A Little-Discussed Consequence of the Pandemic for Children

Everyone talks about learning loss, but a new study highlights that public policy--and public behavior–-during the pandemic led to a crisis of missed medical care.

It is well-accepted now that school closures—and interrupted learning from hybrid schedules, distancing, forced masking, and the cancellation of athletics and other extracurricular activities—had a profound effect on millions of American kids. Test scores have fallen over all, but there are multiple studies that show the longer a school was closed the worse the students did. Hispanic, and especially Black kids fared the worst of all from being out of school. Current evidence suggests these deficits have still not been made up, and will permanently alter the trajectory of many children’s lives. Mental health deterioration, weight gain, and an accelerated dependence on screens have all been documented as well as from kids’ increased isolation, sedentariness, and remote learning.

These effects did not happen “because of Covid.” They happened because of the reaction to Covid. The “pandemic” did not shut down schools, as some journalists continue to falsely report. Policy decisions shut down schools. More broadly, at a societal level, restrictions on movement, gatherings, business operations and so on—and the climate of fear those policies and media coverage engendered—also had deleterious effects on people’s income, health, and over all well-being. Whether these policies saved lives, and were worth the downsides, is an argument outside the scope of this post. But what is inarguable is that these downsides did occur.

A great harm of Covid policies and the environment of fear—though, because it’s somewhat nebulous, not adequately discussed—is that during the pandemic millions of people either were not able to seek medical care or fear of Covid kept them from doing so. A new study, published in JAMA Network Open, offers unsettling evidence of this effect for children: for more than a year and a half, from June 2020 through January 2022, more than one-quarter of American children (27.6%) delayed or missed preventive care because of the pandemic.

As with any study, there are limitations here. It’s not clear what the baseline rate of missed appointments is outside of the pandemic; the results are self reported, so it’s possible some percentage of parents inaccurately characterized their child’s care status; and delayed and missed care were grouped together, even though they likely lead to different outcomes.

Still, these data, based on the responses of more than 50,000 caregivers to a question in the National Survey of Children’s Health, echo results from another national survey, which found 26.4% of kids missed or had delayed care. Yet another, smaller survey, of 2,074 caregivers, found 41.3% of parents reported a missed routine medical visit for their child due to the COVID-19 pandemic. Extrapolated nationally, these are massive numbers, potentially totalling in the tens of millions.

Medicaid statistics for children tell a worrisome story:

Graph from Kaiser Family Foundation.

Though it can be hard to pin down, delayed or missed care has consequences.

The Office of Disease Prevention and Health Promotion, for example, recommends that newborns see a pediatrician six times before their first birthday. This enables a clinician to continually assess whether the baby is reaching various milestones on schedule. When newborns went unseen by clinicians, those with developmental issues were unable to get the early diagnosis and intervention that was needed.

Preventative care in the form of vaccines was also affected. Newborns through older pediatric ages have a vaccine schedule for a range of diseases from polio to tetanus to measles. The CDC estimated that in the 2020/2021 school year a decrease in vaccinations represents 250,000 kindergartners potentially not protected against measles. While part of the decrease in vaccinations may be due to a change in attitudes toward vaccines, given the high rate of missed pediatric appointments, some portion of the vaccination decrease is likely related to parents and their child simply not showing up at medical facilities.

Since numbers can be numbing, a few case studies will bring the effect of missed and delayed care into focus. An Italian study did an effective job documenting a number of cases where parental fears of Covid led to delayed care for their children, with disturbing consequences:

A 3 -year-old boy with by Down Syndrome with a diagnosis of mild thrombocytopenia was admitted to emergency department. His parents had decided to skip the scheduled follow-up appointments because they were afraid of the COVID-19 infections. For the same reason, when the first symptoms showed up, they waited for over 1 week, even though they had undergone training for recognizing those symptoms requiring immediate medical care. He was eventually diagnosed with acute myeloid leukemia.

One child complained of neck pain with walking abnormalities and weight loss for almost 1 month. He was never seen by a doctor until he started with morning vomiting. When he arrived in Hospital… a cerebellar mass with a diameter of 5 cm was found [leading to a] compressed and dislocated the brain stem, threatening the life of the patient.

A 2 -year-old boy was kept at home for 1 week with high fever and a cough. At arrival [at the hospital] he was diagnosed with severe bacterial pneumonia with a massive parapneumonic pleural effusion requiring thoracic drainage and subsequent thoracoscopic decortication.

A child complained of abdominal pain, high fever and vomiting for 5 days. The child underwent urgent surgery for an acute perforated appendicitis causing a stercoraceous peritonitis.

All of the children tested negative for Covid. The authors concluded:

Many children that would have been otherwise visited by a general practitioner or seen earlier to the [emergency department], showed a significant and dangerous diagnostic delay at admission. The cases described all share a clinical profile worsened by the diagnostic delay caused by the widespread tendency of parents to avoid hospitals and pediatricians’ assistance.

Studies have found a spike in delayed care for complicated appendicitis, “all with late diagnosis resulting from different aspects of the fear from the current global COVID‐19 pandemic.”

Delays in diagnosing and treating children with new-onset type 1 diabetes, leading to presentation in severe diabetic ketoacidosis, have also been documented. The authors of one study noted the delay was in relation to parental “fear of contracting COVID-19 in a hospital setting, and the inability to contact a medical provider for timely evaluation.”

The evidence that there were harms from delayed care for children is not just retrospective:

Doctors at a major children’s hospital in the Bronx, New York, saw a marked decrease in pediatric cancerous tumor diagnoses early in spring 2020. “In April we saw only four new patients with solid tumors, three of whom were sarcoma patients who presented with a long duration of symptom and were found to have metastatic disease,” they wrote. The authors hypothesized that this was due to a “reluctance on the part of patients and their families to seek care.” And they explained, “the delay in presentation correlates with advanced disease at diagnosis. Advanced disease at presentation has been linked to worse outcomes and overall survival.”

Similarly, as early as March through July 2020, according to medicaid statistics, children insured by Medicaid and the Children’s Health Insurance Program (CHIP) received 12% fewer routine vaccinations (among beneficiaries aged ≤2 years), 29% fewer screening services, and 35% fewer outpatient mental health services.

It’s clear that indications that children were not getting the basic care they needed were evident from the beginning of the pandemic. Knowing this, the health authorities could have made messaging about the importance of pediatric care a priority, but instead they chose to emphasize fear and danger. The media, naturally, went along with that narrative.

The result of this messaging from public health authorities and the media was a profound distortion in risk assessment. A Gallup survey in 2020 found that Democrats overestimated the share of Covid deaths of those under age 25 by 8,700 percent. (It was 0.1%, and they thought it was 8.7%.) In fact, both Republicans and Democrats overestimated deaths among all Americans in every single age bracket up to age 64. And the estimates were not just off but wildly off for everyone under age 55.

And so, the reaction to a virus that posed a minimal risk to nearly all children, and was of limited risk for most adults, nevertheless, led to millions of children put at greater risk of harm from delayed and missed care.