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The Impact of Visiting Restrictions During the COVID-19 Pandemic on Pediatric Patients

Published:September 07, 2021DOI:https://doi.org/10.1016/j.pedn.2021.09.004

      Abstract

      Visitor restriction policies have been implemented on many hospital units as a result of the Covid-19 pandemic. These policies are integral to the strategies that hospitals are using to limit exposure risks during the pandemic. However, visitor restriction policies disproportionally affect hospitalized children. The trauma caused by lack of family at the bedside of adult patients during the Covid-19 pandemic has been studied but there is a lack of primary research on the impact of the Covid-19 visiting policy restrictions on pediatric patients. Long term studies are needed to understand the effect of this separation on children and their caregivers.

      Keywords

      Visitor restriction policies have been implemented on many hospital units as a result of the Covid-19 pandemic. These policies are integral to the strategies that hospitals are using to limit exposure risks and conserve personal protective equipment (PPE) during the pandemic. However, visitor restriction policies disproportionally affect hospitalized children. Pediatric units have special obligations regarding the management of caregivers and visitors. Children depend on their caregivers, not just for help with their activities of daily living and for their communication needs, but also for their emotional well-being. Severely limiting or eliminating caregivers and visitors from hospital units is challenging for pediatric hospitals.
      A recent study compared the visitor restriction policies at different pediatric institutions in the United States and Canada (
      • Kitano T.
      • Piché-Renaud P.P.
      • Groves H.E.
      • Streitenberger L.
      • Freeman R.
      • Science M.
      Visitor restriction policy on pediatric wards during novel coronavirus (COVID-19) outbreak: A survey study across North America.
      ). Of the 36 hospital infection specialists responding to the survey, 94% reported that their hospitals had changed their policies in response to the pandemic. These changes included implementing active screening for all visitors (56%), entry screening (26%) and temperature screening (24%). Most of the pediatric hospitals restricted visitors to one visitor (67%) or two visitors (25%), only one hospital did not allow any visitors. Of the responding hospitals 81% did not allow any visitors who were non-household contacts. Most (86%) of the hospitals did not allow household contacts to be outside of their child's room. Some hospitals allowed one consistent caregiver through the entire hospitalization, while others allowed a second caregiver to take over after a set period of time.
      Allowing at least one caregiver to remain with their hospitalized child is consistent with 2020 pediatric guidelines from the Centers for Disease Control and Prevention (CDC) that recommended limiting visitors to one essential caregiver for pediatric patients (
      • Centers for Disease Control and Prevention (CDC)
      Management of visitors to healthcare facilities in the context of COVID-19 2020.
      ). This differs from the policies implemented in adult hospitals where visitors were generally not allowed during the Covid-19 outbreak. In compliance withs the CDC's recommendations for PPE use by essential visitors, the researchers found that a two-thirds of hospitals required PPE for household contacts visiting a child, 69% required surgical masks, 17% gloves, 17% gowns and 3% eye protection. (
      • Kitano T.
      • Piché-Renaud P.P.
      • Groves H.E.
      • Streitenberger L.
      • Freeman R.
      • Science M.
      Visitor restriction policy on pediatric wards during novel coronavirus (COVID-19) outbreak: A survey study across North America.
      ). A majority of the hospitals allowing caregivers at the bedside required them to wear PPE in the patients' rooms, with surgical masks being the most commonly required (
      • Kitano T.
      • Piché-Renaud P.P.
      • Groves H.E.
      • Streitenberger L.
      • Freeman R.
      • Science M.
      Visitor restriction policy on pediatric wards during novel coronavirus (COVID-19) outbreak: A survey study across North America.
      ). The researchers noted two rationales for the use of surgical masks by caregivers. The first is that masks could control the spread of disease from the caregiver to the child since caregivers could be asymptomatic carriers and unknowingly transmit the infection to others. The second rationale is to protect the caregiver from becoming infected by the patient. The researchers noted that these justifications are questionable because it is likely that household contact would have already happened before the child's hospitalization. At some hospitals, caregivers were swabbed for Covid-19, and if they were negative, they could stay at the bedside, while caregivers who were Covid positive had to return home for seven days or until they had a negative Covid swab. The researchers did not investigate whether there was a correlation between the local incidence of Covid-19 infection and the implementation of restrictive visitor policies at hospitals. The researchers concluded that standardizing visitor restrictions would assist pediatric hospitals balance of optimial family-centered care and decreasing potential sources of transmission (
