The effect of the COVID-19 pandemic on pediatric emergency department utilization in three regions in Switzerland.

PURPOSE: The COVID-19 pandemic was associated with a decrease in emergency department (ED) visits. However, contradictory, and sparse data regarding children could not yet answer the question, how pediatric ED utilization evolved throughout the pandemic. Our objectives were to investigate the impact of the pandemic in three language regions of Switzerland by analyzing trends over time, describe regional differences, and address implications for future healthcare. METHODS: We conducted a retrospective, longitudinal cohort study at three Swiss tertiary pediatric EDs (March 1st, 2018-February 28th, 2022), analyzing the numbers of ED visits (including patients` age, triage categories, and urgent vs. non-urgent cases). The impact of COVID-19 related non-pharmaceutical interventions (NPIs) on pediatric ED utilization was assessed by interrupted time series (ITS) modelling. RESULTS: Based on 304'438 ED visits, we found a drop of nearly 50% at the onset of NPIs, followed by a gradual recovery. This primarily affected children 0-4 years, and both non-urgent and urgent cases. However, the decline in urgent visits appeared to be more pronounced in two centers compared to a third, where also hospitalization rates did not decrease significantly during the pandemic. A subgroup analysis showed a significant decrease in respiratory and gastrointestinal diseases, and an increase in the proportion of trauma patients during the pandemic. CONCLUSIONS: The COVID-19 pandemic had substantial effects on number and reasons for pediatric ED visits, particularly among children 0-4 years. Despite equal regulatory conditions, the utilization dynamics varied markedly between the three regions, highlighting the multifactorial modification of pediatric ED utilization during the pandemic. Furthermore, future policy decisions should take regional differences into account.

Hair-thread strangulation syndrome in childhood: a systematic review.

INTRODUCTION: Hair-thread strangulation syndrome describes the constriction of a body part by a tightly wound hair or thread. This research aims to review the literature about this entity. METHODS: A systematic review was performed to characterise hair-thread strangulation syndrome in subjects aged ≤16 years. This pre-registered review (PROSPERO ID: CRD42022363996) followed the PRISMA methodology. RESULTS: Subjects with digital strangulation were significantly younger (median = 4.0 [interquartile range: 2.0-6.1] months; n = 143) than females with genital strangulation (9.0 [6.8-11] years; n = 36), males with genital strangulation (5.1 [1.9-8.0] years; n = 36), and subjects with non-digital and non-genital strangulation (24 [13-48] months; n = 11). Digital strangulation was followed by an amputation in five (3.5%) and a reconstructive surgical intervention in seven (4.9%) cases. Sequelae occurred in four (11%) cases after female genital strangulation: clitoris autoamputation (n = 2) and surgical removal of a necrotic labium minus (n = 2). Severe complications were observed in 14 (39%) cases with male genital strangulation: urethral fistula (n = 7), urethral transection (n = 2), and partial penile autoamputation (n = 5). A partial uvular autoamputation was observed in one case (9.0%) with non-digital and non-genital strangulation. CONCLUSIONS: Early recognition and management are crucial to avoid sequelae or long-term care in hair-thread strangulation syndrome.

External Male Genitalia in Henoch-Schönlein Syndrome: A Systematic Review.

