open access original research impact of lockdown and

1Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043

Open access

Impact of lockdown and school closure on children’s health and well- being during the first wave of COVID-19: a narrative review

Luis Rajmil ,1 Anders Hjern,2 Perran Boran,3 Geir Gunnlaugsson,4 Olaf Kraus de Camargo,5 Shanti Raman ,6,7 and on behalf of International Society for Social Pediatrics & Child Health (ISSOP) and International Network for Research on Inequalities in Child Health (INRICH) COVID-19 Working Group

To cite: Rajmil L, Hjern A, Boran P, et al. Impact of lockdown and school closure on children’s health and well- being during the first wave of COVID-19: a narrative review. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043

► Additional supplemental material is published online only. To view, please visit the journal online (http:// dx. doi. org/ 10. 1136/ bmjpo- 2021- 001043).

Received 2 February 2021Accepted 1 May 2021

For numbered affiliations see end of article.

Correspondence toDr Luis Rajmil; 12455lrr@ comb. cat

Original research

© Author(s) (or their employer(s)) 2021. Re- use permitted under CC BY- NC. No commercial re- use. See rights and permissions. Published by BMJ.

ABSTRACTBackground In the context of containment measures against the COVID-19 pandemic, the aims were to examine the impact of lockdown and school closures on childs’ and adolescents’ health and well- being and social inequalities in health.Methods Literature review by searching five databases until November 2020. We included quantitative peer- reviewed studies reporting health and well- being outcomes in children (0–18 years) related to closure measures' impact due to COVID-19. A pair of authors assessed the risk of bias of included studies. A descriptive and narrative synthesis was carried out.Findings Twenty- two studies, including high- income, middle- income and low- income countries, fulfilled our search criteria and were judged not to have an increased risk of bias. Studies from Australia, Spain and China showed an increase in depressive symptoms and decrease in life satisfaction. A decrease in physical activity and increase in unhealthy food consumption were shown in studies from two countries. There was a decrease in the number of visits to the emergency department in four countries, an increase in child mortality in Cameroon and a decrease by over 50% of immunisations administered in Pakistan. A significant drop of 39% in child protection medical examination referrals during 2020 compared with the previous years was found in the UK, a decrease in allegations of child abuse and neglect by almost one- third due to school closures in Florida, and an increase in the number of children with physical child abuse trauma was found in one centre in the USA.Interpretation From available reports, pandemic school closure and lockdown have adverse effects on child health and well- being in the short and probably long term. We urge governments to take the negative public health consequences into account before adopting restrictive measures in childhood.

INTRODUCTIONThe global COVID-19 pandemic caused by SARS- CoV-2 is the largest since the Spanish flu pandemic in 1918, with almost 100 million confirmed cases and over two million deaths.1 This virus impacts relatively few children in terms of severe morbidity or mortality;

however, they experience heightened adver-sity as governments intervene with drastic social control measures.2 Over 1.5 billion children were out of school during the first peak, and economic insecurity has affected the most vulnerable, with several potential adverse effects.3

Governments around the world have reacted in variable ways with strategies to mitigate the pandemic. A review on the effect of school closure in the transmission of the SARS- CoV-2 in the general population predicted that school closures alone would prevent only 2%–4% of deaths, much less than other social

What is already known

► School closure and lockdown were measures initial-ly adopted almost worldwide in the first wave to fight the COVID-19 pandemic.

► Lockdown and school closure cause disproportion-ate impacts on the most vulnerable populations.

► Decisions on how to apply quarantine and school closures should be based on the best available evidence.

What this study adds

► The negative impact of school closures and lock-down has been felt by children across diverse ge-ographies, involving high and low- income settings.

► Containment measures have produced a range of adverse effects including an increase in depressive symptoms, decrease in satisfaction with life, de-crease in immunisation and an increase in unhealthy lifestyle.

► Along with a decrease in emergency presentations, there was also a significant decrease in the number of child abuse and neglect allegations and child pro-tection medical assessments.

on March 19, 2022 by guest. P

rotected by copyright.http://bm

jpaedsopen.bmj.com

/bm

jpo: first published as 10.1136/bmjpo-2021-001043 on 25 M

ay 2021. Dow

nloaded from

http://bmjopen.bmj.com/

http://orcid.org/0000-0002-6625-0649

http://orcid.org/0000-0002-4546-3231

http://crossmark.crossref.org/dialog/?doi=10.1136/bmjpo-2021-001043&domain=pdf&date_stamp=2021-05-25

http://bmjpaedsopen.bmj.com/

2 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043

Open access

distancing interventions.4 On the other hand, school closures carry high social and economic costs for people across communities associated with interrupted learning, poor nutrition, gaps in childcare, the unintended strain on healthcare systems, rise in dropout rates from school and social isolation, among other effects.5

The pandemic is a universal crisis that has affected all population groups across the globe. For some children, the impact could be lifelong, particularly the most vulnerable groups and those with less economic, educational and social resources.6 In response to school closures and depending on settings, online teaching accentuated the digital divides between those who have access and those without access.7 Moreover, schools have health promotion potential by implementing diverse health interventions and opportuni-ties to advocate for reforms and innovations to promote all students’ health.8 Arguments over whether to close schools or not to prevent transmission during a pandemic need to weigh in the potential health promotional benefits for chil-dren by attending school, in particular, those in vulnerable situations. This disconnect needs to be addressed with closer

cooperation that would revitalise not only their educational potential but also child and adolescent health and well- being9 10

Large- scale ‘lockdowns’ as occurred with little warning in many countries, involving the complete shutting down of all economic activity, along with stringent travel bans, with punitive action for any violation, have been shown to cause

Figure 1 Sample.

Box 1 Definitions of lockdown and school closure

► Although the term lockdown is not well defined, it is used to nomi-nate any measure adopted to contain the pandemic employing so-cial distancing measures.

► Lockdown measures range considerably, from mandatory total con-finement in the home during prolonged periods to be only a rec-ommendation to reduce social interactions and avoid nonessential work as much as possible.

► School closure and online classes or home schooling was the measure adopted in almost all cases during the first wave of the COVID-19 for primary and secondary schools in all included studies.



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Tab

le 1

S

tud

ies

on m

enta

l hea

lth a

nd g

ener

al h

ealth

Firs

t au

tho

r (jo

urna

l)C

oun

try

(ies)

Typ

e o

f st

udy

Mai

n su

bje

ctO

bje

ctiv

esA

ge

(n)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

N

R, e

t al

. (J

You

th

Ad

oles

c)

Aus

tral

ia (N

ew

Sou

th W

ales

)C

ohor

t st

udy

(Ris

ks t

o A

dol

esce

nt

Wel

lbei

ng

Pro

ject

, the

RA

W P

roje

ct)

Men

tal h

ealth

, lif

e sa

tisfa

ctio

nTo

ass

ess

the

imp

act

of t

he

CO

VID

-19

pan

dem

ic o

n ad

oles

cent

s’

men

tal h

ealth

, an

d m

oder

ator

s of

cha

nge,

as

wel

l as

ass

essi

ng t

he

fact

ors

per

ceiv

ed

as c

ausi

ng t

he

mos

t d

istr

ess.

13–1

6 ye

ars

(resp

onse

rat

e 53

% a

t tim

e T2

d

urin

g lo

ckd

own,

n=

248)

T1=

pre

viou

s ye

ar (2

019)

T2=

2 m

onth

s af

ter

star

t lo

ckd

own)

May

5 t

o M

ay 1

4

Gen

eral

ised

A

nxie

ty, D

epre

ssiv

e sy

mp

tom

s,

Stu

den

t’s L

ife

Sat

isfa

ctio

n S

cale

(S

LSS

)

Age

, sex

, sc

hool

ing,

pee

r an

d fa

mily

re

latio

nshi

ps,

so

cial

con

nect

ion,

m

edia

exp

osur

e,

CO

VID

-19

rela

ted

st

ress

, and

ad

here

nce

to

gove

rnm

ent

stay

- at

- hom

e d

irect

ives

at

T2

Sig

nific

ant

incr

ease

in

dep

ress

ive

sym

pto

ms

and

an

xiet

y, a

nd

a si

gnifi

cant

d

ecre

ase

in

life

satis

fact

ion

from

T1

to T

2,

high

er a

mon

g gi

rls. M

oder

ator

s w

ere

CO

VID

-19-

re

late

d w

orrie

s,

onlin

e le

arni

ng

diffi

culti

es, a

nd

incr

ease

d c

onfli

ct

with

par

ents

as

pre

dic

tors

of

incr

ease

s in

m

enta

l hea

lth

pro

ble

ms

from

T1

to T

2. A

dhe

renc

e to

sta

y- at

- hom

e an

d fe

elin

g so

cial

ly

conn

ecte

d d

urin

g th

e lo

ckd

own

pro

tect

ed a

gain

st

poo

r m

enta

l he

alth

.

Ezp

elet

a L,

et

al. (

Int

J E

nviro

n R

es P

ublic

H

ealth

)20

Bar

celo

na (S

pai

n)C

ohor

t st

udy

(sta

rted

10

year

s ag

o)

Men

tal h

ealth

To a

sses

s lif

e co

nditi

ons

dur

ing

lock

dow

n as

soci

ated

with

m

enta

l hea

lth

pro

ble

ms

in

child

ren,

and

to

anal

yse

the

men

tal

heal

th s

tatu

s of

th

e p

opul

atio

n d

urin

g th

e lo

ckd

own

per

iod

.

