Effect of COVID-19 on Health-Related Quality of Life in Adolescents and Children: A Systematic Review

In e na ional Jou nal o En i onmen al Resea ch and Public Heal h Re iew E ec o COVID-19 on Heal h-Rela ed Quali y o Li e in Adolescen s and Child en: A Sys ema ic Re iew Hadi Noba i 1,2,3,*,† , Mohamad Fashi 4,*,† , A ezoo Eskanda i 5, San os Villa aina 6, Ál a o Mu illo-Ga cia 6and Jo ge Pé ez-Gómez 3   Ci a ion: Noba i, H.; Fashi, M.; Eskanda i, A.; Villa aina, S.; Mu illo-Ga cia, Á.; Pé ez-Gómez, J. E ec o COVID-19 on Heal h-Rela ed Quali y o Li e in Adolescen s and Child en: A Sys ema ic Re iew. In . J. En i on. Res. Public Heal h 2021,18, 4563. h ps://doi.o g/10.3390/ije ph 18094563 Academic Edi o : S e an Nilsson Recei ed: 31 Ma ch 2021 Accep ed: 21 Ap il 2021 Published: 25 Ap il 2021 Publishe ’s No e: MDPI s ays neu al wi h ega d o ju isdic ional claims in published maps and ins i u ional a il- ia ions. Copy igh : © 2021 by he au ho s. Licensee MDPI, Basel, Swi ze land. This a icle is an open access a icle dis ibu ed unde he e ms and condi ions o he C ea i e Commons A ibu ion (CC BY) license (h ps:// c ea i ecommons.o g/licenses/by/ 4.0/). 1Depa men o Physical Educa ion and Spo s, Uni e si y o G anada, 18010 G anada, Spain 2 Depa men o Exe cise Physiology, Facul y o Spo Sciences, Uni e si y o Is ahan, Is ahan 81746-7344, I an 3HEME Resea ch G oup, Facul y o Spo Sciences, Uni e si y o Ex emadu a, 10003 Cáce es, Spain; [email p o ec ed] 4 Depa men o Biological Sciences in Spo s, Facul y o Spo Sciences and Heal h, Shahid Behesh i Uni e si y, Teh an 198396-3113, I an 5Depa men o Exe cise Physiology, Facul y o Physical Educa ion and Spo s Science, Teh an Uni e si y, Teh an 1417935840, I an; [email p o ec ed] 6Physical Ac i i y and Quali y o Li e Resea ch G oup (AFYCAV), Facul y o Spo Sciences, Uni e si y o Ex emadu a, A . De Uni e sidad s/n, 10003 Cace es, Spain; [email p o ec ed] (S.V.); [email p o ec ed] (Á.M.-G.) *Co espondence: [email p o ec ed] (H.N.); [email p o ec ed] (M.F.) † Au ho s con ibu ed equally o his s udy. Abs ac : The aim o he p esen sys ema ic e iew was o assess and p o ide an up- o-da e analysis o he impac o co ona i us disease 2019 (COVID-19) pandemic on he heal h- ela ed quali y o li e (HRQoL) o child en and adolescen s. Thus, an elec onic sea ch o he li e a u e, in wo well-known da abases (PubMed and Web o Science), was pe o med un il Feb ua y 2021 (wi hou da e es ic ion). PRISMA guideline me hodology was employed and da a ega ding he HRQoL we e ex ac ed om eligible s udies. A icles we e included i hey me he ollowing inclusion c i e ia: (a) child en and/o adolescen popula ion (4 o 19 yea s old); (b) HRQoL as a main assessmen ; (c) Ge man, Spanish, Po uguese, F ench, and English language; and (d) p e-pandemic and du ing pandemic HRQoL da a. Following he ini ial sea ch, 241 possible ela ed a icles we e iden i ied. A o al o 79 a icles we e iden i ied as duplica es. Mo eo e , 129 a icles we e emo ed a e eading he i le and abs ac . O he emaining 33 a icles, 27 we e emo ed since hey we e no ocused on child en o adolescen s (n= 19), a icles did no epo p e- and pos - pandemic HRQoL alues ( n= 6 ), a icles we e no ocused on HRQoL (n= 6), and one a icle was an edi o ial. Finally, six s udies ul illed he inclusion c i e ia and, he e o e, we e included in he sys ema ic e iew. A o al o 3177 child en and/o adolescen s du ing COVID-19 we e included in his sys ema ic e iew. Th ee a icles showed ha COVID-19 pandemic signi ican ly impac ed he HRQoL o child en and adolescen s, and ano he did no epo compa ison be ween p e- and du ing COVID-19 pandemic, al hough a educ ion in he HRQoL can be obse ed. Ne e heless, wo a icles did no ind signi ican changes and ano he one did no epo p- alues. Rega ding sex di e ences, only wo s udies analyzed his opic, obse ing no di e ences be ween gi ls and boys in he impac o COVID-19 pandemic on HRQoL. Taking in o accoun hese esul s, his sys ema ic e iew migh con i m ha COVID-19 has a nega i e impac on he HRQoL o child en and/o adolescen s. Keywo ds: adolescen ; COVID-19; child en; HRQoL; li es yle; wellbeing 1. In oduc ion Heal h- ela ed quali y o li e (HRQoL) has been de ined as he le el o wellbeing con- sequen om he e alua ion ha a pe son makes o di e se domains o his li e, conside ing he impac hese ha e on his heal h s a us. I is cha ac e ized as subjec i e, mul idimen- sional, and changing o e ime [ 1 ]. The HRQoL assessmen inco