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The Effect of COVID-19 Stay-At-Home Orders on the Rate of Pediatric Foreign Body Ingestions

Published:September 13, 2022DOI:https://doi.org/10.1016/j.jemermed.2022.09.019

      Abstract

      Background

      Foreign body ingestions are a common presentation in the emergency department (ED), particularly in young children.

      Objective

      We sought to determine whether the COVID-19 pandemic lockdowns had an effect on the proportion of foreign body ingestions.

      Methods

      We performed a retrospective review of the Pediatric Health Information System for patients younger than 19 years who were identified by International Classification of Diseases, Tenth Revision codes for foreign body ingestion. We analyzed patients in the following three groups: young children (younger than 5 years), school-aged children (5–12 years), and adolescents (13 years and older), using an interrupted time series analysis. Our primary outcome was the difference in proportion of foreign body ingestions. We compared 1 year after the declaration of the COVID-19 pandemic (March 13, 2020 to March 31, 2021) with the previous 3 years (March 1, 2017 to March 12, 2020).

      Results

      Total pediatric ED encounters decreased in the post period (p < 0.01); 4902 patients per year presented for foreign body ingestion pre–COVID-19 shutdown vs. 5235 patients per year post–COVID-19 shutdown. In all three age groups (young children, school-age children, and adolescents), there was a higher proportion of foreign body ingestions post–COVID-19 shutdown (p < 0.01, p < 0.01, and p = 0.028, respectively), driven primarily by the decrease in total ED encounters. In the youngest age group (younger than 5 years), there was also a significant increase in slope for foreign body ingestions post–COVID-19 (p = 0.010).

      Conclusions

      The proportion of foreign body ingestions increased after the declaration of the COVID-19 pandemic, primarily driven by an overall decrease in total ED volume.

      Keywords

      Introduction

      Foreign body ingestions are common in pediatric emergency departments (EDs) (
      • Wyllie R.
      Foreign bodies in the gastrointestinal tract.
      ). Certain presentations, such as those associated with button batteries, can be life-threatening due to corrosive damage to the esophagus requiring emergent intervention (
      • Shafiq S
      • Devarbhavi H
      • Balaji G
      • Patil M.
      Button battery ingestion in children: experience from a tertiary center on 56 patients.
      ,
      • Kramer RE
      • Lerner DG
      • Lin T
      • et al.
      Management of ingested foreign bodies in children: a clinical report of the NASPGHAN Endoscopy Committee.
      ). A recent study demonstrated that the annual rate of foreign body ingestions per 10,000 children increased by 91.5% during a 20-year period (
      • Orsagh-Yentis D
      • McAdams RJ
      • Roberts KJ
      • McKenzie LB.
      Foreign-body ingestions of young children treated in US emergency departments: 1995-2015.
      ). Coins are the most commonly ingested object; other objects include toys, button batteries, magnets, marbles, and sharp objects (such as screws or safety pins) (
      • Wyllie R.
      Foreign bodies in the gastrointestinal tract.
      ). Certain measures, such as the Consumer Product Safety Improvement Act (CPSIA) in 2008—which requires batteries for use in toys intended for children younger than 3 years to be secured in compartments—have attempted to reduce pediatric foreign body ingestions (
      Committee on Injury, Violence and Poison Prevention. Prevention of choking among children.
      ). Nevertheless, despite an initial decrease until 2011, the overall trend of foreign body ingestions has continued to increase year after year (
      • Orsagh-Yentis D
      • McAdams RJ
      • Roberts KJ
      • McKenzie LB.
      Foreign-body ingestions of young children treated in US emergency departments: 1995-2015.
      ).
      On March 11, 2020, the World Health Organization declared the COVID-19 outbreak a pandemic (
      • Cucinotta D
      • Vanelli M.
      WHO declares COVID-19 a pandemic.
      ). Shortly after this declaration, governors throughout the United States issued statewide lockdowns through stay-at-home mandates and shuttered schools, after which students transitioned to remote learning modalities. At the peak of school closures, it is estimated that at least 55.1 million students in approximately 124,000 schools were affected (

      Map: coronavirus and school closures. Education Week. Published March 6, 2020. Updated October 13, 2021. Accessed September 28, 2022. https://www.edweek.org/leadership/map-coronavirus-and-school-closures-in-2019-2020/2020/03.

