Underuse of Palliative Medications and Services in Children with Life-Limiting Conditions

Children with life-limiting conditions experience substantial pain, depression, and anxiety, yet the real-world use of symptom-directed medications and palliative services in this population is largely uncharacterized.

To examine the use, and potential underuse, of antidepressant and other symptom-directed psychotropic medications, psychological services, and dedicated palliative care services (palliative consultation, hospice referral, and pain consultation) among children with life-limiting conditions.

Retrospective population-based cohort study using the electronic medical records of Clalit Health Services, Israel's largest health care organization. Children aged 0-18 years with chronic life-limiting or life-threatening conditions diagnosed between 2000 and 2025 were followed until death or end of follow-up. Medication dispensing, psychiatric and psychological consultations, and palliative care services were compared across age groups and regions.

The cohort included 83,419 children, of whom 3,267 died. In the final year of life, only 18.2% of children who died received benzodiazepines and fewer than 3% received selective serotonin reuptake inhibitors (SSRIs). Psychiatric and psychological consultations reached only 1.8% and 0.6%, respectively; 95.7% received no palliative consultation, and hospice referrals and pain consultations were each provided to 0.2%. SSRI, SNRI, and methylphenidate use rose steeply with age (SSRIs: 0.5% of infants vs. 13.1% of adolescents; p<0.001). Benzodiazepine use was higher in the center and north, whereas palliative consultations were more common in the south and center (p<0.001). Among living children, palliative service use was virtually absent.

Children with life-limiting conditions in Israel experience profound, systematic underuse of symptom-directed medications, psychological services, and dedicated palliative care across the entire disease trajectory, demanding urgent policy action.