The external genitalia are notoriously implicated in every fifth male with Henoch−Schönlein syndrome. Nonetheless, the underlying conditions are poorly categorized. To characterize the involvement of the external male genitalia in this vasculitis, we performed a systematic review of the literature. For the final analysis, we selected 85 reports published between 1972 and 2022, which reported on 114 Henoch−Schönlein cases (≤ 18 years, N = 104) with a penile (N = 18), a scrotal (N = 77), or both a penile and a scrotal (N = 19) involvement. The genital involvement mostly appeared concurrently with or after the cutaneous features of Henoch−Schönlein syndrome, while it preceded the presentation of Henoch−Schönlein syndrome in 10 cases. Patients with penile involvement (N = 37) presented with swelling (N = 26), erythema (N = 23), and purpuric rash (N = 15). Most patients were otherwise asymptomatic except for transient micturition disorders (N = 2) or priapism (N = 2). Patients with scrotal involvement (N = 96) presented with pain (N = 85), swelling (N = 79), erythema (N = 42), or scrotal purpura (N = 22). The following scrotal structures were often involved: scrotal skin (N = 83), epididymis (N = 49), and testes (N = 39). An ischemic testicular damage was noted in nine patients (four with torsion and five without). The scrotal skin involvement was mostly bilateral, while that of the epididymis and testis were mostly (p < 0.0001) unilateral (with a significant predilection for the left side). In conclusion, this analysis allows for better categorization of the involvement of external male genitalia in Henoch−Schönlein vasculitis. Scrotal involvement can result from skin inflammation, epididymitis, orchitis, or testicular ischemia.

Should COVID-19 vaccines be mandated in schools? - an international caregiver perspective.

OBJECTIVES: Caregiver attitudes toward mandating COVID-19 vaccines for their children are poorly understood. We aimed to determine caregiver acceptability of COVID-19 vaccine mandates for schools/daycares and assess if opposition to mandates would result in removal of children from the educational system. STUDY DESIGN: Perform a cross-sectional, anonymous survey of adult caregivers with children ≤ 18 years presenting to 21 pediatric emergency departments in the United States, Canada, Israel, and Switzerland, November 1st through December 31st, 2021. The primary outcome was caregiver acceptance rates for school vaccine mandates, and the secondary outcomes included factors associated with mandate acceptance and caregiver intention to remove the child from school. RESULTS: Of 4,393 completed surveys, 37% of caregivers were opposed to any school vaccine mandate. Caregiver acceptance was lowest for daycare settings (33%) and increased as the child's level of education increased, college (55%). 26% of caregivers report a high likelihood (score of 8-10 on 0-10 scale) to remove their child from school if the vaccine became mandatory. Child safety was caregivers' greatest concern over vaccine mandates. A multivariable model demonstrated intent to vaccinate their child for COVID-19 (OR = 8.9, 95% CI 7.3 to 10.8; P < 0.001) and prior COVID-19 vaccination for the caregiver (OR = 3.8, 95% CI 3.0 to 4.9; P < 0.001) had the greatest odds of increasing mandate acceptance for any school level. CONCLUSIONS: Many caregivers are resistant to COVID-19 vaccine mandates for schools, and acceptance varies with school level. One-fourth of caregivers plan to remove their child from the educational system if vaccines become mandated.

Atypical primary varicella rash: Systematic literature review.

AIM: In previously healthy subjects, primary varicella presents with a distinctive vesicular rash that is more intense on the trunk and head than on the extremities. However, an atypical presentation may occasionally develop. We aimed at systematically assessing the characteristics of cases affected by atypical primary varicella rash. METHODS: The United States National Library of Medicine, Excerpta Medica and Web of Science databases were reviewed, without date or language restrictions. Articles were eligible if reporting previously healthy and immunocompetent subjects with a primary varicella rash (i.e., a photo-localised primary varicella or skin inflammation-associated primary varicella). RESULTS: Thirty-eight reports providing information on 59 cases of atypical primary varicella were identified. Twenty-four cases (median 8.5 years of age, 19 females) were photo-localised and 35 (median 4.8 years of age, 15 females) were associated with pre-existing skin inflammation (including cast occlusion, diaper irritation, operative sites, burns, insect bites, vaccinations or pre-existing skin disease). The skin rash was monomorphic and without a "starry sky" appearance. CONCLUSION: Primary varicella may have a modified presentation in areas of irritation such as sun exposure or pre-existing inflammation. There is a need for a wider awareness of these modulators of varicella rash.

Caregiver-reported delay in presentation to pediatric emergency departments for fear of contracting COVID-19: a multi-national cross-sectional study.

