Segura Nino had spent 10 sleepless hours in a suburban Houston emergency room with her 3-month-old son when she boarded a medical helicopter to Corpus Christi, 200 miles away. Nino was told that Houston, a city renowned for its world-class health system, did not have a bed for one more baby with RSV.

"It's crazy to have to go to another city to get care for your child," Nino, 29, said a few days later, after Maleek had come home, his breathing back to normal.

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Stories like Maleek's have played out across the United States this season as hospitals have strained under the load of RSV infections and, more recently, influenza and the coronavirus. Infants and children have been transported out of their home cities and even to other states to find care. Emergency rooms overflow. Hospitals set up triage tents outside for RSV patients. Families endure excruciating waits - for many hours and even days - for children to be placed in pediatric hospital beds.

Yet the shortage of beds across the United States is not simply the result of a deluge of sick children. Over the past two decades, hospital systems across the country have whittled down the supply of pediatric beds, which lose money because they often are unoccupied. Even when they are occupied by sick children, pediatric beds generate less revenue for hospitals than do adult beds, medical experts say.

The number of hospitals offering pediatric services in the United States plunged by nearly one-third from 2000 to 2022, The Washington Post found in a review of federal health records.

More than 3,500 hospitals provided pediatric specialists in 2000, but this year, only 2,412 said they do, a decline of 32 percent, according to a Washington Post analysis of data gathered by the U.S. Centers for Medicare and Medicaid Services. The data includes hospitals that eliminated pediatric services and hospitals that went out of business altogether.

Another measure - the number of pediatric inpatient beds - tells a similar story. The total number of such beds nationwide dropped 11.8 percent from 2008 to 2018, according to a study published last year in the journal of the American Academy of Pediatrics.

These trends have weakened the country's ability to handle surges of childhood infections, doctors say. Instead of finding inpatient care at community hospitals near their homes, parents often must travel to larger children's hospitals that have the most beds. Not only are those facilities farther away, but they also are thronged by patients from an entire region - and even from neighboring states.

"The major driver is economics," said Daniel Rauch, a pediatrician at Tufts Medical Center in Boston, where the hospital cut 41 pediatric beds this year, citing market pressures.

Hospitals make less money from pediatric patients because children usually have less complex health problems than adults, experts say. Child hospital admissions also are in decline because of advances in care. Procedures that were once the bread-and-butter of pediatric wings of hospitals, such as tonsillectomies, are now routinely performed on an outpatient basis.

Beds often are empty. If a child is in a community hospital, it is more often for observation instead of for an expensive procedure. With dwindling demand, nurses and respiratory technicians with special training in the care of small children are disappearing. These factors have combined to make pediatric beds a target for cost-cutting by hospitals.

The trend accelerated during the coronavirus pandemic as hospitals adjusted to new pressures.

Children stayed home from school, wore masks and became sick less often. At the same time, there was a soaring need for beds to treat adults with covid-19. That resulted in at least temporary declines in the pediatric bed count in the states. In Minnesota, for instance, the number of staffed pediatric inpatient beds plunged to 438 this fall from 527 in 2020, according to state statistics - a decline the state attributed mostly to a lack of staff.

Although the surge of respiratory syncytial virus, or RSV, has begun to subside among children, authorities continue to warn of the impact on hospitals of a "tripledemic" of RSV, influenza and the coronavirus that began this fall and may continue to peak at various times all winter. U.S. weekly hospitalization rates for RSV peaked in November and dipped to 2.5 per 100,000 people by Dec. 3, only to be supplanted by surging influenza hospitalizations, which reached 5.9 per 100,000 that week.

"This big surge is really a wake-up call to our health-care system to figure out how to adequately staff and maintain quality care and capacity in our communities for children," said Scott Krugman, a pediatrician at Sinai Hospital in Baltimore.

The American Hospital Association says government, insurance companies and consumers want to curb health-care costs and make systems more efficient. In that context, eliminating underused beds has been seen as a positive step, said Nancy Foster, the AHA's vice president for quality and patient safety policy.

Hospitals have been strategizing since 2020 on how to prepare stronger surge capacity for infectious-disease outbreaks, with facilities such as heated tents, medical trailers and quickly convertible spaces in hospitals, she said. But even if temporary beds can be added quickly, staff shortages pose major challenges, she added.

"These surges in RSV and flu have reminded us that we need surge capacity beyond what we might have expected for all, including children, and I don't know we have the perfect solution yet," she said. "We're going to have to MacGyver our way through the next few weeks to meet the surge."

In the Houston metropolitan area, the number of hospitals offering pediatric services has declined from 32 to 26 since 2000. The HCA Houston Healthcare Kingwood medical campus, where Maleek was taken to the pediatric emergency room on Nov. 29, has eight pediatric inpatient beds out of a total of 457 beds, according to the hospital, which is owned by the nation's largest for-profit hospital chain. The hospital declined to say how the number of pediatric beds at that hospital has changed over time.

