Where PICU Beds Are Lacking, the Model of “Extended NICU” May Help to Treat Infants and Small Toddlers Who Are Critically Ill, Even During the COVID-19 Pandemic

To the Editor:

We read, with great interest, the article by King et al¹ in CHEST (May 2022). The authors highlight that PICU capacity is far less than that of adult ICUs and is extremely important to plan PICU surge capacity in case of a new COVID-19 pandemic wave in children < 12 years old who are not vaccinated. The authors propose to admit children in adult ICUs if they are ≥ 12 years old with illnesses common in adulthood. Pozzi et al² recently published an analysis on PICU beds in Italy underlying the necessity of increasing its total number and distribution in the country. Data suggest that critically ill children who are admitted to PICUs receive higher quality of care with lower mortality rates than those admitted to adult ICUs.³ Considering that infants account for approximately 30% of all PICU admissions, the authors suggest, for areas with limited PICU beds, to establish some “extended NICUs” to treat infants and small toddlers, after staff members have received appropriate training in pediatric critical care medicine. We think this model could have several advantages compared with that proposed by King et al.¹ First, the majority of infants and toddlers who necessitate admission in PICUs have diseases contracted during the perinatal period, such as congenital disorders, perinatal asphyxia, or consequence of prematurity. Neonatologists are more prone to treat such diseases than adult intensivists. The second consideration regards the need for PICU admission of pediatric patients with COVID-19 disease.⁴ The recent analysis by Ward et al⁵ shows that risk of PICU admission and death from COVID-19 in children was very low. The odds of PICU admission with COVID-19 disease were increased in children younger than 1 month and decreased among 15- to 17-year-old patients compared with 1- to 4-year-old patients. All considered, 51.1% of children admitted to PICU for COVID-19 disease were ≤ 4 years old. These data suggest that the model of “extended NICU” would also be beneficial for a possible COVID surge among children in areas with few or even no PICU beds. The authors also highlighted the role of teleconsultation that could be a valuable tool in the context of PICU bed shortage. Moreover, the model proposed by the authors is based on the health care system in the United States. Differences among health care organizations and medical training should be taken into consideration if the proposed model will be considered in other countries around the world.