Delayed access to care and late presentations in children during the COVID-19 pandemic: a snapshot survey of 4075 paediatricians in the UK and Ireland.

The UK has witnessed large reductions in children attending emergency departments (ED) and paediatric assessment units (PAU) during the COVID-19 pandemic,1 which began in late January and peaked in mid-April before declining.2 These reductions raised concerns about the late presentation of critical illness in children. To address this, the British Paediatric Surveillance Unit undertook a snapshot electronic survey on 24 April 2020 of 4075 paediatric consultants representing >90% of paediatric consultants in the UK and Ireland, asking whether, during the previous 14 days, they had seen any children who, in their opinion, presented later than they would have expected prior to the COVID-19 pandemic (ie, delayed presentation).

Over the next 7 days, 2433 (60%) paediatricians responded. Overall, 241 (32%) of 752 paediatricians working in ED/PAU had witnessed delayed presentations, with 57 (8%) reporting ≥3 patients with delayed presentation. Delayed presentation reports ranged between 14% in Wales and 47% in the Midlands (figure 1). Free text responses revealed diabetes mellitus (new diagnosis/diabetic ketoacidosis) as by far the most common delayed presentation,3 but also sepsis and malignancy (table 1). There were also nine deaths where delayed presentation was considered a contributing factor, resulting mainly from sepsis and malignancy.

Figure 1

Number of paediatricians working in different clinical areas by region in the UK and Ireland who responded to the survey and the proportion who reported delayed presentation in children during the previous 14 days. ED, emergency department; PAU, paediatric assessment unit.

Table 1

Summary of the main conditions reported in children and the perinatal period and deaths where delayed presentation was considered by the reporting paediatrician to be a contributing factor

n
Top 5 delayed diagnoses reported
Diabetes mellitus (diabetic ketoacidosis)	44 (23)
Sepsis	21
Child protection	14
Malignancy	8
Appendicitis	6
Delayed perinatal presentations
Pregnant women presenting late in labour	2
Hypoxic ischaemic encephalopathy	1
Unbooked pregnancy resulting in adverse outcomes	1
Poor feeding after early hospital discharge	2
Dehydration following poor feeding	4
Reported deaths associated with delayed presentation
Sepsis	3
New diagnosis of malignancy	3
Cause not reported	2
New diagnosis of metabolic disease	1

Of the paediatricians working on hospital wards and in clinics, 18% (178 of 997) had also witnessed delayed presentations. Neonatologists’ concerns included late presentations during labour resulting in adverse maternal/neonatal outcomes and early hospital discharges after birth due to COVID-19 concerns before feeding had been established and infants then returning with feeding difficulties and severe dehydration (table 1). Community paediatricians and oncologists were particularly concerned by the fall in referral rates for child protection and cancer assessment, respectively.

A 60% response rate in 7 days highlights the importance given to the survey by paediatricians in the UK and Ireland and the widespread professional concern about delayed presentations. Elsewhere, others have raised concerns about declining immunisation rates,4 and the mental health and well-being of children during lockdown.5 While the information collected in the survey was subjective and based on the opinion of individual paediatricians, and although we do not have baseline data for comparison, our findings highlight an urgent need to improve public health messaging for parents, which until recently instructed everyone to stay at home. Children attending primary care and hospitals remain at very low risk for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. Parents should continue to access medical care if they are concerned and must not delay getting emergency treatment if their child appears seriously ill. Otherwise, the unintended consequences of the lockdown will do more harm and claim more children’s lives than COVID-19.

BPSU Scientific Committee: Nick Bishop, Dr Gavin Dabrera, David Elliman, Lamiya Samad, Ellen Pringle, Simon Nadel, Marc Tebruegge, Hani Ayyash, Sarah Clarke, Chenqu Suo, Jane Sutton, Madeleine Wang, Peter Davis, Ifeanyichukwu Okike, Robert Negrine, Arlene Reynolds.