      • Kitano T.
      • Piché-Renaud P.P.
      • Groves H.E.
      • Streitenberger L.
      • Freeman R.
      • Science M.
      Visitor restriction policy on pediatric wards during novel coronavirus (COVID-19) outbreak: A survey study across North America.
      ).
      The distress inherent in caregiver restriction policies is widely acknowledged (
      • Akbari R.
      • Karimi Moonaghi H.
      • Mazloum S.R.
      • Bagheri Moghaddam A.
      Implementation of a flexible visiting policy in intensive care unit: A randomized clinical trial.
      ;
      • Crawley E.
      • Loades M.
      • Feder G.
      • Logan S.
      • Redwood S.
      • Macleod J.
      Wider collateral damage to children in the UK because of the social distancing measures designed to reduce the impact of COVID-19 in adults.
      ;
      • Lisanti A.J.
      • Allen L.R.
      • Kelly L.
      • Medoff-Cooper B.
      Maternal stress and anxiety in the pediatric cardiac intensive care unit.
      ). The psychological burden has largely been considered a necessity of pandemic safety protocols. However, the effect of visitor restrictions on reducing the spread of Covid-19 infections is not fully known (
      • Jefferson T.
      • Del Mar C.B.
      • Dooley L.
      • Ferroni E.
      • Al-Ansary L.A.
      • Bawazeer G.A.
      • van Driel M.L.
      • Jones M.A.
      • Thorning S.
      • Beller E.M.
      • Clark J.
      • Hoffmann T.C.
      • Glasziou P.P.
      • Conly J.M.
      Physical interventions to interrupt or reduce the spread of respiratory viruses.
      ). There have been relatively few studies measuring the effectiveness of the visitation policies on preventing nosocomial infections. One quasi-experimental study at a children's hospital reported that healthcare associated viral respiratory infection transmission was 59% lower during the months when visitor restrictions were implemented (
      • Forkpa H.
      • Rupp A.H.
      • Shulman S.T.
      • Patel S.J.
      • Gray E.L.
      • Zheng X.
      • Kociolek L.K.
      Association between children’s hospital visitor restrictions and healthcare-associated viral respiratory infections: a quasi-experimental study.
      ). The researchers hypothesized that limiting the number of visitors in a hospital room decreased transmission by avoiding overcrowding. Another pre-Covid-19 study reported that limiting the number of visitors at one children's hospital during the winter respiratory season resulted in a 37% reduction of nosocomial respiratory viral infections (
      • Washam M.
      • Woltmann J.
      • Ankrum A.
      • Connelly B.
      Association of visitation policy and health care-acquired respiratory viral infections in hospitalized children.
      ). The researchers concluded that hospitals should consider implementing year-round visitor restriction policies. Identifying how restrictive visiting policies affected the spread of the Covid-19 virus is complicated because of the multiple routes of in-hospital Covid-10 transmission (
      • Rickman H.M.
      • Rampling T.
      • Shaw K.
      • Martinez-Garcia G.
      • Hail L.
      • Coen P.
      • Shahmanesh M.
      • Shin G.Y.
      • Nastouli E.
      • Houlihan C.F.
      Nosocomial Transmission of Coronavirus Disease 2019: A Retrospective Study of 66 Hospital-acquired Cases in a London Teaching Hospital.
      ). Visitor restrictions are only one of multiple interventions that were implemented to reduce the spread of the Covid-19 virus. No study to date has separated the effects of visitor restrictions from other Covid-19 precaution measures.
      As a result of the pandemic, previously liberal caregiver visiting policies, which are the cornerstone of family-centered care, have been limited. Pre-Covid-19, in many U.S. pediatric units caregivers were allowed to visit their child at any time of the day or night with siblings, extended family and friends allowed to visit during the day. In the past, caregivers, siblings, extended family members, and friends have been encouraged to play an active role in providing personal and psychological support for a child helping to reduce the adverse psychological effects of hospitalization on both children and their caregivers (
      • Pong A.L.
      • Beekmann S.E.
      • Faltamo M.M.
      • Polgreen P.M.
      • Shane A.L.
      (2018). Visitor restriction policies and practices in children’s hospitals in North America: Results of an emerging infections network survey.
      ;
      • Yagiela L.M.
      • Carlton E.F.
      • Meert K.L.
      • Odetola F.O.
      • Cousino M.K.
      (2019). Parent medical traumatic stress and associated family outcomes after pediatric critical illness: A systematic review.
      ).
      Separating hospitalized children from their caregivers during an illness can be extremely distressing for both the children and their caregivers. Parents and families are the decision-makers for children and are needed at bedside for help with activities of daily living, care planning, and emotional support. Some researchers have expressed concerns that strict limitations on visitors may have a negative impact on patient care (
