Pediatrics: Child Health & Development Overview

Overview of Pediatrics

• Pediatrics is dedicated to the care and well-being of infants, children, and adolescents, focusing on their physical, mental, social, and psychological development
• The National Institute for Child Health and Development (NICHD) was created in 1962 to promote scientific inquiry in pediatrics
• Pediatricians address social and environmental factors affecting health, like racism and poverty
• The UN issued the Declaration of the Rights of the Child in 1959, but the United States has not ratified these rights
• Pediatricians advocate for children, especially those disenfranchised due to factors like culture, religion, gender identity, race, or ability
• Global interconnectedness makes a global perspective necessary due to emerging illnesses and events like war, climate change, and social injustice incidents

Vital Statistics on Children's Health

• From 1990 to 2020, the world population grew annually by 1%, reaching almost 8 billion, with the growth rate declining
• The Pew Research Center predicts a population of 10.9 billion by 2100, with a growth rate under 0.1%
• Africa is expected to continue strong population growth
• India, China, and Nigeria are projected to be the largest countries by 2100
• The global average birthrate in 2019 was 17.9 births per 1,000 population
• Youth under 19 make up about 32% of the world's population, with Africa having the largest share of youth under 15 (40%)
• The health of children and youth varies based on economic conditions, education, infrastructure, climate, agriculture, industrialization, genetics, infectious agents, social stability, and political focus
• Social and structural influences, like the environment and economic conditions, significantly affect health outcomes
• The international community established eight Millennium Development Goals (MDGs) in 2000 to address worldwide needs
• MDG 4 focused on reducing the under-5 mortality rate (U5MR) by two-thirds between 1990 and 2015
• Poor nutrition contributes to over a third of child deaths worldwide
• The global U5MR decreased by 60% between 1990 and 2021, from 93 to 38 deaths per 1,000 live births
• The WHO cites that 5.2 to 5.4 million children die from preventable causes worldwide
• Infants under 28 days account for over half of these deaths
• Children in sub-Saharan Africa are 9 times more likely to die before age 5 than those in developed countries
• The global infant mortality rate (2023) is 27.4 deaths per 1,000 live births
• Female infants have a lower mortality rate than male infants
• Infant death rates are highest in Afghanistan (106.8), Somalia (88.0), and Central African Republic (84.2) per 1,000 live births
• In developing nations, over half the deaths in children under 5 result from infectious and parasitic diseases, including diarrheal disease (10%) and pneumonia (15%)

The Changing Pediatric World

• Child health in industrialized nations improved in the 20th century due to vaccines, antibiotics, hygiene, and scientific clinical practice
• Efforts to control infectious diseases were supported by better understanding of nutrition's role in preventing illness
• Publicly funded well-child clinics were established for low-income families
• Control of infectious diseases led to decreased morbidity and mortality globally
• Pediatric medicine shifted focus to noninfectious acute and chronic conditions, including leukemia, cystic fibrosis, sickle cell disease, congenital heart disease, genetic defects, and metabolic disorders
• Early penicillin prophylaxis led to an 84% risk reduction for pneumococcal sepsis in children with sickle cell disease, increasing life expectancy
• Innovation in diagnosis and management of sickle cell disease increased
• 95% of individuals born with sickle cell disease now live to their 18th birthday
• Treatment for acute lymphoblastic leukemia (ALL) has improved, with five-year survival rates increasing from under 10% in the 1960s to over 90% in 2023
• Advances in pulmonary and nutritional therapies have increased the life expectancy for children with cystic fibrosis to 39-56 years

The New Normal: Pandemics

• The coronavirus disease 2019 (COVID-19) pandemic has affected global health and socioeconomic lives
• Identification of COVID-19 and vaccine development occurred rapidly, highlighting the need for scientific research
• Children could transmit the virus with or without symptoms
• Some children experienced severe illnesses related to chronic conditions or developed multiinflammatory syndrome (MIS-C)
• By spring 2023, there were over 766 million cases and nearly 6.9 million deaths from COVID-19 worldwide, with the United States having the highest numbers
• Children in the United States accounted for 6 million COVID-19-positive cases
• Children experienced mental health and psychosocial challenges, grief, and loss
• Many children faced learning challenges due to school closures, dependence on electronic devices, and widening educational disparities
• Children who received nutritional support or in-school services faced disruptions, increasing mental and emotional health burdens
• The pandemic disproportionately affected poor families and families of color, who faced economic hardship, loss of caregivers, and safety concerns
• Children with special healthcare needs experienced challenges like lack of essential medicines and services

