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.