From the view in the ICU, a patient’s clinical course before arriving there often looks remarkably clear in hindsight.
By the time we receive a child in the ICU, we usually know that something is seriously wrong. The diagnosis may already have been made. Other times, the exact diagnosis remains uncertain, but the severity of the illness is not. The child may have respiratory failure, shock, heart failure, kidney injury, or overwhelming infection. Whatever the cause, there is little question that the child needs to be in the hospital.
That does not make caring for critically ill children easy. Far from it. The decisions we make in the ICU can be extraordinarily difficult, and the margin for error can be small.
But, we have one enormous advantage.
We know the child is sick.
And the longer I have practiced pediatric critical care, the more I have come to appreciate how much harder that distinction can be before a child ever reaches us.
Finding the Sick Child Before They Look Sick
General pediatricians do something that I rarely have to do.
They see child after child with coughing, fevers, headaches, stomachaches, vomiting, fatigue, poor feeding, congestion, and more nonspecific symptoms. Nearly all of those children will get better. Most will never see the inside of a hospital, much less an ICU.
But hidden among them is occasionally a child who will.
The challenge is figuring out which one.
To put this in perspective, most childhood illnesses never come close to requiring hospitalization, much less intensive care. In one prospective study of respiratory viral infections in children younger than two years, only 0.5% of detected infections resulted in hospitalization.(1) And even among children who are hospitalized, only a minority require intensive care.(2)
That is the reality of general pediatrics. Serious illness is buried within an enormous number of ordinary childhood illnesses. The challenge is recognizing the uncommon child whose seemingly common symptoms are telling a different story.
That infant with cough, congestion, and poor feeding may have a viral respiratory infection, just like countless other infants seen that week. Or those symptoms may be the earliest manifestations of heart failure.
The child complaining of headaches may have one of the many benign causes of headaches in childhood. Or that headache may be an early symptom of a brain tumor.
The teenager with recurrent abdominal pain may have one of numerous common causes of abdominal discomfort. Or those symptoms may represent the beginning of inflammatory bowel disease.
When I see these children in the ICU, the distinction may seem obvious.
But I am seeing the end of the story.
The general pediatrician is seeing the first few pages.
The Advantage of Hindsight
It is easy to do well on a quiz when someone gives you the answers beforehand.
In some ways, that is the advantage we have in the ICU.
A child arrives hypotensive, poorly perfused, tachycardic, and in respiratory distress, and everyone in the room knows that something is wrong. We may debate the diagnosis. We may struggle with the physiology. We may face extraordinarily difficult decisions about how best to support that child.
But nobody is deciding whether the child should go home and come back if things get worse.
That decision was made earlier, often when the picture was far less obvious.
The general pediatrician must distinguish the beginnings of serious disease from the enormous background of ordinary childhood illness. And serious diseases are inconsiderate enough not to announce themselves by reading from the textbook.
They often begin looking remarkably ordinary.
The Literature Reflects What Pediatricians Experience
The literature demonstrates just how difficult this can be.
Puri and colleagues examined 191 children who were ultimately hospitalized with new-onset systolic heart failure. Nearly half had not been recognized as having heart failure at their first presentation.(3) Many had initially been diagnosed with far more common illnesses, including viral infections, bacterial infections, and gastrointestinal disease.
That is not particularly surprising when we consider how heart failure can present in children. Symptoms such as fatigue, difficulty breathing, abdominal discomfort, nausea, vomiting, poor feeding, and wheezing can overlap substantially with much more common respiratory and gastrointestinal illnesses.(4)
The same problem extends well beyond heart disease.
In one study of children presenting to primary care with acute abdominal pain, general practitioner assessment did not identify appendicitis at the initial presentation in a meaningful proportion of children who ultimately had the disease.(5)
The diagnosis of pediatric brain tumors can also be delayed. Flores and colleagues reported that only 38% of primary brain tumors in their cohort were diagnosed within the first month after symptoms began.(6)
None of this should make us conclude that pediatricians are failing to recognize obvious disease.
I think it tells us almost the opposite.
The disease frequently is not obvious yet.
The View Changes From the ICU
There is a cognitive trap for those of us who care for children later in their illness.
Once we know the diagnosis, the earlier clues suddenly acquire meaning.
