Ambulatory pediatrics encompasses the diagnosis and management of acute disease, developmental problems, and psychosocial illnesses; the continuing care of children with a long-term illness or disability; health promotion; and disease prevention. Approximately one-third of pediatric ambulatory visits are for acute illnesses, usually viral, respiratory, or gastrointestinal; an additional 3% to 10% are for chronic illness or disability; and a further 25% to 30% for health supervision. Psychosocial symptoms or disorders are estimated to affect 20% to 25% of the children and adolescents seen in the pediatric office.

The Institute of Medicine’s Committee on the Future of Primary Care has defined primary care as “the provision of integrated, accessible health care services by clinicians who are available for addressing a large majority of personal health needs, developing a sustained partnership with patients, and practicing in the context of family and community.”

Ambulatory care, largely synonymous with the primary or general pediatric care given by the pediatrician alone or in partnership with a nurse practitioner, includes health supervision; developmental surveillance; treatment of acute illness and minor trauma; early identification of psychosocial, educational, or biomedical problems; and continuing care of children with chronic illness or disability. In addition to traditional office-based settings, primary care is available in some primary and secondary schools, especially in medically underserved areas. Provided by nurse practitioners or physicians working part-time, with backup by community pediatric and other consultants, school-based services are accessible during school hours, often with arrangements for after-hours emergency care. In addition to treatment for acute illnesses or minor trauma, health clinics in secondary schools may offer early intervention for depression and other psychologic symptoms. The staff also may participate in health education programs to prevent sexually transmitted diseases, unintended pregnancies, substance abuse, risk-taking behaviors, and violence.

Except for families living in poverty, in whom illness continues to be overrepresented on a population basis, children in the United States are physically healthier than ever before. The infectious and nutritional problems that were encountered so frequently in the past by the pediatrician have, to some extent, been supplanted by those of a developmental, behavioral, social, or educational nature. The new Diagnostic and Statistical Manual for Primary Care (DSM-PC), Child and Adolescent Version, includes diagnostic codes for these disorders.

The American family also has changed dramatically, with an increase in the number of mothers who work outside the home, single-parent households, and the prevalence of parental separations, desertions, divorces, remarriages, live-in partners, and blended families. Children seen by the pediatrician come from much more diverse ethnic, cultural, linguistic, and religious backgrounds than they did a decade ago. In the highly migratory American society, extended family members are also less available than in the past to give child-rearing advice and to provide emotional and physical support; however, the number of grandparents rearing young children has significantly grown. Increasingly, parents invested in the optimal development of their children look to their pediatrician for authoritative guidance concerning child development.

The delivery of pediatric health services is in transition from solo to group practice, team care, and the integration of office- with community-based services. Only about one of four pediatricians is in solo practice. Although 75% of pediatricians still practice in communities of more than 100,000 persons, an increasing number work in small or rural towns. A major shift has occurred from inpatient to ambulatory and day hospital care. Day surgery has greatly expanded in scope, and day hospitals or short-stay units are being used for the regulation of diabetes, the treatment of cystic fibrosis, the infusion of blood and chemotherapeutic agents, and the management of acute asthmatic episodes.

Most children in the United States are covered by health insurance for ambulatory care (Box 13.1). Membership in the managed care programs of health maintenance organizations, independent practice associations, preferred provider organizations, and hospital-based health services is steadily increasing. Fee-for-service costs paid directly by the parent are being replaced by reimbursement from third-party payers such as health maintenance organizations. Some pediatric practitioners are salaried or paid on a capitation basis. Primary-care pediatricians serve an average of 3,000 patients each year, including approximately 100 newborns. Because of fewer children per family in the United States, the reduced prevalence of episodic illness in economically secure families, the discovery of new vaccines, and an increased number of pediatricians, many practitioners have more time available to care for adolescents, children with chronic disease, prenatal consultations, sports medicine, and the management of psychosocial, developmental, educational, and genetic problems.

Except in small towns, in which the number of children is not large enough to support more than one pediatrician, or for the physician who prefers solo practice, compelling reasons exist to practice in a pediatric or multidisciplinary group. Advantages include the opportunity to share knowledge as well as call duty; plan family time; participate in continuing pediatric education; develop an area of special interest; work in a community child health program; collaborate in office practice research projects; or teach medical students and residents.

To meet the needs of parents who work outside the home, some pediatric practices have early morning, evening, and weekend hours. Much care continues to be given, however, in hospital emergency rooms or urgent care centers. Some hospitals and pediatric practices have established satellite offices to increase the geographic access to their services. In rural areas, a pediatrician from a nearby community may hold office hours a few times a week, or the satellite office may be staffed by a nurse practitioner with access to pediatric consultation by phone.

In addition to such primary health care services, ambulatory care may be given by pediatricians with special competence in child development, learning problems, neurodevelopmental disabilities, infectious disease, chronic illness, behavior, allergy, gastroenterology, pulmonology, dermatology, nephrology, rheumatology, adolescent medicine, sports medicine, neurology, cardiology, genetics, hematology/oncology, or endocrinology. Regrettably, some managed-care plans do not authorize consultation with a pediatric subspecialist if an adult subspecialist is on their panel. Referral to a mental health consultant or service frequently is denied.

Psychosocial and developmental problems now require more of the pediatrician’s time, including help in promoting adaptation to major family changes or crises such as death, separation, divorce, or remarriage; the care of a child with a long-term illness or disability; developmental delay; and learning disabilities, underachievement, and other school problems. Additional psychosocial symptoms and behavioral complaints include failure to thrive, out-of-control behavior in toddlers, persistent sleep problems, separation anxiety, hyperactivity, chronic headaches, recurrent abdominal pain, poor social skills, and other clinical presentations classified in the DSM-PC, Child and Adolescent Version. No aspect of primary pediatric care offers a greater challenge or more promise than the prevention and management of behavioral, social, and learning problems. The major deterrents to its realization are lack of adequate reimbursement by third-party payers and limited training during a pediatric residency.