226

par

ents

(m

ainl

y m

othe

rs)

answ

ered

the

q

uest

ionn

aire

(re

spon

se r

ate

55%

). M

ean

age=

13.9

yea

rs

Lock

dow

n M

arch

13

to

May

24.

Que

stio

nnai

res

answ

ered

on

June

.C

omp

are

resu

lts

with

201

9

SD

Q p

aren

t- p

roxy

ve

rsio

nP

hysi

cal

envi

ronm

ent,

C

OV

ID-1

9d

isea

se, t

he a

dul

ts

shar

ing

the

hous

e,

adol

esce

nts’

re

latio

nshi

ps,

ac

tiviti

es, a

nd

feel

ings

/beh

avio

urs

Tota

l diffi

culti

es

incr

ease

d

and

pee

r, an

d

pro

soci

al,

afte

r ad

just

ing

for

pre

viou

s p

atho

logy

. Effe

ct

size

sm

all t

o m

ediu

m. Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Firs

t au

tho

r (jo

urna

l)C

oun

try

(ies)

Typ

e o

f st

udy

Mai

n su

bje

ctO

bje

ctiv

esA

ge

(n)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Zha

ng L

, et

al. (

JAM

A N

et

Op

en)21

Chi

na (C

hizh

ou,

Anh

ui P

rovi

nce)

Coh

ort

Men

tal h

ealth

To in

vest

igat

e p

sych

olog

ical

sy

mp

tom

s,

nons

uici

dal

sel

f-

inju

ry, a

nd s

uici

dal

id

eatio

n, p

lans

, an

d a

ttem

pts

am

ong

a co

hort

of

chi

ldre

n an

d

adol

esce

nts

Age

ran

ge 9

:3–

15.9

. Mea

n ag

e:

12.6

yea

rsfo

urth

to

eigh

th

grad

es.

N=

1241

out

of

1387

par

ticip

ants

in

tw

o w

aves

Two

wav

es: w

ave

1, e

arly

Nov

emb

er

2019

; and

2

wee

ks a

fter

sch

ool

reop

enin

g (w

ave

2, m

id- M

ay 2

020)

. A

fter

3 m

onth

s of

lo

ckd

own,

sch

ools

in

Chi

zhou

wer

e re

open

ed o

n A

pril

26

Dat

a on

dep

ress

ive

and

anx

ious

sy

mp

tom

s (M

ood

an

d F

eelin

gs

Que

stio

nnai

re;

Mac

Art

hur

Hea

lth

& B

ehav

ior

Que

stio

nnai

re),

nons

uici

dal

sel

f-

inju

ry, s

uici

de

idea

tion,

sui

cid

e p

lan,

and

sui

cid

e at

tem

pt

wer

e co

llect

ed in

tw

o w

aves

Ad

just

ing

for

age,

sex

, bod

y m

ass

ind

ex,

self-

per

ceiv

ed

hous

ehol

d

econ

omic

sta

tus,

fa

mily

coh

esio

n,

par

enta

l con

flict

, ac

adem

ic

stre

ss, p

aren

tal

educ

atio

nal l

evel

, fa

mily

ad

vers

e lif

e ev

ents

, sel

f-

per

ceiv

ed h

ealth

, sl

eep

dur

atio

n, a

nd

slee

p d

isor

der

s.

The

pre

vale

nce

of m

enta

l hea

lth

outc

omes

am

ong

stud

ents

in w

ave

2 in

crea

sed

si

gnifi

cant

ly fr

om

leve

ls a

t w

ave

1: d

epre

ssiv

e sy

mp

tom

s (2

4.9%

vs

18.5

%;

adju

sted

OR

(a

OR

), 1.

50 (9

5%

CI,

1.18

–1.9

0);

nons

uici

dal

sel

f-

inju

ry (4

2.0%

vs

31.

8%; a

OR

, 1.

35(9

5% C

I, 1.

17–

1.55

)°; s

uici

de

idea

tion

(29.

7%

vs 2

2.5%

aO

R,

1.32

(95%

CI,

1.08

–1.

62);

suic

ide

pla

n (1

4.6%

vs

8.7%

; aO

R, 1

.71(

95%

CI,

1.31

–2.2

4); a

nd

suic

ide

atte

mp

t (6

.4%

vs

3.0%

aO

R, 1

.74(

95%

C

I, 1.

14–2

.67)

. N

o d

iffer

ence

s in

an

xiet

y sy

mp

tom

s.

Trom

ans

S, e

t al

. (B

r J

Psy

O

pen

)23

Leic

este

r- U

KE

lect

roni

c d

ata

regi

ster

of

apro

xim

atel

y 1

000

000

hab

of

the

NH

S

Men

tal h

ealth

To d

escr

ibe

seco

ndar

y m

enta

l hea

lth

serv

ice

utili

satio

n p

relo

ckd

own

and

d

urin

g lo

ckd

own

Gra

l pop

ulat

ion.

C

hild

ren

and

ad

oles

cent

s’

men

tal h

ealth

care

se

rvic

es (C

AM

HS

)

Janu

ary

27–M

arch

22

com

par

ed w

ith

Mar

ch 2

3–M

ay 1

7 (lo

ckd

own)

Men

tal h

ealth

ad

mis

sion

s an

d

refe

rral

s

Ad

mis

sion

s p

re-

lock

dow

n n=

14;

lock

dow

n n=

17,

refe

rral

s p

re-

lock

dow

n n=

2193

; lo

ckd

own

n=10

81.

Tab

le 1

C

ontin

ued

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

disproportionate impact on the most vulnerable popula-tions, for example, in India.11 Decisions on how to apply quarantine and school closure should be based on the best available evidence. In situations where quarantine is deemed necessary, officials should quarantine individuals no longer than required, provide clear rationale for quarantine and information about protocols, and ensure sufficient supplies are provided.12 In summary, during the fight against coro-navirus in several countries, while adopting social distancing measures in order to reduce the spread of a disease that mainly causes direct harm to adults, children’s needs have not been taken into due consideration.13 For children, the risks of such measures might be greater and have a poten-tial for short- term and long- term negative effect, mostly in low- income and middle- income countries and also in high- income countries, especially in the prenatal and in early childhood periods.14

At the current stage of the pandemic, it is important to summarise and compile existing information on the pandemic’s impact on child health given the measures that have been taken. The aim of this narrative review is, there-fore, to study the impact of COVID-19 lockdown measures and school closures on child’s and adolescent’s health and well- being. Our research questions were (a) What impact do lockdowns and closure of schools have on child health and well- being? and (b) to what extent do the effects of confine-ment increase social inequalities in child health?

METHODSA literature review was carried out by search in PubMed, Medline, Psychinfo, Web of Science and Google Scholar, using the following terms: ‘(Lockdown OR School closure) AND (COVID-19 OR SARS- CoV-2) AND (children OR adolescent) AND (secondary effects OR physical OR mental)’. Secondary hand search also was done. The time period analysed was 1 December 2019 until 24 November 2020.

The research questions followed the Population Interven-tion Comparison Outcome tool15: p=0–18 years, I=school closures and/or lockdown due to COVID-19; C=a compar-ison group—could be compared with same population before or unexposed population as control, O=physical, developmental or mental health, psychosocial (would include child maltreatment, domestic violence, violence etc), access and use of healthcare services.

The Preferred Reporting Items of Systematic reviews Meta- Analyses (http://www. prisma- statement. org/) guideline was followed, although some items were not applicable given the characteristics of included studies.

The risk of bias of each included study was assessed by a pair of authors (PB, AH, LR) using the Mixed Methods Appraisal Tool16 and was further stratified as low, intermediate or high risk by consensus of each pair of authors. In the first step, the risk of bias of each study was independently assessed, and in the second step, a consensus was achieved according to the number and characteristics of negative scores.Fi

rst

auth

or

(jour

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Isum

i A, e

t al

. (C

hild

Ab

use

Neg

l)22

Jap

anD

ata

on

mor

talit

y b

y ag

e in

Jap

an

Sui

cid

esTo

inve

stig

ate

the

acut

e ef

fect

of

the

firs

t w

ave

of t

he C

OV

ID-1

9 p

and

emic

on

suic

ide

amon

g ch

ildre

n an

d

adol

esce

nts

dur

ing

scho

ol

clos

ure

in J

apan

.

Tota

l num

ber

of

suic

ides

am

ong

child

ren<

20 y

ears

Sch

ool c

losu

re

Mar

ch–M

ay 2

020.

C

omp

are

Mar

ch t

o M

ay 2

020

with

the

sa

me

dat

a on

201

8 an

d 2

019

Sui

cid

e in

cid

ence

ra

te r

atio

(IR

R) b

y m

onth

No

chan

ge in

su

icid

e ra

tes

dur

ing

the

scho

ol

clos

ure

(iIR

R=

1.15

, 95

% C

I: 0.

81

to 1

.64)

and

no

inte

ract

ion

with

sc

hool

clo

sure

.

Tab

le 1

C

ontin

ued



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from

http://www.prisma-statement.org/



Open access

Tab

le 2

S

tud

ies

on p

hysi

cal a

ctiv

ity/o

bes

ity s

tud

ies

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn/

scho

ol

clo

sure

and

ti

me

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Zen

ic N

, et

al.

