Vast regions of the rural U.S. and three states have no pediatric emergency specialists, a new study shows.

The number of clinically active physicians who are board certified in both pediatrics and emergency medicine nearly doubled to 2,403 from 2008 to 2020, the JAMA Network Open study found. But these doctors worked almost exclusively in urban areas, and not even one was practicing in Montana, South Dakota or Wyoming last year.

Dr. Christopher Bennett, the study’s lead author and an assistant professor of emergency medicine at Stanford University in California, described the absence of a single pediatric emergency physician in three states and hardly any in a band of states from North Dakota to Texas as “a little startling.” Parents sometimes have to drive hundreds of miles or more to be with a critically ill child who was helicoptered to a medical center, he said.

“It is a situation that does require a fresh look given that it’s not great now, and in the coming years it will likely be worse,” Dr. Bennett told Reuters Health in a phone interview.

Dr. Bennett and colleagues at Stanford and at Harvard Medical School in Boston examined the American Medical Association Physician Masterfile database on March 11, 2020. They found that pediatric emergency physicians in rural areas were significantly older than those in urban areas, likely compounding the problem when the limited rural workforce retires.

While roughly one-quarter of patients seen in U.S. emergency departments are children, pediatric emergency physicians comprise less than 5 percent of the emergency medicine workforce. Dr. Bennett’s team reports. More than 85 percent of the 30 million children who visit emergency departments are seen in facilities designed to treat adults.

Moreover, nearly one-fourth of the doctors working in emergency departments had no form of emergency board certification, the study found.

Training in pediatric emergency care began in the 1980s, according to an accompanying commentary by Dr. Gillian Schmitz, president-elect of the American College of Emergency Physicians. Residency-trained emergency physicians are capable of caring for children in emergency settings, she says, but few practice in rural areas.

It would be impractical for a pediatric emergency medicine physician to staff every emergency department, Dr. Schmitz says. “Future models of health care delivery will need to embrace new ways of providing access, specialty consultation, and emergency care for pediatric patients,” she writes.

The COVID-19 pandemic forced a turn to telemedicine, which has worked better than some might have expected and holds “real promise,” said Dr. Chris Merritt, an associate professor of emergency medicine and pediatrics at Brown University in Providence, Rhode Island.

Though he would prefer to see every patient in person, when a doctor in a distant emergency department meets with a sick child and his or her family, Merritt can talk to them all by video, and the other doctor can perform the exam for him.

“I think the place for these pediatric specialists is to provide consultation using telehealth,” said Merritt, who was not involved with the new study. “Instead of sending that child to the specialist, you can bring the specialist to the child. We can do that over a video screen.”

“Telehealth is going to play, and already is playing, a bigger role,” he said in a phone interview. In addition, he believes emergency physicians should be trained to care for children.

“I would just like to be sure that these folks are supported and resourced. You want to be sure they have the equipment and ongoing training to take care of kids,” he said.

Dr. Bennett also predicted that telemedicine would play an increasingly pronounced role in pediatric emergency care.

Another way to fill the gap, he said, would be to reduce the number of children seen in emergency departments by improving access to primary pediatric care. An asthmatic child who visits a doctor three or four times a year is less likely to need emergency care, for example, Dr. Bennett said.

“One component is getting more preventative care,” he said.