po a es a ea ly ages In . J. En i on. Res. Public Heal h 2021,18, 4563. h ps://doi.o g/10.3390/ije ph18094563 h ps://www.mdpi.com/jou nal/ije ph In . J. En i on. Res. Public Heal h 2021,18, 4563 2 o 12 he pe cep ion o physical, psychological, and social wellbeing acco ding o e olu iona y de elopmen and indi idual di e ences, wi hin a speci ic cul u al con ex , and conside s he abili y o ully pa icipa e in he ac i i ies and he physical, social, and psychosocial unc ions app op ia e o hei age. Child en wi h poo HRQoL a e less likely o de elop no mally and ma u e in o heal hy adul s [2]. Many child en and adolescen s in de eloped coun ies lead seden a y li es yles, e- duced ac i e leisu e ac i i ies, and inc eased eliance on seden a y li es yles [ 3 ]. Be o e he COVID-19 pandemic, a p e ious s udy s a ed ha 81% o s uden s aged 11–17 yea s we e insu icien ly physically ac i e [ 4 ]. Independen ly o physical ac i i y le els, seden a y ac i i ies, especially hose based on he use o elec onic de ices, a e associa ed wi h an inc eased isk o obesi y, a educ ion in physical condi ion, sel -es eem, and p osocial beha io [ 5 ]. In his ega d, he COVID-19 pandemic has inc eased he amoun o sc een ec ea ional ime [ 6 , 7 ]. This is qui e ele an since a p e ious sys ema ic e iew o e- iews indica ed ha he e idence ha sc een ime was associa ed wi h poo e HRQoL was mode a e [8]. In addi ion o inac i i y, s ess ul si ua ions such as co ona i us disease 2019 (COVID- 19) pandemic ha e a ec ed he HRQoL o child en. Home qua an ine condi ions and he use o he In e ne o mobile phones ha e also been e ec i e in c ea ing hese condi ions. The COVID-19 pandemic has led o apid, unp eceden ed changes o he li es o billions o child en and adolescen s [9,10]. The impac o pandemic COVID-19 on HRQoL is no ye unde s ood su icien ly well. Child en and adolescen s ace massi e changes in hei daily li es, including school closu es, home con inemen , and social dis ancing ules, which can bu den hem sub- s an ially [ 11 , 12 ]. Managing wi h he cu en si ua ion and complying wi h he cu en es ic ions on op o his can be especially di icul o child en and adolescen s since hese ci cums ances can be expe ienced as being incong uen wi h hei de elopmen al asks. The challenges and consequences o COVID-19 migh he e o e ha e a emendous impac on hei HRQoL [ 13 ]. In his ega d, p e ious o COVID-19 pandemic, anxie y was he main men al diso de in bo h, child en, and adolescen s, wi h mo e han 15% o his popula ion a ec ed by his diso de [14]. Fu he mo e, as commen ed be o e, es ic ion in mobili y, social dis ancing, o school closu es ha e been inc eased seden a y beha io . Thus, i is expec ed ha HRQoL would be educed in child en and adolescen s. P e ious s udies ha e indica ed ha HRQoL ha e been educed due o COVID-19 [ 15 , 16 ] whe eas o he s did no ind di e ences [ 17 , 18 ]. Howe e , o he bes o ou knowledge, no sys ema ic e iew has syn hesized he exis ing esul s in o de o cla i y his di e gence. To aim o he p esen sys ema ic e iew was o assess and p o ide and up- o-da e analysis o he impac o he co ona i us disease 2019 (COVID-19) pandemic on he heal h- ela ed quali y o li e (HRQoL) o child en and adolescen s. 2. Ma e ials and Me hods The p esen sys ema ic e iew was conduc ed ollowing he guidelines included in he P e e ed Repo ing I ems o Sys ema ic Re iews and Me a-Analyses Guidelines (PRISMA), o sea ch p ocedu es, s udy selec ion, and da a collec ion and analysis [ 19 ]. To achie e he objec i e o his esea ch we sys ema ically e iewed he li e a u e o analyze obse a ional s udies which compa ed he HRQoL da a o he same child en and adolescen s p e and pos /du ing COVID-19 pandemic. This would allow us o analyze i COVID-19 pandemic had a nega i e e ec on HRQoL in child en and adolescen s. 2.1. Da a Sou ces and Sea ches Two well-known da abases, PubMed and Web o Science (whe e Cu en con en s connec , De wen inno a ions index, Ko ean jou nal da abase, Medline, Russian science ci a ion index, and SciELO ci a ion index a e included), we e used o iden i y all he obse a ional s udies, published un il 8 Feb ua y 2021, e alua ing HRQoL du ing COVID- In . J. En i on. Res. Public Heal h 2021,18, 4563 3 o 12 19 pandemic in child en and/o adolescen s. The sea ch s ing used in all da abases was (“co ona i us”[MeSH Te ms] OR “co ona i us”[All Fields] OR “co ona i uses”[All Fields] OR (“sa s co 2”[MeSH Te ms] OR “sa s co 2”[All Fields] OR “co