Early Voluntary Care

Prior to the 19th century hospital reforms, the well-being of the child was thought to be in the hands of the mother; therefore, there was little discussion of children's medicine, and as a result next to no widespread formal institutions which focused on healing children. There were however centres which focused on helping abandoned children and offering care in hopes that these children might survive into adulthood. Some examples include orphanages, dispensaries, and foundling hospitals. Florence's Hospital of the Innocent (Ospedale degli Innocenti) was originally a charity based orphanage which opened in 1445; its aim was to nurse sick and abandoned infants back to health. A later example and better established institution whose goal it was to help rehabilitate infants was the Foundling Hospital founded by Thomas Coram in 1741. Foundling hospitals were set up to receive abandoned infants, nurse them back to health, teach them a trade or skill, and integrate them back into society. Coram's foundling hospital was revolutionary because it was one of the United Kingdoms first children charities.^[16] Moreover, it was largely made successful by the powerful people who donated money to the hospital.^[17] Coram's hospital would eventually be faced with the fact that the number of infants needing care outweighed their hospitals capacity. In order to accommodate the number of children in need, there were attempts to set up similar hospitals throughout the UK; they ultimately were unsuccessful due to the lack of funding.^[18] Simultaneously, dispensaries which were also funded by donations were being opened in order to provide medicine and medical attention to those who could not afford private care. Dispensaries and foundling hospitals were the earliest forms of what would later become children's hospitals. The establishing of the Foundling Hospital by Thomas Coram was a direct response to the high infant mortality rate in London, England. Although foundling hospitals acknowledged the high infant mortality rate, infant mortality would not be addressed in a wide spread way until the early 19th century when children's hospitals would begin to open in Vienna, Moscow, Prague, Berlin, and various other major cities throughout Europe.^[19]

19th-century models

In America, by the mid-19th century middle-class women and physicians became increasingly concerned about the well-being of children in poor living conditions. Although infant mortality had begun to decline, it still remained a prominent issue. Social reformers blamed the emergence of the industrial society and poor parents for not properly caring for their children.^[20] In response, reformers and physicians founded children's hospitals across the country. Early children's hospitals were set up in converted houses not only to help the children transition from leaving their home to being in a hospital, but also because it was often the only space available.^[20] Early children's hospitals focused more on short-term care and treating mild illnesses rather than long-term intensive care. Treating serious diseases and illnesses in early children's hospitals could result in the disease spreading throughout the hospital which would drain their already limited resources. A serious disease outbreak in a children's hospital would result in more deaths than lives saved and would therefore reinforce the previous notion that people often died while in the hospital.^[20]

Like those found in the United States, children's hospitals in the United Kingdom in the 19th century often resembled middle-class homes. British children's hospitals introduced rules to which patients and their families were expected to adhere; these rules carefully lined out middle-class values and expectations.^[19] British children's hospitals, like their American and Canadian counterparts, relied heavily on donations from the rich. Donations came in the form of money, food, toys, and clothes for the children. The United Kingdom's children's hospitals were soon faced with the reality that their small and vulnerable patient would soon outnumber their resources.^[19] In order to maintain the cost of running these new hospitals throughout the United Kingdom, the upper classes needed to market their hospitals as centres for reform. In order to brand themselves as reformers, they had to contrast themselves against the parents; this meant they had to portray the poor parents as incompetent.^[19] Despite their mission to save children, hospitals in Britain and Glasgow rarely admitted children under the age of two; such children were deemed costly and needed constant attention.^[19] Similar to the American hospitals, those located in Europe were also hesitant to admit children who required long-term care in fear that those lives would be lost or that long-term care would block beds for those in immediate need.^[19] The intentions of the hospitals built in Europe were to provide care for those who could not afford care. Care was primarily provided to those who met the age requirements and were willing to adhere to the hospital's rules. Since early children's hospitals relied on donations, they were often underfunded, overcrowded, and lacking medical resources.

The first formally recognized paediatrics hospital was the Hôpital des Enfants Malades in Paris, France, which opened in 1802. The United Kingdom followed, establishing The Great Ormond Street Hospital in London, England, in 1852, which marked the opening of the first British children's hospital.^[21] The United States would soon follow and established The Children's Hospital of Philadelphia in Pennsylvania in 1855.^[22] Canada established their first children's hospital in 1875; The Hospital for Sick Children in Toronto, Ontario, along with the latter all remain open today.^[23] By the end of the 19th century, and the during the first two decades of the 20th century, the number of children's hospitals tripled in both Canada and the United States.^[20] The first children's hospital in Scotland opened in 1860 in Edinburgh.^[24]

Professionalization of Children's Hospitals

In the 19th century, there was a societal shift in how children were viewed. This shift took away some of the parents' control and placed it in the hands of medical professionals.^[25] By the early 20th century, a child's health became increasingly tied to physicians and hospitals. Unlike the professionalization of nursing, the medical field professionalized at a greater speed.^[26] This was a result of licensing acts, the formation of medical associations, and new fields of medicine being introduced across countries.^[26] These new areas of medicine offered physicians the chance to build their careers by "overseeing the medical needs of private patients, caring for and trying new therapies on the sick poor, and teaching medical students."^[26] In order to raise their status further, physicians began organizing children's hospitals; by doing so, it also brought attention and importance to their speciality in the modern health care system.^[20] This idea brought about the creation of children's hospitals in Philadelphia, Boston, Washington, D.C., and San Francisco – all which emphasized children as their focus.^[20] Along with specialized physicians, the 20th century brought the removal of voluntary or religiously associated female care and replaced it with professionally trained nurses.^[27] In addition to separate institutions for children and a professional staff, both medical and technological advancement helped solidify children's hospitals as centres of physical healing. The discovery of vaccines, anaesthetics, and surgical improvements made children's hospitals more reliable and more effective in the treatment of childhood disease and illness.