NSSP)* for three surveillance periods: March 15, 2020–January 2, 2021 (2020), January 3, 2021–January 1, 2022 (2021), and January 2, 2022–January 29, 2022 (January 2022), and compared them with corresponding weeks in 2019 from health care facilities consistently† reporting data during 2019– January 2022. Data were evaluated by total visits among children and adolescents aged 0–17 years, and by three age groups (0–4, 5–11, and 12–17 years), and visit diagnoses. The Healthcare Cost and Utilization Project (HCUP) Clinical Classifications Software Refined (CCSR) (version 2022; CCSR) tool§ was used to group International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes into clinically meaningful diagnostic categories. All ICD-10-CM codes associated with an ED visit were mapped to CCSR categories using a one-to-many approach: a visit with multiple codes could be counted across more than one category; however, if multiple codes in a single visit mapped to the same category, the visit was counted only once. CDC selected 15 categories with the largest increases and decreases in number of mean weekly visits and identified 20 categories with the largest relative change measured by visit ratios (VRs)¶ and 95% CIs; CIs that excluded 1 were considered statistically significant. Categories with both largest change in mean weekly visits and in VRs were included only once. To retain practical relevance, categories were restricted to those with a total difference of ≥100 visits between surveillance and comparison periods. All analyses were conducted using R software (version 4.1.2; R Foundation). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.**
Pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022, compared with 2019 (Figure 1), with some differences by age (Figure 2) but negligible differences between sexes. Overall, the largest decreases in mean weekly visits and proportion of visits were for non–COVID-19 respiratory illnesses when compared with 2019; however, proportion of visits for fever increased during January 2022 (Supplementary Table 1, https://stacks.cdc.gov/view/cdc/114478). The largest increases in mean weekly visits during 2020–2022 occurred in diagnostic categories for infectious disease exposure and screening, and COVID-19. Proportion of visits also increased for infectious disease exposure and screening. Number and proportion of visits related to pedal cycle injuries and visits for some chronic conditions and their treatment (e.g., specific cancers, cancer therapy, and connective tissue disorders) also increased, with pandemic year and pediatric age variations.
Figure 1.
Weekly number of emergency department visits* among children and adolescents aged 0–17 years — National Syndromic Surveillance Program, United States, 2019–2022
Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*NSSP is a collaboration among CDC, local, and state health departments, and federal, academic, and private sector partners. To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with a coefficient of variation ≤40 and average weekly informative discharge diagnosis ≥75% complete with consistent discharge diagnosis code formatting throughout 2019–2022. Visits from 1,674 facilities from 41 states were eligible to be included in the study. All facilities from three counties in California (El Dorado, Plumas, and Yosemite), the District of Columbia, Florida, Guam, Hawaii, Maryland, Nebraska, Ohio, Oklahoma, South Dakota, Virginia, Wyoming, and one facility from Washington were excluded because they do not meet one of the inclusion criteria. https://www.cdc.gov/nssp/index.html
Figure 2.
Weekly number of emergency department visits* among children and adolescents aged 0–17 years, by age group — National Syndromic Surveillance Program, United States, 2019–2022
Abbreviations: ED = emergency department; NSSP = National Syndromic Surveillance Program.
*NSSP is a collaboration among CDC, local, and state health departments, and federal, academic, and private sector partners. To reduce artifactual impact from changes in reporting patterns, analyses were restricted to facilities with a coefficient of variation ≤40 and average weekly informative discharge diagnosis ≥75% complete with consistent discharge diagnosis code formatting throughout 2019–2022. Visits from 1,674 facilities from 41 states were eligible to be included in the study. All facilities from three counties in California (El Dorado, Plumas, and Yosemite), the District of Columbia, Florida, Guam, Hawaii, Maryland, Nebraska, Ohio, Oklahoma, South Dakota, Virginia, Wyoming, and one facility from Washington were excluded because they do not meet one of the inclusion criteria. https://www.cdc.gov/nssp/index.html
Compared with 2019, the number and proportion of cannabis-involved visits among children aged 0–4 years increased during 2020 and 2021, with an increase of eight visits per week in 2020 (VR = 3.94) and an increase of 15 visits per week during 2021 (VR = 3.14). The number and proportion of firearm injury visits among children in this age group also increased during 2020 and 2021, with an increase of three visits per week during 2020 (VR = 4.20) and two visits per week during 2021 (VR = 2.33). Similarly, the number and proportion of visits for psychosocial factors among children aged 0–4 years increased during 2021 and January 2022, with an increase of 38 visits per week during 2021 (VR = 1.53) and 55 visits per week during January 2022 (VR = 1.91) compared with 2019. The number and proportion of visits for neurodevelopmental disorders among children in this age group also increased during 2021 and January 2022, with an increase of 18 visits per week during 2021 (VR = 1.35) and 45 visits per week during January 2022 (VR = 1.71) (Supplementary Table 2, https://stacks.cdc.gov/view/cdc/114478). During January 2022, although visits for epilepsy decreased by 35 visits per week and visits for respiratory symptoms (e.g., cough) decreased by 2,063 visits per week in this age group, the proportion of visits increased both for epilepsy (VR = 1.37) and respiratory symptoms (VR = 1.12).