id”[All Fields] OR “co id 19”[MeSH Te ms] OR “co id 19”[All Fields])) AND “Quali y o li e”[All Fields] AND (“child”[MeSH Te ms] OR “child”[All Fields] OR “child en”[All Fields] OR “child s”[All Fields] OR “child en s”[All Fields] OR “child ens”[All Fields] OR “childs”[All Fields] OR (“adolescences”[All Fields] OR “adolescency”[All Fields] OR “adolescen ”[MeSH Te ms] OR “adolescen ”[All Fields] OR “adolescence”[All Fields] OR “adolescen s”[All Fields] OR “adolescen s”[All Fields])). Th ee esea che s (M.F., A.E., and H.N) independen ly conduc ed he sea ch. Disc ep- ancies we e sol ed by a discussion wi h a ou h in es iga o (A.D). Figu e 1shows he a icle selec ion p ocess. The s udies we e included i hey me he ollowing inclusion c i e ia: (a) child en (0–10 yea s-old) and/o adolescen s (10–19 yea s- old) popula ion [ 20 ]; (b) HRQoL as a main assessmen ; (c) Ge man, Spanish, Po uguese, F ench, and English language; and (d) p e-pandemic and du ing pandemic HRQoL da a. Exclusion c i e ia we e (a) abs ac s, edi o ials, commen s, e iews, and guidelines, and (b) pa icipan s we e su e ing om a majo heal h condi ion such as cance o disabili ies. In . J. En i on. Res. Public Heal h 2021, 18, x FOR PEER REVIEW 3 o 13 2.1. Da a Sou ces and Sea ches Two well-known da abases, PubMed and Web o Science (whe e Cu en con en s connec , De wen inno a ions index, Ko ean jou nal da abase, Medline, Russian science ci a ion index, and SciELO ci a ion index a e included), we e used o iden i y all he ob- se a ional s udies, published un il Feb ua y 8, 2021, e alua ing HRQoL du ing COVID- 19 pandemic in child en and/o adolescen s. The sea ch s ing used in all da abases was (“co ona i us”[MeSH Te ms] OR “co ona i us”[All Fields] OR “co ona i uses”[All Fields] OR (“sa s co 2”[MeSH Te ms] OR “sa s co 2”[All Fields] OR “co id”[All Fields] OR “co id 19”[MeSH Te ms] OR “co id 19”[All Fields])) AND “Quali y o li e”[All Fields] AND (“child”[MeSH Te ms] OR “child”[All Fields] OR “child en”[All Fields] OR “child s”[All Fields] OR “child en s”[All Fields] OR “child ens”[All Fields] OR “childs”[All Fields] OR (“adolescences”[All Fields] OR “adolescency”[All Fields] OR “ad- olescen ”[MeSH Te ms] OR “adolescen ”[All Fields] OR “adolescence”[All Fields] OR “adolescen s”[All Fields] OR “adolescen s”[All Fields])). Th ee esea che s (M.F., A.E., and H.N) independen ly conduc ed he sea ch. Dis- c epancies we e sol ed by a discussion wi h a ou h in es iga o (A.D). Figu e 1 shows he a icle selec ion p ocess. The s udies we e included i hey me he ollowing inclusion c i e ia: (a) child en (0–10 yea s-old) and/o adolescen s (10–19 yea s-old ) popula ion [20]; (b) HRQoL as a main assessmen ; (c) Ge man, Spanish, Po u- guese, F ench, and English language; and (d) p e-pandemic and du ing pandemic HRQoL da a. Exclusion c i e ia we e (a) abs ac s, edi o ials, commen s, e iews, and guidelines, and (b) pa icipan s we e su e ing om a majo heal h condi ion such as cance o disa- bili ies. Figu e 1. Flow cha o he selec ion p ocess in his sys ema ic e iew. 2.2. Risk o Bias The E idence P ojec isk o bias ool [21] has been used o assess he isk o bias. This scale consis ed o eigh i ems, assessed as no, yes, no applicable, o no epo ed. The Figu e 1. Flow cha o he selec ion p ocess in his sys ema ic e iew. 2.2. Risk o Bias The E idence P ojec isk o bias ool [ 21 ] has been used o assess he isk o bias. This scale consis ed o eigh i ems, assessed as no, yes, no applicable, o no epo ed. The eigh i ems a e: (1) coho ; (2) con ol o compa ison g oup; (3) p e-pos in e en ion da a; (4) andom assignmen o pa icipan s o he in e en ion; (5) andom selec ion o pa icipan s o assessmen ; (6) ollow-up a e o 80% o mo e; (7) compa ison g oups equi alen on sociodemog aphic; and (8) compa ison g oups equi alen a baseline on ou come measu es. Two au ho s (A.M. and A.D.) e alua ed he isk o bias independen ly, and disag eemen s we e sol ed by a discussion wi h ano he au ho (J.P.-G.). In . J. En i on. Res. Public Heal h 2021,18, 4563 4 o 12 2.3. Da a Ex ac ion We de eloped a da a ex ac ion shee (based on he s udy design, sample size, coun y, popula ion—child en o adolescen s, ins umen o assessing HRQoL, p e and du ing HRQoL alues). One e iew au ho (S.V) ex ac ed he ollowing da a om included s udies and a second au ho checked he ex ac ed da a (A.M.-G). Disag eemen s we e esol ed by a discussion wi h ano he au ho (J.P.-G.). 