For years, hospitals have been winding down pediatric services. At the same time, workforce pressures are especially acute in pediatrics, where compensation is lower and training longer than other areas of medicine.
If left unchecked, these combined pressures could significantly limit access to high-quality pediatric care in the years ahead, leaders say. In a JAMA Pediatrics study published in January, researchers found that U.S. hospitals closed nearly 30% of inpatient pediatric units between 2008 and 2022.
Anecdotally, that trend does not appear to be slowing down. In 2025 alone, Becker’s has reported on at least six hospitals that have ended inpatient pediatric services. Financial constraints and low patient volumes are often the deciding factors. For hospitals already operating under financial strain, decisions about service cuts are rarely simple. Maintaining the staffing, resources and infrastructure required to support a low-volume pediatric unit may not be feasible while also sustaining overall operations.
Still, as the pace of closures accelerates, critical questions arise about the long-term sustainability of inpatient pediatric care and where children who require hospitalization will receive treatment when specialized units are no longer available nearby.
Becker’s recently spoke to five healthcare leaders about the key challenges straining pediatric care and what’s ultimately needed to solve for them.
The biggest pressures
Insufficient reimbursement, compensation and talent shortages are the top stressors on the nation’s pediatric care infrastructure, according to health system leaders.
Nearly half of all children in the U.S. are covered by Medicaid, which reimburses providers less than the cost required to deliver care. The majority of hospitals report losing money while providing care to Medicaid patients, according to American Hospital Association data.
“If a child needs complex medical care, we know Medicaid is not enough for hospitals to break even,” said Chhavi Katyal, MD, chief quality officer at Catholic Health in Rockville Centre, N.Y.
Similarly, Angelo Milazzo, MD, chief medical officer of integrated practice at Durham, N.C.-based Duke Health, described an intricate economics problem facing pediatrics.
“If you are the CEO of a small hospital and you’re trying to make a financial decision about whether you should maintain a pediatric unit and all of the competencies that are required, then you’ve got to balance some really complicated financial factors,” he said. “At the end of the analysis, it may be financially advantageous to close the unit, but that has significant impacts on the health of the community.”
On the labor front, not enough medical school graduates are pursuing careers in pediatrics to adequately care for the nation’s children. The percentage of pediatric residency positions that were filled fell from 97% in 2023 to 92% in 2024. This year brought a slight rebound, with more than 95% of pediatric residency positions filled. Still, experts say that is below the number of pediatricians needed to replace those who are retiring, especially at a time when the number of children living with complex conditions rises due to medical advancements.
“We are looking at a talent workforce crisis that we’re just beginning to see the trends of today and those trends will deepen over the next decade,” Dr. Milazzo said.
That extends beyond pediatricians. Pediatric nurses are also in shortage. Around 35% of children’s hospitals reported a severe or major shortage of registered nurses, according to a survey conducted by the Children’s Hospital Association at the end of 2023.
Compensation and medical school debt are significant yet largely underdiscussed factors in what’s behind pediatric workforce issues, leaders said. Pediatrics and pediatric specialties consistently rank among the lowest paid physician specialties.
“Students are looking at the math and saying, ‘I literally cannot afford this career choice,'” Dr. Milazzo said. “And if you want to do a specialty in pediatrics where training is even longer, the calculation becomes even more complicated.”
In 2024, medical school students graduated with an average debt of $212,341, according to data from the Association of American Medical Colleges. Pediatricians earn around $265,000 annually. Meanwhile, new provisions passed under H.R.1 cap the amount of federal student loans medical students can take out at $200,000. Experts warn the cap could limit access to medical education, emphasizing that any added financial strain could either push students further toward higher-paying specialties or deter them from a career in medicine altogether.
To adapt to growing pediatric workforce pressures, several leaders said they anticipate adult specialists having to routinely manage care for children in the years ahead — a reality Dr. Milazzo described as a “paradigm shift” the industry isn’t fully prepared for.
“I’m not sure that anybody’s happy about that, because children are not small adults,” he said.
Peter Pronovost, MD, PhD, chief quality and clinical transformation officer at Cleveland-based University Hospitals, said the nation’s shortage of specialty pediatricians is a safety and quality issue.
Despite the pediatric workforce shortage, many systems do not have clear policies on which patients can and cannot be cared for by a nonpediatrician, Dr. Pronovost said.
“The age cut-offs are varied, but a 12-year-old, probably an adult [physician] can do. A neonate or an infant, no way, right?” he said. “There are huge safety risks if you’re operating on [children] and you’re not trained in this.”
For example, a non-pediatrician might say they are comfortable caring for a 12-year-old, an 8-year-old or patients younger than 4, but the health system or hospital does not have a solidified policy. Dr. Pronovost said organizations should clarify which age groups need to have pediatric specialists and which ones might benefit from teleconsult. Sometimes, nonpediatricians just require a competency check to ensure they do not make small — but crucial — mistakes, such as dosing a child’s medication as though they are an adult.
“I think this is a really big, big issue,” Dr. Pronovost said. “The other thing that we’re seeing because of this, because there’s such [a] shortage of ped specialists — whether it’s heart surgeons or the medical side — there’s this crazy war for talent. Peds systems are competing, and there’s a price war.”
He characterized the issue as a financial and safety “race to the bottom,” or a competition for talent so fierce that quality of care could erode.
