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Evolution of Pediatric Critical Care Over 75 Years

July 6, 2023

Commentary From the AAP Section on Critical Care

The mission of the American Academy of Pediatrics (AAP) Section on Critical Care (SOCC) is to optimize the care of critically ill infants, children, and adolescents through education, advocacy, and professional support of its members. The AAP established SOCC in 1984, after fellowship training programs in pediatric critical care had appeared in the 1970s and the Society of Critical Care Medicine had created the section on pediatric critical care in 1981. The American Board of Pediatrics offered its first certifying examination for the sub-board in critical care medicine in 1987.

In the process of selecting seminal Pediatrics publications pertinent to pediatric critical care medicine, we found that beginning in 1969, Pediatrics published one article in each monthly issue dedicated to the care of critically ill children as our subspecialty was emerging. The articles highlighted in this commentary represent both evolutions and revolutions in practice in pediatric critical care. Three members of the SOCC each reviewed 25 years’ worth of Pediatrics issues to identify celebratory landmark works in our subspecialty.

Evolution of Pediatric Critical Care Over 75 Years

Deanna Behrens, MD1, Anna Rodenbough, MD, MPH2, Elizabeth Mack, MD, MS3

Affiliations: 1Division of pediatric critical care, Department of Pediatrics, Advocate Children’s Hospital, Park Ridge, IL; 2Division of critical care, Department of Pediatrics, Emory/Children’s Healthcare of Atlanta, Atlanta, GA; 3Division of Pediatric Critical Care, Department of Pediatrics, Medical University of South Carolina, Charleston, SC

First Quarter Century (1948 to 1973)

Highlighted Articles From Pediatrics

Several publications in the first quarter century of Pediatrics introduced novel methods of vascular access and laboratory sampling. In 1959, Hohn and Vlad published a method of cannulating small vessels via a cutdown technique and a guide along with an accompanying diagram.1 Cutdowns continued to be a cornerstone of vascular access in critically ill children prior to the routine use of ultrasound-guided access. In 1971, Veasy et al published on the development of a computerized automated blood gas analysis developed at Primary Children’s which required only a 0.3 mL sample of blood withdrawn automatically under computer control from an arterial line.2 Since this era, point of care blood gas analysis has evolved significantly but has lost the unique automated feature described by Veasy.

Second Quarter Century (1973 to 1998)

Highlighted Articles From Pediatrics

In the second quarter century, the focus of publications shifted to guidelines and outcomes. In 1981, Lyrene and Truog published a retrospective chart review that sought to determine the incidence, risk factors, and outcomes of children with adult respiratory distress syndrome (ARDS), now generally referred to as acute respiratory distress syndrome.3 This was one of the first papers that described a cohort of pediatric patients with ARDS and documented a high rate of mortality (60%) that was comparable to that among adult patients with ARDS. Since the publication of this article, our field has made considerable advances in understanding the pathophysiology, diagnosis, and treatment of pediatrics ARDS.

With increasing recognition of the new and burgeoning field of pediatric critical care medicine, the AAP Committee on Hospital Care and the Pediatric Section of the Society of Critical Care Medicine jointly developed the first “Guidelines for Pediatric Intensive Care Units” in 1983.4 These guidelines set forth a variety of considerations for those aiming to develop or modify pediatric ICUs, including equipment, services, and programs; organization and staffing models; and physical characteristics. These guidelines served as an early template for pediatric critical care units and established a foundation on which our field continues to build as we grow and adapt to new challenges.

As the field of pediatric critical care has witnessed considerable advancements in technologies over the years, a growing proportion of pediatric patients experience increasingly long ICU hospitalizations, characterized by high utilization and often relatively poor outcomes. As Pollack et al noted in 1987, “the ability of intensive care medicine to support life has progressed at a faster rate than knowledge and guidelines of who will benefit from therapy, as well as guidelines for limitation or withdrawal of [life-sustaining therapies].”5 This paper raised important questions regarding the ethical provision of therapies in the pediatric critical care setting with which we continue to wrestle today.

