Abstract
The coronavirus disease 2019 (COVID-19) pandemic and related community mitigation measures had a significant psychosocial impact. We suspected that more patients were admitted to our pediatric intensive care unit (PICU) for toxic ingestions since the start of the pandemic. We therefore investigated if PICU admissions related to toxic ingestions were higher in 2020 as a result of COVID-19 compared with previous years. We completed a cross-sectional study at a tertiary children's hospital comparing admissions to our PICU between April 2020 and October 2020, during which COVID-19 and community mitigation measures were in place, to those during the same 7-month period in the previous 3 years. Total PICU admissions, admissions for all toxic ingestions (intentional ingestions and accidental ingestions), and demographic and clinical characteristics of patients were compared. Total PICU admissions in 2020 during COVID-19 pandemic months were lower compared with the same months in the preceding 3 years (−16%, p < 0.001), however, admissions for toxic ingestions were higher during COVID-19 (+64%, p < 0.001). When separated by type, intentional (+55%, p = 0.012) and accidental ingestions (+94%, p = 0.021) were higher during COVID-19. COVID-19 with community mitigation measures has led to an increase in PICU admissions for intentional and accidental ingestions, indicating an increase in severity of toxic ingestions in children associated with the pandemic. Mental health of adolescents, and safety of infants and toddlers in their home environment, should be targeted with specific interventions in the ongoing COVID-19 pandemic.
Keywords: COVID-19, pediatric intensive care unit, pandemic, toxic ingestion
Introduction
Intentional ingestion is the most frequently used suicide attempt method in adolescents. 1 In infants and toddlers, accidental ingestion is a frequent indication for pediatric intensive care unit (PICU) admission. 2 Reports have suggested that the coronavirus disease 2019 (COVID-19) pandemic, with its associated community mitigation measures, has negatively impacted the mental health of adolescents, 3 while increased time at home has been suggested to lead to more accidental ingestions in infants and toddlers. 4 5 School closures and therefore the increased exposure to potentially hazardous home environments for children, have been associated with households reporting more injuries and ingestions during the COVID-19 pandemic compared with households without children. 6 It has been our impression that more patients were admitted to our PICU for toxic ingestions associated with the COVID-19 pandemic. We therefore aimed to investigate if PICU admissions for toxic ingestions were higher in 2020 during COVID-19 pandemic months with community mitigation measures when compared with the same months in the 3 preceding years.
Methods
We conducted this cross-sectional study to review PICU admissions to a tertiary children's hospital when COVID-19 with community mitigation measures were in place (April 1st through October 31st, 2020) in the large multistate hospital catchment area by comparing with the same 7-month period in the previous 3 years (2017–2019). The Nemours institutional review board approved this study (IRB # 1676802–2) with waiver for informed consent for this retrospective study. The principles of the Helsinki declaration were followed in the conduct of the research. 7 We included patients who were admitted to the PICU with diagnoses of intentional or accidental toxic ingestions. The primary indication for PICU admission for all patients included was related to their toxic ingestion. There were no institutional changes to the structured approach to define need for PICU admission in this patient population across the time periods studied. Demographic and clinical data, including the types of toxic ingestion, were obtained from the electronic medical record. The Pediatric Risk of Mortality (PRISM) score 8 was retrieved for each patient included. We compared total PICU admissions per month, PICU admissions for all toxic ingestions, PICU admissions for intentional toxic ingestions per month, and PICU admissions for accidental toxic ingestions per month between the months with COVID-19 and community mitigation measures in 2020 and the previous 3 years using Poisson regression. To assess if there were ongoing COVID-19 independent temporal trends in total, intentional, or accidental toxic ingestions, we performed separate Poisson regressions in the three control years with factor “year.” Demographic and clinical characteristics of patients admitted for intentional or accidental toxic ingestions during months with COVID-19 and community mitigation measures were compared with characteristics of patients admitted during months in the preceding 3 years prior to COVID-19 using Mann-Whitney Rank Sum tests, and Fisher's exact tests with Freeman Halton extension for nominal variables with more than two possible categories. 9 Normality of data was tested using the Shapiro-Wilk test. IBM SPSS (Armonk, New York, United States) was used for all analyses. A p -value of <0.05 was considered significant.