Historically, emergency departments depended on pediatricians coming in to support them with care for children. But when hospitals shutter inpatient pediatric units, that backup support mechanism disappears, said Dr. Katyal of Catholic Health. As nonpediatricians take on a greater role in caring for children, medical school curriculum changes may be necessary to ensure physicians are better prepared to treat them, she said.
Emergency medicine physicians typically spend about four months of their residency in pediatrics. “It’s not enough to manage the breadth and depth” needed to adequately provide care to children, Dr. Katyal said. The level of experience and comfort a resident gains also varies widely depending on whether the hospital they train at sees a lot of emergency pediatric patients.
How health systems are strategizing
Hospitals and health systems are increasingly leaning into collaboration and training initiatives to enhance clinicians’ skill sets and knowledge in treating children. Such efforts are critical in reducing unnecessary transfers to children’s hospitals, many of which routinely operate at capacity caring for severely ill patients.
Prior to joining Catholic Health, Dr. Katyal was medical director of The Children’s Hospital at Montefiore in New York City’s Bronx borough. There, much of her time was spent leading training courses for ED staff at Montefiore’s network of general acute care hospitals. Those courses, she said, were created to train emergency physicians in better managing pediatric patients and limit transfers to the children’s hospital.
Over the years, children’s hospitals have experienced increases both in volumes and patient acuity, said David Christensen, MD, chief physician executive at Madera, Calif.-based Valley Children’s Healthcare.
“The kids who are now in the hospital are kids who are really, really sick,” he said. “Years ago, kids who would have been admitted are no longer even being admitted. We send them home. And kids who used to be in the ICU are now actually treated on the floor, and the kids in the ICU now are the sickest of the sick. We’ve seen an evolution of acuity to the point where it’s almost that the children’s hospital has become one large intensive care unit.
“So strategically, what we’ve looked at is can we help our community partners take care of the lower acuity kids closer to home, which is better for the family and allows us to have more access here for the really sick kids.”
Ten years ago, Valley Children’s established a clinical partnership program to send their nursing staff and hospitalists out to general acute care hospitals throughout the Valley region to host training sessions on caring for children. Often, community hospitals need support with IV insertion and medication dosing, he said. The pediatric system now partners with more than a dozen hospitals along the Valley.
Valley Children’s also relies on telemedicine to consult physicians in community hospitals who are taking care of pediatric patients. Dr. Christensen said such strategies are a “win-win” for the children’s hospital, community hospitals and most importantly, patients.
“We’re always available if a child needs to be transported here, but our goal is to really improve care up and down the Valley as best we can and optimize it,” he said.
A Kansas system’s case study
At Hutchinson (Kan.) Regional Medical Center, which reopened its pediatric unit in January after a two-year closure, leaders are working to establish the hospital as a regional hub for pediatric care.
The 190-bed hospital shuttered its pediatric unit in December 2022 due to a low patient census and a high turnover in its nursing staff. After local pediatricians advocated for the medical center to reopen its 14-bed pediatric unit, Hutchinson Regional reopened the unit in early 2025, starting with four beds.
“Reopening a dead [pediatric] unit is a massive lift,” Ben Anderson, CEO and president of the medical center, previously told Becker’s. “We’re going in the other direction — it’s a lot easier to close a unit than it is to reopen one.”
Research supports Mr. Anderson’s claim. Between 2008 and 2022, pediatric bed counts dropped 19.5%, while adult bed counts decreased 4.4%.
This shrinking availability can exacerbate long wait times at emergency departments, delay care and increase medical costs, according to researchers. It can also further strain children’s hospitals.
Bucking the national trend, Hutchinson Regional not only reopened its pediatric unit, it also cemented clinical agreements with Wesley Medical Center in Wichita, Kan., and Children’s Hospital of Colorado in Denver.
The clinical agreements allow Hutchinson Regional nurses to immerse themselves at either hospital for up to five days. Early on in orientation, new Hutchinson nurses starting in pediatrics who have no pediatric experience are sent for three 12-hour shifts to Wesley or Children’s Hospital of Colorado. They are allotted two extra days to solidify their learning.
Experienced nurses seeking a refresher on pediatric care are utilizing the agreements, too.
“With not having had pediatrics in the building for several years, our team members outside of pediatrics let a lot of their training go,” Chief Nursing Officer Jill White, BSN, told Becker’s. Thanks to the agreements, “our nurses feel so much better prepared to care for these sicker patients.”
A call for broader policy reforms
Collaborations like the one at Hutchinson Regional Medical Center can be effective as a hospital-level tactic, according to healthcare leaders. Dr. Milazzo said preventive care models and telehealth investments can act as broader strategies. But to make real change, the industry is calling for reforms to achieve long-term stability.
For years, the Children’s Hospital Association has advocated for Congress to implement several policies related to this issue. Recommendations include investments in the Children’s Hospital Graduate Medical Education program, hospital-based pediatric clinician training and retraining, loan repayment and scholarship programs, and Medicaid reimbursements for the pediatric workforce.
Rather than pointing fingers on who or what caused the emerging pediatric care issue, Dr. Pronovost called for stakeholders to collaborate on lasting solutions.
“How do we design safe systems that elevate the care where they are and have backup when you need it?” Dr. Pronovost said. “It’s doable, but it doesn’t happen sitting in your silo throwing barbs at each other, right? It happens by collaborating, figuring it out, seeing what problem we’re going to solve, and working together to make it happen.”
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