These cases have become increasingly common in EDs nationwide, reflecting a dramatic shift in pediatric urolithiasis prevalence over the past two decades. What was once considered a rare condition primarily affecting children with metabolic disorders or anatomical abnormalities has evolved into an increasingly common presentation, likely driven by shifts in dietary patterns, rising obesity rates, and environmental factors. This epidemiological shift prompted our group to initiate a nationwide study of current ED practices in pediatric stone management.
Across the United States, stone disease accounted for 57 ED presentations per 100,000 pediatric individuals. However, this overall rate masks important demographic patterns. The frequency of ED presentations rose dramatically with age, from just 3 per 100,000 in children under 2 years to 176 per 100,000 in the 17-21 age group. A notable gender disparity also emerged during adolescence, with females presenting more frequently than males in both the 12-16 and 17-21 age groups.
Pediatric visits for urinary stone diagnosis by age group and sex in US emergency departments. Visits (per 100,000 population) were 3 for <2 years (female=3; male=3), 7 for 2-11 years (female=7; male=7), 50 for 12-16 years (female=65; male=37), and 176 for 17-21 years (female=215; male=139).
Our analysis also revealed considerable variations in care delivery across the United States. While some variation in practice was expected, the magnitude of the differences we observed was remarkable, with hospital admission rates ranging from 1% to 55% across different patient populations and healthcare settings. Similarly, CT utilization varied from less than 2% to over 77% among different subgroups, highlighting significant inconsistencies in diagnostic approaches.
The admission patterns observed in our study highlight potential opportunities to improve care delivery. While most pediatric stone patients can be managed as outpatients, the 6.9% admission rate represents a significant healthcare burden. Notably, our analysis found that comorbidities like depression, obesity, or hypertension increased the odds of admission approximately six-fold. This finding suggests we need better protocols to identify which patients truly require admission. The results of our study can serve as an initial framework for building evidence-based admission criteria for pediatric stone patients in the emergency setting.
One of the most striking findings from our study was the persistent reliance on CT imaging despite accumulating evidence supporting ultrasound as the initial imaging modality of choice in pediatric patients. This raises important questions about our clinical practice patterns. Are we ordering CTs due to a lack of confidence in ultrasound interpretation, concern about missing alternative diagnoses, or simply because CT is more readily available in many ED settings? These are questions that every urologist must grapple with, especially given the cumulative radiation exposure risks in young patients who may face multiple stone episodes throughout their lifetime.
The prevalence of pediatric stone disease continues to rise, and the substantial variations in care across the country require immediate attention. Urologists can lead this change by taking an active role in healthcare systems rather than simply responding to acute cases. This could involve developing standardized evaluation protocols in partnership with ED colleagues, establishing efficient referral pathways, developing imaging protocols prioritizing ultrasound, and ensuring that EDs have ready access to ultrasound services. Implementing these changes could optimize patient outcomes, minimize unnecessary testing, and ensure evidence-based care for every child with suspected stone disease from their first ED visit.
Written by:
- Naeem Bhojani, Division of Urology, Centre Hospitalier de l'Université de Montréal, Montréal, Québec, Canada
- Jonathan S. Ellison, Department of Urology, Medical College of Wisconsin, Milwaukee WI, United States
- Larry E. Miller, Department of Biostatistics, Miller Scientific, Johnson City, TN, United States
- Samir Bhattacharyya, Boston Scientific, Marlborough, MA, United States
- Gregory E. Tasian, Department of Surgery, Division of Urology, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States; Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, United States