Rising paediatric emergency department use despite demographic decline: a 23-year analysis

Background Over the past two decades, paediatric emergency departments (PEDs) worldwide have experienced an increase in attendance, despite declining birth rates and enhanced access to primary care. This paradox suggests that the rising demand may be attributed to non-urgent conditions rather than genuine paediatric emergencies. Understanding the impact of demographic decline on PED utilisation is essential for effective health-service planning. This study assessed long-term trends in PED utilisation and hospitalisations in relation to declining birth rates in Liguria, Italy. Methods A retrospective time-series analysis of PED visits and hospitalisations at Istituto di Ricerca e Cura a Carattere Scientifico (IRCCS) Giannina Gaslini Children’s Hospital from 2002 to 2024 was conducted. Data on annual live births and residents aged ≤14 years were obtained from regional datasets. The incidence rates of PED visits and hospitalisations were calculated relative to births and the paediatric population. Trends were analysed using correlation coefficients, with sensitivity analyses excluding the COVID-19 years (2020–2021). Results Over 23 years, 840 221 PED visits and 85 186 hospitalisations were recorded. Hospitalisations per 1000 PED visits decreased significantly (p<0.001). PED visits per 1000 live births increased significantly, both regionally (p<0.001) and provincially (p<0.001). Hospitalisations per 1000 paediatric residents aged ≤14 years declined significantly (p<0.001). After excluding the COVID-19 years, per-capita PED utilisation increased significantly, confirming a rising demand for emergency care despite demographic decline. Conclusions Despite reduced birth rates and a declining paediatric population, PED visits have increased disproportionately, driven by non-urgent cases. This discrepancy highlights systemic inefficiencies and behavioural determinants of inappropriate PED use, contributing to crowding. Comprehensive strategies, including enhanced primary care access, parental education, care integration and innovative organisational models, are necessary to ensure sustainable paediatric emergency care delivery.