      • Jacob M.
      • Horton C.
      • Rance-Ashley S.
      • Field T.
      • Patterson R.
      • Johnson C.
      • Frobos C.
      (2016). Needs of Patients’ family members in an intensive care unit with continuous visitation.
      ). One study looked at the impact of visitor restrictions on work of healthcare workers and found that excluding caregivers increases the time required for nursing care and may require adjustments in staffing (
      • Bichard E.
      • Herring D.
      (2020). The psychological burden of restricted parental visiting in paediatric intensive care.
      ). A recent review of the consequences of visiting restrictions during the Covid-19 pandemic investigated the unintended consequences of restrictive visitation policies (
      • Raphael J.L.
      • Kessel W.
      • Patel M.
      Unintended consequences of restrictive visitation policies during the COVID-19 pandemic: implications for hospitalized children.
      ). The physical consequences included reduced nutrition intake, decreased activities of daily living and increased physical pain and symptoms (
      • Hugelius K.
      • Harada N.
      • Marutani M.
      Consequences of visiting restrictions during the COVID-19 pandemic: An integrative review.
      ). Mental health consequences for patients included an increase in loneliness, depressive symptoms, agitation, aggression, reduced cognitive ability and overall dissatisfaction (
      • Bichard E.
      • Herring D.
      (2020). The psychological burden of restricted parental visiting in paediatric intensive care.
      ). Family members reported an increase in worry, anxiety and uncertainty (
      • Andrist E.
      • Clarke R.G.
      • Harding M.
      Paved with good intentions: hospital visitation restrictions in the age of coronavirus disease 2019.
      0,
      • Berwick D.M.
      • Kotagal M.
      (2004). Restricted visiting hours in ICUs: Time to change.
      ). In the NICU families reported less bonding with their child and family relation disturbances due to the restrictions (
      • Murray P.D.
      • Swanson J.R.
      Visitation restrictions: is it right and how do we support families in the NICU during COVID-19?.
      ).
      It is important to consider the ways that caregiver restrictions disproportionately harm families with lower socioeconomic status. Some single parents who lack family support or the financial means to afford childcare for siblings, may struggle with policies that restrict siblings from the bedside. These restrictions may contribute to mistrust in the health care system and compound stress for families without the financial means to mitigate the effects. Policies that permit exceptions to be granted on a case-by-case basis can help balance the inequitable impact of visitor restriction and safety precautions. Further research is needed to explore the unintended consequences of caregiver restriction policies on specific populations and families (
      • Raphael J.L.
      • Kessel W.
      • Patel M.
      Unintended consequences of restrictive visitation policies during the COVID-19 pandemic: implications for hospitalized children.
      ).
      Visiting restrictions place extra burdens on healthcare providers by increasing the need for communication with family members and changing established ways to provide psychosocial support. Many healthcare facilities have tried to replace physical visits with a variety of digital and technical means. These kinds of meetings have limitations compared to face-to-face meetings potentially limiting a comprehensive understanding of a patient's condition (
      • Kaye E.C.
      COVID-19 caregiver restrictions in pediatrics.
      ;
      • Vance A.J.
      • Duy J.
      • Laventhal N.
      • Iwashyna T.J.
      • Costa D.K.
      (2021). Visitor guidelines in US Children’s hospitals during COVID-19.
      ).
      As the pandemic has unfolded, it has become clear the incidence of hospital admissions and mortality is lower for children than adults. However, even though the physical impact of the Covid-19 virus on children has been more limited than on adults, the psychological burden of the separation caused by severely restricting caregivers needs to be considered. Implementing visitor restriction policies in pediatric hospitals requires balancing optimizing family-centered care and decreasing potential sources of transmission of Covid-19. The trauma caused by lack of family at the bedside of adult patients during the Covid-19 pandemic has been studied (
      • Hart J.L.
      • Turnbull A.E.
      • Oppenheim I.M.
      • Courtright K.R.
      Family-centered care during the COVID-19 era.
      ;
      • Montauk T.R.
      • Kuhl E.A.
      (2020). COVID-related family separation and trauma in the intensive care unit.
      ), but there is a lack of primary research on the impact of the Covid-19 visiting policy restrictions on pediatric patients. Long term studies are needed to understand the effect of this separation on children and their caregivers.

      Declaration of Competing Interest

      The views expressed in this article are the authors' own and not an official position of their institutions.
      The authors declare that there are no conflicts of interest.

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