The start of the pandemic

When COVID-19 reached the UK in early 2020, the emphasis was, appropriately, on caring for adults. From spring to autumn 2020, COVID-19 had minimal direct impact on children, with few severe cases or deaths.1 School closures and other restrictions meant children were mixing much less than usual, and when schools reopened they were protected by bubbles and, at times, masks. This also meant that children suffered fewer severe respiratory illnesses than in a ‘normal’ year.2 However, children’s health was affected in other ways: many elective National Health Service (NHS) treatments were suspended, space was taken in several UK paediatric intensive care units (PICUs) by adult patients, and unmet need grew for diagnosis and treatment of physical and mental health problems and for child protection. So there were a range of risks to children, but what about direct risks from COVID-19?

Serious illness requiring intensive care is relatively rare in childhood. Across the four nations of the UK, 26 PICUs are commissioned, but in 2020 a single PICU was unlikely to admit more than a few children with severe COVID-19. However, among them there were some with a pandemic-related paediatric phenotype, the paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 (PIMS-TS; affecting the kidneys, heart, lungs and brain).3 The existence of an excellent national audit, collecting data from PICUs, allowed it to be characterised, while further insights came from enrolment of children in large national studies, such as the International Severe Acute Respiratory and emerging Infection Consortium (ISARIC) study and Randomised Evaluation of COVID-19 Therapy (RECOVERY) trials.

From Alpha to Delta

Fortunately, the initial policy responses were effective and paediatric cases fell, but by autumn 2020 a new Alpha variant had emerged, spreading rapidly once schools returned. Over 3 winter months (see figure 1) NHS England recorded 2603 hospital paediatric admissions, the …