(Ap

pl S

ci)24

Cro

atia

Follo

w- u

pP

hysi

cal

activ

ity (P

A)

To e

valu

ate

the

chan

ges

in P

AL

and

fa

ctor

s as

soci

ated

w

ith P

ALs

N=

823;

Mea

n ag

e=16

.5 y

ears

‘Soc

ial

dis

tanc

ing

mea

sure

s’:

Mar

ch 1

5. T

1:

Oct

ober

201

9 to

Mar

ch 2

020

and

T2

Ap

ril

2020

Ant

hrop

omet

rics,

p

hysi

cal fi

tnes

s st

atus

, and

ev

alua

tion

of P

ALs

(P

hysi

cal A

ctiv

ity

Que

stio

nnai

re fo

r A

dol

esce

nts,

PA

QA

) ev

alua

ted

by

an

inte

rnet

ap

plic

atio

n

Urb

an v

s ru

ral

A d

ecre

ase

in

PAL

for

the

tota

l sa

mp

le (f

rom

2.9

7 to

2.6

3, p

<0.

01)

and

mai

nly

in

urb

an a

dol

esce

nts

(from

3.1

1 to

2.

68, p

<0.

001)

. S

igni

fican

t d

iffer

ence

s b

etw

een

adol

esce

nts

livin

g in

urb

an a

nd r

ural

en

viro

nmen

ts

wer

e ob

serv

ed fo

r b

asel

ine-

PAL.

Gili

c B

, et

al. (

Chi

ld

(Bas

el)25

Bos

nia

and

H

erze

govi

naFo

llow

- up

pre

an

d d

urin

g p

and

emic

PAL

Cha

nges

in P

AL

amon

g ad

oles

cent

s fr

om B

osni

a an

d

Her

zego

vina

an

d t

o ev

alua

te

soci

odem

ogra

phi

c an

d p

aren

tal/f

amili

al

fact

ors,

whi

ch m

ay

influ

ence

PA

L b

efor

e an

d d

urin

g th

e C

OV

ID-1

9 p

and

emic

an

d im

pos

ed

lock

dow

n.

N=

688

adol

esce

nts

(322

fem

ales

), m

ean

age

17 y

ears

at

the

bas

elin

e (1

5–18

yea

rs),

atte

ndin

g hi

gh

scho

ol.

N=

794

bas

elin

e F-

up=

695

Bas

elin

e Ja

nuar

y 6–

12Lo

ckd

own

Mar

ch 1

6Fo

llow

- up

Ap

ril

20–2

6

The

Phy

sica

l Act

ivity

Q

uest

ionn

aire

for

Ad

oles

cent

s

Par

enta

l ed

ucat

ion

leve

l, in

com

e le

vel,

fam

ily c

onfli

cts

50%

of

adol

esce

nts

und

erw

ent

su

ffici

ent

PAL

at

bas

elin

e, w

hile

on

ly 2

4% o

f the

m

wer

e ac

hiev

ing

suffi

cie

nt P

AL

at

the

time

of fo

llow

- up

mea

sur e

men

t.

Pat

erna

l lev

el o

f ed

ucat

ion

was

as

soci

ated

to

PAL

dur

ing

lock

dow

n (O

R: 1

.33,

95%

C

I: 1.

19 t

o 2.

01).

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn/

scho

ol

clo

sure

and

ti

me

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Pie

trob

elli

A,

et a

l. (O

bes

ity

Sp

ring)

18

Italy

(ver

ona)

Long

itud

inal

ob

serv

atio

nal

stud

y- O

BE

LIX

S

tud

y

Ob

esity

To a

naly

se if

you

ths

with

ob

esity

, whe

n re

mov

ed fr

om

stru

ctur

ed s

choo

l ac

tiviti

es a

nd c

onfin

ed

to t

heir

hom

es

dur

ing

the

CO

VID

-19

pan

dem

ic, w

ill d

isp

lay

unfa

vour

able

tre

nds

in

lifes

tyle

beh

avio

urs.

N=

41 o

ut o

f 50

. Mea

n ag

e 13

.0±

3.1

year

s

Chi

ldre

n en

rolle

d

bet

wee

n 13

M

ay a

nd 3

0 Ju

ly 2

019.

Th

e in

terv

iew

s w

ere

cond

ucte

d a

t th

e b

asel

ine

visi

t an

d

agai

n 3

wee

ks

follo

win

g th

e m

and

ator

y q

uara

ntin

e st

artin

g on

10

Mar

ch 2

020.

Bod

y w

eigh

t,

heig

ht, a

nd w

aist

ci

rcum

fere

nce

wer

e m

easu

red

at

the

bas

elin

e vi

sit;

BM

I w

as c

alcu

late

d

Gen

der

d

iffer

ence

sTh

e nu

mb

er o

f m

eals

eat

en p

er

day

incr

ease

d

by

1.15

±1.

56

(p<

0.00

1).

Sle

ep t

ime

incr

ease

d

sign

ifica

ntly

(0

.65±

1.29

hou

rs/

day

, p=

0.00

3)

and

sp

orts

tim

e d

ecre

ased

si

gnifi

cant

ly b

y 2.

30±

4.60

hou

rs/

wee

k (p

=0.

003)

. S

cree

n tim

e in

crea

sed

by

4.85

±2.

40 h

ours

/d

ay (p

<0.

001)

.Th

ere

was

an

inve

rse

corr

elat

ion

bet

wee

n ch

ange

in

sp

orts

p

artic

ipat

ion

and

b

oth

a ch

ange

in

num

ber

of m

eals

/d

ay a

nd in

scr

een

time

(r=

−0.

27,

bor

der

line

sign

ifica

nt a

t p

=0.

084)

. The

nu

mb

er o

f m

eals

eat

en p

er

day

incr

ease

d

sign

ifica

ntly

mor

e in

the

mal

es t

han

in fe

mal

es.

BM

I, b

ody

mas

s in

dex

; PA

L, p

hysi

cal a

ctiv

ity le

vel.

Tab

le 2

C

ontin

ued



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Inclusion criteria: all quantitative studies from peer- review literature describing studies that provided primary data about child (0–18 years) health and well- being related to the measures of school closure and any level of lockdown adopted regarding of COVID-19 and the impact on child health were included. Articles in Catalan, Danish, English, French, German, Icelandic, Italian, Norwegian, Spanish, Portuguese, Swedish and Turkish were included in the first screening. Following the initial screening, all included arti-cles in the study were published in English- language journals. Original studies (cohort studies, repeated cross- sectional studies etc) were included if they reported children’s data. We also included studies on changes in access/use of health-care services during lockdown.

Exclusion criteria: studies that did not present separate data on childhood population, as well as commentaries, theoretical frameworks, without the analysis of empirical data, and preprint not peer- reviewed articles were excluded. Comments not based on specific empirical data (eg, opinion papers, protocols, letters without specific reviewed data) were also left out. Furthermore, articles regarding clinical mani-festations and school transmission of COVID-19 impact on adults (ie, teachers, parents, except if it included specifically secondary impact on children) and cross- sectional studies analysing retrospective data without comparison or control group were also excluded.

Procedures: abstracts obtained by the initial search strategy were assessed for possible inclusion by at least two authors. Full- text papers of the studies were obtained in doubtful cases and independently evalu-ated by the authors. Differences of opinion on inclu-sion were decided by discussion and consensus among all authors (ie, one study that was initially included in the first screening was excluded by agreement of the authors due to a high risk of bias associated to the type of study and data collection; see the online supple-mental material).

Data extraction: LR led data extraction that was checked initially by AH and PB, followed by a consensus with the rest of the authors. Data extraction included a summary of find-ings to answer the research questions and characteristics of the included studies: author; setting (country: international, national or regional study); type of study; age(s); lockdown (time in days/months); school closure and lockdown (time period); type of outcome; impact on child health and social inequalities.

Analysis: a meta- analysis was not possible to carry out given the nature of the study design and heterogeneity of the find-ings. Consequently, the authors carried out a descriptive and narrative synthesis of the results. First, studies were grouped according to their main subject and methodological simi-larities. LR, AH and PB identified the thematic content and described the results, followed by discussion among all the authors. The results were then analysed and summarised to distil out findings to subsequently integrate those with the rest of studies.

RESULTSStudy selection and risk of bias.

After excluding one study due to a high risk of bias,17 22 studies were included in the synthesis (figure 1). Included studies were from 15 countries, thereof 11 European. Eleven studies were a follow- up of children, while the rest of the studies analysed clinical databases, mortality regis-ters or registries on child abuse and maltreatment.

Almost all of the included studies showed low to moderate risk of bias, except one study that was consid-ered as moderate- high risk of bias; the sample was small, an unstructured questionnaire was administered, anthro-pometric measurements were taken at baseline only, and measures used were not appropriate for age (online supplemental Table 1).18

Exposure measure (box 1)School closure was the most commonly adopted restric-

tive measure, although in most countries closure of schools and home confinement were both implemented at the same time; in some cases, the latter was established as a mandatory norm and especially for the child popula-tion, and in other cases, it was given as a general recom-mendation. The impact of school closure and lockdown or any measure of restriction such as stay- at- home, manda-tory or recommended, was assessed between 2 weeks and 2–3 months after implementing these measures.