OBJECTIVE: To determine if caregivers of children presenting to pediatric emergency departments (EDs) during the COVID-19 pandemic are delaying presenting to care for fear of contracting COVID-19. METHODS: This was a pre-planned secondary analysis of a cross-sectional survey study of caregivers accompanying their children aged 0-19 years to 16 pediatric EDs in 5 countries from May to June 2020. An anonymous online survey, completed by caregivers via RedCAP, included caregiver and child demographics, presenting complaints, if they delayed presentation and whether symptoms worsened during this interval, as well as caregiver concern about the child or caregiver having COVID-19 at the time of ED visit. RESULTS: Of 1543 caregivers completing the survey, 287 (18.6%) reported a delay in seeking ED care due to concerns of contracting COVID-19 in the hospital. Of those, 124 (43.2%) stated their child's symptoms worsened during the waiting interval. Caregiver relationship to child [mother] (OR 1.85, 95% CI 1.27-2.76), presence of chronic illness in child (OR 1.78. 95% CI 1.14-2.79), younger age of caregiver (OR 0.965, 95% CI 0.943-0.986), and caregiver concerns about lost work during the pandemic (OR 1.08, 95% CI 1.04-1.12) were independently associated with a COVID-19-related delayed presentation in multivariable regression analysis. CONCLUSIONS: Almost one in five caregivers reported delaying ED presentation for their ill or injured child specifically due to fear of contracting COVID-19 while in hospital, with mothers, younger caregivers, caregivers of children with chronic illness, and those concerned about lost work more likely to report delaying ED presentation.

RéSUMé: OBJECTIF: Déterminer si les aidants des enfants qui se présentent aux services d'urgence pédiatriques (SU) pendant la pandémie de COVID-19 retardent leur présentation pour prendre soin d'eux par crainte de contracter la COVID-19. MéTHODES: Il s'agissait d'une analyze secondaire planifiée à l'avance d'une étude d'enquête transversale auprès des soignants accompagnant leurs enfants âgés de 0 à 19 ans dans 16 urgences pédiatriques de 5 pays entre mai et juin 2020. Une enquête anonyme en ligne, remplie par les soignants via RedCAP, comprenait les données démographiques du soignant et de l'enfant, les plaintes présentées, s'ils ont retardé la présentation et si les symptômes se sont aggravés pendant cet intervalle, ainsi que l'inquiétude du soignant quant à la présence de COVID-19 chez l'enfant ou le soignant au moment de la visite aux urgences. RéSULTATS: Sur les 1 543 soignants ayant répondu à l'enquête, 287 (18.6 %) ont déclaré avoir retardé le recours aux urgences par crainte de contracter le COVID-19 à l'hôpital. Parmi eux, 124 (43.2%) ont déclaré que les symptômes de leur enfant s'étaient aggravés pendant l'intervalle d'attente. Dans l'analyse de régression multivariable, le lien entre la personne qui s'occupe de l'enfant et la mère (OR 1.85, IC95 % 1.27­2.76), la présence d'une maladie chronique chez l'enfant (OR 1.78, IC95 % 1.14-2.79), le jeune âge de la personne qui s'occupe de l'enfant (OR 0.965, IC95 % 0.943-0.986) et les préoccupations de la personne qui s'occupe de l'enfant concernant la perte de travail pendant la pandémie (OR 1.08, IC95 % 1.04­1.12) ont été associés de manière indépendante à une présentation tardive. CONCLUSIONS: Près d'un soignant sur cinq a déclaré avoir retardé la présentation aux urgences de son enfant malade ou blessé par crainte de contracter le COVID-19 pendant son séjour à l'hôpital, avec les mères, les jeunes aidants, les soignants d'enfants souffrant de maladies chroniques et les personnes préoccupées par la perte de travail sont plus susceptibles de retarder la présentation aux urgences.

A tale of two parts of Switzerland: regional differences in the impact of the COVID-19 pandemic on parents.

