Impact of the COVID-19 Pandemic on the Emotional Health of Children Under 6 Years in Washington, DC

<b>Background/Objective:</b> A growing body of international research continues to show evidence of worsening youth mental health since the beginning of the COVID-19 global pandemic, yet very little research in this area has included young children under 6 years. Given the potential impact of early life stress during this critical period of development, it is crucial to better understand the effects on this age group. The objective of this study was to better understand the impact of the COVID-19 pandemic on the emotional health of very young children. <b>Methods:</b> This study utilized retrospective chart review of primary care records to compare the prevalence of markers of stress in two cohorts of children under the age of 6 years, comparing children presenting for care prior to the pandemic (1 April 2019-31 March 2020; control period) with those presenting for care during the first year of the pandemic (1 April 2020-31 March 2021; study period) in a large pediatric primary care clinic in Washington, DC, USA. Based on power calculations, charts of 200 patients from each cohort were reviewed and prevalence of stress markers were summarized using counts and percentages and compared between groups using chi-squared tests. Multivariable logistic regression models were also conducted for each domain adjusting for age, gender, and insurance type. <b>Results:</b> Overall, sleep difficulties were significantly more prevalent during the pandemic period compared to the control period (14% vs. 6.5%, <i>p</i> = 0.013). In addition, signs of stress presented differently across age groups. For example, during the pandemic period toddlers (13-35 months) were 13 times more likely (OR = 13, 95% CI [2.82, 60.4], <i>p</i> < 0.001) and preschool-aged children (36-71 months) were 18.5 times more likely (OR = 18.5, 95% CI [4.0, 86], <i>p</i> < 0.001) than infants to present with behavior problems, indicating substantially higher risk of externalizing symptoms in older children compared to infants. Toddlers were less likely than infants to present with mood changes (e.g., fussiness or crying) (OR = 0.15, 95% CI [0.03, 0.65], <i>p</i> = 0.011). In addition, toddlers (OR = 0.55, 95% CI [0.31, 0.97], <i>p</i> = 0.038) and preschool-aged children (OR = 0.15, 95% CI [0.06, 0.4], <i>p</i> < 0.001) were also less likely to present with feeding difficulties compared to infants. <b>Conclusions:</b> One of the very few studies of young children under 6 years (including infants) during the COVID-19 pandemic, this study found that even very young children experienced stress during the pandemic. Signs of emotional stress were identified in a primary care office during routine care, highlighting an important opportunity for early intervention and/or prevention, such as counseling and resources for caregivers, in settings where young children are already presenting for routine care.