Results
Total admissions in 2020 during which COVID-19 and community mitigation measures were in effect were significantly lower compared with the same months in the preceding 3 years (102 ± 27 vs. 122 ± 13; −16%, p < 0.001; Table 1 ). At the same time, total admissions per month for toxic ingestions were significantly higher during months with COVID-19 and community mitigation measures (10 ± 4.5 vs. 6.1 ± 3.1; +64%, p < 0.001). Intentional (7.1 ± 3.3 vs. 4.6 ± 2.6; +55%, p = 0.012) and accidental (2.9 ± 1.5 vs. 1.5 ± 1.3; +94%, p = 0.021) toxic ingestions, when analyzed separately, were significantly higher during months with COVID-19 and community mitigation measures as well. During COVID-19 months in 2020 there were a total of 70 admissions for toxic ingestions of which 50 were for intentional toxic ingestion and 20 were for accidental toxic ingestion. During the control months in the preceding 3 years there were a total of 128 admissions for toxic ingestions of which 97 were for intentional toxic ingestion and 31 were for accidental toxic ingestion. In the 3 years used as control period (2017–2019) we did not find a significant temporal trend in total ( p = 0.19 for year), intentional ( p = 0.13), or accidental ( p = 0.42) toxic ingestions.
Table 1. Pediatric intensive care unit (PICU) admission characteristics per month during the coronavirus disease 2019 (COVID-19) pandemic with community mitigation measures (April–October 2020) and admission characteristics per month during the previous 3 years (April–October 2017–2019).
|
Pre COVID-19
a
mean ± SD median (IQR) |
COVID-19 mean ± SD median (IQR) |
Exponentiated coefficient (95% CI) | p -Value | |
|---|---|---|---|---|
| Overall PICU admissions per month | 122 ± 13 | 102 ± 27 | 0.84 (0.77–0.91) | <0.001 |
| 123 (113–129) | 115(72–123) | |||
| Total PICU admissions for toxic ingestion per month | 6.1 ± 3.1 | 10 ± 4.5 | 1.64 (1.23–2.20) | <0.001 |
| 6 (3–8) | 9 (7–13) | |||
| Intentional toxic ingestion PICU admissions per month | 4.6 ± 2.6 | 7.1 ± 3.3 | 1.55 (1.10–2.18) | 0.012 |
| 4 (3–7) | 6 (4–9) | |||
| Accidental toxic ingestion PICU admissions per month | 1.5 ± 1.3 | 2.9 ± 1.5 | 1.94 (1.10–3.40) | 0.021 |
| 1 (1–2) | 3 (2–4) |
Abbreviations: IQR, interquartile range; SD, standard deviation.
Pre-COVID-19 is the reference category.
In patients admitted for intentional toxic ingestions, demographic and clinical characteristics were similar, with median age approximately 15 years and roughly three quarters of patients being female, although length of stay in the PICU tended to be longer during COVID-19 (median 1.31 days vs. median 1.01, p = 0.051; Table 2 ). Patients admitted for accidental toxic ingestion were younger (median 2.0 vs. 2.4 years, p = 0.029) and stayed longer in the PICU (median 0.97 vs. 0.75 days, p = 0.023) during months with COVID-19 when compared with prior years. The pharmacological types of ingestion were similar between COVID-19 and control months. The severity of ingestions appeared similar as evidenced by similar PRISM scores, need for mechanical ventilation, and continuous renal replacement therapy or hemodialysis. There was no mortality associated with ingestions during any time periods.
Table 2. Demographic and clinical characteristics of pediatric intensive care unit (PICU) patients admitted for intentional toxic ingestion and accidental toxic ingestion during the coronavirus disease 2019 (COVID-19) pandemic with community mitigation measures (April–October 2020) and during the same period in the previous 3 years (2017–2019).