BACKGROUND: We aimed to document the impact of the coronavirus disease 2019 (COVID-19) pandemic on regions within a European country. METHODS: Parents arriving at two pediatric emergency departments (EDs) in North of Switzerland and two in South of Switzerland completed an online survey during the first peak of the pandemic (April-June 2020). They were asked to rate their concern about their children or themselves having COVID-19. RESULTS: A total of 662 respondents completed the survey. Parents in the South were significantly more exposed to someone tested positive for COVID-19 than in the North (13.9 and 4.7%, respectively; P <  0.001). Parents in the South were much more concerned than in the North that they (mean 4.61 and 3.32, respectively; P <  0.001) or their child (mean 4.79 and 3.17, respectively; P <  0.001) had COVID-19. Parents reported their children wore facemasks significantly more often in the South than in the North (71.5 and 23.5%, respectively; P <  0.001). CONCLUSION: The COVID-19 pandemic resulted in significant regional differences among families arriving at EDs in Switzerland. Public health agencies should consider regional strategies, rather than country-wide guidelines, in future pandemics and for vaccination against COVID-19 for children.

Parents' intent to vaccinate against influenza during the COVID-19 pandemic in two regions in Switzerland.

AIMS OF THE STUDY: The COVID-19 pandemic is likely to overlap with the seasonal influenza epidemic, increasing the risk of overextending the health system capacity in Switzerland. Influenza vaccine uptake has remained low in most countries, including Switzerland. The aim of the study was to determine parents’ intentions towards influenza vaccination of their children, as well as themselves, and to assess regional differences. METHODS: Parents presenting to four paediatric emergency departments (Zurich, Bern, Bellinzona, Geneva) were asked to complete an online survey during and after the first lockdown of the COVID-19 pandemic (April to June 2020). The anonymised survey included demographic information, vaccination history and intentions to vaccinate against influenza, as well as attitudes towards future vaccination against COVID-19. RESULTS: The majority of children (92%; 602/654) were up-to-date on their vaccination schedule. In 2019/2020, 7.2% (47/654) were vaccinated against influenza. Children with chronic illnesses were more frequently vaccinated than healthy children (19.2% vs 5.6%; p = 0.002). For the coming winter season, 111 (17%) parents stated they plan to vaccinate their children against influenza, more than double the rate from last year, and 383 (59.2%) parents suggested they will vaccinate against COVID-19 once a vaccine is available. Regional differences between “German” and “Latin” Switzerland were found for parents’ intent to have their children vaccinated against influenza next season (Zurich and Bern 14.3%, Bellinzona and Geneva 27.2%, p <0.001), but not for a hypothetical vaccination against COVID-19 (Zurich and Bern 59.1%, Bellinzona and Geneva 59.7%, p = 0.894). CONCLUSIONS: The COVID-19 pandemic resulted in a substantial increase of parents’ intention to vaccinate their children against influenza, especially in hard-hit “Latin” Switzerland. The Swiss government and public health organisations can leverage these regional results to promote influenza vaccination among children for the coming seasons.

Parents' intent to vaccinate against influenza during the COVID-19 pandemic im two regions in Switzerland.

AIMS OF THE STUDY: The COVID-19 pandemic is likely to overlap with the seasonal influenza epidemic, increasing the risk of overextending the health system capacity in Switzerland. Influenza vaccine uptake has remained low in most countries, including Switzerland. The aim of the study was to determine parents' intentions towards influenza vaccination of their children as well as themselves, and to assess regional differences. METHODS: Parents presenting to four pediatric emergency departments (PEDs; Zurich, Bern, Bellinzona, Geneva) were asked to complete an online survey during and after the first lockdown of the COVID-19 pandemic (April - June 2020). The anonymized survey included demographic information, vaccination history and intentions to vaccinate against influenza, as well as attitudes towards future vaccination against COVID-19. RESULTS: The majority of children (92%; 602/654) were up-to-date on their vaccination schedule. In 2019/2020, 7.2% (47/654) were vaccinated against influenza. Children with chronic illnesses were more frequently vaccinated compared to healthy children (19.2% vs 5.6%; p = 0.002). For the coming winter season, 111 (17%) parents stated they plan to vaccinate their children against influenza, more than double the rate from last year, and 383 (59.2%) parents suggest they will vaccinate against COVID-19 once a vaccine is available. Regional differences between "German" and "Latin" Switzerland were found for parents' intent to have their children vaccinated against influenza next season (Zurich and Bern 14.3%, Bellinzona and Geneva 27.2%, p < 0.001) but not for a hypothetical vaccination against COVID-19 (Zurich and Bern 59.1%, Bellinzona and Geneva 59.7%, p = 0.894). CONCLUSIONS: The COVID-19 pandemic resulted in a substantial increase of parents' intention to vaccinating their children against influenza, especially in hard-hit "Latin" Switzerland. The Swiss government and public health organizations can leverage these regional results to promote influenza vaccination among children for the coming seasons.

