Perforated Appendicitis In Kids More Common After COVID-19 Outbreak

The rates of perforated appendicitis in children in the New York City metropolitan region increased after the beginning of the COVID-19 pandemic, researchers report.

"What I found most interesting was that even though we saw an overall higher perforation rate, we found that children who tested positive for SARS-CoV-2 showed absolutely no differences in perforation rates, hospital stay, or postoperative outcomes," said Dr. Jason C. Fisher of Hassenfeld Children's Hospital at NYU Langone, in New York City.

"This was a pleasant surprise, as at the time there were so many reports of SARS-CoV-2 infection presenting with gastrointestinal symptoms and negatively impacting multiple organ systems, that we initially feared that appendicitis in a COVID-19 patient might result in worse outcomes," he told Reuters Health by email.

Early in the pandemic, there were concerns that limited access to pediatrician's offices and fears of contracting SARS-CoV-2 might deter families from obtaining timely assessment early in the course of appendicitis.

Dr. Fisher and colleagues compared perforated-appendicitis rates among all children younger than 18 years old treated for acute appendicitis across three large academic medical centers in the New York City metropolitan region during the first two months of the COVID-19 pandemic (March 1 to May 7) with rates in a control period (January 2014 through June 1, 2019).

The proportion of children with perforated appendicitis was higher during the COVID-19 study period (25/55, 45%) than during the control period (351/1,291, 27%; P=0.005), the researchers report in the Annals of Surgery.

Across the 22 consecutive quarters in the control period, there was no three-month period that individually demonstrated a statistically different perforation rate when compared to the overall 27% rate.

The mean preoperative duration of symptoms was significantly longer in COVID-19-era patients (71 hours) than in control-era patients (47 hours), but there were no significant differences in the median ages of patients or mean numbers of appendicitis cases.

During the 10-week COVID-19 period, there were more perforations in the latter half (56%, when maximum public controls were in place and universal SARS-CoV-2 testing was performed) than in the earlier half (26%, when state-recommended restrictions were first initiated and SARS-CoV-2 testing was less consistent).

Despite these differences, there were no significant differences in median white blood cell count at presentation or median length of stay between these periods.

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About half of the children who presented with appendicitis in the COVID-19 era tested positive for SARS-CoV-2, but there were no differences in perforation rates or any other measured clinical variable between those testing positive and those testing negative for the virus.

"Our main message is to reassure physicians and families that our emergency rooms, hospitals, and operating rooms remain extraordinarily safe environments where the likelihood of becoming infected with SARS-CoV-2 is extremely low," Dr. Fisher said. "In contrast, a delayed presentation to the hospital for something like appendicitis does significantly increase the likelihood of a complication such as perforation, which can have serious consequences."

"We hope our study further encourages providers, especially those who care for children, to strongly advocate that they do not delay seeking emergency care for acute problems, and that they can rest assured they will receive safe, world-class care, without added risks of COVID-19 exposure," he said.

Dr. Ori Snapiri of Schneider Children's Medical Center of Israel, in Petah Tikva, recently reported there had also been delays in the diagnosis of pediatric appendicitis during the COVID-19 pandemic there. He told Reuters Health by email, "Currently, during the pandemic, children are experiencing more severe medical conditions since the diagnosis and treatment are being delayed. Pediatricians should not withhold necessary medical care, since delay in diagnosis and treatment in routinely seen medical emergencies may become as big of a threat as COVID-19 itself in the pediatric population."

"Policymakers should address this issue, since the COVID-19 pandemic may not vanish in the near future. As time passes, children will suffer greatly from the medical, psychological, and social effects of the pandemic," added Dr. Snapiri, who was not involved in the New York study.

Dr. Rebecca Rentea of Children's Mercy Kansas City, UMKC School of Medicine, in Missouri, who recently reviewed the diagnosis and management of pediatric appendicitis, told Reuters Health by email, "Families require reassurance to take children to the emergency department/emergency care when they are not feeling well. Additionally, while COVID-19/SARS-CoV-2 precautions are necessary, surgery if required should take place as the child may be asymptomatic."

"The impact of anesthesia on a COVID-19/SARS-CoV-2 asymptomatic child has not been defined but was reassuring based on the small sample presented in this article," she said.

Dr. Rentea, who also did not participate in the study, added, "It will be interesting to see what happens to pediatric surgical patients in general for volumes with the start of the new school year."

—Will Boggs MD

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