Focus on Children's Long-term, Post-COVID Health as New RCPCH Presidency Starts

Becky McCall

May 10, 2021

Under-25s have been disproportionately impacted by the pandemic, with a loss of social-mixing that threatens their long-term health outcomes and life expectancy, asserts the outgoing president of the Royal College of Paediatrics and Child Health (RCPCH) as he handed over the post to his successor today.

Dr Camilla Kingdon, consultant neonatologist at Guy's and St Thomas' NHS Foundation Trust, London, and previously vice president for education and professional development at the RCPCH, has taken up the role of college president.

"This scenario [pandemic-related health issues in children] will play out over a long time as these children struggle to catch up and manifest the consequences of COVID," Dr Kingdon said. "We shouldn't underestimate the size of the problem. The next few years are going to be equally challenging for both children and the professionals who work with them."

Dr Kingdon will replace Russell Viner, professor in adolescent health at the UCL Great Ormond Street Institute of Child Health, London, whose 3-year tenure as RCPCH president took an unexpected turn when the COVID-19 pandemic hit the UK in March 2020. Addressing the annual symposium of the British Paediatric Surveillance Unit (BPSU), he emphasised the damaging impact of COVID-19 on children and young people.

In essence, loss of social mixing in a variety of forms is extremely detrimental to young people, he said. "The irony of closing schools to reduce short-term death rates among the middle-aged and elderly will only increase long-term mortality in the young," said Prof Viner.

He specified two key issues of concern with respect to young people. Firstly, the big drop in social mixing: the social mixing rate in under-25s is usually the highest in society, so children and young people were the group with the greatest reduction in social contact and mixing over lockdown. Secondly, the shutdown of the safety net that child health and wellbeing professionals have spent 50-100 years building. "Essentially, when you close down schools and broader society then you close down the mixing that's so important to health and wellbeing, and you close down our ability to both support and watch children," Prof Viner said.

School closures also had indirect effects, he added, including not only the loss of education, but also of other school-related activities such as the social mixing related to travel to and from school, extra-curricular activities, loss of exercise, routine, and peer relationships.

Loss of Schooling

"The biggest concern for me from this pandemic relates to the longer-term effects on young people," said Prof Viner. "There is a direct relationship between years of education and mortality and life expectancy. This balancing of mortality between reducing short-term death rates in the middle-aged and elderly, while increasing long-term mortality in the young has ignored the fact that loss of education increases mortality in the longer-term," he said. 

Generally, there is evidence to suggest that better-educated people live longer lives, with better health and fewer non-communicable diseases, he explained. Referring directly to the 6 to 12 months' loss of schooling in different countries, including the UK, he said that: "Even a 6 month loss of education, as we've seen in this country, and the school closures of nearly a year in Italy and the US, means those children will probably have a shorter life expectancy unless their education is made up. Online education does not do that.

"There are real concerns that loss of schooling will lead to higher death rates in the longer-term."

Mental Health

However, in the immediate term, Prof Viner is extremely worried around the mental health of children and young people. "This is happening now and will be ongoing," he said. He shared findings from national survey data initially collected in 2017 and again in July 2020 (post-lockdown) with the same cohort of young people. "These data suggest that mental health problems had increased from 1 in 9, to 1 in 6 across the 3 years. We can't prove it is all due to the pandemic, but actually for a 2 to 3-year time span it is unlikely that these data are due to something else." 

Reinforcing his point about the mental health impacts of the pandemic on young people, he referred to a systematic review that he had co-authored, currently under peer review, which shows extraordinary estimates of the mental health impact of the pandemic on young people. "We also recognise that there are likely to be extraordinary impacts on obesity, diet, and broader areas of child protection in ways we don't understand."

Dr Kingdon also highlighted that the numbers of children currently on wards with mental health issues had increased. "We see more eating disorders in particular, as well as other forms of self-harm. And the impact will be felt more in areas of greatest deprivation, where families live in crowded housing with limited internet access that affects their ability to keep up with school. 

"This scenario will play out over a long time as these children struggle to catch up and manifest the consequences of COVID," she said.

Long COVID

The new president also noted the issue around long COVID in children, saying that it was another clear consequence of the pandemic and was in urgent need of addressing. Importantly, a developmentally appropriate definition for long COVID was needed. "The case definition of this is really important and this is being worked on now. We can't necessarily take an adult case definition and apply that to children, because they manifest differently. Neither can we compare an 8-year-old to a 12-year-old to a 16-year-old.

