Children Are Not Little Adults: Ensuring Adequate Pediatric Emergency Care in U.S. Hospitals

As a parent, there is perhaps nothing more terrifying than the helplessness felt when your child is gravely ill or injured. The rush to the emergency room is fraught with fear and uncertainty. When a child’s life hangs in the balance, every second feels like an eternity, and every decision made by health care professionals at a hospital carries immense weight.

The trust parents place in the hands of emergency room staff is profound and often well-placed. After all, they are the experts…until they are not.

The National Academy of Sciences’s report, Emergency Care for Children: Growing Pains explains:

Children represent a special challenge for emergency and trauma care providers, in large part because they have unique medical needs in comparison with adults. Respiratory rates, heart rates, and blood pressure levels all change as children grow, so vital signs that would be normal for an adult patient may signal distress in a child. Special care is necessary when providers intubate a child to accommodate a shorter trachea and higher larynx. Medication doses must be carefully calculated specifically for each pediatric patient based on his or her weight. Providers must also know how to handle children’s emotional reactions to illness and injury, which vary by age. Children may not be old enough to communicate what is wrong with them or how they became injured, making triage more difficult.[1]

As the pediatric community often points out, “Children are not little adults.”

The failure to address these differences threatens the health and well-being of children. In emergency rooms that are not appropriately equipped or that have providers not appropriately trained on the unique health care needs of children, this failure can lead to delayed or incorrect diagnoses, inappropriate treatments, suboptimal care, and tragic outcomes, including death.

In a study published by the JAMA Network, the authors studied the experiences of children in different types of emergency rooms and found 60–76% lower odds of in-hospital death for children who received care in “high pediatric readiness” emergency departments.[2] Children are needlessly dying in emergency rooms with inadequate equipment and staff training.

While parents should be encouraged to take their children to children’s hospital emergency departments, if possible, the solution cannot be for kids to be seen only in children’s hospitals.

According to data cited in the JAMA study, there are over 30 million emergency department visits by children annually and less than 1-in-5 of those children are treated in children’s hospitals.[3] A large percentage of children in this country are simply not close enough to a children’s hospital, particularly those in rural areas. Therefore, the solution demands better staffing and training in hospital emergency departments across this country.

Sadly, this is not a new issue. The Emergency Medical Services for Children (EMS-C) program was established at the federal level in 1984 to address these shortcomings. Despite progress in some states, the Wall Street Journal reported that “most hospitals haven’t taken action” to meet pediatric readiness standards and that “25 states don’t check ERs’ pediatric preparedness at all, and even some that do check don’t publish names of the hospitals that earned recognition for being prepared.”[4]

The WSJ adds that the Joint Commission, which accredits hospitals, considered “adding pediatric equipment requirements in 2019” but withdrew them after hospitals criticized the standards.[5]

For decades, we have known that in emergency situations every second counts, and that the lack of proper equipment or expertise can lead to misdiagnosis, delayed treatment, and, in the worst cases, increased morbidity and mortality in children. This can and must be avoided.

The Case for Minimum Pediatric Readiness Standards

Introducing minimum standards for pediatric care in emergency rooms is not just about having the right size of equipment or appropriately trained staff. It’s about a holistic approach to pediatric emergency care — one that includes:

1. Specialized Training for Staff: Emergency room personnel should be trained in pediatric care, understanding the physiological and psychological differences in treating children.
2. Appropriate Pediatric Equipment: From smaller needles and blood pressure cuffs to pediatric-sized airway management tools, having the right equipment is crucial.
3. Child-Friendly Environments: A child in crisis needs a comforting environment, which can play a vital role in their recovery.
4. Established Protocols for Pediatric Emergency Care: Clear guidelines and protocols set by either the Centers for Medicare and Medicaid Services (CMS) and Joint Commission, should be put into place for pediatric emergencies.
5. Pediatric Readiness Standards Should Be Tied to Hospital Payment Rates: CMS should tie both Medicare and Medicaid participation standards to require compliance with pediatric readiness standards, such as through a requirement for compliance to receive disproportionate share hospital (DSH) funding,[6] and value-based payments should be increased to hospitals that meet pediatric readiness standards.
6. Integration with Pediatric Specialists: Emergency rooms should have ready access to pediatric specialists and include a pediatric emergency care coordinator.
7. Levels of Pediatric Readiness Should Be Made Public: Parents and the public at large deserve to know which hospitals are child-friendly and best for the treatment and care of children.
8. Lawmakers Should Increase Funding for EMS-C and Promote the National Pediatric Readiness Project: With additional funding and support, all states and hospitals should come into compliance with minimal pediatric readiness standards as soon as possible.