2.4. E idence Syn hesis and Da a Analysis Syn hesis o esul s a e p esen ed wi h an ini ial desc ip ion o he s udy popula ion (child en o adolescen s), including o al sample size and age ange, as well as he s udy design o included s udies. Then, ins umen s used o assess he HRQoL and a gene al summa y o COVID-19 impac on HRQoL o child en and adolescen s included in each s udy will be p esen ed. A e ha , o each s udy a simple summa y wi h main esul s will be ex ac ed. Due o he s udy design and he e ogenei y o included a icles, an es ima ed e ec ac oss s udies wi h a con idence in e al could no be calcula ed. 3. Resul s 3.1. S udy Selec ion Figu e 1 epo s he PRISMA low diag ams o he s udy selec ion. Following he ini ial sea ch, 241 possible ela ed a icles we e iden i ied. A o al o 79 a icles we e iden i ied as duplica es. Mo eo e , 129 a icles we e emo ed a e eading he i le and abs ac (see Figu e 1 o easons). O he emaining 33 a icles, 27 we e emo ed since hey we e no ocused on child en o adolescen s (n= 19), a icles did no epo p e- and pos - pandemic HRQoL alues (n= 6), a icles we e no ocused on HRQoL (n= 6), and one a icle was an edi o ial. Finally, six a icles we e included in he sys ema ic e iew (see Figu e 1). De ails and cha ac e is ics o hese a icles a e also p o ided in Table 1. Table 1. Risk o bias o included a icles using he E idence P ojec isk o bias ool. S udy 1 2 3 4 5 6 7 8 Abawi (2020) Yes No Yes No No No NA NA D agun (2020) Yes No Yes No No No NA NA Ma os (2020) Yes No Yes No No Yes NA NA Ra ens-Siebe e (2021) Yes No Yes No No Yes NA NA Vallejo-Slocke (2020) Yes No Yes No No No NA NA Syzmanski (2018) Yes No Yes No No Yes NA NA The eigh i ems a e (1) coho ; (2) con ol o compa ison g oup; (3) p e-pos in e en ion da a; (4) andom assignmen o pa icipan s o he in e en ion; (5) andom selec ion o pa icipan s o assessmen ; (6) ollow-up a e o 80% o mo e; (7) compa ison g oups equi alen on sociodemog aphic; and (8) compa ison g oups equi alen a baseline on ou come measu es. NA: non applicable. 3.2. Risk o Bias The E idence P ojec isk o bias ool was employed in he p esen s udy (see Table 1 ). This ool e alua ed he isk o bias o he six a icles included in his sys ema ic e iew. A e e alua ing all o hem, six a icles ul illed c i e ia one and h ee (coho and p e-pos measu emen s). Th ee a icles ul illed he c i e ia ela ed o he ollow-up a e o 80% o mo e. Howe e , he mos c i ical conce ns a e ela ed o he andom assignmen o pa icipan s o he in e en ion and he andom selec ion o pa icipan s o assessmen . Two c i e ia, he compa ison g oup’s equi alen on sociodemog aphic measu es, and he compa ison g oups equi alen a baseline on ou come measu es, we e no assessed due o he obse a ional design o he s udies included in his sys ema ic e iew. 3.3. Syn hesis o Resul s Table 2summa izes he impac o he COVID-19 pandemic on he HRQoL o child en and adolescen s. A o al o 3177 child en and adolescen s ha e been included in his sys ema ic e iew. The age anged be ween 4 o 18 yea s. In . J. En i on. Res. Public Heal h 2021,18, 4563 5 o 12 Table 2. Main indings o child en and/o adolescen s HRQoL p e- and du ing COVID-19 pandemic. Au ho Coun y S udy Design Sample Size (Gi ls) Age (Yea s) Ques ionnai e HRQoL p-Value P e-Pandemic Du ing-Pandemic Abawi 2020 Ne he lands C oss-Sec ional 40 10.5 (7.6–15.2) PedsQL 66.2 (17.7) Change o −6.3 (29.9) 0.26 D agun (2020) C oa ia C oss-Sec ional 531 (384) 18 (6.0) Like scale 8.0 (2.0) 7.0 (2.0) <0.001 Ma os (2020) B azil C oss-Sec ional 25 child en (10) 44 adolescen s (25) 9.56 (1.47) 16.3 (1.67) SF-36 - - <0.001 a Ra ens-Siebe e (2021) Ge many C oss-Sec ional 793 (396) 12.25 (3.30) KIDSCREEN-10 Low HRQol in Boys: 10.4% Low HRQol in Boys: 35.7 % <0.001 Low HRQol in Gi ls: 20.4% Low HRQol in Gi ls: 44.7 % <0.001 Low HRQol in Boys and gi ls: 15.3% Low HRQol in Boys and gi ls: 40.2 % <0.001 P oxy esul s o 7- o 10-yea s-olds: 7.4% P oxy esul s o 7- o 10-yea s-olds: 26.8% <0.001 P oxy esul s o 11- o 13-yea s-olds: 12.8% P oxy esul s o 11- o 13-yea s-olds: 14.5% <0.001 Vallejo-Slocke (2020) Spain C oss-Sec ional 33 8–18 KIDSCREEN-10 50 (10) 50.4 (10.1) 0.4 Wunsch (2021) Ge many C oss-Sec ional 1711 4–10 11–17 KIDSCREEN-10 Male child en 44.89 (3.92) Male child en 40.68 (4.33) Female child en 45.49 (4.88) Female child en 41.27 (4.34) Male adolescen s 43.87 (4.19) Male adolescen s 40.77 (4.70) Female adolescen s 43.15 (4.32) Female adolescen s 40.83 (4.27) a : The e was a signi ican dec ease in all aspec s o quali y o