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Risk appetite in the Paediatric Emergency Department (PED) is a complex interplay between a clinician's personal tolerance for uncertainty, the professional imperative to "err on the side of caution," and external pressures from caregivers and health systems.
Unlike adult medicine, risk assessment in paediatrics often involves a "triadic" decision-making process—between the clinician, the patient, and the parents—which significantly influences diagnostic and management thresholds (European University Institute, 2023).
Key Drivers of Risk Appetite in the PED
Clinical Experience: There is a stark difference in risk tolerance based on seniority. Junior staff tend to be more risk-averse, relying heavily on strict adherence to guidelines, admission criteria, and second opinions (Cray et al., 2017). Conversely, senior clinicians often integrate "tacit knowledge" and intuition, allowing for a more nuanced management of risk (Cray et al., 2017).
Parental Influence: Parental anxiety and pressure are significant non-clinical drivers of risk appetite. GPs and ED physicians may "err on the side of caution" or perform low-value diagnostic tests (such as blood work or imaging) to appease parents or mitigate conflict, even when the clinical utility is low (O'Shea et al., 2020; European University Institute, 2023).
Safety Culture vs. Defensive Medicine: While a strong safety culture (teamwork, communication, and error reporting) promotes better outcomes, many clinicians report practicing defensive medicine. This includes ordering tests or admitting patients due to a fear of malpractice or the potential personal consequences of a rare adverse outcome (O'Shea et al., 2020; European University Institute, 2023).
Risk Tolerance and Diagnostic Testing
Research into whether personal risk tolerance directly correlates with testing behavior has yielded mixed results:
Febrile Children: A major study of 55 paediatric emergency physicians found that while testing rates varied significantly (ranging from 30% to 71% of encounters), these variations were not significantly associated with the physicians' scores on the Risk Tolerance Scale (RTS) or the Malpractice Fear Scale (MFS) (Reese et al., 2022).
Guidelines as a Neutralizer: The use of clinical guidelines, such as sepsis screening tools or respiratory protocols, often serves to homogenize care, effectively "blunting" the impact of an individual doctor's personal risk appetite (Cray et al., 2017; Reese et al., 2022).
Summary of Influencing Factors
| Factor | Impact on Risk Appetite | Source |
| Junior Seniority | Increases risk aversion and reliance on rules. | (Cray et al., 2017) |
| Parental Anxiety | Lowers the threshold for referral and testing. | (O'Shea et al., 2020) |
| Safety Culture | Improves risk management through teamwork. | (Birima Noureldin et al., 2025) |
| Systemic Pressure | High volume and lack of follow-up can lead to defensive admissions. | (O'Shea et al., 2020) |
References
Birima Noureldin, W., Noureldin, H., & Noureldin, E. (2025). Integrating safety culture and quality improvement in paediatric emergency departments: Evidence from a systematic review. Cureus, 17(11), e96959.
https://doi.org/10.7759/cureus.96959 Cray, A. J., et al. (2017). The transition to clinical expert: Enhanced decision making for children aged less than 5 years attending the paediatric ED with acute respiratory conditions. Emergency Medicine Journal, 34(2), 76–81.
https://doi.org/10.1136/emermed-2016-205805 European University Institute. (2023). Diagnostic testing in children: A qualitative study of pediatricians' considerations. [White Paper/Thesis].
https://pure.eur.nl/files/93230915/Diagnostic_testing_in_children_A_qualitative_study_of_pediatricians_considerations.pdf O'Shea, M., et al. (2020). Factors influencing general practitioners decisions to refer Paediatric patients to the emergency department: A systematic review and narrative synthesis. BMC Family Practice, 21(1), 1–12.
https://doi.org/10.1186/s12875-020-01258-w Reese, J., et al. (2022). Physician risk perception and testing behaviors for children with fever. Pediatric Emergency Care, 38(8), e1443–e1448.
https://doi.org/10.1097/PEC.0000000000002711
Are you interested in how specific clinical guidelines (like those for head injuries or sepsis) are designed to mitigate these variations in risk appetite?
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