As a JAMA commentary notes, “Remarkably, an estimated 1,442 pediatric deaths could have been prevented if all lower readiness EDs had performed similarly to high readiness EDs” in the top quartile.[7]

We Must Make Cutting Infant and Child Mortality a Priority

The health and well-being of children should be a priority of any society. But we are failing our children and must address these fundamental issues with great urgency:

• Child and Teen Mortality: Child and teen mortality increased by 20% between 2019 and 2021,[8] the largest increase in 50 years. These tragic figures come after a previous study found U.S. children had a 70% greater chance of dying in childhood than kids born in other wealthy countries.[9] We are failing our children.
• Infant Mortality: The U.S. infant mortality rate, which was already much higher than in other wealthy nations, increased for the first time in two decades between 2021 and 2022.[10] We are failing our babies.

Lawmakers should adopt a children’s health agenda that includes ensuring all children have health coverage, improving maternal and child health, addressing the children’s mental health crisis, preventing gun violence, increasing immunization rates, and improving health system access and quality.

On this last point, investing in pediatric emergency care is both a moral obligation and economically prudent. By ensuring effective and immediate care, we can avoid the long-term costs associated with delayed or inadequate treatment. Moreover, it strengthens the overall health system, leading to a healthier, more productive future generation.

It is long past time for us to turn our attention, resources, and policies toward creating a health care environment where every child, regardless of their circumstance or zip code, has access to the best emergency care possible. Let us advocate for and establish minimum standards for pediatric care in emergency rooms — our children deserve nothing less.

Thanks to Elaine Dalpiaz and Megan Condon for their contributions to this blog.

And for more information on this issue, check out The Journal’s podcast entitled “Why So Many Emergency Rooms Are Failing Kids in America.”

Endnotes

[1] Institute of Medicine. (2007). Emergency Care for Children: Growing Pains. Washington, D.C.: National Academies Press.

[2] Newgard, C. D., Lin, A., Malveau, S., Cook, J. N., et al. (2023). Emergency Department Pediatric Readiness and Short-term and Long-term Mortality Among Children Receiving Emergency Care. JAMA Network, 6(1), 1–14.

[3] Ibid.

[4] Whyte, L. E., & Evans, M. (2023, Oct. 1). Children Are Dying in Ill-Prepared Emergency Rooms Across America. Retrieved from Wall Street Journal: https://www.wsj.com/health/healthcare/hospitals-emergency-rooms-cost-childrens-lives-d6c9fc23.

[5] Ibid.

[6] DSH funding is designed to support hospitals that serve a significantly disproportionate number of low-income patients. It’s logical and morally imperative that part of this responsibility includes providing adequate pediatric emergency care. By mandating that hospitals receiving Medicare or Medicaid DSH funding meet minimum standards for pediatric care, we can ensure that a baseline level of care is available for all children going to hospital emergency departments.

[7] Foster, A. A., & Hoffmann, J. A. (2023). Saving Children’s Lives by Improving Pediatric Readiness for Emergency Care. JAMA Network, 5(1), 1–2.

[8] Woolf, S.H., Wolf, E.R., Rivara, F.P. (2023, Mar. 13). The New Crisis of Increasing All-Cause Mortality in US Children and Adolescents. JAMA. 329(12): 975–976. doi:10.1001/jama.2023.3517.

[9] Thakrar, A.P., Forrest, A.D., Maltenfort, M.G., & Forrest, C.B. (2018, Jan.). Child Mortality in the U.S. and 19 OECD Comparator Nations: A 50-Year Time-Trend Analysis. Health Affairs: https://doi.org/10.1377/hlthaff.2017.0767.

[10] Ely D.M. & Driscoll A.K. (2023, Nov.). Infant mortality in the United States: Provisional data from the 2022 period linked birth/infant death file. Centers for Disease Control and Prevention, National Center for Health Statistics. Vital Statistics Rapid Release; no 33. https://www.cdc.gov/nchs/data/vsrr/vsrr033.pdf.