2022–2023 pediatric care crisis

Lore & Background

In the waning months of 2022, hospitals in the United States and Canada began to see overwhelming numbers of pediatric patients, primarily due to a massive upswing in respiratory syncytial virus (RSV) cases, but also flu, rhinovirus, enterovirus, and SARS-CoV-2. Children born during the early pandemic years had particularly low levels of exposure to RSV due to high levels of hand-washing, mask-wearing, and social isolation, leading to extremely low RSV transmission in 2020 and 2021. In 2022, this trend dramatically reversed. Starting in September 2022, many emergency departments and intensive-care units in the United States were at-capacity or over-capacity, with hospitals resorting to extreme measures such as a makeshift tent outside Johns Hopkins Children's Center and the proposed deployment of the National Guard in Connecticut.

Reader's Guide

The 2022–2023 pediatric care crisis exposed the consequences of a multi-year disruption in viral circulation patterns due to pandemic precautions. Children born during the pandemic had little natural immunity to common respiratory viruses, leading to a massive rebound of infections when precautions were relaxed. The crisis overwhelmed pediatric hospitals, with bed occupancy reaching 99% in some regions and forcing field tents and transfer requests across state lines. It also revealed systemic issues such as staffing shortages and shortages of children's acetaminophen and ibuprofen in Canada. The crisis prompted joint letters to government leaders, declarations of local emergencies, and a CDC health advisory on Strep A. The event underscored the fragility of pediatric healthcare infrastructure and the need for preparedness for post-pandemic infectious disease surges. Its legacy includes increased awareness of the impact of pandemic-era isolation on childhood immunity and the importance of surveillance for coinfections, which were found to increase the risk of adverse outcomes.

Did You Know?

• In November 2022, 75% of beds in US children's hospitals were full, with Rhode Island at 99% occupancy.
• Canadian pediatric hospitalizations for seasonal influenza alone were 20 times the usual rate by the end of November 2022.
• A study released on February 7, 2023 found that 40 percent of US households had experienced infection by one of the three primary drivers of the crisis during the 2022–2023 winter season.
• Children who experienced a coinfection of SARS-CoV-2 and influenza were more likely to require respiratory support than those with influenza alone.

The Immunity Gap and Sudden Reversal

Years of rigorous hand hygiene, universal masking, and social distancing during the early pandemic years created an unintended immunological consequence for a generation of young children. Public health surveillance recorded exceptionally low RSV transmission rates in 2020 and 2021, meaning that infants and toddlers born in that window entered their second and third years of life with virtually no prior contact with the virus. When public health restrictions were lifted and the first fully open northern-hemisphere autumn arrived in late 2022, those children encountered RSV for the first time in large numbers simultaneously. The result was a dramatic and rapid reversal: what had been a quiet pathogen suddenly became the dominant driver of pediatric hospital admissions. Because so many children in the same age cohort lacked any immunological memory, the virus spread with an intensity that overwhelmed hospital systems far beyond what seasonal norms would predict. This immunity-debt dynamic helped explain why the 2022 wave was so disproportionate compared to pre-pandemic autumns.

Hospitals at the Breaking Point

By the autumn of 2022, pediatric emergency departments and intensive-care units across the United States and Canada were operating at or beyond their physical limits. Nationally, roughly 80 percent of children's hospital beds were occupied, and in Rhode Island the figure climbed to 99 percent, prompting some facilities to erect field tents to accommodate overflow patients. At Johns Hopkins Children's Center in Maryland, a makeshift tent was set up outside the building to handle the surge. In Connecticut, authorities floated the idea of calling in the National Guard to assist overwhelmed hospitals. In Ontario, staff infections layered on top of existing workforce gaps forced multiple hospitals to shut down emergency rooms and other units entirely. A children's hospital in Ottawa reported running at more than 130 percent of both its intensive-care and inpatient capacity. In California, Orange County declared a pediatric health emergency after record numbers of children flooded its emergency rooms, while in Alberta, over fourteen thousand students in the Edmonton region were absent from school due to illness. The sheer volume of simultaneous admissions made routine triage nearly impossible in many settings.

A Multi-Pathogen, Multi-Continent Wave

The 2022 pediatric surge was not a single-virus event. RSV dominated the narrative, but rhinovirus, enterovirus, seasonal influenza, and SARS-CoV-2 all contributed to the same overcrowded wards, and by early November researchers confirmed that the United States was simultaneously experiencing epidemics of flu, RSV, and COVID-19 among children. The geographic spread was equally broad. In the United Kingdom, a different pathogen took center stage: Group A streptococcal infection drove a wave of scarlet fever that killed nineteen children by mid-December, and the outbreak subsequently crossed into North America and mainland Europe. By late 2023, a parallel pattern emerged in China, where Mycoplasma pneumoniae caused a sharp rise in pediatric pneumonia during the first full autumn-winter season after the country lifted its Zero-COVID restrictions. Denmark independently declared that Mycoplasma infections had reached epidemic levels in its own pediatric population. The recurrence of this pattern across continents and across different pathogens underscored that the underlying vulnerability—children with limited prior immune exposure meeting a post-restriction world—was a global phenomenon rather than a regional one.

Policy Responses and the Limits of Government Action

Despite the severity of the crisis, governmental responses were fragmented and often delayed. In the United States, the Children's Hospital Association and the American Academy of Pediatrics jointly petitioned President Biden and Health Secretary Xavier Becerra to declare a national pediatric emergency that would unlock dedicated funding and regulatory flexibilities comparable to those available under the ongoing COVID-19 declaration. The Department of Health and Human Services declined, opting instead to assist struggling communities on a case-by-case basis. Oregon had already declared its own state-level public health emergency before the national appeal. In Canada, the Public Health Agency's FluWatch program formally declared influenza an epidemic in mid-November, and the Government of Canada issued an advisory about a national shortage of children's acetaminophen and ibuprofen. The Canadian Medical Protective Association advised physicians on the legal implications of practicing outside their usual scope due to what it called unprecedented overcrowding. A coalition of parents and caregivers published an open letter to federal and provincial governments describing a palpable sense of hopelessness, signaling that institutional channels had not yet met the scale of the emergency.