li e analyzed by he SF-36 (Func ional capaci y, Limi a ion by physical aspec , Gene al Heal h S a us, Vi ali y, Social Aspec s, Emo ional Aspec s, and Men al Heal h) in bo h child en and adolescen s. Da a can be checked in he o iginal a icle. HRQoL: heal h- ela ed quali y o li e. COVID-19: co ona i us disease 2019. PedsQL: Pedia ic Quali y o Li e In en o y Ques ionnai e. In . J. En i on. Res. Public Heal h 2021,18, 4563 6 o 12 Rega ding he ins umen s used o e alua e he HRQoL, ou di e en scales we e used o e alua e he HRQoL o child en and adolescen s: KIDSCREEN-10 index, he SF-36, he Pedia ic Quali y o Li e In en o y Ques ionnai e, and a Like Scale (0–10). Th ee a icles explici ly s a ed ha used language alida ed e sions [ 16 , 22 ] whe eas he o he h ee a icles only desc ibed he ques ionnai e in hei a icle [ 15 , 17 , 18 ]. To summa ize, h ee a icles epo ed ha COVID-19 signi ican ly educed he HRQoL o child en and adolescen s [ 15 , 16 ], wo a icles did no ind a signi ican impac [ 17 , 18 ], and one a icle did no epo s a is ical compa ison be ween p e- and pos -pandemic da a. Di e ences be ween gi ls and boys we e explo ed in wo a icles [ 16 , 22 ] and non-signi ican di e ences we e obse ed in he e ec o he COVID-19 pandemic on he HRQoL. The impac o COVID-19 on he di e en dimensions o HRQoL was only analyzed in one s udy [ 16 ], showing ha COVID-19 has nega i ely a ec ed unc ional capaci y, physical aspec , gene al heal h s a us, i ali y, social aspec s, emo ional aspec s, and men al heal h in bo h child en and adolescen s. Howe e , nei he o he s udies analyzed whe he he COVID-19 pandemic has equally impac ed he HRQoL o child en and adolescen s. The KIDSCREEN-10 index co e s he physical, social, and psychological sphe es o heal h, p o iding a global HRQoL sco e [ 23 ]. I s en i ems (e.g., “Ha e you el ull o ene gy?”) we e p esen ed wi h 5-poin esponse scales (0 = “ne e ” o 4 = “always” o 0 = “no a all” o 4 = “ex emely”), ha ing a mean sco e anging om 0 o 4. The SF-36 measu es he pa icipan s’ sel - epo ed opinion abou hei physical and men al well- being [ 24 ]. I has eigh domains o HRQoL: gene al heal h, ene gy/ i ali y, body pain, physical unc ioning, emo ional well-being, ole limi a ions due o physical heal h, ole limi a ions due o emo ional p oblems, and social unc ioning. Responses o each ques ion wi hin a domain a e combined o gene a e a sco e om 0 o 100, whe e 100 indica es “good heal h”. The 23-i em PedsQL ™ 4.0 Gene ic Co e Scales [ 25 ] con ain ou dimensions wi h di e en i ems: (1) Physical Func ioning (8 i ems), (2) Emo ional Func ioning ( 5 i ems ), (3) Social Func ioning ( 5 i ems ), and (4) School Func ioning (5 i ems). A i e-poin e- sponse scale is in he pa en p oxy- epo (0 = ne e a p oblem; 1 = almos ne e a p oblem ; 2 = some imes a p oblem ; 3 = o en a p oblem; 4 = almos always a p oblem). I ems a e e e se-sco ed and linea ly ans o med o a 0–100 scale. The Like scales, wi h a 0–10 scale , which was used o measu e he HRQoL, ep esen ed he 0 as he absence o heal h and 10 ep esen ing comple e heal h. In his sys ema ic e iew, h ee a icles employed he KIDSCREEN-10 index o assess he quali y o li e o child en and adolescen s [ 13 , 18 , 22 ], one a icle used he SF-36 [ 16 ], ano he he Pedia ic Quali y o Li e In en o y Ques ion- nai e [17], and ano he used a Like Scale (0–10) [15]. Th ee a icles epo ed ha COVID-19 signi ican ly educed he HRQoL o child en and adolescen s [ 15 , 16 ]. D agun, Veˇcek, Ma endi´c, P ibisali´c, Ði i´c, Cena, Polašek and Kolˇci´c [ 15 ] analyzed a o al o 531 adolescen s. Thei esul s showed ha lockdown signi ican ly a ec ed HRQoL, happiness, op imism (p< 0.001), as well as pe cei ed s ess. In e es ingly, he Medi e anean die adhe ence posi i ely co ela ed o HRQoL p e and du ing COVID-19 lockdown. The e o e, his s udy concludes ha gi en he nume ous bene icial e ec s associa ed wi h he Medi e anean die adhe ence, modi ica ion o li es yle h ough applica ion o li es yle medicine dese es a p io i y app oach. In he s udy o de Ma os, Aida , Almeida-Ne o, Mo ei a, Souza, Ma çal, Ma cucci-Ba bosa, Ma ins Júnio , Lobo and dos San os [ 16 ], a o al o 69 child en and adolescen s pa icipa ed in an online su ey, based on he SF-36, in o de o e alua e he HRQoL. Resul s showed ha HRQoL signi ican ly dec eased in all aspec s o quali y o li e analyzed by he SF-36 in bo h adolescen s and child en. Au ho s concluded ha he scena io o social isola ion nega i ely