Written evidence submitted by the Royal College of Paediatrics and Child Health (DEL0237)
The Royal College of Paediatrics and Child Health (RCPCH) is responsible for training and examining paediatricians, setting professional standards and informing research and policy. RCPCH has over 19,000 members in the UK and internationally. We work to transform child health through knowledge, research and expertise, to improve the health and wellbeing of infants, children and young people across the world.
RCPCH is carefully monitoring the risks and impacts of COVID-19 on our members and the wider child health workforce, and on children and young people. We have produced guidance for our members on paediatric services, staffing and rotas, and education and training. We have also produced advice for parents. We are currently collecting data on the impact of COVID-19 on child health services, to assist future planning of services.
Children and young people are generally less seriously affected by COVID-19 than adults in direct terms, but they are more at risk from being impacted by the longer-term consequences of the current pandemic.
We are already seeing some of the impact of COVID-19 on the delivery of core services. Necessity has seen staff and resource diverted away from primary care, and we know we are seeing fewer children in our A & E departments. Paediatricians are seeing children and young people present to health services later than they would in normal circumstances. In a very small number of cases, this has had serious consequences.
We expect to see a more widespread impact of COVID-19 on child health outcomes in the coming months and years. Reduced access to public health services in current the circumstances disproportionately impacts upon children and young people. Vital prevention and early intervention initiatives have and will likely continue to be undelivered for some weeks.
The Government must work with local authorities, NHS bodies and other organisations to reduce the chance of children becoming the ‘collateral damage’ of the COVID-19 pandemic. This includes providing long-term funding to ensure community services can effectively address the impacts of COVID-19, and work to stop the pandemic entrenching existing health inequalities. RCPCH considers that a multi-departmental children and young people’s health strategy will see this achieved.
1.1 Nature of COVID-19 in children
COVID-19 appears to take a milder course in children than in adults: most infected children present with mild symptoms or are asymptomatic. There is evidence of critical illness and death, but it is rare.
Most children are asymptomatic or exhibit mild symptoms from COVID-19 infection. However, a very small number have recently been identified who develop a significant systemic inflammatory response. A group of leading paediatricians in the UK, convened by RCPCH, have set out a working definition of this condition.
According to the NHS England service evaluation and audit results, 10% of children admitted to hospital in the UK have had a positive test for COVID-19. The average age of these children is 20 months old. Overall, 100 children had tested positive for COVID-19 by the 30th April, across 48 hospital trusts.
1.2 Symptoms and Treatment
Just under 80% of children in hospital with COVID-19 have needed no respiratory support. 15.5% have required low flow support, 3% have required high flow support, 1% of these children required continuous positive airway pressure CPAP and 3% have required ventilation.
90% of children who hospitalized with COVID-19 were treated on a regular ward. 7% were treated on a High Dependency Unit and 3% on an Intensive Care Unit.
Of children hospitalised with COVID-19, 55% have had no co-morbidity. Of those children hospitalised with COVID-19 with co-morbidities, the highest percentage have had respiratory or neurological conditions – 15% of children have had one or both of these co-morbidities.
80% of children admitted to hospital with COVID-19 have had a fever, just under 40% have presented with a cough, 34% have presented with lethargy, 28% with shortness of breath, 22% with coryzal symptoms and 15% with vomiting. Less than 10% of children hospitalized with COVID-19 exhibited other symptoms, including a rash, seizure, a wheeze and abdominal pain.
Just over 4% of children that tested positive for COVID-19 when admitted to hospital have been asymptomatic.
The role of children in transmission is unclear, and although it seems likely that they do not play a significant role, evidence that they are not a reservoir of disease does not exist. Symptoms are non-specific and most commonly cough and fever. There is no clear evidence of vertical transmission, and early evidence suggests both infected mothers and infants are no more severely affected than other groups. Early evidence suggests no significant increased risk for children with immunosuppression, but further data is needed.
2. Delivery of child health services during the pandemic
2.1 Delayed presentations
RCPCH has heard from members working on the frontline of child health services that parents may be reluctant to bring their children for health care in light of the current pandemic. We know that attendances to Emergency Departments have greatly reduced. The British Paediatric Surveillance Unit (BPSU) is currently undertaking a ‘snap-shot’ study into delayed presentations in hospitals to develop an evidence base.
In response to this, RCPCH launched a public information campaign to speak to parents to assure them that they must access health advice and attend hospitals if their child is unwell or injured.
With regard to delayed presentations, RCPCH has worked with NHS England/NHS Improvement to deal with increased demand for NHS 111. We contacted paediatricians who are shielding, have recently retired or have stepped down from frontline service, to ask them to help in providing cover for NHS 111 services in England, and providing expert clinical advice to call handlers.
2.2 Impact of workforce changes
In the meantime, many paediatric services have had reduced availability of staff due to self-isolation, or paediatric staff redeployed to adult services. RCPCH is working with Trusts and Health Board Organizations to track this percentage. As of the first of May, 21.1% of acute paediatric medical staff had been redeployed to acute adult services, and 13.2% of community career grade staff (plus 31% of community trainees) had been deployed to other areas of paediatric care.
All these changes may have an impact on the safety and quality of services for children, but we don’t have an accurate picture of these changes, or their “unintended consequences” - for instance, late presentation or non-accidental injury. RCPCH is currently undertaking a data collection project across local services, in order to track trends and patterns, highlight service pressures, and help identify pinch points. 
