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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
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.
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
3Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
4 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
5Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
6 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
7Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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ay 2021. Dow
nloaded from
8 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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rotected by copyright.http://bm
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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
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rotected by copyright.http://bm
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ay 2021. Dow
nloaded from
10 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
11Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
12 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
13Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
14 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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
15Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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16 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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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.
on March 19, 2022 by guest. P
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17Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
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
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18 Rajmil L, et al. BMJ Paediatrics Open 2021;5:e001043. doi:10.1136/bmjpo-2021-001043
Open access
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