Reply to letter to the editor regarding New York's COVID-19 shelter-in-place and acute appendicitis in children.

Dear Editor,

Thank you to Dr. Hassoun and colleagues [1] for their comments on our manuscript [2]. The varying experiences across the New York area during the peak of the COVID-19 pandemic in our region highlight how differences in access to care, transfers within and across hospital networks, and rates of the disease within neighborhoods make it difficult to track cases and efficiently allocate resources.

During the height of the pandemic in New York, our pediatric ER expanded its criteria to accommodate all patients more than 30 years of age presenting with any disease process to help offload the burden of the adult hospital. Given this, and the hospital-wide shifts in care delivery, we are unable to compare our volumes during the pandemic to prior years.

Further, we would hesitate to extrapolate our experience at Cohen's during this unprecedented 5-week period to the underlying etiology of acute appendicitis. Variation in case volumes and presentation may be because of a wide host of reasons, as Hassoun and colleagues enumerate. In normal times, parents of children with abdominal pain may variously choose to present to their pediatrician, urgent care centers, and emergency departments of local and referral hospitals, to say nothing of the expansion of virtual visits during the pandemic. The factors at play for each individual family in deciding how, when, and where to seek medical care for an ill child are complex. A more comprehensive study of patients presenting with acute appendicitis, including all hospitals within a large catchment region, would be useful to help tease out whether total cases of appendicitis and rates of perforation were different during the pandemic.