COVID-19, primary care, and paediatrics: winter is coming

Children are unlikely to get sick, need hospitalisation, or die from COVID-19.¹ This is a demonstrable fact that has been well known since the very first data sets to come out of China.² Infrequently is data so clear cut. Medicine and disease, however, are rarely so simple. Schools re-opening combined with the approaching winter viral season will inevitably lead to an increase in paediatric infections. In the current climate new barriers to health care, namely fear of COVID-19 and the lack of easily accessible face-to-face GP appointments, are likely to result in late presentations with non-COVID-19 illnesses and increased harm. We need to start planning to prevent this.

FEAR OF THE VIRUS

The media and, to a certain extent, the medical profession have increased anxiety both among parents and GPs about the dangers of COVID-19 in children. The media’s publication³ of a very small number of children developing PIMS-TS, a multisystem inflammatory disorder similar to Kawasaki disease,⁴ has caused understandable anxiety among parents. Similarly the relentless focus on concerns about opening schools has led some parents to conclude it is not safe, resulting in poor attendance.⁵

During previous viral outbreaks, such as the H1N1 scare, evidence showed that presentations to medical services went up when the initial ‘fear’ was publicised.⁶ During this pandemic, however, the opposite has happened. A&E attendances in the UK have significantly reduced; by 33% in June 2020 compared to the previous year.⁷

The climate of fear has had severe consequences. A group of increased deaths and significant harm were reported in North London recently, many of these caused by a delayed presentation to hospital.⁸

BARRIERS TO PRIMARY CARE

There is scant evidence that remote assessments are effective in acute paediatrics.

Under pre-COVID-19 circumstances children often attended A&E when their care could have been more effectively managed in primary care.⁹ Easy access to a GP has been shown to reduce presentations to A+E by 9%.¹⁰ Primary care, then, should offer a potential alternative to A&E during this period.

Unfortunately, COVID-19 has created a situation in general practice where there is, in appearance at least, a reluctance to see patients face-to-face.¹¹ This is especially the case if they are ‘hot’ with potential COVID-19 symptoms. This problem will be amplified as childhood respiratory viruses, with their associated ‘hot’ symptoms, begin to rise due to a combination of seasonal winter peaks¹² and increased social mixing between children.¹³

A PERFECT STORM

This combination of factors may create a perfect storm, with parents scared to attend A&E due to concerns about COVID-19 coupled with a reluctance of GPs to see ‘hot’ patients and potentially delivering substandard care over the telephone. This could result in delayed presentations similar to those seen in North London but on a much larger scale.

Immediate action is needed to consider how we deal with the surge in ‘hot’ paediatric patients this winter. We need to make it clear to parents that GPs and A&E are open for business and create a safe, easily accessible system by which children can be seen face-to-face to minimise any risk of increased harm.¹⁴