Response

To the Editor:

We are grateful for the comments made by Decembrino et al. We chose in our article to focus on the role that adult ICUs may play in the care of critically-ill children during a public health emergency, given that the readership of CHEST includes a preponderance of physicians in adult pulmonary and critical care medicine. However, the broader point made in their letter is an important one. During public health emergencies, flexibility in age-based admission criteria can be a useful tool for offloading potentially overwhelmed parts of a health care system. Adults who received care in PICUs during the COVID-19 pandemic appear to have had acceptable outcomes when compared with anticipated mortality outcome in an adult unit.¹

We note that the study by Cogo et al² that reported worse outcomes for children in adult ICUs specifically studied these outcomes in children ≤ 14 years old. We agree wholeheartedly that the care of children is best entrusted to experts in that care, at least under normal conditions. In our article, we only recommend consideration of admitting children ≤ 14 years old to an adult ICU in the setting of genuine crisis of care, when a health care system is overwhelmed and the customary standard of care cannot be maintained. Interestingly, children aged ≥ 12 years old had comparable outcomes when admitted to either an adult or pediatric unit based on prospective data from the United Kingdom, although there may be differential outcomes, depending on the admitting diagnosis.³

There are approximately 23,000 neonatal ICU beds in the United States, which is considerably fewer than the 75,000 adult medical, surgical, and cardiac ICU beds but dramatically more than the 5,000 PICU beds.⁴ Although the impact of the COVID-19 pandemic on infants and young children has been significantly less than the impact on adults, it is not difficult to imagine a future emergency with greater numbers of ill children. In such a setting, both neonatal and adult ICUs may need to support our pediatric colleagues, with the common aim of sustaining systems of care for all patients.