COVID-19 Fears Tied to More Appendix Perforations in Kids

In Virginia, the incidence of perforated appendicitis rose in coincidence with the pandemic-related closure of public schools on March 16, 2020, while emergency department visits declined, a single-center study found.

During the 10-week study period from March 16 to June 7, the pediatric emergency department at Inova Children’s Hospital in Northern Virginia diagnosed 90 children with acute appendicitis, with perforation occurring in 35 cases (39%), which represented an absolute increase of 20% (P=0.009) in the incidence of perforated appendicitis over the same period in 2019, reported Rick Place, MD, MHA, of Virginia Commonwealth University in Richmond, and colleagues.

The analysis, published online in JAMA Network Open, was part of a quality improvement initiative designed to alert the community to the dangers of delayed medical care, the researchers noted, pointing to a concerning pattern of delayed medical care as the pandemic stoked general fears of viral exposure in healthcare settings.

During the study period, eight children (9%) presented with a pelvic abscess requiring initial medical management before delayed interval appendectomy, while none required medical management in the 2019 control period.

Patient volumes in the emergency department also decreased during the pandemic, from a mean of 144 patients per day in 2019 (95% CI 136-152) to 65 per day in 2020, reflecting a 55% decrease (95% CI 39-90, P<0.001), the team reported. There was, however, a nonsignificant increase in the admission rate of 16.4% over the 10 weeks of the 2020 period compared with a baseline admission rate of 10.5% in 2019 (P=0.07).

Parental anxiety about exposing their children to the novel coronavirus is thought to be driving the decline, Place and co-authors said. “Over the 3 months studied, parents displayed visible signs of anxiety when in the emergency department and openly expressed reluctance to visit the hospital for fear of contracting COVID-19.”

Similarly, in May of this year, the CDC reported a dangerous drop in routine childhood vaccinations after the state of emergency was declared on March 13, putting children at risk of other serious infections such as measles and chickenpox. The CDC noted a cumulative COVID-19–related decline of 2.5 million doses in orders for non-influenza pediatric vaccines recommended by the the agency’s Advisory Committee on Immunization Practices and in particular a decline of 250,000 doses of measles vaccines.

In other settings, Lazzerini et al. reported a substantial drop in emergency department and pediatrician visits during Italy’s spring lockdown and described 12 children (four of whom died) presenting in a severe condition because of delays in accessing care.

Such findings parallel those in adults, Place and co-authors pointed out, noting that Garcia et al. reported a 38% pandemic-related decline in cardiac ST-segment elevation myocardial infarction activations, while another study found fewer ischemic stroke patients presenting within the recommended therapeutic window.

Other recent research has observed a significant COVID-related decline in inpatient, outpatient, and emergency department revenues.

Asked for his perspective, C. Anthoney Lim, MD, director of pediatric emergency medicine at Mount Sinai Health System in New York City, who was not involved with the research, said: “Anecdotally, many of our colleagues have experienced children presenting with more severe presentations of pneumonia, diabetes, and other conditions during the initial wave that impacted areas like New York City. This is supported by overall increases in pediatric admission rates resulting from a combination of decreases in minor illnesses and/or increases in severe illnesses that require admission.”

Lim called it an important finding that the severe illnesses were due to delays in seeking care. Overall, pediatric volumes were significantly reduced by general quarantine orders and fell by 55%, but the incidence of appendicitis was about the same at 70 cases versus 90. “This means that children with appendicitis still found their way to hospitals, albeit potentially later in their disease course — hence the resultant increase in perforation rates,” he told MedPage Today.

Such reports often drive larger multisite and population-based studies, Lim added. “Those will better determine if general quarantine orders during the COVID pandemic truly impacted the incidence of complicated appendicitis.”

Study Details

In the study by Place and co-authors, the median patient age of the 90 children in 2020 was 10 (interquartile range [IQR] 7-13); 46 (51%) were boys; and 30 (33%) were white, 14% were Latino or Hispanic, and 1% were Black. During the same period in 2019, 70 children presented with acute appendicitis, and perforation occurred in 13 (19%); median patient age was 11 (IQR 9-14), 44 (63%) were boys, and 33 (47%) were white.

Unlike their adult counterparts, children do not commonly experience medical conditions with a high risk of mortality. But in some conditions, delayed diagnosis and management can lead to a significant increase in morbidity, prolonged hospitalization, and increased financial expense, the authors explained, noting that in this cross-sectional study, appendiceal perforation resulted in pelvic abscess, bowel obstruction, and sepsis.

“Although the reduction in ‘unnecessary’ emergency care may be welcomed by some, broad avoidance of the emergency department may lead to increased morbidity and mortality in both children and adults,” Place and co-authors wrote.

The main limitation of the study, they said, was that it was conducted in only a single institution and thus generalizability to other settings may not be possible.