Outcome measuresFive studies addressed mental health,19–23 three studies

analysed physical activity and obesity,18 24 25 three studies examined diabetes mellitus,26–28 eight studies approached changes in the access and use of healthcare services,29–36 while three studies analysed data regarding child abuse and violence.37–39

Mental healthOne Australian study showed a significant increase in depressive symptoms and anxiety and a significant decrease in life satisfaction during school closure and lockdown, mainly in girls (table 1).19 A Spanish study gave evidence to a worse total difficulty score of the Strengths and Difficulties Questionnaire according to parent- proxy responses.20 A cohort of Chinese chil-dren and adolescents showed that all indicators of depressive symptoms (nonsuicidal self- injury, suicide ideation, a suicide plan and suicide attempt) deteri-orated significantly during lockdown compared with previous baseline data.21 No difference in the number of suicides was found in a Japanese study.22 Refer-rals to the mental healthcare services for children and adolescents decreased during the lockdown in England compared with the previous year.23

Physical activity, obesityA decrease in physical activity level (PAL) was found in a child cohort from Croatia (from 2.97 to 2.63, p<0.01) and significant differences were observed between adoles-cents living in urban and rural environments (table 2).24 A study from Bosnia & Herzegovina found that 50% of



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from

https://dx.doi.org/10.1136/bmjpo-2021-001043






Open access

Tab

le 3

S

tud

ies

on d

iab

etes

mel

litus

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sc

hoo

l clo

sure

an

d t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Bre

ner

A, e

t al

. (A

cta

Dia

bet

ol)26

Isra

elFo

llow

- up

Clin

ical

co

ntro

l of

T1D

To a

sses

s th

e im

pac

t of

CO

VID

-19

lock

dow

n on

th

e gl

ycae

mic

co

ntro

l of

pae

dia

tric

p

atie

nts

with

T1

D.

102

T1D

M

pat

ient

s (5

2.9%

m

ales

), m

ean

age

11.2

yea

rs,

mea

n d

iab

etes

d

urat

ion

4.2y

rom

23

Feb

ruar

y 20

20 t

o 7

Mar

ch

2020

and

dur

ing

the

lock

dow

n fr

om

25 M

arch

202

0 to

7

Ap

ril 2

020.

Mea

n gl

ucos

e le

vel,

time-

in- r

ange

(TIR

, 70

–180

mg/

dL;

3.

9–10

mm

ol/L

), hy

pog

lyca

emic

(<

54 m

g/d

L;<

3 m

mol

/L),

hyp

ergl

ycae

mic

(>

250

mg/

dL;

>13

.3

mm

ol/L

), co

effic

ient

of

var

iatio

n, a

nd

time

CG

M a

ctiv

e b

efor

e an

d d

urin

g lo

ckd

own.

Age

, sex

, ho

useh

old

s (s

ingl

e/tw

o p

aren

ts),

soic

oeco

nom

ic

pos

ition

by

hom

e ad

dre

ss S

EP

cl

uste

r an

d S

EP

in

dex

In t

he y

oung

er a

ge

grou

p, a

mul

tiple

line

ar

regr

essi

on m

odel

re

veal

ed a

ssoc

iatio

ns

of a

ge a

nd lo

wer

S

EP

clu

ster

with

d

elta

- TIR

(F=

4.41

6,

p=

0.01

9) a

nd w

ith

del

ta- m

ean

gluc

ose

(F=

4.45

9, p

=0.

018)

. No

sign

ifica

nt c

orre

latio

ns

wer

e fo

und

in t

he

adol

esce

nt a

ge g

roup

.

Chr

isto

forid

is A

, et

al.

(Dia

bet

es

Res

Clin

Pra

ct)27

Gre

ece

Follo

w- u

pT1

DM

co

ntro

lTo

mon

itor

the

effe

ct o

f th

e lo

ckd

own

in g

lyca

emic

va

riab

ility

, ins

ulin

re

qui

rem

ents

an

d e

atin

g p

ortio

ns a

nd

hab

its in

ch

ildre

n w

ith

T1D

M w

earin

g in

sulin

pum

p

equi

pp

ed w

ith

a co

ntin

uous

gl

ucos

e m

onito

ring

syst

em

34 o

ut o

f 250

ch

ildre

n w

ith

T1D

M, m

ean

age=

11.3

y

3 w

eeks

bef

ore

and

3 w

eeks

aft

er

Mar

ch 1

0 (s

tart

ing

lock

dow

n an

d

scho

ol c

losu

re)

Con

trol

of i

nsul

in

pum

p e

qui

pp

ed

and

glu

cose

m

etab

olis

m

A h

ighe

r C

V in

dic

atin

g an

incr

ease

d g

luco

se

varia

bili

ty in

the

pre

- lo

ckd

own

per

iod

was

ob

serv

ed (3

9.52

% v

s 37

.40%

, p=

0.01

1). N

o si

gnifi

cant

diff

eren

ce

was

reco

rded

rega

rdin

g th

e to

tal d

aily

dos

e of

insu

lin a

nd t

he

rep

orte

d c

arb

ohyd

rate

s co

nsum

ed, h

owev

er,

mea

l sch

edul

e ha

s ch

ange

d.

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

adolescents achieved sufficient PAL at baseline, while 24% at the time of follow- up measurement during lock-down; moreover, paternal education level was associated with PAL during lockdown (OR: 1.33, 95% CI 1.19 to 2.01).25 The follow- up of Italian obese adolescents found that the number of meals per day increased by 1.15±1.56 (p<0.001) during the lockdown and also unhealthy food consumption and sedentary behaviours.18

Diabetes mellitusThree studies on children with type 1 diabetes mellitus from Israel,26 Greece27 and Italy28 showed no changes or improvements in glucose control indicators. However, in some cases, younger age and low family socioeconomic status were associated with worse control during the lock-down period (table 3).

Healthcare services access/useThere were no differences in the proportion of caesarean deliveries between the observation and control groups in a Chinese study. Furthermore, birth weight in the obser-vation group during lockdown was higher than in the control group among infants born >34 gestational weeks (table 4).29

In Canada, the number of visits to the emer-gency department (ED) due to injuries in children decreased in 2 months in 2020 compared with the same period from 1993 to 2019.30 An increase in the number of admissions due to seizures was found in an Italian children’s hospital.32 In another Italian study, the mean paediatric ED daily consultations decreased from 326.3 (95% CI 299.9 to 352.7) in March–May 2019 to 101.4 (95% CI 77.9 to 124.9) in the same period in 2020 (p<0.001).34

Similarly, a decrease in the number of visits by 63.8% to the ED was observed compared with the same period in 2019 in a German hospital except for malig-nant/neoplastic diseases.33 An Australian study found a 47.2% decrease in total visits to the ED (26 871 vs 14 170), with a significant difference in daily mean. Conversely, there was a 35% (485 vs 656) increase in mental health diagnoses, while neonatal visits did not change significantly.31

There was a 52.5% decline in the daily average of the total number of vaccinations administered during lock-down than baseline data in Pakistan.35 A study from Cameroon showed a drastic drop in hospitalisations, and child mortality rates doubled comparing with the previous year.36

Violence, abuse against childrenRoutinely collected clinical data on Child Protection Medical Examinations (CPME) from Birmingham (UK) showed a significant drop of 39% (95% CI 14% to 57%) in CPME referrals during 2020 compared with previous years, mainly associated with decreased school staff refer-rals.37 A study from the US found an increase in the Fi

rst

auth

or

(Jo

urna

l)C

oun

try

(ies)

Typ

e o

f st

udy

Mai

n su

bje

ctO

bje

ctiv

esA

ge

(n)

Lock

do

wn

/sc

hoo

l clo

sure

an

d t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Di D

alm

azi G

, et

al. (

BM

J O

pen

D

iab

etes

Res

C

are)

28

Italy

(Ors

ola

Pol

iclin

ic,

Bol

ogna

)

A c

ohor

t of

D

M-1

Clin

ical

co

ntro

l in

dia

bet

ics

To in

vest

igat

e co

ntin

uous

gl

ucos

e m

onito

ring

(CG

M) m

etric

s in

chi

ldre

n an

d

adul

ts w

ith T

1D

dur

ing

lock

dow

n an

d t

o id

entif

y th

eir

pot

entia

lly

rela

ted

fact

ors.

130

cons

ecut

ive

pat

ient

s w

ith

T1D

M (3

0 ch

ildre

n (≤

12

year

s), 2

4 te

enag

ers

(13–

17 y

ears

),

Bef

ore

the

lock

dow

n in

Ital

y,

from

20

Feb

ruar

y to

10

Mar

ch 2

020,

an

d a

lso

Janu

ary

30 t

o Fe

bru

ary

19

(pre

- loc

kdow

n)

and

20

day

s st

artin

g fr

om t

hat

dat

e, fr

om 1

1 to

30

Mar

ch 2

020

(dur

ing

lock

dow

n).

Out

com

e m

easu

res:

ind

ex

of g

luco

se c

ontr

ol:

GM

I, LB

G in

dex

, et

c

In c

hild

ren,

sig

nific

antly

lo

wer

(im

pro

vem

ent)

gluc

ose

SD

(SD

glu)

(p

=0.

029)

and

tim

e b

elow

ran

ge

(TB

R) <

54 m

g/d

L (T

BR

2) (p

=0.

029)

w

ere

det

ecte

d

afte

r lo

ckd

own.

C

GM

met

rics

wer

e co

mp

arab

le in

te

enag

ers

bef

ore

and

d

urin

g lo

ckd

own.

GM

I, gl

ucos

e m

anag

emen

t in

dic

ator

; LB

G, l

ow b

lood

glu

cose

ind

ex; S

EP,

soc

ioec

onom

ic p

ositi

on.

Tab

le 3

C

ontin

ued



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Tab

le 4

S

tud

ies

on a

cces

sing

hea

lthca

re s

ervi

ces

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Li M

, et

al.