| Pre-COVID-19 ( n = 96) | COVID-19 ( n = 50) | p -Value | |
|---|---|---|---|
| Intentional toxic ingestion | |||
| Age in years, median (IQR) | 15.2 (14.1–16.4) | 15.1 (14.5–15.8) | 0.843 a |
| Sex, male/female, n (%) | 21/75 (22/78) | 13/37 (26/74) | 0.680 b |
| Type of ingestion, n (%) | 0.822 b | ||
| Alcohol | 2 (2) | 1 (2) | |
| Alpha blocker | 1 (1) | 0 (0) | |
| Analgesic | 11 (12) | 4 (8) | |
| Anticholinergic | 1 (1) | 2 (4) | |
| Anticonvulsant | 4 (4) | 0 (0) | |
| Antidepressant | 15 (16) | 9 (18) | |
| Antihistamine | 7 (7) | 4 (8) | |
| Antipsychotic | 2 (2) | 0 (0) | |
| Polypharmacy | 38 (40) | 25 (50) | |
| Sedative | 3 (3) | 0 (0) | |
| Stimulant | 2 (2) | 1 (1) | |
| Unknown | 10 (10) | 4 (8) | |
| Pediatric Risk of Mortality score, median (IQR) | 0 (0–3) | 0 (0–3) | 0.964 a |
| Pediatric Risk of Mortality death risk, median (IQR) | 0.34 (0.34–0.71) | 0.34 (0.34–0.71) | 0.622 a |
| Mechanical ventilation, n (%) | 10 (10) | 5 (10) | 1.000 b |
| Continuous renal replacement therapy, n (%) | 1 (1) | 0 (0) | 1.000 b |
| Hemodialysis, n (%) | 0 (0) | 0 (0) | 1.000 b |
| Length of PICU stay in days, median (IQR) | 1.01 (0.71–1.51) | 1.31 (0.81–1.93) | 0.051 a |
| Mortality, n (%) | 0 (0) | 0 (0) | 1.000 b |
| Pre COVID-19 ( n = 31) | COVID-19 ( n = 20) | p -Value | |
| Accidental toxic ingestion | |||
| Age in years, median (IQR) | 2.4 (1.5–4.4) | 2.0 (0.9–2.3) | 0.029 a |
| Sex, male/female, n (%) | 21/10 (68/32) | 12/8 (60/40) | 0.765 b |
| Type of ingestion, n (%) | 0242 b | ||
| Analgesic | 7 (23) | 7 (35) | |
| Anticonvulsant | 2 (7) | 1 (5) | |
| Antidepressant | 0 (0) | 4 (20) | |
| Antihistamine | 1 (3) | 0 (0) | |
| Antihypertensive | 2 (7) | 1 (5) | |
| Antipsychotic | 1 (3) | 0 (0) | |
| Cannabis | 2 (7) | 0 (0) | |
| Kerosene | 1 (3) | 0 (0) | |
| Polypharmacy | 6 (19) | 1 (5) | |
| Sedative | 4 (13) | 5 (25) | |
| Stimulant | 3 (10) | 1 (5) | |
| Sulfonylurea | 1 (3) | 0 (0) | |
| Unknown | 1 (3) | 0 (0) | |
| Pediatric Risk of Mortality score, median (IQR) | 0 (0–1.5) | 0 (0–3) | 0.655 a |
| Pediatric Risk of Mortality death risk, median (IQR) | 0.34 (0.34–0.69) | 0.34 (0.34–0.71) | 0.838 a |
| Mechanical ventilation, n (%) | 2 (6) | 3 (15) | 0.369 b |
| Continuous renal replacement therapy, n (%) | 0 (0) | 0 (0) | 1.000 b |
| Hemodialysis, n (%) | 0 (0) | 0 (0) | 1.000 b |
| Length of PICU stay in days, median (IQR) | 0.75 (0.54–1.00) | 0.97 (0.82–1.45) | 0.023 a |
| Mortality, n (%) | 0 (0) | 0 (0) | 1.000 b |
Abbreviation: IQR, interquartile range.
Mann-Whitney Rank sum test.
Fisher's exact test. Data was tested for normality using the Shapiro-Wilk test.
Note: Significant p -values < 0.05.
Discussion
PICU admissions for toxic ingestions were significantly increased in the months during which COVID-19 and community mitigation measures were in effect when compared with prior years, while overall PICU admissions were lower. Intentional and accidental toxic ingestions were significantly increased independently as well.
Our findings are clinically relevant since there were already an estimated 8,554 (children ≤5 years) and 27,328 (children 13–19 years) pediatric patients with moderately severe to deadly cases of toxic ingestions in the United States each year 10 prior to the COVID-19 pandemic. Our findings are in line with reports that have identified ingestions representing a larger proportion of total pediatric emergency department visits during COVID-19 compared with prior years. 11 12 However, our report is the first of our knowledge to describe the impact of COVID-19 and community mitigation measures on PICU admissions for toxic ingestions. In contrast to visiting the emergency department, PICU admission indicates at least a moderately severe intoxication from ingestion with increased risk of morbidity and mortality. Our results indicate an increase in severity of toxic ingestions in children associated with the COVID-19 pandemic.