"I also think we need an open mind. We need to support these families and their children. We need to define it and understand how it presents in different age groups and then consider how we resource support for this," she added.

Implications of Reduced Attendance at Child Healthcare Services 

Healthcare services were restricted during lockdown as resources were redeployed to COVID-19 care. Across most high-income countries, attendance at emergency departments and hospital admissions were down by 30-70%, and there was a reduction in less severe presentations to the emergency department, as well as a reduction in overall admissions, but an increase in intensive care admissions.

There was also a significant impact on waiting lists, with some estimates suggesting that it will take 2 to 4 years to work through the surgical elective waiting lists unless capacity is increased. But overall, largely, "our health system dealt with that quite effectively," Prof Viner said.

Turning to the more direct effects of COVID-19 on children, and the dilemma it presented to child health professionals from the beginning, he noted that faced with an unknown virus and disease, a balance had to be struck between clinical needs and public health needs. Some children were admitted to intensive care, including those with paediatric inflammatory multisystem syndrome (PIMS), and there was also a small number of COVID-19 related child deaths. From a wider public health perspective, COVID-19 barely affected children directly, but indirectly they have been strongly affected by the response to the pandemic, he said.

"Through the College we've tried hard to get the dual focus right – that is the clinical response, by helping paediatricians challenged with sick children presenting during times of COVID and, in addition, how to treat COVID itself. But from a public health perspective we've been trying to ensure children's needs are up there, firmly on the agenda."

Health visitor provision was shut down in many areas, and some children's wards were redeployed into adult intensive care. Social workers could not work, and schools were closed. "Our protective safety net around children disappeared. We recognised this early on, but it was increasingly apparent when we saw the delayed presentations of sick children and the potential for severe outcomes including death."

As reported by Medscape Medical News, the BPSU, lead by Dr Shamez Ladhani, paediatrician at St George's University Hospitals NHS Foundation Trust, conducted a rapid snapshot of what was happening on the ground. "There were disturbing reports, including eight deaths where paediatricians believed that late presentations had serious impacts on outcomes."

The RCPCH advocated for changing the NHS 111 systems to ensure children were triaged, and NHS England ran a campaign to drive home the message that if a parent had a sick child then they should bring them to hospital. 

Other issues of concern related to the visibility of child abuse cases. "How was the child protection system operating? We heard a lot of reports about how concerning this was," said Prof Viner. 

He added that they saw a signal relating to a rise in teenage suicides. "This was hugely concerning. We tracked this with NHS England and the National Child Mortality database and made these data visible to the chief medical officer and Prime Minister."

Much of these data were instrumental in ensuring schools opened early, and in May 2020 there was a commitment to opening some years in primary but not secondary schools at that time.

The Financial Cost of the Pandemic for Children

Unsurprisingly, those from poorer families have been more affected by COVID-19 directly, but also indirectly, a pattern seen across health and disease.

Prof Viner drew attention to how children would shoulder the financial burden in years to come.  "The Government's response has been to borrow £300 billion. There is only one place the borrowing comes from, and essentially that is from the future of our children and young people.

"Essentially that is a debt whereby we borrow from our children's future to protect the health of the middle-aged and healthy.  We owe it to our children and young people to recognise the indirect effects and actually recognise that once the adults are vaccinated, the next few years are those where we give back to children and young people who have given so much to this pandemic."

Paediatric Workforce Going Forward

The RCPCH has a dual mandate to represent paediatricians and child health professionals as well as children and adolescents. "We can't advocate for children and young people if we don't have a healthy, flourishing workforce, and as we move beyond the pandemic, renewed attention to our workforce is important," said Dr Kingdon.

She noted that paediatrics as a specialty was becoming less popular and as such recruitment and retention needed attention. "This is a particular interest of mine," she said - her mandate for election rested on this. "Unless we role model the job of being a paediatrician we won't attract the next generation."

She said that given the backlog and long waiting lists, referred to by Prof Viner, the problems around recruitment were more pressing than ever. Approximately 12% of paediatricians retire early, she pointed out in an interview with Medscape UK. "That means there's a problem. We need these doctors to enter senior leadership and teaching roles. We need to start thinking differently."

Dr Kingdon wants to see child healthcare professionals supporting each other better, with more innovative thinking around the roles that nurses and allied health professionals adopt, as well as those of paediatricians. "We need to break down some of the hierarchical ways of working and take a fresh look at how we work and look after each other so people can continue into their mid-60s."

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