(Plo

sOne

)29C

hina

(Wuh

an)

Ana

lysi

s of

re

gist

er o

f p

erin

atal

dat

a

Per

inat

al

serv

ices

To c

omp

are

the

ind

icat

ions

for

caes

area

n d

eliv

ery

(CD

) and

the

birt

h w

eigh

ts o

f new

bor

ns

dur

ing

and

pre

- lo

ckd

own

N=

3432

(out

of

3,4

42)

pre

gnan

t w

omen

w

ho g

ave

birt

h d

urin

g lo

ckd

own

and

715

9 (o

ut o

f 29

,799

) m

atch

ed

pre

gnan

t b

efor

e lo

ckd

own.

On

23 J

anua

ry

2020

, the

mun

icip

al

gove

rnm

ent

of

Wuh

an a

nnou

nced

th

e lo

ckd

own

of t

he

entir

e ci

ty. D

ata

wer

e co

llect

ed u

ntil

Mar

ch

14. C

ontr

ol g

roup

: fro

m

1 Ja

nuar

y 20

19 t

o 22

Ja

nuar

y 20

20.

Typ

e of

d

eliv

ery.

The

ne

onat

es’ d

ata

incl

udin

g b

irth

wei

ght,

clin

ical

sy

mp

tom

s,

Ap

gar

scor

e,

and

out

com

es

Ther

e w

as n

o d

iffer

ence

s in

C

D b

etw

een

the

obse

rvat

ion

and

co

ntro

l gro

ups.

B

irth

wei

ght

in

the

obse

rvat

ion

grou

p w

as

heav

ier

than

tha

t in

the

con

trol

gr

oup

am

ong

thos

e w

ith >

34

gest

atio

nal

wee

ks (p

<0.

05).

Ther

e w

as

no s

igni

fican

t d

iffer

ence

in

neo

nata

l as

phy

xia

bet

wee

n th

e tw

o gr

oup

s.

Kea

ys G

, et

al. (

Hea

lth

Pro

mot

C

hron

ic D

is

Pre

v C

an)30

Can

ada

(Mon

trea

l C

hild

ren’

s H

osp

ital)

Dat

a fr

om

the

Can

adia

n H

osp

itals

Inju

ry

Rep

ortin

g an

d

Pre

vent

ion

Pro

gram

me

(CH

IRP

P)

Use

of

heal

thca

re

serv

ices

(ED

)

To e

valu

ate

if in

jury

- re

late

d E

D v

isits

d

urin

g th

e C

OV

ID-1

9 p

and

emic

dec

reas

e.

Gen

eral

p

opul

atio

n st

ratifi

ed b

y ag

e

Com

par

e d

ata

from

a

2 m

onth

s p

erio

d

dur

ing

the

CO

VID

-19

lock

dow

n (M

arch

16

to

May

15)

to

the

sam

e p

erio

d in

pre

viou

s ye

ars

(199

3–20

19).

Vis

its t

o E

D

due

to

inju

ries:

m

otor

veh

icle

co

llisi

ons,

sp

orts

- rel

ated

in

jurie

s an

d

inju

ries

that

oc

curr

ed d

urin

g re

crea

tiona

l ac

tiviti

es.

No

dat

aC

omp

ared

with

th

e 20

15–2

019

aver

age,

the

d

ecre

ase

was

sm

alle

st in

ch

ildre

n ag

ed

2–5

year

s (3

5%

dec

reas

e), a

nd

grea

test

in t

he

grou

p a

ged

12–

17 y

ears

(83%

). M

ore

child

ren

aged

6–1

7 ye

ars

pre

sent

ed w

ith

less

urg

ent

inju

ries

dur

ing

the

CO

VID

-19

lock

dow

n.

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Che

ek

JA, e

t al

. (E

mer

g M

ed

Aus

tral

as)31

Aus

tral

ia (f

our

hosp

itals

fr

om V

icto

ria)

Ana

lysi

s of

ED

re

gist

erU

se o

f he

alth

care

se

rvic

es (E

D)

To d

eter

min

e if

chan

ges

to

com

mun

ity- b

ased

se

rvic

es h

ave

affe

cted

pae

dia

tric

E

D a

tten

dan

ces

for

men

tal h

ealth

is

sues

and

neo

nate

s d

urin

g th

e C

OV

ID-1

9 p

and

emic

.

<18

ye

ars

and

ne

onat

al

visi

ts

Clo

sure

of b

ord

ers

to

non-

r esi

den

ts o

n 20

M

arch

202

0.

Com

par

e to

tal

visi

ts t

o th

e E

D,

visi

ts fo

r m

enta

l he

alth

dia

gnos

es

and

neo

nata

l vi

sits

.

Ther

e w

as

47.2

% d

ecre

ase

in t

otal

p

rese

ntat

ions

(2

6 87

1 vs

14

,170

), w

ith

sign

ifica

nt

diff

eren

ce in

d

aily

mea

n.

Con

vers

ely,

th

ere

was

a

35%

(485

vs

656)

incr

ease

in

men

tal h

ealth

, w

hile

neo

nata

l p

rese

ntat

ions

d

id n

ot c

hang

e (2

% in

crea

se,

498

vs 5

07.

Pal

lad

ino

F,

et a

l. (N

euro

l S

ci)32

Italy

. San

tob

ono-

P

ausi

lipon

Chi

ldr e

n’s

Hos

pita

l (S

outh

ern

Italy

)

Rep

eate

d c

ross

- se

ctio

nal s

tud

y of

cl

inic

al r

egis

ters

Clin

ical

hea

lth,

seiz

ures

To c

omp

are

the

2020

ad

mis

sion

s fo

r se

izur

es a

t th

e E

D

with

pre

viou

s ye

ar

Pat

ient

s (4

–14

year

s)

atte

ndin

g th

e E

D fo

r se

izur

es

n=57

M

edia

n ag

e:

8.03

yea

rs

Com

par

e M

arch

9 t

o up

to

May

4 a

nd t

he s

ame

per

iod

for

2019

Dia

gnos

es

pre

viou

s (e

pile

psy

) or

not

Use

of d

evic

es,

how

con

tact

w

ith h

ealth

care

se

rvic

es

57 p

atie

nts

20 o

f the

m

new

pat

ient

s co

mp

ared

with

13

in 2

019

and

oth

er

diff

eren

ces.

Tab

le 4

C

ontin

ued

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Dop

fer

C,

et a

l. (B

MC

P

edia

tr)33

Ger

man

y (H

anov

er)

Hea

lthca

re

serv

ices

. ED

ut

ilisa

tion

Reg

istr

y of

p

aed

iatr

ic E

DTo

inve

stig

ate

pae

dia

tric

em

erge

ncy

Hea

lthca

re u

tilis

atio

n in

a t

ertia

ry c

are

cent

re

N=

5424

vi

sits

in

the

stud

y p

erio

d.

Mea

n ag

e 7.

1 ye

ars

Sch

ool c

losu

res

beg

inni

ng o

n M

arch

16

, and

an

offic

ial

lock

dow

n of

pub

lic

life,

on

23 M

arch

202

0.

Ana

lysi

s: M

arch

18

to

Ap

ril 1

4 in

201

9 an

d

Mar

ch 1

6 to

Ap

ril 1

2 in

20

20.

Num

ber

of

visi

ts; I

CD

-10

dia

gnos

es

Age

, sex

In 2

020,

cas

e nu

mb

ers

dec

reas

ed

by

63.8

%

com

par

ed

with

the

sam

e p

erio

d o

f 201

9.

The

% o

f vis

its

to c

hild

ren<

1 ye

ar in

crea

sed

in

202

0.

The

dis

ease

ca

tego

ry w

ith

incr

ease

d d

aily

E

R v

isits

aft

er

the

lock

dow

n b

egan

was

m

alig

nant

/ ne

opla

stic

d

isea

se.

Valit

utti

F,

et a

l. (F

ront

P

edia

tr)34

Italy

(Cam

pan

ia r

egio

n)H

ealth

care

se

rvic

es u

se

bef

ore

afte

r

ED

reg

istr

yTo

hig

hlig

ht t

he

imp

act

of t

he

CO

VID

-19

pan

dem

ic

on E

D c

onsu

ltatio

n

Mea

n ag

e=5.

4 ye

ars

in

2019

and

5.

9 ye

ars

in

2020

Reg

iste

rs o

f trim

este

r M

arch

–May

201

9 vs

re

gist

ers

of t

rimes

ter

Mar

ch–M

ay 2

020

Num

ber

of

cons

ulta

tions

, d

iagn

oses

, ca

uses

of

emer

genc

y vi

sits

Mea

n p

aed

iatr

ic

ED

dai

ly

cons

ulta

tions

w

ere

326.

3 (9

5% C

I 299

.9

to 3

52.7

) in

Mar

ch–M

ay

2019

and

101

.4

(95%

CI 7

7.9

to

124.

9) in

Mar

ch–

May

202

0 (p

<0.

001)

.

Tab

le 4

C

ontin

ued

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Cha

ndir

S, e

t al

. (Va

ccin

e)35

Pak

ista

n (S

ind

h)A

naly

sis

of

Ele

ctro

nic

Imm

unis

atio

n R

egis

try

Hea

lthca

re

serv

ices

. P

reve

ntiv

e m

easu

res.

Im

mun

isat

ion

To m

easu

re t

he

red

uctio

n in

dai

ly

imm

unis

atio

n ra

tes

in S

ind

h p

rovi

nce,

re

por

t an

tigen

- wis

e co

vera

ge, a

nd

dro

pou

t ra

tes

for

0–23

mon

th c

hild

ren,

id

entif

y b

asel

ine

char

acte

ristic

s as

soci

ated

with

d

rop

out,

and

ob

serv

e th

e sp

atia

l d

istr

ibut

ion

of

imm

unis

atio

n ac

tivity

.

