The Profession of
Karen J. Marcdante and Benjamin S. Siegel
POPULATION AND CULTURE: THE CARE OF CHILDREN IN SOCIETY
Health care professionals need to appreciate the interactionsbetween medical conditions and social, economic, and environmental influences associated with the provision of pediatriccare. New technologies and treatments help improve morbidity,mortality, and the quality of life for children and their families,but the costs may exacerbate disparities in medical care. Thechallenge for pediatricians is to deliver care that is socially equitable; integrates psychosocial, cultural, and ethical issues intopractice; and ensures that health care is available to all children.
Many challenges affect children’s health outcomes. These include access to health care; health disparities; supporting their social, cognitive, and emotional lives in the context of families and communities; and addressing environmental factors, especially poverty. Early experiences and environmental stresses interact with the genetic predisposition of every child and, ultimately, may lead to the development of diseases seen in adulthood. Thus, pediatricians have the unique opportunity to address not only acute and chronic illnesses but also the aforementioned issues and toxic stressors to promote wellness and health maintenance in children.
Many scientific advances have an impact on the growing role of pediatricians. Incorporating the use of newer genetic technologies allows the diagnosis of diseases at the molecular level, aids in the selection of medications and therapies, and provides information on the prognosis of some diseases. Prenatal diagnosis and newborn screening improve the accuracy of early diagnosis of a variety of conditions, allowing for earlier treatment even when a cure is impossible. Functional magnetic resonance imaging allows a greater understanding of psychiatric and neurologic problems, such as dyslexia and attention-deficit/hyperactivity disorder.
Challenges persist with the incidence and prevalence ofchronic illness having increased in recent decades. Chronic illness is now the most common reason for hospital admissions among children (excluding trauma and newborn admissions). From middle school and beyond, mental illness is the main non–childbirth-related reason for hospitalization amongchildren. Pediatricians must also address the increasing concern about environmental toxins and the prevalence of physical, emotional, and sexual abuse, as well as violence. Since the September 11, 2001, destruction of the World Trade Centerin New York City, fear of terrorism in the United States hasincreased the level of anxiety for many families and children.
To address these ongoing challenges, pediatricians must practice as part of a health care team. Many pediatricians already practice collaboratively with psychiatrists, psychologists, nurses, and social workers. Team composition can change, depending on location and patient needs. Although school health and school-based health clinics have improved access and outcomes for many common childhood and adolescent conditions, the shortage of available general pediatricians and family physicians has led to the development of retail medical facilities in pharmacies and retail stores.
Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly being recognized. Maternal health status can affect the fetus. Infants who are a smaller size and relatively underweight at birth because of maternal malnutrition have increased rates of coronary heart disease, stroke, type 2 diabetes mellitus, obesity, metabolic syndrome, and osteoporosis in later life. Because of improved neonatal care, a greater percentage of preterm, low birth weight, or very low birth weight newborns survive, increasing the number of children with chronic medical conditions and developmental delays with lifelong implications.