      ). Approximately 66% of parents and caregivers who primarily worked from home during this time stated that they had at least some childcare responsibilities while working from home (

      Igielnik R. A rising share of working parents in the U.S. say it's been difficult to handle child care during the pandemic. Accessed November 10, 2021. Pew Research Center. https://www.pewresearch.org/fact-tank/2021/01/26/a-rising-share-of-working-parents-in-the-u-s-say-its-been-difficult-to-handle-child-care-during-the-pandemic/.

      ).
      In this investigation, we attempted to determine the impact of the COVID-19 lockdowns on the proportion of pediatric foreign body ingestions presenting to EDs throughout the United States. We hypothesized that the proportion of foreign body ingestions would increase due to children being at home for longer periods of time than expected, with less supervision due to parental work responsibilities and other distractions. These findings could help raise parental and governmental awareness of the need for additional public health measures to protect children during this particularly vulnerable time, as coronavirus variants continue to surge throughout the United States, potentially leading to additional school closures.

      Materials and Methods

      Study Design and Setting

      We performed a retrospective review of pediatric patients younger than 19 years who presented to the ED for foreign body ingestion. We obtained data for this study from the Pediatric Health Information System (PHIS), an administrative database that contains inpatient, ED, ambulatory surgery, and observation encounter-level data from more than 50 not-for-profit, tertiary care pediatric hospitals in the United States. These hospitals are affiliated with the Children's Hospital Association (Lenexa, KS). Data quality and reliability are assured through a joint effort between the Children's Hospital Association and participating hospitals. For the purposes of external benchmarking, participating hospitals providedischarge or encounter data, including demographic characteristics, diagnoses, and procedures. Nearly all of these hospitals also submit resource utilization data (e.g., pharmaceuticals, imaging, and laboratory) to PHIS. Data are de-identified at the time of data submission and are subjected to several reliability and validity checks before being included in the database. The PHIS Review Board and the Institutional Review Board of our institution approved this study.
      To understand the effect of the COVID-19 lockdowns, we defined two study periods as “pre–COVID-19 lockdown” and “post–COVID-19 lockdown.” Given the varying school closure dates as the pandemic grew, we defined the study periods according to the U.S. declaration of a national emergency on March 13, 2020 (

      Declaring a National Emergency Concerning the Novel Coronavirus Disease (COVID-19) Outbreak. A Proclamation. Executive Office of the President. Federal Registister, March 13, 2020. Accessed September 28, 2022. https://www.federalregister.gov/documents/2020/03/18/2020-05794/declaring-a-national-emergency-concerning-the-novel-coronavirus-disease-covid-19-outbreak.

      ). We compared the visits for the 3 years prior to this date (pre–COVID-19 lockdown: March 1, 2017 to March 12, 2020) with the visits after this date (post–COVID-19 lockdown: March 13, 2020 to March 31, 2021). Although statewide lockdowns and school closures happened at different times, we thought that the date of the declaration of a national emergency would reflect an appropriate division between the pre-lockdown and post-lockdown periods. The end of the post–COVID-19 lockdown period was driven by the most recently available data provided by PHIS.

      Selection of Participants

      We included patients younger than 19 years who presented to the ED with a primary discharge diagnosis of foreign body ingestion. We collected data from PHIS hospitals with complete administrative and billing data during the entire study period from March 1, 2017 through March 31, 2021. We defined foreign body ingestion using International Classification of Diseases, Tenth Revision (ICD-10) codes T18.8XXA / T18.9XXA (“foreign body in other parts of alimentary tract, initial encounter”) as a principal diagnosis (
      World Health Organization
      International Classification of Diseases, Tenth Revision.
      ). Exclusion criteria included visits by patients with complex chronic conditions (
      • Kuo DZ
      • Houtrow AJ
      Council on Children with Disabilities. Recognition and management of medical complexity.
      ,
      • Hudgins JD
      • Monuteaux MC
      • Bourgeois FT
      • et al.
      Complexity and severity of pediatric patients treated at united states emergency departments.
      ,
      • Feudtner C
      • Christakis DA
      • Connell FA.
      Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997.
      ,
      • Feudtner C
      • Hays RM
      • Haynes G
      • Geyer JR
      • Neff JM
      • Koepsell TD.
      Deaths attributed to pediatric complex chronic conditions: national trends and implications for supportive care services.
      ,
      • Feudtner C
      • Feinstein JA
      • Zhong W
      • Hall M
      • Dai D.
      Pediatric complex chronic conditions classification system version 2: updated for ICD-10 and complex medical technology dependence and transplantation.
      ). We stratified patients a priori into three separate age groups (young children [younger than 5 years], school-aged children [5–12 years], and adolescents [13–18 years old]) based on previous literature showing different rates of foreign body ingestion according to age (
      • Dipasquale V
      • Romano C
      • Iannelli M
      • et al.
      Managing pediatric foreign body ingestions: a 10-year experience.
      ,
      • Litovitz TL
      • Klein-Schwartz W
      • White S
      • et al.
      2000 Annual report of the American Association of Poison Control Centers Toxic Exposure Surveillance System.
      ).