0–23

mon

th

child

ren

Lock

dow

n st

artin

g on

23

Mar

ch 2

020,

w

as in

itial

ly e

xten

ded

to

May

9,2

020.

It

was

a c

omp

lete

ban

on

mov

emen

t, a

nd

exem

ptio

ns w

ere

give

n on

ly t

o es

sent

ial s

ervi

ce

pro

vid

ers,

incl

udin

g he

alth

(inc

lud

ing

imm

unis

atio

n), l

aw

enfo

rcem

ent,

util

ity, a

nd

tele

com

mun

icat

ions

.

Prim

ary

outc

ome

of t

he

anal

ysis

was

the

re

ceip

t of

EP

I re

com

men

ded

va

ccin

atio

ns

(BC

G, p

olio

, p

enta

, PC

V10

, ro

tavi

rus,

and

m

easl

es) d

urin

g th

e C

OV

ID-1

9 lo

ckd

own

per

iod

. Ana

lysi

s of

dat

a fr

om 2

3 S

epte

mb

er 2

019

to 1

1 Ju

ly 2

020.

Ther

e w

as a

52

.5%

dec

line

in t

he d

aily

av

erag

e to

tal

num

ber

of

vacc

inat

ions

ad

min

iste

red

d

urin

g lo

ckd

own

com

par

ed w

ith

bas

elin

e. T

he

high

est

dec

line

was

see

n fo

r B

CG

(40.

6%

(958

/236

0)

imm

unis

atio

n at

fixe

d s

ites.

A

roun

d 8

438

child

ren/

day

w

ere

mis

sing

im

mun

isat

ion

dur

ing

the

lock

dow

n.

Enr

olm

ents

d

eclin

ed fu

rthe

st

in r

ural

dis

tric

ts,

urb

an s

ub-

dis

tric

ts w

ith

larg

e sl

ums,

and

p

olio

- end

emic

su

per

hig

h- ris

k su

b- d

istr

icts

.

Tab

le 4

C

ontin

ued

Con

tinue

d



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

number of children with physical child abuse trauma,38 and the Florida child abuse allegation data showed a decrease in 27% (n=15 000) in the number of allegations of child abuse and neglect comparing with the same 2 months of 2019 (table 5).39

DISCUSSIONThis narrative review provides summaries of peer- reviewed published evidence on the impact of school closures and lockdown on child health, well- being and access to healthcare, during the first wave of COVID-19. The results show worse mental health status of children and adolescents from disparate geography and socio-economic background, reduced physical activity and increased sedentary behaviours. There were changes in the access and use of healthcare services as manifested by decrease in the ED visits, increased child mortality in a study from Cameroon and a reduction on immunisation coverage in Pakistan. Finally, an increased risk of child abuse and violence against children due to decreased access to general and specific care services during the period of lockdown and school closure was seen in the USA and UK. The effect of these measures of restriction indicates an increase in social inequalities. However, only a few of the studies focus specifically on analysing the impact on social determinants of child health. We found a significant negative effect in the most vulnerable groups (ie, higher mortality and less vaccination coverage in the studies from low- income and middle- income countries) and more significant negative impact on mental and physical health and child abuse and maltreatment in the most vulnerable child population in studies from high- income countries.

The results of this ‘nonnatural experiment’ are gener-alisable to most of the countries that applied any level of lockdown or confinement and closure of schools, although each country has different healthcare and education systems and social and redistribution policies. Confinement has produced an increase in previously existing inequalities with respect to access to basic living conditions and care services, with more difficulties in households with fewer resources.40

The results of the present study add to previous analyses on the impact of quarantine and school closure during previous epidemic outbreaks worldwide.12 The latter analysed the impact and reported negative psychological effects including post- traumatic stress symptoms, confusion and anger. On the other hand, social isolation exacerbates personal and collec-tive vulnerabilities while limiting accessible and familiar support options.41 Many countries have seen an increase in demand for domestic violence services and reports of increased risk for children not attending schools, a pattern similar to previous episodes of social isolation associated with epidemics and pandemics.42

The results show an impact on mental health and physical activity mainly in the adolescent population. However, likely, these factors have also affected younger Fi

rst

auth

or

(Jo

urna

l)C

oun

try

(ies)

Typ

e o

f st

udy

Mai

n su

bje

ctO

bje

ctiv

esA

ge

(n)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Che

lo D

, et

al. (

Ped

iatr

P

atho

l)36

Cam

eroo

nB

efor

e af

ter

app

roac

hH

osp

italis

atio

n an

d m

orta

lity

in t

he m

ain

pae

dia

tric

ho

spita

l in

Yaou

nde

To a

naly

se t

he

cons

eque

nces

of

the

pan

dem

ic o

n ho

spita

lisat

ion

and

on

mor

talit

y in

a

pae

dia

tric

hos

pita

l.

Chi

ldre

n (a

ge n

ot

spec

ified

) p

aed

iatr

ic

age

ockd

own

star

ted

on

Mar

ch 1

7.A

naly

sis:

1 t

o 30

Jun

e 20

20 a

nd c

over

ed t

he

per

iod

from

1 J

anua

ry

2016

to

31 M

ay 2

020.

Hos

pita

lisat

ion

rate

s an

d

mor

talit

y ra

tes

by

per

iod

s

A d

rast

ic d

rop

in

hosp

italis

atio

n w

as n

oted

co

inci

din

g w

ith p

artia

l lo

ckd

own.

At

the

sam

e tim

e,

the

num

ber

of

dea

ths

per

mon

th

dou

ble

d t

houg

h th

e ca

uses

re

mai

ned

the

sa

me

as in

the

p

ast.

BC

G, b

acill

us C

alm

ette

Gue

rin; E

D, e

mer

genc

y d

epar

tmen

t; E

PI,

exp

and

ed p

rogr

amm

e on

imm

uniz

atio

n; IC

D, I

nter

natio

nal c

lasi

ficat

ion

of d

isea

se.

Tab

le 4

C

ontin

ued



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

Tab

le 5

S

tud

ies

on c

hild

ab

use

Firs

t au

tho

r (J

our

nal)

Co

untr

y (ie

s)Ty

pe

of

stud

yM

ain

sub

ject

Ob

ject

ives

Ag

e (n

)

Lock

do

wn

/sch

oo

l cl

osu

re a

nd t

ime

of

dat

a co

llect

ion

Out

com

e m

easu

res

Oth

er f

acto

rs

(ineq

ualit

ies)

Sum

mar

y o

f re

sult

s

Gar

stan

g J,

et

al.

(BM

J O

pen

)37

UK

(Birm

ingh

am)

Reg

istr

y of

chi

ld

pro

tect

ion

Rou

tinel

y co

llect

ed c

linic

al

dat

a fr

om C

hild

P

rote

ctio

n M

edic

al

Exa

min

atio

n

To d

eter

min

e an

y ch

ange

in

refe

rral

pat

tern

s an

d o

utco

mes

in

chi

ldre

n re

ferr

ed fo

r ch

ild p

rote

ctio

n m

edic

al

exam

inat

ion

(CP

ME

) dur

ing

the

CO

VID

-19

pan

dem

ic

com

par

ed w

ith

pre

viou

s ye

ars.

Chi

ldre

n (0

–18)

. N=

200

CP

ME

Dat

a w

ere

colle

cted

fo

r al

l CP

ME

for

18 w

eek

per

iod

s in

201

8, 2

019

and

20

20, f

rom

the

last

w

eek

in F

ebru

ary

to

the

end

of J

une

Inci

den

ce

rate

rat

iosI

RR

of

CP

ME

co

mp

arin

g 20

18–1

9 an

d

2020

A s

igni

fican

t d

rop

of

39%

(95%

CI

14%

to

57%

) in

CP

ME

ref

erra

ls

dur

ing

2020

co

mp

ared

with

p

revi

ous

year

s.

CP

ME

201

8=

78; 2

019=

75;

2020

=47

. A

ssoc

iate

d m

ainl

y to

a s

choo

l sta

ff d

ecre

ased

in

refe

rral

s.

Kov

ler

ML,

et

al.

(Chi

ld

Ab

use

Neg

l)38

US

A (M

aryl

and

)C

linic

al r

egis

try

(Joh

ns H

opki

ns

Hos

pita

l of

Mar

ylan

d)

Chi

ld a

bus

e an

d

mal

trea

tmen

tTo

ass

ess

the

pro

por

tion

of

inju

ries

seco

ndar

y to

phy

sica

l ch

ild a

bus

e (P

CA

) at

a le

vel I

p

aed

iatr

ic t

raum

a ce

ntre

dur

ing

the

CO

VID

-19

pan

dem

ic.

Youn

ger

than

15

yea

rsC

hild

care

faci

litie

s cl

osed

on

Mar

ch

27. A

naly

sis:

Mar

ch

28 t

o A

pril

27

and

co

mp

are

with

201

8 an

d 2

019

PC

A d

urin

g lo

ckd

own

Age

, rac

e, s

ever

ity,

typ

e of

tra

uma

Eig

ht p

atie

nts

(13%

of t

otal

tr

aum

a) c

omp

ared

w

ith 4

(201

9, 4

%)

and

3 (2

018,

3%

).

Bar

on E

J, e

t al

. (J

Pub

lic

Eco

n)39

US

A (F

lorid

a)A

llega

tion

dat

a fr

om t

he F

lorid

a D

CF.