Willingness to Vaccinate Children against Influenza after the Coronavirus Disease 2019 Pandemic.

OBJECTIVES: To determine factors associated with parents who plan to vaccinate their children against influenza next year, especially those who did not vaccinate against influenza last year using a global survey. STUDY DESIGN: A survey of caregivers accompanying their children aged 1-19 years old in 17 pediatric emergency departments in 6 countries at the peak of the coronavirus disease 2019 (COVID-19) pandemic. Anonymous online survey included caregiver and child demographic information, vaccination history and future intentions, and concern about the child and caregiver having COVID-19 at the time of emergency department visit. RESULTS: Of 2422 surveys, 1314 (54.2%) caregivers stated they plan to vaccinate their child against influenza next year, an increase of 15.8% from the previous year. Of 1459 caregivers who did not vaccinate their children last year, 418 (28.6%) plan to do so next year. Factors predicting willingness to change and vaccinate included child's up-to-date vaccination status (aOR 2.03, 95% CI 1.29-3.32, P = .003); caregivers' influenza vaccine history (aOR 3.26, 95% CI 2.41-4.40, P < .010), and level of concern their child had COVID-19 (aOR 1.09, 95% CI 1.01-1.17, P = .022). CONCLUSIONS: Changes in risk perception due to COVID-19, and previous vaccination, may serve to influence decision-making among caregivers regarding influenza vaccination in the coming season. To promote influenza vaccination among children, public health programs can leverage this information.

Caregiver willingness to vaccinate their children against COVID-19: Cross sectional survey.

BACKGROUND: More than 100 COVID-19 vaccine candidates are in development since the SARS-CoV-2 genetic sequence was published in January 2020. The uptake of a COVID-19 vaccine among children will be instrumental in limiting the spread of the disease as herd immunity may require vaccine coverage of up to 80% of the population. Prior history of pandemic vaccine coverage was as low as 40% among children in the United States during the 2009 H1N1 influenza pandemic. PURPOSE: To investigate predictors associated with global caregivers' intent to vaccinate their children against COVID-19, when the vaccine becomes available. METHOD: An international cross sectional survey of 1541 caregivers arriving with their children to 16 pediatric Emergency Departments (ED) across six countries from March 26 to May 31, 2020. RESULTS: 65% (n = 1005) of caregivers reported that they intend to vaccinate their child against COVID-19, once a vaccine is available. A univariate and subsequent multivariate analysis found that increased intended uptake was associated with children that were older, children with no chronic illness, when fathers completed the survey, children up-to-date on their vaccination schedule, recent history of vaccination against influenza, and caregivers concerned their child had COVID-19 at the time of survey completion in the ED. The most common reason reported by caregivers intending to vaccinate was to protect their child (62%), and the most common reason reported by caregivers refusing vaccination was the vaccine's novelty (52%). CONCLUSIONS: The majority of caregivers intend to vaccinate their children against COVID-19, though uptake will likely be associated with specific factors such as child and caregiver demographics and vaccination history. Public health strategies need to address barriers to uptake by providing evidence about an upcoming COVID-19 vaccine's safety and efficacy, highlighting the risks and consequences of infection in children, and educating caregivers on the role of vaccination.

