Discussion
In this descriptive cross- sectional study, including 512 children who
presented to the ED for asthma related symptoms during 3 time periods in
two consecutive years, we demonstrated different patterns in ED visits
and in hospitalizations during pre-lockdown, lockdown and post lockdown
periods, compared with 2019.
There was no difference in the demographic data between the groups
except for trend towards older age during 2020 compared with 2019. Male
predominance, as can be expected among this pre-pubertal age group, was
observed.13 The majority of our patients during all
time periods were of Bedouin Arab descent, with a significant increase
in their visits during lockdown. This could be explained by the low
socioeconomic status of the Bedouin population in southern Israel, some
which are living in large families with overcrowding, poor
accommodations/housing conditions, and limited access to health care in
some of the settlements14. In those areas, social
distancing is more difficult to achieve and the exposure to outdoor
allergens was probably not significantly reduced, even during the
lockdown. The mildly lower heart rate and respiratory rate noticed in
2020 is clinically insignificant and could stem from the difference in
patients age between 2019 and 2020, with an average of 1.5 years older
in 2020. Since asthma severity parameters (hospitalization rate and LOS)
were higher during 2020B, we can assume that this change in vital signs
did not reflect milder cases, but probably proportionate to an older
age. Treatment in the ED was similar between all time periods except for
a significant drop in the use of NACL 0.9% inhalations during 2020B and
2020C. Since the COVID-19 outbreak, in accordance with the Israeli
pediatric pulmonology society guidelines, there has been a shift from
using small-volume nebulizers to metered-dose inhalers (MDIs) with
valved-holding chambers for beta-agonist and anticholinergic inhalations
in order to reduce the viral infection transmission by reducing the
spread of aerosol mass by small-volume
nebulizers.15,16
The accumulating evidence on the impact of COVID-19 pandemic on ED
visits patterns, show a substantial decrease in the volume of patients
presenting to the ED during the pandemic, throughout various disciplines
and countries.17 Furthermore, there are increasing
reports on higher hospital admission rates, indicating higher acuity
patients, with increased morbidity and mortality due to delayed medical
care in non-COVID-19 emergency conditions. 18-20
In this descriptive cross-sectional study, we compare three parallel
time periods during two consecutive years, and show a significant
decrease in pediatric asthma related ED visits during COVID-19 lockdown.
Similar trends in asthma related ED visits were observed in different
countries, and possible explanations were suggested by the different
authors 11,21-24. Since the major triggers for asthma
exacerbation in the pediatric population are viral infections, it was
expected that social distancing measures during lockdown will decrease
viral infections transmission, including Influenza virus, Rhinovirus and
Respiratory syncytial virus (RSV)25, 26 . Another
important trigger is outdoor exposure to pollen allergens and air
pollution27, again substantially reduced due to
minimal exposure during lockdown and the reduction of industrial
work28. Reduced physical activity during lockdown was
described in large questionnaires studies, along with an increase in
children’s psychological and behavioral symptoms and elevated
screen-time29-31. Socio-affective complications and
insufficient physical activity were underscored as two of the main
concerns, particularly among socio-economic deprived children32. As a result, a reduction in physical activities
reduces the number of asthma exacerbations related to exercise induced
bronchospasm (EIB) and exercise induced asthma (EIA). The fewer ED
visits during lockdown can also result from better asthma control while
the parents are at home, providing better adherence to anti asthmatic
controllers therapy33. Although, this issue is most
probably of limited effect, since most of the parents that participated
in a telephone visit during lockdown, stated they stopped the preventive
therapy as their child was feeling well. Another issue that should be
discussed is the avoidance of approaching for medical care during
lockdown, due to concerns of parents from increased exposure and the
risk of COVID-19 transmission.
After lockdown, we demonstrated significant rise in number of ED visits,
even in comparison to same time period during the previous year. We
speculate this rise represents the return to routine activity with
everyday exposure to classmates, outdoor pollen exposure, rise in air
pollution and physical activity. This may resemble ”September pandemic”,
when children returning to school after summer vacations with
significant rise in asthma exacerbations8.
Alongside with a significant reduction in ED visits for asthma
exacerbations during lockdown, higher hospitalization rates and longer
LOS were observed, that may indicate more severe exacerbations
predominate this period. This observation could be attributed to delay
in presentation both due to reduced availability of community medical
services during lockdown and transition towards telemedicine-based
practice as well as the hesitation to come to the ED due to the fear to
contract COVID-19. Our data indicated that hospitalization rate was 1.5
times higher during lockdown period compared to the previous year, in
contrary to other publications that reported a reduction in the number
of hospitalizations in the pediatric population during this
period23,34. We believe this fact is related to
different demographics between countries, with majority of Bedouin Arab
population in our region. Another possible explanation for the higher
admission rate and longer LOS seen during lockdown could be a lower
threshold for admission at the ER and higher threshold for discharging
the patient from the wards, in light of the reduced availability of
community health care services and the concern of lack of proper
follow-up in the community.
Our study has a few limitations. This is a single tertiary center
experience, and therefore can be influenced, as mentioned, by the unique
demographics in the region. Another limitation is the retrospective
nature of our study, with all data drawn from electronic files. Some of
the data that was documented in a hard copy, in extremely acute patients
treated in the resuscitation room, may be missing in the electronic
files (e.g. intravenous Magnesium Sulfate).
In conclusion , we report a new pattern of ED visits and hospital stay
of children with asthma related symptoms, associated with the COVID-19
pandemic, that perhaps is not only confined to asthma. Pediatricians
should be aware to this phenomenon at the community and hospital levels.