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Abstract
Child health is at risk from the unintended consequences of the COVID-19 response and will suffer further unless it is given proper consideration. The pandemic can be conceived as a systemic shock to the wider determinants of child health, with impacts on family functioning and income, access to healthcare and education. This article outlines COVID-19 impacts on children in England. Key priorities relate to the diversion of healthcare during lockdown; interruption and return to schooling; increased health risks and long-term impacts on child poverty and social inequalities. We provide an overview of mitigation strategies and policy recommendations aimed to assist both national and local professionals across child health, education, social care and related fields to inform the policy response.
- adolescent health
- epidemiology
Data availability statement
Data sharing is not applicable as no datasets generated and/or analysed for this study.
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What is already known on this topic?
Child health in England was already at crisis point pre-COVID-19.
While the direct health impact of COVID-19 infection on children and young people is rarely severe, longer term indirect impacts are currently unclear.
What this study adds?
Our review highlights a range of risks to child health in England, resulting from the unintended consequences of the COVID-19 response.
Long-terms risks may result from diversion of healthcare, interruption of schooling, impact on mental health and increased social inequalities, among other things.
A considered and multidisciplinary policy response that prioritises children’s right to health is required in order to mitigate against rising inequalities.
Introduction
There is growing concern that child health in England, already at crisis point pre-COVID-19, will suffer further in the pandemic recovery, unless prioritised in policy discussions.1–4 Thankfully, the direct effects of coronavirus infection on children are rarely severe. Despite a small number of children presenting with a multisystem inflammatory state,5 rates of child illness and death have been low.6
Of greatest concern for children is the ‘collateral damage’ caused by the unintended consequences of COVID-19 restrictions, first introduced on 23 March 2020.4 Many are concerned that these indirect effects will disproportionately and dramatically affect disadvantaged children and young people (C&YP) who, in the absence of mitigating policies, risk being overlooked.1 4 This article outlines key COVID-19 impacts on children including diversion of healthcare; interruption of and return to education; increased health risks; and long-term impacts on child poverty and social inequalities. Public health academics and local authority public health leads for C&YP in England hosted a workshop to identify impacts, which informed a targeted, but non-systematic, review of emerging literature between March and July 2020. Issues highlighted relate to England, unless otherwise acknowledged, as restrictions and impacts differ across the UK. Table 1 outlines mitigation strategies and policy recommendations to assist national and local professionals across child health, education, social care and related fields, with the policy response.
Impact of COVID-19 on C&YP and summary of mitigating actions/policy recommendations
Diversion of healthcare
Rising COVID-19 admissions across Europe in early 2020 prompted widespread cancellation of routine National Health Service (NHS) services from 17 March to maximise inpatient beds for the April ‘peak’.7 General practices were asked to deliver remote triage and care to patients, wherever possible.8 In April 2020, emergency department attendances in England were 57% lower than April 2019.9 While representative data on the scale and impact of diversion of care for children is lacking, there is clear concern about children presenting late for acute illnesses. In a recent survey of UK A&E paediatricians, a third reported witnessing delayed presentations, particularly for new diagnoses of diabetes mellitus, diabetic ketoacidosis and sepsis, and 18% reported delays. Community paediatricians expressed concerns about falling referrals for child protection and oncologists for cancer referrals.10 Although another study of routine data suggested that late presentation has been rare,11 disruptions to planned outpatient visits, operations or healthcare have prompted anxiety for families and may have led to increased morbidity for some children.
Some local universal children’s services have been reorganised to deliver health visiting and midwifery services virtually. While appropriate for some families, remote contact may be less effective for the most disadvantaged, curbing opportunities to support families and safeguard children, and potentially widening inequalities. Paediatric dental services were cancelled altogether, including routine dental check-ups and planned hospital treatment.
While infant immunisations have continued through primary care, uptake was reportedly down, with preprint data suggesting that measles, mumps and rubella (MMR) vaccinations in England fell by nearly 20% during early lockdown compared with previous years.12 School-aged programmes were ceased as per national guidance, again prompting concern, particularly for children in marginalised groups with historically low vaccine uptake. An example of successful innovation in this arena is the Derbyshire Community Health Services’ drive-through human papillomavirus (HPV) immunisation clinics, set up to replace school-based clinics from May 2020.
As COVID-19 restrictions are lifted, a double burden on services is anticipated from the combined backlog accrued during lockdown (including rescheduled appointments and delayed care seekers) and mental health issues emerging as a result of the crisis, requiring treatment and support. Catch up programmes will require additional resources to manage backlogs. The Royal College of Paediatrics and Child Health has set out three principles for recovery of paediatric services following COVID-19: ‘reset, restore and recover’.13
Interruption of schooling and early years provision
School closures have interrupted educational trajectories and increased educational inequalities for C&YP.14 In addition to providing education, schools and early years’ settings play a vital role as sources of safety, structure and food for vulnerable children.
