Art Linkletter was an early television pioneer who created a popular broadcast segment that subsequently turned into a best-selling book entitled “Kids Say the Darndest Things”. His interviews with youngsters started in the early 1950s. The candor of children proved to be a decades-long source of entertainment. In addition to the humor, however, there were instances of unexpected insights. Now, nearly 70 years later, what pediatrics is telling us about the impact of COVID has critical implications for the health care system.
The lessons start with a counter-intuitive discovery. Children’s hospitals appear to have been hit even harder than general acute care hospitals by the pandemic, a result I would not have expected. As COVID hit in early 2020, general acute care hospitals suspended elective surgeries to protect scarce ICU capacity and desperately needed ventilators. Children’s hospitals similarly curtailed elective services, despite the fact that the risk for hospitalization for COVID was much lower in children than in adults. Inpatient volumes plummeted. The rebound in adult admissions that occurred months later as surgical programs ramped back up was not as robust in pediatric facilities. The Children’s Hospital Association (CHA) reported a 17% decline in pediatric discharges in 2020, compared with a 4% drop in adult discharges over the same period.
Tertiary medical centers, the best adult analogs to major children’s hospitals, were commonly operating near capacity in early 2021. Emergency room volumes were down approximately 15%, but inpatient volumes had rebounded to 90% or 95% of their pre-pandemic levels. By contrast, according to the CHA study, inpatient discharges at children’s hospitals declined precipitously between November 2020 and January 2021 and have recovered more slowly, while both outpatient volumes and emergency room encounters remain below their pre-pandemic benchmarks.
What could explain these sharp differences in recoveries between adult and pediatric hospitals?
The absence of a rebound in the pediatric facilities similar to that observed among adult hospitals points to a combination of parent/guardian reticence (there has been no clear route to vaccinations for 50 million children under age 12) and systemic barriers peculiar to the subsets of the population that children’s hospitals serve. The differential response should be a red flag to the health system, as it is a harbinger of unmet needs.
CHA reports that the average case mix index for admitted children is up by 11%, a phenomenon mirrored in the adult population. Patients put off seeking care during the pandemic; when they did re-engage, they were much sicker. Lingering parental reticence to expose unvaccinated kids to the health care system reduces the proportion of lower acuity pediatric patients, further intensifying the resulting case mix index.
Another contributing factor may be technology. In adult medicine, as much as one-quarter of ambulatory visits are now virtual. The key to the substitution of virtual encounters for in-person visits is access to technology. Among low socioeconomic populations, the lack of computers or reliable internet connectivity relegated virtual pediatric patient encounters to a parent’s cellular telephone. The substitution of virtual encounters for in-person visits also depends upon the patient’s (or in the case of pediatrics, the parent’s) capacity to interact with the provider effectively via technology. Technological agility is not evenly distributed throughout the population. In a system that had acknowledged health disparities before COVID, the uneven rates of recovery between adult and pediatric hospitals suggest that the gap may be widening.
Deeply concerning is the observed increase in severe mental health encounters in pediatric emergency departments. The CHA report indicates that emergency room visits related to suicide attempts or ideation and neurodevelopment disorders are 20 percentage points higher than ER visits for physical needs and have spiked by 40% over the same period one year earlier.
Adult psychiatry has transformed itself into a largely virtual specialty during the pandemic, with over 90% of encounters now occurring on a virtual platform. Adolescent mental health disorders engage the entire family, including siblings, and often involve kids as big or bigger than their parents, manifesting as violence directed toward the adult, triggering panicked pediatric ED encounters.
Finally, the CHA study identified an alarming unintended consequence of virtual classrooms—the loss of first-line surveillance for child abuse—teachers were now unable to notice the warning signs and the resulting tragedy in pediatric emergency rooms is heartbreaking.
To appreciate the fact that pediatrics more closely tracks the experiences of the lower socioeconomic strata of the population than does adult medicine, one need only look at the payer mix of the typical children’s hospital. Medicaid and uninsured patients account for over 50% of pediatric admissions, with some children’s hospitals being 80% Medicaid or higher. As a result, children’s hospitals serve as a mirror reflecting some of the more challenging social determinants of health.
In 1952, Art Linkletter realized that there is nothing better than listening to children. They have no agendas, so they give it to us straight. Coming out of the pandemic, we would be wise to listen not just to what the kids are telling us, but what we aren’t hearing…or more precisely who we aren’t seeing. The silence has profound consequences.