Caregivers' Willingness to Accept Expedited Vaccine Research During the COVID-19 Pandemic: A Cross-sectional Survey.

PURPOSE: This study determined the predictors of caregivers' willingness to accept an accelerated regulatory process for the development of vaccines against coronavirus disease 2019 (COVID-19). METHODS: An international cross-sectional survey was administered to 2557 caregivers of children in 17 pediatric emergency departments (EDs) across 6 countries from March 26, 2020, to June 30, 2020. Caregivers were asked to select 1 of 4 choices with which they most agreed regarding a proposed COVID-19 vaccine-approval process, in addition to questions regarding demographic characteristics, the ED visit, and attitudes about COVID-19. Univariate analyses were conducted using the Mann-Whitney U test for comparing non-normally distributed continuous variables, an independent t test for comparing normally distributed continuous variables, and a χ2 or Fisher exact test for categorical variables. Multivariate logistic regression analysis was used for determining independent factors associated with caregivers' willingness to accept abridged development of a COVID-19 vaccine. A P value of <0.05 was considered significant. FINDINGS: Almost half (1101/2557; 43%) of caregivers reported that they were willing to accept less rigorous testing and postresearch approval of a new COVID-19 vaccine. Independent factors associated with caregivers' willingness to accept expedited COVID-19 vaccine research included having children who were up to date on the vaccination schedule (odds ratio [OR] = 1.72; 95% CI, 1.29-2.31), caregivers' concern about having had COVID-19 themselves at the time of survey completion in the ED (OR = 1.1; 95% CI, 1.05-1.16), and caregivers' intent to have their children vaccinated against COVID-19 if a vaccine were to become available (OR = 1.84; 95% CI, 1.54-2.21). Compared with fathers, mothers completing the survey were less likely to approve of changes in the vaccine-development process (OR = 0.641; 95% CI, 0.529-0.775). IMPLICATIONS: Less than half of caregivers in this worldwide sample were willing to accept abbreviated COVID-19 vaccine testing. As a part of an effort to increase acceptance and uptake of a new vaccine, especially in order to protect children, public health strategies and individual providers should understand caregivers' attitudes toward the approval of a vaccine and consult them appropriately.

Transient benign hyperphophatasemia.

BACKGROUND AND AIM: Sometimes, a temporary increase in alkaline phosphatase level is found in healthy infants and toddlers without evidence of liver or bone disease. The condition is customarily termed transient benign hyperphosphatasemia of infancy and early childhood. Most textbooks do not refer to the condition. The aim of the study was to promote broader awareness of transient benign hyperphosphatasemia. METHODS: We completed a systematic review of the literature using the principles underlying the UK Economic and Social Research Council guidance on the conduct of narrative synthesis and the Preferred Reporting Items for Systematic Reviews and Meta-analyses statement. RESULTS: The 142 reports retained for analysis included 813 cases (male:female ratio 1.1:1.0): 80 in subjects older than 18 years and 733 in subjects 18 years or younger. The alkaline phosphatase ratio, calculated by dividing the measured level by the upper limit of normal, was ≥5.0 in ≈70% and the duration of the elevation was ≤4 months in 80% of the cases. Transient benign hyperphosphatasemia often followed a benign infection, but available data fail to demonstrate a causal link. The prevalence of transient benign hyperphosphatasemia ranged from 1.1% to 3.5% in infants 2 to 24 months of age. CONCLUSIONS: Transient benign hyperphosphatasemia is likely the most common cause of hyperphosphatasemia among healthy infants and toddlers. Sometimes it also occurs in older children and adults, indicating that the traditional term transient benign hyperphosphatasemia of infancy and early childhood may not be correct. The elevation in alkaline phosphatase persists for >4 months in ≈20% of the cases. Recognition of this benign condition is crucial to avoid unnecessary investigations.