      Measurements

      We abstracted the following data elements electronically from the database: demographic information including age, gender, race, ethnicity, and payer information (private, public, or other), as well as visit information, including check-in time of day (day, evening, or overnight), weekend visit (yes or no), and ED disposition (discharged, admitted, transferred, left against medical advice, or operating room). We also collected clinical information, including imaging (radiography, computed tomography, or fluoroscopy), procedures (identified by ICD-10 procedure codes listed in the Appendix, mean hospital charges, mean lengths of stay, and return visits within 7 days.

      Outcomes

      Our primary outcome was the proportion of pediatric foreign body ingestions within each age group; the denominator included total ED encounters. Secondary outcomes included the absolute count of pediatric foreign body presentations, rates of imaging, mean hospital charges, mean length of stay, and rates of return visits within 7 days of initial ED presentation.

      Analysis

      We used descriptive statistics to characterize the demographic and clinical features of the study population. We performed interrupted time series analyses using logistic regression separately for each age group to assess for changes in the proportion of foreign body ingestions before and after the declaration of the national emergency. We estimated a logistic regression model with the proportion of patients presenting for foreign body ingestions as the dependent variable. The independent variables included time (modeled monthly), intervention period (pre vs. post declaration of the COVID-19 national emergency), and time-by-intervention interaction term. The time variable provides an estimate of the pre-period slope. The intervention variable compares the pre- vs. post-intervention intercepts (i.e., the level change), and the interaction term tests whether the change over time in the pre–COVID-19 lockdown period differed compared with the change over time in the post–COVID-19 lockdown period (i.e., comparison of the pre- vs. post-lockdown slopes or slope change).
      All regression models used robust SEs clustered on hospital to account for intrahospital correlation. We performed statistical analyses using STATA (version 16.0; StataCorp) and IBM SPSS (version 23; IBM SPSS) software. All statistical tests were two-tailed and α was set at 0.05.

