Pediatric ED Visits Before and During the COVID-19 Pandemic

Discussion

Pediatric ED visits sharply declined in the United States during 2020 compared with 2019,^[1] and although the weekly numbers of visits have varied, ED visits remained lower during 2021 and January 2022 compared with those before the pandemic.^[2] These declines might be associated with parents' and caregivers' risk perception and avoidance of EDs or health care, among other reasons. Despite overall declines, weekly ED visits did increase for children aged 0–4 years at the end of 2021, aligning with the increased circulation of the B.1.1.529 (Omicron) variant of SARS-CoV-2, the virus that causes COVID-19, in the United States. These increases were not observed in children aged 5–11 and adolescents aged 12–17 years; both age groups were eligible for vaccination at the end of 2021. COVID-19–associated visits, and those for exposure and screening for infectious disease, were the top two visit diagnoses for children of all age groups during January 2022. Being up to date with vaccinations is critical for adults and eligible children and adolescents^†† to prevent infection, severe illness, or death from COVID-19,^[3,4] and might reduce strain on health care resources. Supplementary testing^§§ strategies for COVID-19 can further alleviate the impact of the pandemic on EDs.^[3,5]

The proportion of visits for non–COVID-19 respiratory illnesses mostly declined across all periods examined, suggesting that COVID-19 prevention measures might have reduced transmission of other respiratory viruses as well.^[6] However, during January 2022, the proportion of visits for fever, viral infection, and respiratory symptoms such as cough increased, with variations by age group. Clinicians should remain vigilant for potentially changing clinical COVID-19 presentations associated with the Omicron variant,^[7] as well as any newly emergent variants of concern.

Elevated proportions of visits for some other diseases, including some chronic conditions and treatments (e.g., cancer therapies), might indicate delay of care and routine well child visits; reduced screening; or postponed procedures to reallocate medical resources during the pandemic.^[1,2] Health care systems should encourage caregivers of children and adolescents to seek necessary and scheduled care.

Higher numbers and proportions of cannabis-involved visits among children aged 0–11 years during 2020 and 2021 might be associated with increases in unintentional ingestion. Although there was some variation by pandemic year, increases in visits with certain injuries across all age groups (e.g., firearm injuries), as well as among children and adolescents aged 5–17 years (e.g., drug poisoning and self-harm), are consistent with reports of increased overdose and violence outcomes during the pandemic.^[8] Factors affecting caregivers, including unavailable or unpredictable child care, illness, financial hardship, and mental health concerns, might increase children and adolescents' vulnerabilities. Children and adolescents' loss of parents or other caregivers,^[9] increases in other adversities, and disruptions in daily routine because of the COVID-19 pandemic^¶¶ might also increase children and adolescents' behavioral health concerns and unhealthy coping behaviors. Comprehensive prevention strategies,***^{,†††,§§§} including strengthening supports to reduce family stress; enhancing access to services and resources; safe storage of firearms and other lethal means; and limiting accessibility to drugs such as cannabis, to reduce use among children and adolescents; can help address these factors. Further, increases in visits for other behavioral concerns and eating disorders align with previous findings, suggesting that the COVID-19 pandemic has exacerbated already high rates of mental health concerns among children and adolescents^¶¶¶,****.^[10] In addition to those who routinely treat children and adolescents' mental and behavioral health, educators and others who work with children and adolescents can also help identify symptoms of distress and unhealthy coping behaviors that might warrant further intervention.

The findings in this report are subject to at least five limitations. First, NSSP ED visit data are a convenience sample and should not be considered nationally representative. Second, fluctuations in underlying data quality, coding practices, and variations in lengths of surveillance periods, particularly during January 2022, might not be reflective of trends from a longer period, potentially over- or underrepresenting visit trends. To help account for this, visit data were analyzed only from facilities with consistent reporting during the study period. Third, many factors, including patterns of care-seeking, changed during the COVID-19 pandemic, and this study was not able to draw conclusions about the underlying prevalence of these conditions outside EDs. Fourth, this report assessed trends in ED visits with one or many diagnosis codes; multiple visits by the same patient are possible, and each would be counted separately. Finally, this analysis could not ascertain which diagnosis was the primary reason for the visit; any visit with a relevant diagnosis was included in that clinical category.

Health care systems should be aware of indirect effects of delayed medical care and maintain vigilance for signs of exacerbated emotional distress and behavioral health concerns, especially among older children and adolescents. Prevention programs that improve children and adolescents' physical and mental health are critical during and after emergencies. Reducing COVID-19 infection through vaccination and other nonpharmaceutical prevention strategies can further protect pediatric health.