impac ed he le el o physical ac i i y, quali y o li e, and s ess le el in B azilians. Thus, implemen ing an adap ed physical aining p og am a home du ing he pe iod o he pandemic may help o dec ease he nega i e physiological and psychological impac o inac i e beha io s. Ra ens-Siebe e , Kaman, E ha , De ine, Schlack and O o [ 13 ] analyzed a o al o 793 child en and adolescen s using he KIDSCREEN-10 ques ionnai e. This s udy showed de ailed da a ega ding he educ ion o HRQoL due o he COVID-19 In . J. En i on. Res. Public Heal h 2021,18, 4563 7 o 12 pandemic. In his ega d, au ho s poin ed ha be o e he pandemic, 15.3% (n= 146; based on weigh ed da a o he BELLA s udy) o child en and adolescen s epo ed low HRQoL whe eas, du ing he pandemic, 40.2% o he child en and adolescen s epo ed low HRQoL (n= 418; based on weigh ed sel - epo ed da a o he COPSY s udy). Fu he mo e, a gende s a i ied analysis showed ha a highe p opo ion o gi ls epo ed low HRQoL, when compa ed o hei male pee s bo h be o e and du ing he pandemic. In e es ingly, younge child en we e a ec ed signi ican ly mo e han olde ones. Fo ins ance, he pe cen age o child en epo ing low HRQoL anged om 7.7% o 41.3% in 11- o 13-yea -old child en and om 17.1% o 39.3% in 14- o 17-yea -olds. Taking in o accoun all hese esul s, au ho s concluded ha heal h p omo ion and p e en ion s a egies a e needed o main ain child en’s and adolescen s’ men al heal h, as well as o imp o e hei HRQoL, and mi iga e he bu den caused by COVID-19, pa icula ly o child en who a e mos a isk. Two a icles did no ind a signi ican impac [ 17 , 18 ] o COVID-19 pandemic on HRQoL. A o al o 40 child en and adolescen s pa icipa ed in he s udy o Abawi, Welling, an den Eynde, an Rossum, Halbe s ad , an den Akke and an de Voo n [ 17 ]. The 23-i em Paedia ic Quali y o Li e in en o y (PedsQL) 4.0 (pa en s’ p oxy- epo e sion) was egis e ed. The mean PedsQL o al sco e be ween baseline and COVID-19 ou b eak dec eased in child en, al hough he change was no s a is ically signi ican (mean change − 6.3 ± 29.9; p= 0.26). Ne e heless, au ho s also s udy anxie y and showed a bigge dec ease in child en o whom anxie y was epo ed s. hose who did no (mean change − 10.3 ± 36.5 s. − 3.3 ± 24.4). Howe e , i was also no s a is ically signi ican . Thus, au ho s concluded ha heal hca e p o essionals should add ess possible COVID-19 ela ed anxie y in child en. Mo eo e , in he s udy o Vallejo-Slocke , F esneda and Vallejo [ 18 ], a o al o 33 child en and adolescen s comple ed he KIDSCREEN-10 ques ionnai e in o de o assess he HRQoL. Resul s showed ha no signi ican di e ences we e de ec ed be ween p e- and du ing COVID-19 pandemic in he HRQoL. In e es ingly, au ho s analyzed he possible di e ences be ween sexes. In his ega d, gi ls sco ed highe (n= 223, M = 3.8; SD = 2.46 ) han males (n= 236, M = 2.9, SD = 2.17) in emo ional p oblems, indica ing wo se unc ioning. In he same line, using he KIDSCREEN-10 o al index, boys ob ained highe esul s (n= 236, M = 51.04; SD = 9.89) han gi ls (n= 223, M = 48.89; SD = 10.01), indica ing highe HRQoL. Thus, au ho s concluded ha i is necessa y o moni o he men al heal h s a us o child en and adolescen s in o de o p e en possible p oblems. Las ly, in he s udy o Wunsch, Nigg, Niessne , Schmid , O iwol, Hanssen-Doose, Bu cha z, Eichs elle , Kolb and Wo h [ 22 ], a o al o 1711 child en and adolescen s we e sc eened using he KIDSCREEN-10 ins umen o assess hei HRQoL. In his s udy, au- ho s did no p esen a - es o compa e p e and du ing HRQoL, bu epo ed whe he physical ac i i y, sc een ime, and HRQoL be o e COVID-19 p edic ed physical ac i i y, sc een ime, and HRQoL du ing he COVID-19 pandemic. This analysis e ealed ha physical ac i i y du ing-COVID-19 was posi i ely p edic ed by p e-COVID-19 HRQoL (s anda dized es ima e = 0.07; p= 0.003) and nega i ely p edic ed by p e-COVID-19 sc een ime (s anda dized es ima e = − 0.21; p< 0.001). Mo eo e , when he in o ma ion we e s a i ied by gende , sc een ime p e- COVID-19 nega i ely p edic ed du ing-COVID-19 physical ac i i y (s anda dized es ima e = − 0.24; p< 0.001), bu no s a is ically signi ican ela ionship be ween HRQoL and physical ac i i y was obse ed (p= 0.112). Fo emales, physical ac i i y du ing-COVID-19 was posi i ely p edic ed by HRQoL p e-COVID-19 (s anda dized es ima e = 0.09, p= 0.007) and nega i ely by leisu e sc een ime p e-COVID- 19 (s anda dized es ima e = − 0.18, p< 0.001). Ne e heless, au ho s compa ed hei esul