Although schools in England remained open to vulnerable and key workers’ children throughout, attendance was low. In May, around 2% of all children attended school and between 4% and 10% of vulnerable children. In June, as schools allowed nursery, reception, year 1 and year 6 pupils to attend, attendance increased to 9% of children, of which 17%–18% were vulnerable.15 In mid-June, when years 10 and 12 were permitted to return, only 16% and 13.8% attended, respectively.16
Although provision was made for most children to learn remotely, engagement and access has differed by socioeconomic status. In May 2020, a survey reported that only 42% of pupils were returning homework. This figure was only 30% in the most deprived areas compared with 49% in the least deprived.17 A quarter of pupils had little or no home IT access, significantly affecting access to learning resources. Children in the highest income quintile reported more home learning resources and parental support and spent over 75 min/day longer on home learning than those in the lowest income quintile.18 Although many local authorities and schools have provided laptops and creative opportunities for connecting and learning,19 inequalities in home education are likely to be substantial and further widen entrenched educational inequalities.18 Some special educational needs schools remained fully closed at the time of writing, leaving families struggling with a lack of respite and support.
Just over a third of early years settings in England remained open during lockdown, with only 5% of places attended.20 Most young children have spent lockdown within home environments where, for some, household dysfunction and parents’ psychological stress may have negatively contributed to early child development. The phased return to early years settings and schools has involved a careful balancing of perceived risk against the provision of childcare and education. In late May, 60% of parents surveyed were not planning to return children to nursery due to safety fears and lack of clear government guidance.20 On 8 June 2020, as lockdown in England eased, average occupancy rates in early years settings were 37%, just over half that in spring 2019 (77%),21 highlighting concern about the potential for collapse of the sector in the absence of government investment.20
Evidence demonstrating lower transmission rates of COVID-19 in children22 has supported the return of all pupils to full-time education from September. However, COVID-19 cases within educational settings will require groups of children to self-isolate for up to 14 days, creating further long-term disruption and uncertainty for many. Central government have committed to £1 billion funding to provide catch-up tutoring for the most disadvantaged pupils.23 In the long term, further systematic changes could consider a reduced focus on results and provision of more support for addressing well-being and mental health.
Increased health risks of lockdown
Safeguarding and domestic abuse
In England, 2 million families struggle with domestic abuse, parental substance misuse or parental mental health issues. Rates of domestic abuse increase in times of crisis, for example, following Hurricane Katrina.24 During the first three weeks of UK lockdown, 14 women and 2 children were killed by men, at least 10 of them allegedly by their partners, ex-partners or fathers. This is over double the average number of women killed over a three week period in the last decade.25 Urgent care proceedings in the family courts have also sharply increased, which may in part reflect prioritisation of care cases but may also suggest a heightened risk to children under lockdown. There has been a concomitant reported surge in calls to domestic abuse helplines and online services.26 The UK’s national domestic abuse helpline saw a 66% rise in calls and a 950% increase in website visits, with an associated increase in demand for refuge places.27 Many services in this chronically underfunded sector have reported staffing issues due to COVID-19 and refuges are at reduced capacity. Hidden need is more likely to remain hidden and reported need unmet.
With few vulnerable children attending school, opportunities for safeguarding interventions by teachers and school nurses may be reduced: schools and education services accounted for 20% of referrals to children’s social care in 2018–2019.28 The relaxation of some statutory child protection duties, including allowing phone calls over face-to-face visits and less frequent health assessments for children in care, in order to ease the burden on children’s services, have been heavily criticised.29 While this legislation has been clarified, these measures remain in place for use at the discretion of local councils.30 Charities and other organisations working to tackle domestic abuse, including the police, courts, children’s and adult’s social care, are advised to develop contingency plans, addressing increased long-term demand for services as lockdown lifts.24 Improved data collection and emergency funding, particularly to support vulnerable groups such as disabled and Black, Asian and minority ethnic (BAME) women, are also required.31
Emotional well-being and mental health
The impact of social isolation on emotional well-being and mental health is an overarching area of concern for all age groups but particularly for children.32 Before the pandemic, C&YP’s mental health was already in crisis.33 The pandemic has exacerbated problems, increasing family stress, removing protective environments such as school and decreasing physical access to services. Many C&YP have experienced higher levels of anxiety and depression during lockdown.34 A survey by Young Minds found that 83% of young people with existing mental health needs found the pandemic had contributed to further deterioration.35 Similarly, younger children appear to have struggled during lockdown, with parents of children aged 4–10 years reporting increased behavioural and attention difficulties. However, for teenagers without prior mental health concerns, there was little change in both parent-reported and self-reported measures.36
While referrals to NHS mental health services initially slowed, a sharp rise in referral rates has now been reported in many areas37 including a surge in use of online mental health platforms.38 Childline have delivered almost 7000 counselling sessions to children who contacted them with concerns directly relating to COVID-19, and over 2000 counselling sessions per week since lockdown began, for C&YP with more general mental health and well-being concerns.39 A recent systematic review suggested that C&YP experiencing loneliness during lockdown may be up to three times as likely to develop depression in future.40
Reliance on social media to maintain social connections while unable to socialise in person has further raised concerns about the impact of excessive screen time on development, particularly for younger children.41 For adolescents, where peer interaction is a vital aspect of development, digital platforms may help mitigate the negative effects of lost face-to-face interactions; however, concerns about the negative influences of social media persist.42 Some teenagers report positives outcomes from lockdown, including learning new skills, appreciating friendships and bonding with parents and siblings. However, there will be huge inequalities in experiences, dependent on access to technology, availability of personal space and relationships with family.43 The Mental Health Foundation warns that pupils will face significant challenges as lockdown eases and suggest that schools should prioritise well-being, and a supported recovery and transition, over academic achievement.42 44
Parental mental health is a major determinant of child mental health.32 The impact on finances and associated financial worries have disproportionately affected anxiety levels for women, in addition to C&YP.34 For pregnant women there may also be an impact on perinatal mental health, related to the well-being of the baby, the impact of lockdown and restrictions on partners and relatives attendance at births. Following birth, limited professional and informal support in the early postnatal period may contribute to worse perinatal mental health and delays in recognition of deteriorating mental health; however, the short-term and long-term consequences to child health and development are as yet unknown.45
Young carers
As parents become ill with COVID-19, caring responsibilities may increasingly fall to C&YP. For those caring for parents with long-term conditions who are ‘shielding’, this burden will continue for the foreseeable future, with potentially long-lasting consequences.