Cou

nty-

le

vel,

mon

thly

in

form

atio

n on

th

e to

tal n

umb

er

of a

llega

tions

of

abus

e, n

egle

ct o

r ab

and

onm

ent

of

child

ren

Chi

ld a

bus

e an

d

mal

trea

tmen

tTo

ana

lyse

the

Fl

orid

a ch

ild

abus

e H

otlin

e re

por

ted

cas

es

and

com

par

e w

ith

pre

viou

s ye

ars

Chi

ldre

n (n

ot

spec

ific

age?

)O

ffici

al s

tate

wid

e st

ay- a

t- ho

me

ord

er in

Flo

rida

was

3 A

pril

202

0.

Com

par

e fr

om

Janu

ary

2004

–201

9 w

ith M

arch

and

A

pril

202

0 m

onth

ly

alle

gatio

ns

Num

ber

of

rep

orte

d c

ases

as

soci

ated

to

scho

ols

open

ed

Eco

logi

cal d

ata

on c

ount

y le

vel o

f ec

onom

ic c

ond

ition

15 0

00 lo

wer

(2

7%) t

han

exp

ecte

d fo

r th

ese

2 m

onth

s.

DC

F, D

epar

tmen

t of

Chi

ldre

n an

d F

amili

es.



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from



Open access

children, a fact that needs to be assessed in future studies. Another review on the impact of COVID-19 on families and children found an increase in parental stress related to the suspension of classroom activities, social isolation measures, nutritional risks, children’s exposure to toxic stress, depressive and anxiety symptoms, especially in previously unstructured homes, and a lack of physical activities.43 Some cross- sectional reports found important differences between households of different socioeco-nomic status regarding home learning and with important potential implications for the long- term impact that the unprecedented circumstances.44 Moreover, some studies carried out modelisations on the impact of inequalities and lost school learning. Christakis et al45 compared the full distribution of estimated years of life lost (YLL) due to COVID-19 under both ‘schools open’ and ‘schools closed’ conditions and observed a 98.1% probability that school opening would have been associated with a lower total YLL than school closure. On the other hand, Azevedo et al46 found that between 0.3 and 0.9 years of schooling losses adjusted for quality, bringing down the effective years of basic schooling that students achieve during their lifetime from 7.9 years to between 7.0 and 7.6 years. This would be associated with lost earnings in the amount between US$6472 and US$25 680 dollars over a typical student’s lifetime, exacerbating inequalities.

Strengths and limitationsOne of the strengths of this narrative review is the inclu-sion of peer- reviewed, longitudinal data or repeated cross- sectional data based on comparable measures. This makes the association between exposure to lockdown and school closure and outcome measures analysed more robust. Nonetheless, there are limitations. First, few of the studies analysed data from low- income and middle- income countries or social inequalities as independent factors, which should be addressed in future studies. Second, the exposure measures that we analysed, both school closure and lockdown, varied between countries and also the period from the beginning of the measures, and the time outcomes were assessed. This fact makes it difficult to evaluate the impact according to the level and duration of confinement and also to establish a clear asso-ciation between exposure and outcomes. However, all the included studies present at least the timeline for initiating the measures adopted and evaluating the results. Third, educational, healthcare and redistributive policies before the pandemic conditioned each country’s responses and results, and these factors must also be taken into account in future studies. Finally, the measures analysed here may have long- term effects and, therefore, future studies will need to factor in longer follow- up.

CONCLUSIONSThis narrative review attempted to provide the best avail-able evidence on the impact of pandemic- related restric-tive measures on child’s and adolescent’s health. The

findings call for the attention of decision- makers to take into account the risks and benefits for children’s health, with respect to public health measures that are adopted. Policymakers and researchers should look into other much less disruptive social distancing interventions given that lockdown measures greatly affect children and with more negative effects than benefits in the short and prob-ably also in the long term. As other public health experts are urging,47 we suggest that a comprehensive public health approach is needed in response to this pandemic with particular attention given to children. Social deter-minants and medical requirements should be addressed simultaneously, with equity and human rights as overar-ching principles.

Author affiliations1Pediatric and Public Health Specialist, Retired, Barcelona, Spain2Centre for Health Equity Studies, Stockholm University/Karolinska Institutet, Stockholm, Sweden3Department of Pediatrics, Marmara University School of Medicine, Istanbul, Turkey4Faculty of Social and Human Sciences, University of Iceland, Reykjavík, Iceland5Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada6Department of Community Paediatrics, South Western Sydney Local Health District, Liverpool, New South Wales, Australia7Women's & Children's Health, University of New South Wales, Sydney, New South Wales, Australia

Twitter Luis Rajmil @LuisRajmil

Contributors LR, PB and AH conceptualised the paper, reviewed full- text articles, extracted the data and wrote the first draft of the manuscript. GG, SR and OK contributed to searches and screening of papers and helped to revise the paper and consider implications. All authors contributed to revision of the final version of the manuscript.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not- for- profit sectors.

Competing interests None declared.

Patient consent for publication Not required.

Provenance and peer review Not commissioned; externally peer reviewed.

Data availability statement All data relevant to the study are included in the article or uploaded as supplementary information.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer- reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY- NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non- commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non- commercial. See: http:// creativecommons. org/ licenses/ by- nc/ 4. 0/.

ORCID iDsLuis Rajmil http:// orcid. org/ 0000- 0002- 6625- 0649Shanti Raman http:// orcid. org/ 0000- 0002- 4546- 3231

REFERENCES 1 Johns Hopkins University & Medicine. Coronavirus resource center,

2021. Available: https:// coronavirus. jhu. edu/ [Accessed 20 Jan 2021].



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from

https://twitter.com/LuisRajmil

http://creativecommons.org/licenses/by-nc/4.0/

http://orcid.org/0000-0002-6625-0649

http://orcid.org/0000-0002-4546-3231

https://coronavirus.jhu.edu/



Open access

2 Raman S, Harries M, Nathawad R, et al. Where do we go from here? a child rights- based response to COVID-19. BMJ Paediatr Open 2020;4:e000714.

3 Gupta S, Jawanda MK. The impacts of COVID-19 on children. Acta Paediatr 2020;109:2181–3.

4 Viner RM, Russell SJ, Croker H, et al. School closure and management practices during coronavirus outbreaks including COVID-19: a rapid systematic review. Lancet Child Adolesc Health 2020;4:397–404.

5 UNESCO. Adverse consequences of school closure. adverse consequences of school closures, 2020. Available: https:// en. unesco. org/ covid19/ educationresponse/ co

6 United Nations. Policy brief: the impact of COVID-19 on children, 2020. Available: https:// unsdg. un. org/ sites/ default/ files/ 2020- 04/ 160420_ Covid_ Children_ Policy_ Brief. pdf

7 Gunnlaugsson G, Whitehead TA, Baboudóttir Fatou N'dure, et al. Use of digital technology among adolescents attending schools in Bissau, Guinea- Bissau. Int J Environ Res Public Health 2020;17:8937–21.

8 Lee A, Lo A, Li Q, et al. Health promoting schools: an update. Appl Health Econ Health Policy 2020;18:605–23.

9 The Lancet. COVID-19: the intersection of education and health. Lancet 2021;397:253.

10 Jourdan D, Gray NJ, Barry MM. Viewpoint supporting every school to become a foundation for healthy lives. Lancet child Adolesc Health 2021;4642:1–9.

11 Dore B. Covid-19: collateral damage of lockdown in India. BMJ 2020;369:m1711–2.

12 Brooks SK, Webster RK, Smith LE, et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 2020;395:912–20.

13 Crawley E, Loades M, Feder G, et al. Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults. BMJ Paediatr Open 2020;4:e000701.

14 Yoshikawa H, Wuermli AJ, Britto PR. Effects of the global coronavirus Disease-2019 pandemic on early childhood development: short- and long- term risks and mitigating program and policy actions. J Pediatr 2020;2507:1–9.

15 Canberra U of. Evidence- based practice in health. PICO framework, 2021. Available: https:// canberra. libguides. com/ c. php? g= 599346& p= 4149722#:~: text= Practitioners of Evidence-Based Practice,and facilitate the literature search.&text=PICO [Accessed 20 Jan 2021].

16 Hong QN, Pluye P, bregues S F. Methods, mixed appraisal tool (MMAT), 2018. Can Intellect Prop Off Ind Canada. Available: http:// hdl. handle. net/ 10609/ 93312 [Accessed 20 Jan 2021].

17 Chahal R, Kirshenbaum JS, Miller JG, et al. Higher executive control network coherence buffers against Puberty- Related increases in internalizing symptoms during the COVID-19 pandemic. Biol Psychiatry Cogn Neurosci Neuroimaging 2021;6:79–88.

18 Pietrobelli A, Pecoraro L, Ferruzzi A, et al. Effects of COVID-19 Lockdown on lifestyle behaviors in children with obesity living in Verona, Italy: a longitudinal study. Obesity 2020;28:1382–5.

19 Magson NR, Freeman JYA, Rapee RM. Risk and protective factors for prospective changes in adolescent mental health during the COVID-19 pandemic. J Youth Adolesc 2020.

20 Ezpeleta L, Navarro JB, de la Osa N, et al. Life conditions during COVID-19 lockdown and mental health in Spanish adolescents. Int J Environ Res Public Health 2020;17:7327–13.

21 Zhang L, Zhang D, Fang J, et al. Assessment of mental health of Chinese primary school students before and after school closing and opening during the COVID-19 pandemic. JAMA Netw Open 2020;3:e2021482.