      Results

      Characteristics of Study Subjects

      Of all eligible PHIS hospitals, 40 had complete administrative and billing data during the entire study period and were included in this study. During the pre-pandemic and post-pandemic periods, there were 8,156,272 and 1,513,493 ED encounters, respectively. Of these visits, there were 14,705 encounters (4902 encounters per year) that had a primary diagnosis of foreign body ingestion during the 3-year period prior to the COVID-19 lockdown (March 1, 2017 to March 12, 2020) compared with 5235 encounters in the 1-year period after the COVID-19 lockdown (March 13, 2020 to March 31, 2021). There was no significant difference between these two populations based on age or gender. In both populations, the patients were more likely to be male than female (56% vs. 44%) and more likely to be younger than 5 years (66%). There was a statistically significant difference regarding race and payer type between the two groups. A higher proportion of White and private payer patients presented to the ED post lockdown. Most ED presentations occurred in the evening (51%). The summary statistics of this population are presented in Table 1.
      Table 1Patient Characteristics of Pediatric Foreign Body Ingestions Treated at Pediatric Health Information System Emergency Departments.
      CharacteristicPre–COVID-19 Shutdown (3/1/2017–3/12/2020) (n = 14,705)Post–COVID-19 Shutdown (3/13/2020–3/31/2021) (n = 5235)p Value
      Comparison of the pre- to post-COVID shutdown groups, testing the null hypothesis of no difference across all subgroups for each bolded patient characteristic.
      n%n%
      Age0.957
       < 5 y966865.8344465.8
       ≥ 5–12 y410527.9145427.8
       13–18 y9326.33376.4
      Gender0.345
       Male817355.6294956.3
       Female652744.4228443.7
      Race0.002
       White872759.4330763.2
       African American237116.182215.7
       Asian4242.91753.3
       Other231115.775014.3
       Unknown8725.91813.5
      Ethnicity0.054
       Hispanic359024.4124623.8
       Non-Hispanic10,19669.3380772.7
       Unknown9196.31823.5
      Payer0.045
       Private576639.2218541.7
       Public784253.3273452.2
       Other7675.22745.2
       Unknown3302.2420.8
      Time of day0.162
       Day (8 am to 4 pm)583039.6214040.9
       Evening (4 pm to 12 am)758851.6267151
       Overnight (12 am to 8 am)12878.842458.1
      Weekend visit404227.5136826.10.058
      Total ED volume8,156,2721,513,493
       ≤ 5 y4,575,81356.1780,95051.6
       >5–12 y2,220,18927.2401,01926.5
       >12 y1,360,27016.7331,52421.9
      ED = emergency department.
      low asterisk Comparison of the pre- to post-COVID shutdown groups, testing the null hypothesis of no difference across all subgroups for each bolded patient characteristic.

      Main Results

      Among the encounters with patients younger than 5 years, there was both a significant level change (odds ratio [OR] 1.72; 95% CI 1.51–1.97) and slope change (OR 1.02; 95% CI 1.00–1.03) in the positive direction, indicating an increase in the proportion of foreign body visits after the onset of the shutdown (p < 0.01 and p = 0.029, respectively). Among the encounters with patients aged 5–12 years, there was a significant level change (OR 1.97; 95% CI 1.73–2.30) in the positive direction (p < 0.01), with no slope change (OR 1.01; 95% CI 0.99–1.02]). Among the encounters with patients aged 13–18 years, there was a significant level change (OR 1.81; 95% CI 1.07–3.06) in the positive direction (p = 0.028), with no slope change (OR 0.97; 95% CI 0.92–1.02) (Figure 1).
      Figure 1
      Figure 1Interrupted time series regression. FB = foreign body.
      The absolute number of pediatric ED visits per month decreased dramatically (z = –8.63; p < 0.01), but the absolute number of monthly visits for foreign body ingestions remained relatively steady (z = 0.82; p = 0.41) after the declaration of the national emergency (Figure 2). The annual number of visits for foreign body ingestions during the study period were as follows: 2017, n = 4156; 2018, n = 4592; 2019, n = 4983; 2020, n = 4876; and 2021, n = 1333 (first quarter only).
      Figure 2
      Figure 2Absolute number of foreign body presentations compared to total emergency department (ED) volume.
      The clinical and management characteristics are presented in Table 2. Most encounters for suspected foreign body ingestions ended in discharge from the ED in both the pre– and post–COVID-19 shutdown periods (94.5% and 93.7%, respectively). Mean hospital charges and mean lengths of stay were not statistically different between the two study periods. There was a statistically significant difference in ED disposition, rates of imaging, procedures, and return visits within 7 days. A higher proportion of patients had imaging and were admitted post lockdown, but fewer procedures and fewer return visits were seen post lockdown.
      Table 2Clinical Characteristics of Pediatric Foreign Body Ingestions Treated at Pediatric Health Information System Emergency Departments.
      CharacteristicPre-COVID Shutdown (3/1/2017–3/12/2020) (n = 14,705)Post-COVID Shutdown (3/13/2020–3/31/2021) (n = 5235)p Value
      ED disposition, n (%)0.006
       Discharge13,888 (94.5)4903 (93.7)
       Admission724 (4.9)302 (5.8)
       Transfer49 (0.3)24 (0.4)
       Against medical advice44 (0.3)6 (0.1)
       Operating room
      Included in admission number.
      316 (2.2)127 (2.4)
      Imaging, n (%)
       X-ray study12,204 (83.0)4551 (86.9)< 0.00
       Computed tomography53 (0.4)42 (0.8)< 0.00
       Fluoroscopy421 (2.9)97 (1.9)< 0.00
       Other16 (0.1)5 (0.1)0.799
      Procedures, n (%)180 (1.2)43 (0.8)0.017
      Hospital charges (US$),
      Adjusted for inflation.
      mean
      6827500.601
      Length of stay (d) mean1.031.030.478
      Return visit within 7 d, n (%)512 (3.5)150 (2.9)0.03
      ED = emergency department.
      low asterisk Included in admission number.
      Adjusted for inflation.