s wi h Eu opean no ms and Ge man child en, obse ing a dec ease. Fo ins ance, p io o he COVID-19 lockdown, mean T-Sco es we e 44 poin s a he 27 h pe cen ile, and du ing he lockdown, sco es dec eased o 41 poin s, e lec ing he 18 h pe cen ile. The e o e, au ho s concluded ha policies o imp o e he HRQoL, especially in child en aged 4 o 10 yea s and emales, should be p omo ed in o de o inc ease esilience. Mo eo e , due o he nega i e associa ion be ween p e-COVID-19 sc een ime and wi hin-COVID-19 physical In . J. En i on. Res. Public Heal h 2021,18, 4563 8 o 12 ac i i y, heal h policy mus implemen coun e measu es o educe sc een ime in child en and adolescen s. 4. Discussion The pu pose o his sys ema ic e iew was o p o ide an up- o-da e analysis o he impac o COVID-19 pandemic on he HRQoL o child en and adolescen s. Thus, a icles ha analyzed p e and pos /du ing pandemic HRQoL alues we e included. Findings sugges ha child en and/o adolescen s expe ienced a educ ion in he HRQoL due o he COVID-19 pandemic. The COVID-19 pandemic, due o he high unce ain y and s ess, has dec eased psychological heal h [ 26 ]. P e ious s udies ha e ound a signi ican impac o COVID-19 con inemen on s ess, dep ession, o anxie y [ 27 , 28 ]. This dec emen in psychological heal h has also been obse ed in child en and adolescen s [ 29 , 30 ]. Fu he mo e, child en and adolescen s expe ienced massi e changes in hei daily li es, such as school closu es, social dis ancing, o home con inemen , signi ican ly dec easing he HRQoL [ 12 , 31 ]. In his ega d, p e ious s udies ha e indica ed ha HRQoL has been educed due o he COVID- 19 pandemic [ 16 , 32 , 33 ]. The esul s o his sys ema ic e iew a e in he same line, wi h h ee a icles showing a signi ican educ ion o HRQoL in child en and adolescen s. Mo eo e , wo s udies independen ly explo ed he impac o COVID-19 in gi ls and boys [ 13 , 22 ]. Resul s showed ha indi e en ly o hei sex, HRQoL was educed. Howe e , a p e ious s udy showed ha gi ls we e mo e likely o expe ience dec eased men al heal h han boys du ing COVID-19 pandemic [ 29 ]. In he same line, p e ious s udies showed ha gi ls a e mo e ulne able o psychological dis ess han boys [ 34 ]. The e o e, u u e s udies should explo e sex-based di e ences on he impac o he COVID-19 pandemic in child en and adolescen s. No ably, due o he go e nmen s’ social isola ion and he measu es o con ol he sp ead o COVID-19, p e ious s udies ha e de ec ed a signi ican dec ease in physical ac i i y le el [ 35 , 36 ]. These measu es ha e limi ed he oppo uni y o s ay physically ac i e. Due o his ac , Cos a, e al. [ 37 ] showed ha du ing he pandemic, B azilians’ le el o physical ac i i y was signi ican ly educed, becoming ha m ul o he heal h o he popula- ion [ 37 ]. Sus ained physical inac i i y is usually associa ed wi h dec eased physical and men al wellbeing and ele a ed disease-speci ic beha io and all-cause mo ali y isk [38]. As commen ed be o e, social isola ion can lead o a educ ion in social con ac and longe pe iods o immobili y. This would lead, di ec ly o indi ec ly, o inc ease he use o in e ac i e de ices, such as TV, compu e s, and mobile phones [ 39 ]. P e ious s udies ha e ound ha he o al amoun o ec ea ional sc een ime has inc eased du ing he COVID-19 pandemic [ 6 , 7 ]. In his ega d, a p e ious s udy showed ha child en and adolescen s inc eased a o al o 61.2 minu es pe day o ec ea ional sc een ime due o he COVID-19 pandemic [ 40 ]. This s udy also ound ha boys spend mo e ec ea ional sc een ime pe day han gi ls, 66.2% and 56.3%, espec i ely. In e es ingly, his a icle showed ha a o i e ec ea ional sc een ac i i y is TV whe eas, o adolescen s, he In e ne ’s use was p edomi- na ely chosen. This is qui e ele an , especially in adolescen s whe e sex ing (exchange o a message con aining sexual con en ia in e ne ) has been shown o be p e alen among ju eniles [ 41 ]. Inc eased ime on ec ea ional in e ne could ha e inc eased his beha io wi h nega i e consequences on child en’s men al heal h and HRQoL. Social isola ion can enhance loneliness and abandonmen , igge ing ad e se beha - io al ela ionships (i.e., agg essi eness, c ying, emo ional pain, e c.) [ 42 ]. Mo eo e , he absence o social in e ac ion can a ec he emo ional pe cep ion ha will in luence he eeling o i ali y and he pe cep ion o gene al heal h. This has a di ec in luence on men al heal h, and all hese in e connec ed eac ions can be ha m ul o he physical aspec s, which can