Among children aged 5–11 years, the number and proportion of cannabis-involved visits increased during 2020 and 2021 compared with 2019, with an increase of four visits per week during 2020 (VR = 3.72) and an increase of nine visits per week during 2021 (VR = 3.54) (Supplementary Table 3, https://stacks.cdc.gov/view/cdc/114478). The number and proportion of visits for psychosocial concerns also increased during 2021 and January 2022 compared with 2019, with an increase of 20 visits per week during 2021 (VR = 1.74) and 35 visits per week during January 2022 (VR = 2.18). During 2021, the number and proportion of visits for firearm injuries, self-harm, and drug-poisoning were higher compared with 2019, with an increase of two visits per week for firearm injuries (VR = 2.01), six visits per week for self-harm (VR = 1.69), and seven visits per week for drug poisoning (VR = 1.55). During January 2022, although the number of visits for viral infection, fever, and epilepsy decreased compared with 2019, the proportion of visits increased, with a decrease of 286 visits per week for viral infection (VR = 1.26), a decrease of 814 visits per week for fever (VR = 1.11), and a decrease of 38 visits per week for epilepsy (VR = 1.29).
Among adolescents aged 12–17 years, during 2020, 2021, and January 2022, the number and proportion of visits for injuries from physical activities (e.g., walking, swimming, and running) decreased compared with 2019, with decreases of 1,669 visits per week during 2020 (VR = 0.80), 966 visits per week during 2021 (VR = 0.80), and 757 visits per week during January 2022 (VR = 0.72). Conversely, the number and proportion of visits for self-harm increased in all 3 years, with increases of 30 visits per week during 2020 (VR = 1.77), 210 visits per week during 2021 (VR = 1.59), and 207 visits per week during January 2022 (VR = 1.48). Similarly, the number and proportion of visits for drug poisonings and eating disorders increased during all 3 years compared with 2019, with increases of 12 visits per week for drug poisonings during 2020 (VR = 1.72), 171 visits per week during 2021 (VR = 1.53), and 178 visits per week during January 2022 (VR = 1.43); and increases of nine visits per week for eating disorders during 2020 (VR = 2.00), 41 visits per week during 2021 (VR = 2.14), and 38 visits per week during January 2022 (VR = 1.92) (Supplementary Table 4, https://stacks.cdc.gov/view/cdc/114478). The number and proportion of visits for firearm injuries increased by 22 visits per week (VR = 2.43) during 2020 and by 20 visits per week during January 2022 (VR = 1.69) compared with 2019. The number and proportion of visits for psychosocial concerns and for symptoms of mental health conditions and substance use increased during 2021 and January 2022, with increases of 78 visits per week during 2021 (VR = 1.66) and 62 visits per week during January 2022 (VR = 1.48) for psychosocial concerns and increases of 113 visits per week during 2021 (VR = 1.35) and 197 visits per week during January 2022 (VR = 1.43) for symptoms of mental conditions and substance use. In January 2022, the number and proportion of visits for respiratory symptoms (e.g., cough) increased by 905 visits per week (VR = 1.55).
Morbidity and Mortality Weekly Report. 2022;71(8):313-318. © 2022 Centers for Disease Control and Prevention (CDC)