In 1992, Kanter et al conducted a novel study that examined the excess morbidity and mortality associated with interhospital transport of pediatric critically ill and injured patients.6 Although the AAP had previously published guidelines for pediatric transport in 1986 and 1991, this study highlighted the significant morbidity associated with transport and underscored the need for highly trained and specialized critical care transport teams. This work promoted development of such teams, leading to improved morbidity and mortality over the last 30 years for critically ill children requiring transport to higher levels of care.

Third Quarter Century (1998 to 2023)

Highlighted Articles From Pediatrics

Reading the table of contents from the third quarter century took us on a journey that included the early days of nosocomial infections, abandoned treatments such as activated protein C, and concepts that now seem ahead of the time, such as a telemedicine publication from 1998. 

We considered as seminal a 2009 article by Pollack et al that described a new functional status scale. This scale was not intended specifically to predict long-term outcomes, but it did provide a framework to measure the changing functional status of children during hospitalization.7 As our current understanding of early mobility and post intensive care syndrome has grown, we recognize that decreased mortality can be accompanied by increased mobility, and this paper contributed to our early steps in this understanding. In testimony to the continued high relevance of this paper, 40% of its citations have appeared in just the past 2 years. 

In 2010, the National Association of Children’s Hospitals and Related Institutions published the results of a quality improvement collaborative focused on pediatric-specific practices to reduce catheter-associated bloodstream infections.8 Many of the prevention bundles the authors described are still in use today, and we continue this journey to reduce cost, morbidity, and mortality related to nosocomial infections. This collaborative effort illustrated that children require a different approach than wholesale adoption of protocols that have succeeded in nearly eliminating bloodstream infections in the adult population. Additionally, the success of the pediatric-focused approach highlighted the need for multidisciplinary design and implementation of these large-scale efforts.  

Crowe et al published in 2017 an honest ethics rounds on grief and burnout in the pediatric intensive care unit, especially relevant today in light of the recent SARS-CoV-2 pandemic.9 The case presented exemplifies the secondary trauma that so many in critical care experience and provides a powerful call to destigmatize mental health issues and to provide support on departmental and institutional levels for clinicians at risk of or experiencing burnout.  

As our final selection, we chose a 2019 study by Andrist et al that analyzed patterns of pediatric intensive care use and neighborhood poverty and concluded that low-income children and their families10 suffered a disproportionate burden of critical illness. This study provides motivation to pediatric critical care providers to engage in efforts to reduce health care disparities in their communities by working to dismantle the systems that keep inequity in place, which include community trauma, systemic racism, or adverse childhood events in our patient population.  


  1. Hohn AR, Vlad P. A guide for introducing catheters when cannulating small vessels. Pediatrics. 1959;24(4):636–637
  2. Veasy LG, Clark JS, Jung AL, Jenkins JL. A system for computerized automated blood gas analysis: its use in newborn infants with respiratory distress. Pediatrics. 1971;48(1):5–17
  3. Lyrene RK, Truog WE. Adult respiratory distress syndrome in a pediatric intensive care unit: predisposing conditions, clinical course, and outcome. Pediatrics. 1981;67(6):790-795
  4. Committee on Hospital Care and Pediatric Section of the Society of Critical Care Medicine. Guidelines for pediatric intensive care units. Pediatrics. 1983;92(1):166-175
  5. Pollack MM, Wilkinson JD, Glass NL. Long-stay pediatric intensive care unit patients: outcome and resource utilization. Pediatrics. 1987;80(6):855-860
  6. Kanter RK, Boeing NM, Hannan WH, Kanter DL. Excess morbidity with interhospital transport. Pediatrics. 1992;90(6):893-898
  7. Pollack MM, Holubkov R, Glass P, et al. Functional status scale: new pediatric outcome measure. Pediatrics. 2009;124(1):e18–e28
  8. Miller M, Griswold M, Harris JM, et al. Decreasing PICU catheter-associated bloodstream infections: NACHRI’s quality transformation efforts. Pediatrics. 2010;125(2):206–213
  9. Crowe S, Sullivant S, Miller-Smith L, et al. Grief and burnout in the PICU. 2017;139(5):e20164041
  10. Andrist E, Riley C, Brokamp C, et al. Neighborhood poverty and pediatric intensive care use. Pediatrics. 2019;144(6):e20190748


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