      Discussion

      Our study investigated the impact of the COVID-19 lockdowns on the proportion of pediatric foreign body ingestions treated at EDs throughout the United States. Although this study did not show a significant increase in the absolute number of foreign body ingestions after the declaration of a national emergency and shutdown of schools, it did demonstrate that the proportion of ED visits related to foreign body ingestions increased. This proportional increase was driven largely by the overall decrease in ED visits, but demonstrates that pediatric foreign body ingestions remained a common presentation even throughout a pandemic. Pediatric ED visits to children's hospitals decreased nationwide throughout the COVID-19 pandemic across a broad range of conditions (
      • DeLaroche AM
      • Rodean J
      • Aronson PL
      • et al.
      Pediatric emergency department visits at US children's hospitals during the COVID-19 pandemic.
      ).
      In this study population, a higher proportion of patients in the post-lockdown group had imaging performed and were admitted to the hospital, with fewer procedures performed. Although there was no difference in the absolute number of foreign body ingestions between the study groups, potential explanations for these findings could include reluctance to perform certain procedures, such as endoscopy, due to concern for COVID-19 infection and more reliance on admission for observation of passage of the foreign body. Additional study is needed to see whether these changes have persisted over the course of the pandemic.
      The COVID-19 lockdowns led to an unprecedented number of school closures throughout the United States, leaving millions of children at home with adult guardians, some of whom were required to manage childcare and virtual work at the same time. Social distancing and stay-at-home orders also led to extended periods of time in homes, where children (unsupervised or not) may have had the opportunity to ingest foreign bodies. A recent study found that most foreign body ingestions during the pandemic occurred while at home (
      • Pizzol A
      • Rigazio C
      • Calvo PL
      • et al.
      Foreign-body ingestions in children during COVID-19 pandemic in a pediatric referral center.
      ). Although our study did not show an increase in the absolute number of foreign body presentations, other studies performed in Italy, Britain, and Japan have reported an increase throughout the COVID-19 pandemic, primarily with magnet and button battery ingestions, as well as with overall hospitalizations (
      • Pizzol A
      • Rigazio C
      • Calvo PL
      • et al.
      Foreign-body ingestions in children during COVID-19 pandemic in a pediatric referral center.
      ,
      • Festa NT
      • Thakkar H
      • Hewitt R
      • et al.
      Foreign body ingestion during the COVID-19 pandemic: a retrospective single centre review.
      ,

      Maruo Y, Ishikawa S, Oura K, et al. The impact of COVID-19 pandemic on pediatric hospitalization in Kitami, Japan. Pediatr Int 64(1):e14937. doi:10.1111/ped.14937.

      ). Furthermore, our study demonstrated that foreign body ingestions remain a common presentation even throughout a pandemic and EDs should be equipped to manage them.
      With the possibility of future variants, such as the recent highly transmissible Omicron variant, there is a possibility that additional school or community lockdowns will be enacted. At the beginning of the 2021-2022 academic school year, many school districts throughout states with low vaccination rates, including Alabama, Florida, and Texas, were forced to close down for portions of the school year due to surging COVID-19 cases (

      Cassels L. School closures reported in five FL counties; districts ‘drowning’ in COVID. Florida Phoenix. Published August 20, 2021. Accessed July 14, 2022. https://floridaphoenix.com/2021/08/20/school-closures-reported-in-five-fl-counties-districts-drowning-in-covid/.

      ,

      Lopez B. Rural schools shut down to keep COVID-19 from overwhelming their small communities. The Texas Tribune. Published August 19, 2021. Accessed July 14, 2022. https://www.texastribune.org/2021/08/19/texas-school-districts-shut-covid/.