2.3 Interrupted pathways of care
RCPCH has identified a number of care pathways that are being interrupted because of workforce changes. This is largely linked to the deprioiritisation of community services.
Along with the Institute for Health Visiting, RCPCH have published advice for parents who may not be able to attend the six-week check for newborn babies. All babies have routine physical examination between six and eight weeks. This is usually undertaken by a GP. These important appointments may be being missed due to the impact of COVID-19.
RCPCH have particular concerns regarding the impact of COVID-19 on immunisation rates. For a number of years, all four nations across the UK have failed to reach the 95% vaccination target that the World Health Organization (WHO) advises is required to ensure a population is adequately protected from a virus like measles. We have worked with NHS England on their recent immunisations campaign in response to this.
A number of public health services, including some immunisations and mental health services, are delivered through schools. Widespread school closure means these services have not been delivered, and there have been significantly fewer opportunities for those working with children and young people to observe and report any concerns about their welfare.
3. Delivery of child health services beyond the pandemic
3.1 Children as collateral damage
Whilst it is fortunate that children are not as severely affected by COVID-19 as adults, we recognised quickly that children and young people became ‘collateral damage’ from the crisis. This risk is escalated due to the impact public health services have on children and young people’s health.
Necessity has meant we have had to reconfigure and pause services, and redeploy child health professionals to adult services - that was the right thing to do. But as a consequence, we are storing up health problems for our children and young people that may have significant impacts on their lives, and increase pressure on services in the future. In many areas, local authorities have needed to pause public health services to allow them to protect the most vulnerable in their communities from COVID-19, which will exacerbate this.
Interrupting normal pathways of care has meant that children have been presenting late to GPs and A&E, and routine appointments may have been deprioritised, paused or missed. This will likely have devastating effects for our measles immunisation status (87% in England), our oral health record (which is the highest cause of paediatric admissions), and our extremely long wait lists for children referred for autism diagnoses (2 years in some parts of the country).
3.2 Restoration of services
We also concerned that the Government and NHS England will prioritise the restoration of acute services as those services that have been paused to build system capacity to deal with COVID-19 begin to be stood up. It is vital for child health outcomes that primary and community care have the resources they need to provide essential public health services and respond to delayed presentations of illness in local communities. In the context of the financial pressures facing local authorities – exacerbated by further demands on local authorities during the current pandemic – mean this will be a challenge.
Our State of Child Health 2020 report shows our challenge in reaching optimum health outcomes for children across the UK. COVID-19 will likely frustrate our journey towards ‘levelling up’ outcomes for health compared with our European counterparts. We have long called for governments to address widening health inequalities and whilst COVID-19 is a human tragedy, it is sending shocks through the global economy. Children from socially vulnerable backgrounds will fall at the sharp end of this pandemic. Public health services will be critical in ensuring the current pandemic does not entrench existing health inequalities.
There have been some positives of the current pandemic for the delivery of child health services in the UK. Local and community services have worked together more closely due to necessity. This is one example of lessons from this pandemic that services should take forward.
The restoration of health services following this outbreak of COVID-19 provides us with an opportunity to reset services, using new models of innovative care, underpinned by data and evidence. This will ensure paediatricians and other child health professionals can delivery the high quality of care they strive to in every shift, and ensure every child gets the best start in life.
4. Calls to the UK Government
In order to support the restoration of services, we are calling on Government to:
 RCPCH and NHSE service evaluation and audit, 2020. https://www.rcpch.ac.uk/resources/covid-19-service-evaluation-audit-care-needs-children-admitted-hospital-england
RCPCH, 2020. https://www.rcpch.ac.uk/resources/guidance-paediatric-multisystem-inflammatory-syndrome-temporally-associated-covid-19
 Zhu Y, Bloxham CJ, Hulme KD, et al. Children are unlikely to have been the primary source of household SARS-CoV-2 infections. medRxiv. 2020. https://www.medrxiv.org/content/10.1101/2020.03.26.20044826v1
 Balduzzi A, Brivio E, Rovelli A, et al. Lessons After the Early Management of the COVID-19 Outbreak in a Pediatric Transplant and Hemato-Oncology Center Embedded within a COVID-19 Dedicated Hospital in Lombardia, Italy. Estote Parati. 2020. https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3559560
 Public Health England, 29th April 2020. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/882234/EDSSSBulletin2020wk17.pdf
 RCPCH, 2020. https://www.rcpch.ac.uk/work-we-do/bpsu/snap-shot-survey-delayed-presentations
 RCPCH, 1st May 2020. https://www.rcpch.ac.uk/resources/impact-covid-19-child-health-services-tool-results
 RCPCH, 2020. https://www.rcpch.ac.uk/resources/impact-covid-19-child-health-services-tool
 RCPCH, 2020. https://www.rcpch.ac.uk/news-events/news/health-visitors-paediatricians-publish-advice-parents-about-six-week-postnatal
 RCPCH, State of Child Health, 2020. https://stateofchildhealth.rcpch.ac.uk/evidence/prevention-of-ill-health/immunisations/
 NHSE, 2nd May 2020. https://www.england.nhs.uk/2020/05/nhs-urges-public-to-get-essential-vaccines-despite-coronavirus-outbreak/
 RCPCH, State of Child Health, 2020. https://stateofchildhealth.rcpch.ac.uk/evidence/prevention-of-ill-health/immunisations/
RCPCH, State of Child Health, 2020. https://stateofchildhealth.rcpch.ac.uk/