My Pediatric Unit Is Almost Empty

Hospitals across the country are seeing fewer sick kids; a pediatrician explores why

It’s a Friday in April, and after a week on service, I’m down to one pediatric patient in the hospital. Not that I’m wishing for sick children, but as a pediatric and adult hospitalist physician, this isn’t what I’m used to. This isn’t what the entire country and much of the world are used to either.

Where Have All the Sick Children Gone? That was the title of a recent article by Scott D. Krugman, MD, an editorial board member for the renowned medical journal, Pediatrics. Dr. Krugman isn’t the only medical provider asking this question.

In mid-March of 2020, it seemed like the whole planet came to a halt. The United States was on lockdown. We seldom exited our homes, and even when we did, we rarely ventured close to another human.

Few were surprised, then, by data published by Jonathan Pelletier, MD, and colleagues in the Journal of the American Medical Association describing a 45% reduction in pediatric hospital admissions in the first half of 2020. After all, when children (even more so than adults) are hospitalized, the reason is often related to some type of respiratory infection transmitted from human to human. Examples include influenza, which can lead to pneumonia, respiratory syncytial virus (RSV), which can cause bronchiolitis, and parainfluenza, the main virus responsible for croup.

Kevin Messacar, an infectious disease pediatrician, commented on the phenomenon he was witnessing at Children’s Hospital Colorado, “We also have not seen significant influenza or RSV on our wards. All the most common childhood infections that land children in the hospital — influenza, croup, bronchiolitis — we are not seeing.”

Interestingly, Pelletier and colleagues note a decline in hospitalizations for many other non-infectious diagnoses as well. “Admissions for appendicitis, atrial septal defects, coarctation of the aorta, dehydration, hypoplastic left heart syndrome, Kawasaki syndrome, mental health conditions, and tetralogy of Fallot decreased below expected levels.”

A similar study from the Journal of Hospital Medicine revealed a 62% decline in the number of children seen or hospitalized for respiratory illnesses compared to a 38% reduction for other conditions over the first three quarters of 2020. The concurrent decline in non-infectious hospitalizations could be explained, at least in part, by the fact that elective surgeries were being postponed and that trauma was less common due to decreased physical activities.

With that idea in mind, it’s certainly reasonable to expect fewer hospitalized children in a society under lockdown. But for many of us, the degree of isolation experienced in the first half of 2020 didn’t last beyond the summer or perhaps the fall.

Though we continued to wear masks, wash our hands, and stay home when sick, not all infections ceased to spread. My kids’ elementary school has held in-person classes this entire school year save a two-week hiatus in December when too many teachers contracted Covid at once. Thankfully, all recovered.

Each of my children caught four or five colds, also known as upper respiratory infections (URIs), this school year, and each tested negative for Covid every time. That’s about the same number of URIs as any other year. Their last few swabs included testing for RSV and influenza as well, and guess what? They were negative for those too. In fact, there has been only one documented case of RSV in my home state of Montana during the entire 2020–2021 season and zero cases of flu. That is absolutely astounding!

It isn’t just Montana witnessing numbers like these.

The CDC estimates 58,000 children under the age of five are hospitalized from RSV each season in the U.S. This season, however, only 1,073 total cases of RSV have been documented across the entire country. Likewise, only 1,766 cases of influenza have been confirmed in the U.S. thus far this season compared to 246,842 confirmed cases at the same time last year. Even Western Australia saw a decrease of 98% or more in pediatric cases of RSV and influenza in their winter of 2020.

Other viruses, like the common cold rhinovirus and even Covid-19, continue to propagate, but because these viruses rarely lead to hospitalization in children, pediatric hospital units continue to look like ghost towns. The financial repercussions are staggering as well. Children’s hospitals in the U.S. have lost hundreds of millions or, by some estimates, even billions of dollars in revenue as a result of the pandemic.

So what’s next? How can those of us who care for hospitalized children adjust to the changing environment? Some have been able to pivot quite quickly. Just weeks into the pandemic, an innovative group of pediatricians formed The Pediatric Overflow Planning Contingency Response Network, also known as POPCoRN.

This network created training tools used to educate pediatric doctors, nurses, respiratory therapists, and other health care personnel on how to care for adults. By equipping staff who normally treat hospitalized children with a refresher course in adult hospital care, otherwise empty pediatric hospital rooms were used to provide quality adult care during surges of Covid-19.

Hospital care was greatly influenced by the use of telemedicine, which took a quantum leap in 2020. For example, telehealth visits for asthma, an illness traditionally managed only in person, increased by 61%. Though asthma attacks sometimes require treatment available only in the hospital, this is a prime example of how a crisis such as a pandemic can accelerate the progress of health care.

Authors of a recent study on health care utilization for pediatric illnesses in the U.S. suggest that prior to the pandemic, there was likely an overuse of hospital services for conditions that could be managed outside the hospital. They conclude, “The pandemic may be driving care to more appropriate settings.”

Could a reduction in unnecessary hospitalizations prove to be a silver lining amid the generally devastating consequences of the pandemic? Better still, might this drop in the number of children requiring care in a hospital outlast the life of the pandemic and be sustained over the coming years? That’s the question lingering in the minds of many pediatric providers, hospital administrators, and others who hold a stake in the well-being of our youngest and most ill.

What will happen if and when influenza, RSV, parainfluenza, and other similar respiratory viruses make a comeback? Will there be a rebound in hospitalizations too? Will nature reconcile its balance with a double portion of ailing children next winter — many belonging to a large population of infants and toddlers whose immune systems have yet to encounter some of these viral foes?

Experts in the U.S. and other industrialized nations in the Northern Hemisphere are paying close attention to events south of the equator since the respiratory viral season in the Southern Hemisphere tends to be a harbinger of things to come half a year later in the North.

The results so far are less than reassuring. Australia experienced an early onset, rapid rise, and exceptionally high peak in RSV cases over the past few months. Not only were the sheer number of cases disturbing, but the fact that RSV has been spreading over the summer months — traditionally a time of few cases — raises the level of concern for what may occur during the Australian winter.

As Dr. Messacar reminds us, “This is something that hasn’t happened in our lifetime.” Despite his expertise in pediatric infectious disease, he concedes the future remains uncertain. “We know there will be more children and adults susceptible to influenza, parainfluenza, [and] RSV. But what will actually happen in reality, we don’t know.”

The ancient Greek philosopher Heraclitus sagaciously coined, “The only constant in life is change.” Over the coming months, many — like me — who care for hospitalized children are assuming a similar posture as we prepare for the worst while hoping for the best.

Health & science writer on Elemental & other pubs. Hospitalist physician in internal medicine & pediatrics. Interpreter of medical jargon.

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