It said patients are sometimes transferred to other hospitals when there is a surge in cases. "Our transfer center works diligently to identify the closest facility to accommodate our patients' needs. Occasionally, it requires a transfer outside of the area. With the family in mind, our top priority is to provide the best possible care for our patients," the hospital said.

Statewide in Texas, pediatric inpatient beds were at 92 percent capacity in November, one of the highest occupancy rates in the country, according to federal data. Nino expressed surprise that Houston's regional health-care system did not maintain greater capacity for sick children.

"It seems like they are not really caring about the kids," Nino said.

In New Mexico, community doctors said they have been burdened by a severe shortage of pediatric inpatient beds for years. In rural and midsize communities in the state, hospitals do not see enough seriously sick children to support pediatric inpatient units, said Alex Cvijanovich, the immediate past president of the New Mexico Pediatric Society. In the recent RSV surge, she said, some New Mexico children were sent as far as El Paso and Denver.

"If you're a mom, a single parent who has five kids, and one of your kids gets sent up to the hospital in Denver, that's a real hardship for families," she said.

The University of New Mexico Children's Hospital in Albuquerque set up an overflow unit with 12 temporary beds separated by curtains to handle the volume of young patients coming in from around the state.

The hospital encountered another shortage: cribs. National suppliers had run out because of a demand spike, so hospital staffers scavenged parts in storage to make a few serviceable cribs, said Maribeth Thornton, the hospital's chief nursing officer, who also oversees operations and logistics.

"Our next plan is to move to Pack-and-Plays," she said, naming a brand of portable crib.

Henrico Doctors' Hospital, a 340-bed facility in Richmond, and one of the largest for-profit hospitals in the country, in April closed its inpatient pediatric and pediatric intensive care units. Hospital executives cited an average low patient count and the increased demand for adult inpatient medical and surgical care, including women's health care.

In 2018, MedStar Franklin Square Medical Center in Baltimore County closed its pediatric emergency department and pediatric inpatient unit. At the time, hospital officials said pediatric visits declined significantly in the previous five years.

The crisis in pediatric emergency rooms this year was foreseeable, said John Cunningham, chairman of pediatrics at the University of Chicago Medicine Comer Children's Hospital, one of several large children's hospitals in the city.

"These community hospitals have decided not to have inpatient pediatric beds. It's large-system hospitals that take the brunt," he said.

The Chicago metro area lost 27 percent of its hospitals offering specialist pediatric care in the past two decades, a drop from 89 to 65.

The University of Chicago Medicine Ingalls Memorial Hospital closed its 17-bed pediatric unit in 2019 "due to chronic underutilization," the hospital said in a statement. "The unit averaged 2-3 patients per day in the years before its closure; about half of whom where there for observation," it said. "This decision was not made lightly and followed a rigorous analysis of Ingalls's occupancy data as well as the needs of the nearby community."

Ingalls said that it continues to see pediatric patients in its emergency room and that if they need hospitalization, they are sent to Comer Children's Hospital.

Chicago families experienced the consequences of such decisions firsthand this fall.

When 8-year-old Valentina Bailon's fever spiked to 104 degrees in mid-November, her parents began to worry. She'd been diagnosed with flu earlier that day, and her parents couldn't bring the fever down with Ibuprofen or a warm bath. Valentina had gone from coughing to vomiting. "She couldn't even talk; she was without strength," said her mother, Mariana Martinez.

About 9:30 p.m., Valentina's father rushed her to Lurie Children's Hospital of Chicago, a half-hour from the family's home on the north side of Chicago. There they waited through the night until, about 6 a.m., a doctor was available to see her and write a prescription for Tamiflu.

Barely a week before, Martinez had taken Valentina to the same ER at 2 a.m. with an asthma attack. On that occasion, the emergency room was teeming with sick children, from babies to teenagers, perhaps 60 or more, she recalled, and a young girl with stomach pain writhed in pain on the floor. No hospital rooms were available, and there was no place to sit. So, Mariana, pregnant and just days away from giving birth, stood with her 8-year-old until an armchair opened up around 4 a.m. Valentina slept for a couple hours, resting her head on her mother's shoulder. Still waiting at 10 a.m., Martinez called Valentina's pediatrician, who agreed to see her right away, so they left.

"It made me sad to see so many sick kids that weren't being attended to," Martinez said. "I never imagined that we'd go to the hospital and it would be so full we couldn't be seen for hours."

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The Washington Post's Staff writer Jenna Portnoy contributed to this report.

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Video: Cases of covid-19, flu and RSV are colliding, prompting worries about a potential "tripledemic." Here's what you should know.(The Washington Post)

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