WHEN SHOULD A CHILD BE IN THE HOSPITAL - NORTH,A.FREDERICK, JR, MD, REVISITED

Objectives. My objective was to revisit the issues and approaches rais ed in a seminal article published in Pediatrics in 1976 by A. Frederic k Noah,Jr, entitled ''When Should a Child Be in the Hospital?'' Dr Nor th proposed a set of nine criteria to guide the evaluation of appropri ateness of admission to hospital. These were based on a core assertion that, ''The need to hospitalize a child is dependent on the special s ervices which the child requires rather than upon the diagnosis.'' Thi s original work antedated more recent activities and publications in t he area of appropriateness evaluation as applied to pediatrics (such a s the Pediatric Appropriateness Evaluation Protocol), but is more cont ext-specific than later works in the field. Methods. A review of the l iterature concerning temporal trends in hospital use for children in N orth America was undertaken. This was done to place some of the subseq uent observations in a macrocontext of overall trends in hospital use. A review of the English language literature focusing on alternatives to hospitalization and contextual evolution affecting patterns of hosp ital care for children is presented. Factors influencing each of the n ine admission criteria proposed by North are reviewed and discussed in turn. Results. Overall rates of hospitalization declined by 46% and 4 1% in the United States and Canada, respectively, during the 1971 to 1 993 interval. The relative composition by diagnostic category in two s pecific pediatric hospital settings also evolved substantially during the 2 decades. Many of North's specific criteria required extensive re vision or updating to match the contextual realities of the 1990s. Con clusions. Although important overall shifts have occurred in the absol ute levels and relative composition of pediatric hospitalization, Dr N orth's core assertion, relating to the need for specific services driv ing the need for hospitalization, has largely stood the test of time.