Of course, the poor feeding was heart failure.
Of course, the persistent headache was concerning.
Of course, the abdominal pain was appendicitis.
But those statements are being made with information that the clinician evaluating the child days or weeks earlier did not have.
Hindsight reorganizes the story.
A symptom that appears glaringly important after a diagnosis may have been nearly indistinguishable from hundreds of benign complaints beforehand.
That is something I think those of us in intensive care need to remember when we review the course that brought a child to us.
It is easy to look backward and ask, How was this missed?
A better question may be, What did this look like at the time?
Respect for the Front Line
I have spent more than two decades caring for critically ill children, and I have enormous respect for the work that happens before those children reach us.
Yes, pediatric critical care is difficult.
We manage ventilators, vasoactive medications, mechanical circulatory support, failing organs, and rapidly changing physiology. We make decisions under pressure, sometimes with seconds to act.
But difficulty comes in different forms.
My general pediatric colleagues face a challenge that I do not face nearly as often: they must repeatedly decide which child among a waiting room full of children with common symptoms might be developing something uncommon and dangerous.
And they need to make that judgment without the monitors, laboratory abnormalities, imaging, consultants, and progression of illness that often make the picture clearer for those of us downstream.
Most importantly, they have to do it knowing that the overwhelming majority of children with those same symptoms will be fine.
That requires knowledge. It requires judgment. It requires experience. And it requires accepting a degree of uncertainty that is inherent to caring for children early in the course of illness.
Before We Ask, “How Did They Miss It?”
When a critically ill child arrives in the ICU, we naturally reconstruct what happened beforehand. We should. Understanding the course can reveal opportunities to improve care.
But there is a difference between learning from an earlier encounter and judging it with information that was only available later.
So, when I review the history of a child who eventually arrives in my ICU, I try to remind myself of something:
I am reading the story after someone has already told me the ending.
The pediatrician who first saw that child did not know the ending.
They were looking at a cough, a headache, a stomachache, poor feeding, fatigue, or fever and trying to determine whether this was one more ordinary childhood illness…or the beginning of something much more serious.
Sometimes the most difficult part of caring for a critically ill child happens before anyone knows the child is critically ill.
And from where I sit in the ICU, that deserves not hindsight judgment, but humility, perspective, and respect.
1. Teoh Z, Conrey S, McNeal M, Burrell A, Burke RM, Mattison C, McMorrow M, Payne DC, Morrow AL, Staat MA. Burden of Respiratory Viruses in Children Less Than 2 Years Old in a Community-based Longitudinal US Birth Cohort. Clin Infect Dis. 2023 Sep 18;77(6):901-909. doi: 10.1093/cid/ciad289. PMID: 37157868; PMCID: PMC10838707.
2. Killien EY, Keller MR, Segar KE, Watson RS, Hartman ME. Updating the Epidemiology of Pediatric Critical Care in the United States: 2001-2022. Crit Care Med. 2026 Aug 10. doi: 10.1097/CCM.0000000000007307. Epub ahead of print. PMID: 42573409.
3. Puri K, Singh H, Denfield SW, Cabrera AG, Dreyer WJ, Tunuguntla HP, Price JF. Missed Diagnosis of New-Onset Systolic Heart Failure at First Presentation in Children with No Known Heart Disease. J Pediatr. 2019;208:258–264.e3. doi:10.1016/j.jpeds.2018.12.029. PMID: 30679055.
4. 2. Price JF. Congestive Heart Failure in Children. Pediatr Rev. 2019;40(2):60–70. doi:10.1542/pir.2016-0168. PMID: 30709972.
5. 3. Blok GCGH, Veenstra LMM, van der Lei J, Berger MY, Holtman GA. Appendicitis in Children with Acute Abdominal Pain in Primary Care, a Retrospective Cohort Study. Fam Pract. 2021;38(6):758–765. doi:10.1093/fampra/cmab039. PMID: 34278425.
6. 4. Flores LE, Williams DL, Bell BA, O’Brien M, Ragab AH. Delay in the Diagnosis of Pediatric Brain Tumors. Am J Dis Child. 1986;140(7):684–686. doi:10.1001/archpedi.1986.02140210082031. PMID: 3012997.
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