22 Isumi A, Doi S, Yamaoka Y, et al. Do suicide rates in children and adolescents change during school closure in Japan? the acute effect of the first wave of COVID-19 pandemic on child and adolescent mental health. Child Abuse Negl 2020;110:104680.

23 Tromans S, Chester V, Harrison H, et al. Patterns of use of secondary mental health services before and during COVID-19 lockdown: observational study. BJPsych Open 2020;6:1–6.

24 Zenic N, Taiar R, Gilic B. Levels and changes of physical activity in adolescents during the COVID-19 pandemic: Contextualizing urban vs. Rural Living Environment. Appl Sci 2020;10.

25 Gilic B, Ostojic L, Corluka M, et al. Contextualizing Parental/Familial influence on physical activity in adolescents before and during COVID-19 pandemic: a prospective analysis. Children 2020;7:125.

26 Brener A, Mazor- Aronovitch K, Rachmiel M, et al. Lessons learned from the continuous glucose monitoring metrics in pediatric patients

with type 1 diabetes under COVID-19 lockdown. Acta Diabetol 2020;57:1511–7.

27 Christoforidis A, Kavoura E, Nemtsa A, et al. Coronavirus lockdown effect on type 1 diabetes management οn children wearing insulin pump equipped with continuous glucose monitoring system. Diabetes Res Clin Pract 2020;166:108307.

28 Di Dalmazi G, Maltoni G, Bongiorno C, et al. Comparison of the effects of lockdown due to COVID-19 on glucose patterns among children, adolescents, and adults with type 1 diabetes: CGM study. BMJ Open Diabetes Res Care 2020;8:e001664–9.

29 Li M, Yin H, Jin Z, et al. Impact of Wuhan lockdown on the indications of cesarean delivery and newborn weights during the epidemic period of COVID-19. PLoS One 2020;15:e0237420.

30 Keays G, Freeman D, Gagnon I. Injuries in the time of COVID-19. Health Promot Chronic Dis Prev Can 2020;40:336–41.

31 Cheek JA, Craig SS, West A, et al. Emergency department utilisation by vulnerable paediatric populations during the COVID-19 pandemic. Emerg Med Australas 2020;32:870–1.

32 Palladino F, Merolla E, Solimeno M, et al. Is Covid-19 lockdown related to an increase of accesses for seizures in the emergency department? an observational analysis of a paediatric cohort in the southern Italy. Neurol Sci 2020;41:3475–83.

33 Dopfer C, Wetzke M, Zychlinsky Scharff A, et al. COVID-19 related reduction in pediatric emergency healthcare utilization - a concerning trend. BMC Pediatr 2020;20:427.

34 Valitutti F, Zenzeri L, Mauro A, et al. Effect of population Lockdown on pediatric emergency room demands in the era of COVID-19. Front Pediatr 2020;8:521.

35 Chandir S, Siddiqi DA, Mehmood M, et al. Impact of COVID-19 pandemic response on uptake of routine immunizations in Sindh, Pakistan: an analysis of provincial electronic immunization registry data. Vaccine 2020;38:7146–55.

36 Chelo D, Mekone Nkwelle I, Nguefack F, et al. Decrease in hospitalizations and increase in deaths during the Covid-19 epidemic in a pediatric Hospital, Yaounde- Cameroon and prediction for the coming months. Fetal Pediatr Pathol 2021;40:18–31.

37 Garstang J, Debelle G, Anand I, et al. Effect of COVID-19 lockdown on child protection medical assessments: a retrospective observational study in Birmingham, UK. BMJ Open 2020;10:e042867.

38 Kovler ML, Ziegfeld S, Ryan LM. Increased proportion of physical child abuse injuries at a level I pediatric trauma center during the Covid-19 pandemic. Child Abuse Negl 2020;104756.

39 Baron EJ, Goldstein EG, Wallace CT. Suffering in silence: how COVID-19 school closures inhibit the reporting of child maltreatment. J Public Econ 2020;190:104258.

40 Statistics O, Directorate D. COVID-19 : Protecting people and societies, 2020. Available: https://www. oecd. org/ inclusive- growth/ resources/ COVID- 19- Protecting- people- and- societies. pdf [Accessed 2 Mar 2021].

41 Usher K, Bhullar N, Durkin J, et al. Family violence and COVID-19: increased vulnerability and reduced options for support. Int J Ment Health Nurs 2020;29:549–52.

42 Ghosh R, Dubey MJ, Chatterjee S, et al. Impact of COVID -19 on children: special focus on the psychosocial aspect. Minerva Pediatr 2020;72:226–35.

43 Araújo LAde, Veloso CF, Souza MdeC, et al. The potential impact of the COVID-19 pandemic on child growth and development: a systematic review. J Pediatr 2020. doi:10.1016/j.jped.2020.08.008. [Epub ahead of print: 23 Sep 2020].

44 Andrew A, Cattan S, Dias MC. Inequalities in Children’s Experiences of Home Learning during the COVID-19 Lockdown in England, 2020. Available: https://www. ifs. org. uk/ uploads/ publications/ wps/ WP202026- Inequalities- childrens- experiences- home- learning- during- COVID- 19- lockdown- England. pdf

45 Christakis DA, Van Cleve W, Zimmerman FJ. Estimation of US children's educational attainment and years of life lost associated with primary school closures during the coronavirus disease 2019 pandemic. JAMA Netw Open 2020;3:e2028786.

46 Azevedo JP, Hasan A, Goldemberg D. Simulating the potential impacts of COVID-19 school closures on schooling and learning outcomes: a set of global estimates. world bank GR, 2020. Available: http://www. worldbank. org/ prwp.% 0Ahttp:// pubdocs. worldbank. org/ en/ 798061592482682799/ covid- and- education- June17- r6. pdf

47 Prasad V, Sri BS, Gaitonde R. Bridging a false dichotomy in the COVID-19 response: a public health approach to the 'lockdown' debate. BMJ Glob Health 2020;5:e002909–5.



jpaedsopen.bmj.com

/bm


ay 2021. Dow

nloaded from

http://dx.doi.org/10.1136/bmjpo-2020-000714

http://dx.doi.org/10.1111/apa.15484

http://dx.doi.org/10.1111/apa.15484

http://dx.doi.org/10.1016/S2352-4642(20)30095-X

https://en.unesco.org/covid19/educationresponse/co

https://en.unesco.org/covid19/educationresponse/co

https://unsdg.un.org/sites/default/files/2020-04/160420_Covid_Children_Policy_Brief.pdf

https://unsdg.un.org/sites/default/files/2020-04/160420_Covid_Children_Policy_Brief.pdf

http://dx.doi.org/10.3390/ijerph17238937

http://dx.doi.org/10.1007/s40258-020-00575-8

http://dx.doi.org/10.1007/s40258-020-00575-8

http://dx.doi.org/10.1016/S0140-6736(21)00142-2

http://dx.doi.org/10.1136/bmj.m1711

http://dx.doi.org/10.1016/S0140-6736(20)30460-8



https://canberra.libguides.com/c.php?g=599346&p=4149722#:~:text=Practitioners%20of%20Evidence-Based%20Practice,and%20facilitate%20the%20literature%20search.&text=PICO



http://hdl.handle.net/10609/93312

http://hdl.handle.net/10609/93312

http://dx.doi.org/10.1016/j.bpsc.2020.08.010

http://dx.doi.org/10.1016/j.bpsc.2020.08.010

http://dx.doi.org/10.1002/oby.22861



http://dx.doi.org/10.1001/jamanetworkopen.2020.21482

http://dx.doi.org/10.1016/j.chiabu.2020.104680

http://dx.doi.org/10.1192/bjo.2020.104

http://dx.doi.org/10.3390/children7090125

http://dx.doi.org/10.1007/s00592-020-01596-4

http://dx.doi.org/10.1016/j.diabres.2020.108307

http://dx.doi.org/10.1136/bmjdrc-2020-001664

http://dx.doi.org/10.1371/journal.pone.0237420

http://dx.doi.org/10.24095/hpcdp.40.11/12.02

http://dx.doi.org/10.1111/1742-6723.13598

http://dx.doi.org/10.1007/s10072-020-04824-5

http://dx.doi.org/10.1186/s12887-020-02303-6

http://dx.doi.org/10.3389/fped.2020.00521

http://dx.doi.org/10.1016/j.vaccine.2020.08.019

http://dx.doi.org/10.1080/15513815.2020.1831664

http://dx.doi.org/10.1136/bmjopen-2020-042867

http://dx.doi.org/10.1016/j.jpubeco.2020.104258

https://www.oecd.org/inclusive-growth/resources/COVID-19-Protecting-people-and-societies.pdf

https://www.oecd.org/inclusive-growth/resources/COVID-19-Protecting-people-and-societies.pdf

http://dx.doi.org/10.1111/inm.12735

http://dx.doi.org/10.1111/inm.12735

http://dx.doi.org/10.23736/S0026-4946.20.05887-9

http://dx.doi.org/10.1016/j.jped.2020.08.008

https://www.ifs.org.uk/uploads/publications/wps/WP202026-Inequalities-childrens-experiences-home-learning-during-COVID-19-lockdown-England.pdf



http://dx.doi.org/10.1001/jamanetworkopen.2020.28786

http://www.worldbank.org/prwp.%0Ahttp://pubdocs.worldbank.org/en/798061592482682799/covid-and-education-June17-r6.pdf



http://dx.doi.org/10.1136/bmjgh-2020-002909


open access original research impact of lockdown and

Documents