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Built for Adults, Adapted for Children: The Hidden Bias in Healthcare Design

Walk into any hospital, and the bias is immediately apparent. Healthcare is designed around the adult body. From architecture and waiting rooms to clinical trials and treatment protocols, adulthood is treated as the default. Children, who make up nearly a quarter of the global population, are expected to adapt to systems built for adults.


Childhood is not a smaller version of adulthood, particularly in the brain. The paediatric brain is a rapidly developing organ, undergoing structural, metabolic, and functional changes. Treating children as “small adults” ignores the fundamental neurobiological and physiological differences that define child health.



A System Built Backwards

Modern medicine evolved around an adult-first research paradigm: study adults, then extrapolate findings to children. This approach emerged from ethical caution and practical constraints, as testing interventions in fully developed bodies seemed safer and simpler. Until relatively recently, the majority of medications prescribed to children had never been systematically tested in paediatric populations. Clinicians relied on dose scaling based on weight or body surface area, operating under the assumption that children are simply “small adults.” We now know this assumption is biologically flawed. Development alters nearly every aspect of drug action, from absorption and metabolism to distribution and excretion.


This adult-first bias extends beyond pharmacology. Globally, children remain underprioritised in health system design and investment. In the United Kingdom, babies, children, and young people make up twenty-five percent of the population but receive only eleven percent of NHS expenditure, reflecting a persistent structural imbalance.



How Children Process Drugs Differently

When a child takes a drug, it enters a biological system governed by different rules. Gastrointestinal absorption differs markedly across development. Neonates and infants have higher gastric pH and delayed gastric emptying, which alters how drugs dissolve and are absorbed. Certain acid-sensitive drugs may be absorbed more readily, while others, such as specific antibiotics, show reduced bioavailability.


Body composition changes dramatically during early life. Infants have a higher proportion of total body water and less adipose tissue compared with adults. This shifts the distribution of both water-soluble and fat-soluble drugs and affects plasma concentrations in ways that cannot be predicted by simple dose reduction. Organ perfusion, regional blood flow, and membrane permeability further influence drug distribution and binding within tissues.


Hepatic metabolism adds additional complexity. The liver’s cytochrome P450 enzyme systems mature at different rates. Some pathways are underdeveloped in neonates, while others are transiently overactive in childhood. A drug may be metabolised too slowly, increasing toxicity risk, or too quickly, reducing effectiveness.


Renal clearance, critical for eliminating many drugs, is also developmentally regulated. Glomerular filtration and tubular secretion are immature at birth and increase rapidly during early years. Drugs that are cleared within hours in adults may persist far longer in infants, raising the risk of accumulation and adverse effects.


These factors demonstrate that paediatric pharmacology is not a matter of scaling doses. Safe and effective treatment requires age-specific understanding of pharmacokinetics and pharmacodynamics.



The Reality of Off Label Prescribing

Because few medications are formally tested in paediatric populations, off-label prescribing is widespread. Off-label drug use occurs when medications are prescribed outside their regulatory approval, such as for a different age group, dosage, indication, or administration route. In neonatal intensive care units, up to 90 percent of prescriptions can be off label or unlicensed. Across paediatric wards in several European countries, nearly half of drug prescriptions were either unlicensed or off label, and more than two-thirds of children admitted received at least one such prescription.


Legislation such as the U.S. Paediatric Research Equity Act and the Best Pharmaceuticals for Children Act, has improved incentives for paediatric drug trials. Despite this, significant gaps remain, particularly for neuroactive drugs, pain management, and rare disease treatments. The result is a healthcare system that often depends on clinical intuition where evidence should guide practice.



When Healthcare Environments Miss Development

Even when treatments are biologically appropriate, healthcare environments often fail children. Medical equipment is frequently designed for adult bodies, requiring adaptation or improvisation. Communication strategies assume adult cognitive and emotional capacities, leaving children confused or frightened during care.


Pain assessment and management remain particularly problematic. Children, especially preverbal infants, are at risk of having their pain underestimated or undertreated. From a neuroscience perspective, this matters. Stress, fear, and unmanaged pain can shape neural development, influencing long-term outcomes in cognition, emotional regulation, and stress responses.


These shortcomings carry safety implications. The World Health Organization warns that many healthcare systems are not designed with the specific needs of children in mind, increasing the risk of preventable harm. Paediatric patients require age-appropriate equipment, medication dosing systems, and trained staff to ensure safe care. 



Structural Inequality in Child Health Systems

The bias against children appears at the level of healthcare policy and system performance. In the United Kingdom, paediatricians report that insufficient investment has created a “two-tier system,” with adult services recovering faster while children’s services fall behind. Long waiting times are now common in paediatric specialties. Three-quarters of surveyed paediatricians say delays have negatively affected children, contributing to worsening symptoms, uncontrolled conditions, and developmental problems.


National policy analyses show that children’s healthcare is often treated as an afterthought. Many health systems lack accountability for child health outcomes, dedicated funding streams, or workforce planning focused on paediatric care.



Rethinking the Model: Designing for Development, Not Downsizing

Healthcare must be designed around developmental biology, not adapted from adult models. Achieving this requires a fundamental shift:

  1. Integrate paediatric physiology and neurodevelopment into drug design from the earliest stages.

  2. Design ethical, age-appropriate clinical trials rather than excluding children by default.

  3. Invest in paediatric-specific formulations instead of adapting adult medications for children.

  4. Create healthcare environments that account for cognitive development, communication needs, and emotional safety.

  5. Ensure healthcare systems allocate equitable funding, workforce planning, and accountability for children’s services.

Health policy experts increasingly argue that healthier populations across the life course begin with investment in childhood. Prevention, early intervention, and child-centred care are among the most effective strategies for improving long-term population health.



References


This article was written by Neave Smith and edited by Rebecca Pope, with graphics produced by Ameesha Gehlot and Neave Smith. If you enjoyed this article, be the first to be notified about new posts by signing up to become a WiNUK member (top right of this page)! Interested in writing for WiNUK yourself? Contact us through the blog page and the editors will be in touch.

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