      ,

      Johnson K. Alabama Superintendent Mackey expects more schools to close as COVID-19 surges. Montgomery Advertiser. Published August 27, 2021. Accessed July 14, 2022. https://www.montgomeryadvertiser.com/story/news/education/2021/08/27/alabama-superintendent-schools-close-covid-19-spike/5605122001/.

      ). It is also possible that younger children will continue to be kept at home until widespread vaccination has been obtained among our most vulnerable age groups. Previous researchers have reported that public health measures, such as advertisements and medical education programs, can lead to a reduction in foreign body ingestions (
      • Karatzanis AD
      • Vardouniotis A
      • Moschandreas J
      • et al.
      The risk of foreign body aspiration in children can be reduced with proper education of the general population.
      ,
      • Sadan N
      • Raz A
      • Wolach B.
      Impact of community educational programmes on foreign body aspiration in Israel.
      ). Therefore, it remains important to continue to educate parents and primary care practitioners on guidance for the safe storage of dangerous objects, such as button batteries or other objects that may pose a threat to young children.
      Several measures put forth by the Consumer Safety Production Commission, such as the CPSIA in 2008—which requires batteries for use in toys intended for children younger than 3 years to be secured in compartments—have attempted to improve safety surrounding the ingestion of foreign bodies (
      Committee on Injury, Violence and Poison Prevention. Prevention of choking among children.
      ). Additional measures, such as a federal safety standard with regard to high-powered magnets, initially led to a decrease in magnet ingestions, but ultimately was overturned in 2016, leading to a rebound in presentations for magnet ingestions (
      • Flaherty MR
      • Buchmiller T
      • Vangel M
      • Lee LK.
      Pediatric magnet ingestions after federal rule changes, 2009-2019.
      ). As we have shown, foreign body ingestions remain a frequent problem requiring ED utilization throughout a pandemic, and continued research should focus on legislation regarding this important issue.

      Limitations

      Our study has limitations to consider. First, this is a retrospective study in an administrative database. Therefore, we are limited to data collected from the ED encounter, which do not include clinical information from the visit, type of foreign body ingested, or risk factors for ingestion.
      Second, the data were limited to the hospitals included within the PHIS database, which are all academic children's hospitals. Therefore, the results of this study may not be generalizable to other hospitals throughout the United States, such as community hospitals, where a large proportion of children are treated annually.

      Conclusions

      The proportion of foreign body ingestions increased after the declaration of the COVID-19 pandemic, driven primarily by an overall decrease in the total pediatric ED volume.

      Article Summary

      1. Why is this topic important?
      Foreign body ingestions are a very common presentation in emergency departments (EDs). It is important to know the burden of these presentations so that EDs, particularly community-based EDs, have appropriate pediatric readiness.
      2. What does this study attempt to show?
      This study attempts to show the effect of national lockdowns during the COVID-19 pandemic on the rate of pediatric foreign body ingestions at selected Pediatric Health Information System hospitals.
      3. What are the key findings?
      The rate of foreign body ingestions as a proportion of ED volume increased after the declaration of the worldwide COVID-19 pandemic, primarily driven by an overall decrease in the total pediatric ED volume.
      4. How is patient care impacted?
      Pediatric foreign body ingestions remain a common presentation, even during global pandemics, and EDs should be prepared with resources in place to provide effective care for pediatric patients.

      Appendix. List of Internationl Classification of Diseases, Tenth Revision Procedure Codes Included

      Tabled 1
      0DB98ZZ0DB98ZX0DB58ZX0DBA8ZX0DB38ZX
      0DB28ZZ0DB28ZX0DB88ZX0DB68ZZ0DB68ZX
      0DB78ZZ0DB78ZX0DB18ZX0DCQ7ZZ0DCK8ZZ
      0DCH8ZZ0DC98ZZ0CCR8ZZ0DC48ZZ0DC58ZZ
      0DCB8ZZ0DC38ZZ0DC28ZZ0WC3XZZ0CCM8ZZ
      0CCM7ZZ0DCP7ZZ0DC68ZZ0DC78ZZ0DC18ZZ
      0DD98ZX0DD58ZX0DD68ZXBD14ZZZBD11ZZZ
      BD15ZZZBD16ZZZ0WJP8ZZ0DJD8ZZ0DJD7ZZ
      0CJY8ZZ0WJ3XZZ0DJ68ZZ0DJ08ZZ

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