The main challenge in providing safe care to children in ambulances may be the limited experience many emergency medical service (EMS) providers have in treating kids, a U.S. survey of first responders suggests.

Though children make up almost one quarter of the U.S. population – or roughly 73 million kids – they account for just 13 percent of EMS transports and only one percent of rides requiring advanced life support, researchers report in the Journal of Pediatrics.

Asked what factors may be most responsible for errors, EMS workers cited inexperience with airway management for tiny bodies, heightened anxiety working with children, and limited proficiency in pediatric skills requiring pint-sized equipment as the top culprits, the survey found.

The need for intense, complex care in these situations, and EMS workers’ limited experience with them, “make the medical management of children’s emergencies particularly challenging,” said lead author Dr. Jeanne-Marie Guise, an emergency medicine researcher at Oregon Health and Science University in Portland.

To understand what first responders perceive as the biggest challenges in treating young patients, Guise and colleagues surveyed 753 emergency physicians and EMS providers in 44 U.S. states.

Most of the survey participants were emergency medical technicians (EMTs) and had been working for 17 years on average, with equal numbers from rural, suburban and urban communities.

When asked what factors were most likely to result in serious injuries or death, mistakes, or near misses, about 73 percent cited lack of experience with pediatric breathing tubes, and heightened anxiety working with children.

Lack of proficiency in pediatric skills was the number three concern, with 67 percent of participants saying this was very likely to contribute to problems, followed by inexperience with pediatric equipment, cited by 58 percent of participants.

What was surprising, however, is that the participants didn’t cite two problems often linked to medical errors in hospitals – poor communication and medication mix-ups – Guise said.

Instead, the top concerns in the study appeared connected to anxiety that comes with treating the smallest and youngest patients.

“When combined with the anatomic and physiologic differences in children, compared to adults, a potentially challenging and stressful situation is likely to result,” Guise said by email.

One shortcoming of the study is that not all participants completed all three stages of the survey, the authors acknowledge. The survey also received fewer responses from California and the Southeast.

More research is needed to understand how anxiety develops during pediatric cases and what may be done to address it, Guise added.

“Between a relatively lower level of experience caring for sick children and their own emotional responses – what human does not feel for that hurt child – caring for children can be difficult,” Dr. Manish Shah, an emergency medicine researcher at the University of Wisconsin School of Medicine and Public Health, said by email.

EMS workers might become more familiar with pediatric equipment by practicing with simulation and mannequins, said Shah, who wasn’t involved in the study. In addition, it’s important to gather data on EMS care provided to children to help identify what works and what needs improvement, he said.

“It is most critical to note this study doesn’t say that EMS provides bad care to children,” Shah added. “We all have many cases where EMS was able to provide essential care to benefit children.”