educe he unc ionali y and inc ease he pe cep ion o physical pain [ 43 ]. The e o e, he sel -pe cei ed quali y o li e ends o su e nega i e changes du ing he isola ion pe iod o he COVID-19 pandemic [ 44 ]. Siebe e e al. showed ha lowe HRQoL and mo e In . J. En i on. Res. Public Heal h 2021,18, 4563 9 o 12 men al heal h p oblems du ing pandemic COVID-19 and heal h p omo ion and p e en ion s a egies need o be execu ed [13]. P e ious s udies ha e explo ed he bene i s o physical exe cise o comba he nega i e impac o he COVID-19 pandemic [ 45 ]. In his ega d, a p e ious s udy ound ha hose who we e no en olled in physical exe cise du ing COVID-19 con inemen showed a highe le el o s ess, anxie y, and dep ession [ 9 ]. In he same line, a p e ious andomized con- olled ial which ocused on he e ec s o wo home-based physical exe cise in e en ions (using high-in ensi y in e al aining and mode a e-in ensi y aining) showed ha bo h g oups educed s ess, anxie y, and dep ession as well as inc eased esilience. Howe e , he g oup who pe o med high-in ensi y in e al aining signi ican ly ob ained he g ea - es educ ion o dep ession when compa ed o mode a e-in ensi y aining. Rega ding esilience, he signi ican e ec on esilience is qui e impo an o ace he s ess ul and unce ain si ua ion caused by he COVID-19 pandemic [ 46 , 47 ]. Acco ding o a sys ema ic e iew, child en should pe o m 60–180 min o daily mode a e o igo ous physical ac i i y and use hei own bodyweigh o ligh weigh s du ing s eng h aining [ 48 ]. Howe e , in child en and adolescen s who we e no in ol ed p e ious o he COVID-19 pandemic, i is ecommended o con inue mode a e-in ensi y exe cise e e y day o 10 o 15 min [49]. Fu he mo e, ano he ele an ac o which should be conside ed in he dec ease o HRQoL in child en and adolescen s a e pa en s. In his ega d, a p e ious s udy has shown how iolence agains child en has inc eased unde home con inemen lea ing child en a isk o abuse and auma [ 50 ], pa icula ly in hose amilies wi h a low socioeconomic s a us [ 51 ]. Fu he mo e, poo e amilies a e less inancially esilien and a e mo e ex- posed o job and ea nings losses while hei child en a e likely o be disp opo ionally disad an aged by school-closu es [ 52 ]. Mo eo e , g owing up in poo e neighbo hoods inc eases he isk o ca ching he i us [ 52 ]. Addi ionally, he COVID-19 ou b eak has inc eased he likelihood o inancial and social insecu i y o low-income g oups, which could hypo he ically con ibu e o low HRQoL o child en and adolescen s [ 52 ]. Thus, a p e ious s udy showed ha pa en al job and income losses a e associa ed wi h pa en s’ dep essi e symp oms, s ess, diminished sense o hope, and nega i e in e ac ions wi h child en [53,54]. The p incipal limi a ion o his e iew is he small numbe o a icles abou HRQoL ha compa e p e and du ing pandemic alues. In addi ion, he a icles analyzed a e om child en and adolescen s om di e en coun ies. This can be a limi a ion because each coun y has had di e en ime and con inemen es ic ions. This conside a ion may be a u u e line o esea ch when mo e s udies appea on his opic. Addi ionally, a icles in languages o he han English, Spanish, Ge man, F ench, o Po uguese we e no included in his sys ema ic e iew. Thus, i is plausible o suppose ha some impo an pedia ic coho s we e no included in ou sys ema ic e iew. Fu he mo e, one a icle included a Like scale [ 15 ], while ano he included he SF-36 ques ionnai e o assess he HRQoL. In o de o measu e HRQoL in child en and adolescen s, o he ques ionnai es such as PedsQL and KIDSCREEN-10 can be use ul. Fu u e s udies should explo e i COVID-19 has equally a ec ed gi ls and boys, as well as adolescen s and child en. Addi ionally, s udies should explo e, in a deepe way, which aspec s o he HRQoL ha e been mo e a ec ed by he COVID-19 pandemic in child en and adolescen s. Despi e he limi a ion, his s udy has some s eng hs which should be acknowledged. Fi s , his is he i s sys ema ic e iew which analyzes he impac o COVID-19 pandemic on he HRQoL o child en and adolescen s. Addi ionally, mo e han 3100 child en and adolescen s we e included in his s udy. Las ly, his s udy showed how COVID-19 has neg- a i ely impai ed he HRQoL o child en and adolescen s, so in e en ions a e encou aged o eco e he HRQoL le el p e-pandemic. 5. Conclusions The COVID-19 pandemic could ha e signi ican ly dec eased he HRQoL o child en and adolescen s. Rega ding sex di e ences and HRQoL dimensions, s ong e idence was