Objective To compare hospital activity, patient casemix and medication prescribing and administration before and during the COVID-19 emergency. Design Retrospective observational study Setting A specialist children's hospital in the UK Patients Inpatients aged 25 and younger treated at a specialist children's hospital between 29 April 2019 and 6 September 2020 Results There were 21,471 day cases and inpatients treated during the 16 month study period. Day cases (no overnight stay) dropped by

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... und 37% per week. Both admissions and discharges for inpatients (at least one overnight stay) decreased leading to a small reduction in hospital bed days but no reduction in hospital bed nights. The effect on hospital activity on different patient groups varied substantially with some groups such as medical oncology day cases increasing by 13%. As a result, the patient case mix in the hospital was very different during the pandemic. Overall weekly medication administrations decreased for day cases and inpatients, but weekly medication administrations per bed day increased by 10% for day cases and 6% for inpatients. Conclusions Despite not being badly affected by the disease itself, specialist paediatric hospital services have been greatly affected by the pandemic. The average number of medications per inpatient bed day increased, likely reflecting changes to the patient population, with only those children with severe conditions being treated during the pandemic. These data demonstrate the complex pattern of implications on specialist services and provide evidence for planning the impact of future emergencies and resolution strategies.