Increased PICU admissions for intentional toxic ingestions may be due to reduced access to mental health services through clinical and school programs, while higher admissions for accidental toxic ingestions may be due to increased time spent without adequate supervision at home in infants and toddlers as caretakers are trying to balance working from home with childcare. The impact of COVID-19 and community mitigation measures on mental health in adolescents, as well as its impact on the safety of infants and toddlers in their home environment, deserves attention from clinicians and government agencies. Children's mental health during public health emergencies can have both short- and long-term consequences to their overall health and well-being. 13 As a result of the COVID-19 pandemic, pediatric specialties in particular have noted reduced immunization rates and outpatient well child visits. 14 15 16 Adolescents may have missed annual pediatrician appointments during this time and as a result, depression screening tools and mental health resources as well.
In the context of the current renewed intense community mitigations in many U.S. states related to the increase in COVID-19 cases, increasing the availability of mental health services outside the in-person setting would seem to be important. 17 Suicide attempts by intentional ingestion in children and adolescents have previously been temporally associated with school year months as opposed to summer vacation months. 18 However, our data were collected while children were not attending in-school services, and yet the incidence of intentional ingestions was increased compared with prior years. These findings indicate that the time at home during the COVID-19 pandemic had a different effect on children's mental health than the normal school break during summer months, likely related to the loss of in-school mental health services, outpatient clinical resources, and significant increase in social isolation. Predictive models of COVID-19 suggest continued periods of social distancing may continue, 19 disrupting in-person school instruction and childcare, indicating an urgent need for home safety promotion and education going forward.
Unintentional ingestions in younger children result from a combination of developmental and environmental factors, however these injuries are often predictable and can be largely prevented. In the United States, each year, approximately 1 million poison exposures among children younger than 6 years of age are reported to the American Association of Poison Control Centers, with over 90% of exposures occurring in homes. 20 Prevention of accidental ingestions in infants and toddlers could include product safety strategies such as child-proof packaging, storage, and locking devices to prevent access for children, and legislation about taste and smell being used as a deterrent in certain products. Receiving information on poison prevention and home safety may have been missed altogether for families who have not been able to follow-up regularly with their pediatricians during the pandemic, due to appointment availability or interruptions in insurance coverage. Even when provided, counseling regarding poison prevention at regular follow-up visits, as recommended by the American Academy of Pediatrics 21 may not have been as effective during telehealth appointments. Health education campaigns to increase public and health professional awareness regarding the importance of poison-proofing homes and keeping toxic items out of reach of children could be incorporated in some public messaging regarding COVID-19 community mitigation measures.
Limitations
A limitation of this study is that it was conducted at a single center, which limited the sample size. However, a benefit of this approach is that our data are not influenced by varying participation of hospitals in databases on a national level. 12
Compared with previous studies 11 12 we primarily aimed to analyze a potential increase in total toxic ingestion admissions per month as opposed to analyzing an increase in ingestions as an increased proportion of total cases versus previous years, which could be influenced by an overall lower number of patients presenting at the hospital during COVID-19. Our hospital catchment area has been stable during the study period and the indications for PICU admission surrounding toxic ingestions have not changed during the study period. We did not find any significant temporal trends in total, intentional, or accidental toxic ingestions, suggesting that the observed changes are specific to changes due to COVID-19. A previous study on pediatric admission in the emergency department, similar to our design, used grouped patients from months in the calendar years 2017 to 2019 as controls for the COVID-19 period. 11
Pediatric patients in our multistate catchment area have always been referred to pediatric facilities for observation or admission for toxic ingestions. While surrounding adult facilities were much busier during the pandemic, we do not believe that would have significantly affected referral rates to our facility. However, the increased length of stay for patients in the PICU, particularly younger patients, may have been influenced by the COVID-19 pandemic, as total pediatric admissions were decreased and the need to transfer patients out of the ICU was reduced, while proper testing and isolation also became important factors in regard to transferring patients.
We believe that the significantly increased absolute number of PICU admissions for ingestions, while overall PICU admissions were significantly lower, represents an important and generalizable result, which informs national concerns about the psychosocial impact of the pandemic on children.
In conclusion, COVID-19 with community mitigation measures has led to an increase in PICU admissions for intentional and accidental toxic ingestions. These findings are consistent with an increase in severe toxic ingestions requiring intensive care admission. Given the unpredictable nature of the COVID-19 pandemic in the coming months, mental health of adolescents and safety of infants and toddlers should be targeted with specific interventions in the ongoing COVID-19 pandemic with renewed intense community mitigations measures in many U.S. states.
Footnotes
Conflict of Interest None declared.
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