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Pediatric intensivists adapt to changes brought about by COVID-19 pandemic

July 1, 2021

Pediatric intensivists have stretched their skill set, adaptability and capacity in the last year to accommodate for new disease states and shifts in seasonal trends.

Pediatric intensive care units (PICUs) have always been on the front lines of epidemic childhood illnesses. While the first PICUs in the U.S. were established in the 1960s, polio and tuberculosis units had cared for critically ill children for more than a century. Thanks to enhanced sanitation protocols, understanding of infectious diseases and vaccines, gone are the days of wards filled with children with polio and more recently, rotavirus.

The COVID-19 pandemic has led to another shift in the pediatric critical care community as hospital admission diagnoses have changed.

PICUs generally see an increased number of admissions during the winter months due to respiratory failure secondary to viral illness, particularly influenza and respiratory syncytial virus (RSV). However, many PICUs and inpatient hospital medicine teams did not see a single case of influenza or RSV over the past year. From the 2019 to 2020 season, RSV cases fell by more than 99% (, and a single pediatric death was attributed to influenza compared to 195 deaths during the 2019-’20 season ( Cases of parainfluenza also were down drastically. While rhinovirus infections continued at their normal levels, there was far less bronchiolitis than in a typical winter.

Pediatric intensivists have shifted much of their time and skill caring for patients with COVID-19 and multisystem inflammatory syndrome in children (MIS-C). While some children with acute COVID-19 have required intubation and vasopressor support, the variable presentation of MIS-C has presented clinical challenges. MIS-C phenotypes have varied widely, and associated shock often prompts PICU admission.

Some PICUs have expanded the age range of patients accepted to help decompress the surge of adults with critical illness. Dual trained intensivists have assisted in providing guidelines for PICUs caring for adults (

While respiratory admissions have decreased, the nation faced a surge of pediatric admissions for psychiatric crises, including suicide attempts. Often cited in their histories are concerns of social isolation related to virtual schooling.

One bright spot during the pandemic was the rise of telemedicine in primary care and subspecialty practices. Many PICUs now can evaluate patients in a remote hospital and determine which patients require immediate and temporizing treatment, as well as those who require transfer to a higher level of care.

The pandemic has shed light on how behavioral changes, including physical distancing, hand hygiene and masking, can nearly eliminate bronchiolitis and influenza hospitalizations and deaths ( Yet, social distancing and school closures have fueled mental health crises in children.

COVID-19 remains a threat to our children and communities, and the pediatric critical care community has pivoted accordingly.

Dr. Mack is chair of the AAP Section on Critical Care Executive Committee.

Dr. Smallcomb is a member of the AAP Sections on Medicine-Pediatrics and Pediatric Trainees.

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