An estimated 700 000 children regularly shoulder caring responsibilities in UK households.46 Young carers already face significant inequalities including higher rates of school absenteeism and lower educational attainment. They are often from lower income households, have worse levels of mental and physical health themselves and can be ‘hidden’ within other marginalised groups such as BAME communities.47 Despite this, young carers often have limited contact with support agencies such as social services, relying instead on schools, voluntary organisations and more informal family support networks.48 School holidays can significantly increase caring responsibilities, and during term time, young carers rely on after-school provision for completing homework.48 Meanwhile, undertaking shopping trips for food and medication may increase the risk of infection for young carers (table 1).
Child poverty and social inequalities
The COVID-19 pandemic is predicted to precipitate the worst global recession since the Great Depression, much worse than the 2008 Great Recession.3 Previous recessions have exacerbated child poverty, with long-lasting consequences for children’s health, well-being and learning outcomes.49 Prepandemic, child poverty, a major driver of poor child health, had risen to 4.1 million children (2017), amounting to over 30% of all English children.50 Child poverty was already predicted to rise beyond 5 million by 2022,51 and now these predictions may be far worse in the absence of mitigating policies.
In 2019, 1.3 million UK children were eligible for free school meals, with a further 1 million ineligible but still considered to be living in food insecurity. Many of these children who rely on school meals to sustain their nutrition have gone hungry over the lockdown period.52 Initial survey data show that at the start of lockdown, half of eligible children received no form of free school meal provision. While the Government did continue free school meal vouchers throughout the summer holidays following lobbying by professional footballer Marcus Rashford,53 further recommendations to increase eligibility for free schools meals and develop a Child Food Poverty Taskforce have not been taken forward.54
Long-term recovery planning must prioritise families with children.2 A real concern is that the burden of fiscal stabilisation after the initial phase of the pandemic response will fall disproportionately on poor families with children and lead to a new round of cuts to local authority services. Any new policy should therefore be assessed according to its impact on household finances and service provision for families with children. Modelling from the Child Poverty Action Group has shown how even small increases to child benefits can have widespread impacts: an additional £10 a week for each child would reduce child poverty by a 5%. In addition, many policy recommendations stress the need for more generous universal credit payments to families with children and advocate the scrapping of the two-child limit.3
Conclusions
Children are especially vulnerable to determinants of health, such as living conditions, family income, parental employment, education and access to health services. The pandemic can be conceived as a systemic shock to these determinants, with complex short-term and long-term impacts. Evidence of these impacts and appropriate mitigation strategies is rapidly evolving and requires careful synthesis. Many impacts will be long term and take time to emerge, for example, life-course effects on obesity and mental health stemming from increased early years adversity.55
However, we already know what is required to improve child health and reduce inequalities in the context of a crisis and should stick to accepted principles56 developed with and in the best interests of C&YP and aligned to the UN Convention on Rights of the Child.57 The voices of C&YP should inform policy responses. When surveyed about what makes them happy, C&YP continually emphasise the importance of being loved, safe and listened to, and while they do not deal with finances directly, they stress the importance of having well-funded schools and family finances to meet basic needs.58 Within this rapidly evolving situation, a proactive and concerted policy focus on children is required at a national and local level to ensure that they are not further overlooked in the pandemic recovery phase.
Data availability statement
Data sharing is not applicable as no datasets generated and/or analysed for this study.
Footnotes
CH and CT are joint first authors.
RK and DT-R are joint last authors.
CH and CT contributed equally.
Contributors RK and DT-R conceptualised the study. CH, CT, CF, DB, MC, RK and DT-R conducted the literature review and edited the manuscript. All of the coauthors reviewed and agreed on the finalised version.
Funding DB, DT-R and RK are funded by the National Institute for Health Research School for Public Health Research. DT-R is funded by the MRC on a Clinician Scientist Fellowship (MR/P008577/1).
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.