The New Morbidities

• "New morbidities" refers to behavioral, developmental, and psychosocial conditions, along with societal inequities, linked to health outcomes and quality of life
• Focus is on prevention, early detection, and management by expanding knowledge of factors affecting behavior, normal child development, health behaviors, and behavioral disorders
• Professional training, clinical communication, mental health resources, and time allocation are being reevaluated
• In 2001, the need to address environmental and social aspects was reemphasized, including violence, substance use, food insecurity, and poverty
• Behavioral, environmental, and psychosocial problems account for a large portion of health outcomes, requiring changes in clinical practice and collaboration with other professionals
• The family, especially the caregiver, is now seen as a more equitable partner in identifying issues and deciding on therapeutic options
• Health influences are interconnected, with biology, genetics, healthcare, behaviors, social conditions, and environment interacting on multiple levels
• From 40% to 70% of the variation in health outcomes is caused by social and economic conditions, health behaviors, environmental factors, and structural inequality in healthcare

Racism

• Racism and racial discrimination is a worldwide problem occurring at systemic, interpersonal, and psychological levels
• Structural racism, built on White supremacy, has created pediatric health disparities for over 400 years
• Pediatricians are called to dismantle structural racism and address harm perpetuated through healthcare policies, practices, beliefs, and ideals
• Racism and adverse childhood experiences are pressing challenges for pediatricians to promote equitable health access and outcomes
• Relevant due to children in the United States, ~50% are non-White

Adverse Childhood Experiences

• Adverse childhood experiences (ACEs) are stressful events during childhood with health consequences
• ACEs include abuse, neglect, and household challenges/family dysfunction
• Retrospective studies show a dose-response effect of ACEs on future adult health, including increased risks of heart disease, lung disease, depression, obesity, and cancer
• Expanded to include macro-level stressors in the neighborhood and community, such as violence, poverty, bullying, unsafe environments, and discrimination
• ACEs and psychosocial traumas may influence health through risky behaviors, disrupted neurodevelopment, cognitive impairment, and toxic stress
• Although ACE screening may not be the optimal approach approach to incorporating a trauma lens into individual clinical care, a discussion around ACEs can help the clinician to begin collaborative communication with patients and families on the importance of psychosocial stress and adversity in health and well-being in childhood and throughout the life course
• The importance of ACEs has resulted in transition step for recognizing "what's wrong with you?" to "what's happened to you," towards healing-centered care, which includes assets

Toxic Stress and Allostatic Load

• Effects of stress are moderated by the intensity of the stress, the bio-logic response to the stress, and the social and physical environment in which the stress is experienced
• Toxic stress occurs when a child experiences stressful events that are chronic, intense, or prolonged and are inadequately buffered by the child's social support system
• Toxic psychosocial stress influences physical health by producing allostatic load, or pathophysiologic dysregulation of normal regulatory systems
• Framework can be seen as a mechanism underlying health disparities

Chronic Illness and Children with Special Healthcare Needs

• Care of children with chronic conditions has become a large part of clinical pediatrics
• Children and youth with special healthcare needs (CSHCN) require health and related services of a type or amount beyond that required by children generally

• 14.1 million, or 19% of U.S. children, have a special health need

• Conditions are heterogeneous, and most children need specialty care in addition to primary care
• CSHCN have functional difficulties in the sensory, cognitive, movement, emotional, or behavioral domains
• Families experience financial difficulties because of their children's special health needs
• Pediatricians provide data and expert opinion to procure needed services and resources

Systems of Care

• Traditional practice models concentrate efforts toward the preventive and therapeutic needs of those patients who present for care
• Effectiveness of such a system improves with greater collaboration between healthcare providers and payers to identify gaps in care
• The concept of the patient and family-centered medical home (PFCMH) approach to providing care is defined as a medical home that provides care that is accessible, continuous, comprehensive, family-centered, coordinated, compassionate, and culturally effective
• The medical neighborhood expands the medical home concept and refers to coordinated and efficient integration between primary care pediatricians and the subspecialists, including integrated EHRs
• The health neighborhood concept is based on the recognition of the importance of coordination with community-based and nonmedical providers to address comprehensively and efficiently the social and structural influences on health
• Expanded care models achieve the "quadruple aim" for healthcare: focusing on care, health, provider satisfaction, and cost