Dagmar Rinnenburger
There is a shortage of places in the pediatric intensive care unit in the USA. How can this happen in a country so advanced in treatments and technologies? The answer is in the lower profit. Taking care of children is not a business and large hospitals invest in other sectors.
It is no scandal if sick people, and children in particular, remain without appropriate treatment in most of the world: unfortunately we are used to scenarios of this kind. It caused a scandal when it was discovered that, at home, the rich Lombardy did not have enough hospital capacity to deal with the Covid pandemic at the beginning of 2020 and that the intensive care workers had to choose between the people to send to intensive care. Rights advocates loudly proclaimed that everyone should always have all the necessary care. But with a lot of amazement and a sad emotion I saw a video published on January 6, 2023 by the New York Times (1) with the title: “Saving children is not a business”. It is a strong complaint. Not only did the NYT cover it: there’s a long article in the Washington Post. The reporter of the short film recounts his three days in the pediatric intensive care unit, the arrival of the helicopter with a critical child and everyone’s rush to get him to safety. Interview exhausted nurses, desperate parents facing the fact that their child might die, show a small child underreacting on non-invasive mechanical ventilation, capture everyone’s concern that he might not make it.
AND an exciting documentary, which manages to shake. These days there is a greater influx of children in the emergency rooms and pediatric intensive care units in the United States and Europe, precisely due to the combination of influenza infections, RSV (respiratory syncytial virus) and Covid, the tridemia. A greater need that collides with a reduction in pediatric intensive care beds in the USA. You are forced to transfer young patients to other states, far from home. Why?, one wonders; how can this happen in a country like the USA, the most advanced for so many treatments and technologies? One of the answers is that of the least gain. Children need less complex treatments, therefore hospitalization is paid less; in addition, most of it is reimbursed through “Medicaid”, which pays too little: this is why it is not a bargain and the large hospitals invest in other sectors. The problem does not only concern respiratory viral infections, but many other clinical conditions such as polytrauma.
Pediatric ICU beds have had a 20% reduction since 2018 in the United States; pediatric intensive care units have been closed. Part of the reduction was due to the conversion of children’s ICU beds into adult beds during the Covid pandemic and have remained so. During the pandemic years in America, 230,000 health workers resigned; in previous years 10% since the pandemic hit 20% (2), a trend that we also see in Europe. When there are few intensive care beds, many patients and few operators, a vicious circle begins. Healthcare workers assist the young patients, but the family unit is also extremely suffering. The few nurses are exhausted, the shifts uncertain, it is impossible to provide regular and healthy meals, sleep is disturbed. Private family life suffers. Plus the psychological suffering, moral pressure and eventually burnout that leads to leaving the profession.
The situation in Italy, which has not yet led to headlines in the newspapers such as the sick on the floor in the emergency rooms of the capital, is not much better. There are 116 neonatal intensive care units in Italy. There are only 23 pediatric intensive care units. “ There are around 202 pediatric intensive care beds in Italy with an average of 3 beds per 1 million inhabitants, well below the European 8. This difference becomes even more evident if we evaluate each region: here we range from 2 beds per million inhabitants in Puglia to 10.6 in Liguria, passing through some regions that do not have any pediatric intensive care beds (Valle d’ Aosta, Trentino Alto Adige, Umbria, Abruzzo, Sardinia Molise, Basilicata)” (3): like this Rinaldo Zanini, pediatrician, former director of the Maternal and Child department of the Lecco hospital, in a statement from the SIP of the 2020 congress.
During the Covid we have witnessed cynical comments of the type: only the old people who would have died anyway die, or the exhausting discussion of whether they died of or with Covid. Forgetting that perhaps without it they would probably still be alive. But if the unassisted dead are children, the youngest? The is missing preparedness: and it seems to repeat what happened three years ago. You can’t always go on in emergency mode. Intensive therapies cannot “make”, but are part of a healthy robust public health system.
It is worth mentioning that we are in the midst of a surge in three major respiratory viruses these days: always Covid 19, the flu like every year and RSV (respiratory syncytial virus). In English they call this situation the “Tridemic”. More than 90% of children encounter the syncytial virus in the first two years of life in “normal”, non-pandemic times. RSV is an infection that leads to a much feared and difficult to cure bronchiolitis. If the infection is severe and the young patient is in respiratory distress, hospitalization in intensive care or in a place that can deal with respiratory failure appropriately, with non-invasive mechanical ventilation or in advanced stages with intubation is needed . We have become accustomed to seeing adult patients with the so-called helmet to overcome the respiratory crisis, or with a non-invasive ventilation mask or with a device that has been particularly useful in the pandemic: that of high-flow oxygen. The same may be necessary for children. RSV can also affect elderly and frail people. They look like asthma attacks, but they don’t respond to treatment with cortisone and bronchodilators like asthma. Those affected can find themselves in serious breathing difficulties in a short time. RSV is circulating more these months and the risk of increased bed needs for one of the three tridemia viruses is high, with an incidence of disease among healthcare workers (4). There is currently no vaccine; some monoclonal treatment is available for at-risk children.
A work of Lancet (5) as of 2019 reports approximately 100,000 children died annually from RSV worldwide (52 million children died between 0-60 months, from all causes); most in low-income countries, where statistics are often difficult. Definitely more than the deaths of Covid 19 (Unicef data up to June 2022 say that of the 4 million deaths from Covid, 0.4% were children and adolescents under the age of 20, i.e. 17,200). Influenza affects between 5-15% of adults and between 20 and 30% of children, but it is still difficult to have certain figures on mortality, especially in children: 28,000-111,00 in 2008 (6).l ‘WHO recommends flu vaccination for children under 5 years of age. Of course, looking at the numbers alone, we are not talking about high mortality; however, with the right care in equipped countries, they are children that can be saved. The child is not a small adult and needs pediatric intensive care, nurses and resuscitators specialized in the very young. The material must be the right one for every age. The mortality of the child who does not meet a super-specialized reality for respiratory insufficiency increases fourfold. This year both influenza and RSV arrived earlier than in other years. It is assumed that many children born during the pandemic have not had contact with the virus due to the use of masks and the lockdown, while with the opening in 2022 many more than usual have had first contact with RSV.
To conclude, we recall the words of the WHO Director General, Tedros Adhanom Ghebreyesus (7):
“One of the most important lessons of the pandemic is that all countries need to strengthen their public health systems to rapidly prepare for, prevent, detect and respond to outbreaks, epidemics and pandemics. An advanced medical care system is not the same as a strong public health system. Of course, this virus will not go away. It is here to stay and all countries will need to learn how to manage it along with other respiratory diseases including influenza and RSV which are now circulating intensively in many countries.”
Dagmar Rinnenburger, pulmonologist and allergologist.
Bibliographical references
- https://www.nytimes.com/2023/01/04/opinion/covid-flu-rsv-children-hospitals.html?smid=nytcore-ios-share&referringSource=articleShare
- https://www.pbs.org/newshour/health/hospital-finances-play-a-major-role-in-the-critical-shortage-of-pediatric-beds-for-rsv-patients
- https://sip.it/2021/05/26/in-italia-poche-terapie-intensive-pediatriche-con-circa-202-posti/
4.https://www.ecdc.europa.eu/sites/default/files/documents/RRA-20221128-473.pd
5.https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(22)00478-0/fulltext
6.https://pubmed.ncbi.nlm.nih.gov/22078723/