Keywords
Pediatric mortality, pediatric morbidity, health disparities
Care of Children in Society
Health care professionals need to appreciate the interactions between medical conditions and social, economic, and environmental influences associated with the provision of pediatric care. New technologies and treatments improve morbidity, mortality, and the quality of life for children and their families, but the costs may exacerbate disparities in medical care. The challenge for pediatricians is to deliver care that is socially equitable; integrates psychosocial, cultural, and ethical issues into practice; and ensures that health care is available to all children.
Current Challenges
Challenges that affect children’s health outcomes 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. 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. Newer genetic technologies allow the diagnosis of diseases at the molecular level, aid in the selection of medications and therapies, and may provide information on prognosis. Prenatal diagnosis and newborn screening improve the accuracy of early diagnosis and 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 as the incidence and prevalence of chronic illness increase over 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 among children. Pediatricians must also address the increasing concern about environmental toxins and the prevalence of physical, emotional, and sexual abuse, and violence. World unrest and terrorism, such as the September 11 attack on New York’s World Trade Center, have caused an increased level of anxiety and fear for many families and children.
To address these ongoing challenges, many pediatricians now practice as part of a health care team that includes psychiatrists, psychologists, nurses, and social workers. This patient-centered medical home model of care is designed to provide continuous and coordinated care to maximize health outcomes. Other models, such as school-based health clinical and retail medical facilities, may improve access but may not support continuity and coordination of care.
Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly recognized. Infants who are relatively underweight at birth due to maternal malnutrition are at higher risk of developing certain health conditions later in life, including diabetes, heart disease, hypertension, metabolic syndrome, and obesity. Improved neonatal care results in greater survival of preterm, low birthweight, or very low birthweight newborns, increasing the number of children with chronic medical conditions and developmental delays with their lifelong implications.
Current Challenges
Challenges that affect children’s health outcomes 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. 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. Newer genetic technologies allow the diagnosis of diseases at the molecular level, aid in the selection of medications and therapies, and may provide information on prognosis. Prenatal diagnosis and newborn screening improve the accuracy of early diagnosis and 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 as the incidence and prevalence of chronic illness increase over 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 among children. Pediatricians must also address the increasing concern about environmental toxins and the prevalence of physical, emotional, and sexual abuse, and violence. World unrest and terrorism, such as the September 11 attack on New York’s World Trade Center, have caused an increased level of anxiety and fear for many families and children.
To address these ongoing challenges, many pediatricians now practice as part of a health care team that includes psychiatrists, psychologists, nurses, and social workers. This patient-centered medical home model of care is designed to provide continuous and coordinated care to maximize health outcomes. Other models, such as school-based health clinical and retail medical facilities, may improve access but may not support continuity and coordination of care.
Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly recognized. Infants who are relatively underweight at birth due to maternal malnutrition are at higher risk of developing certain health conditions later in life, including diabetes, heart disease, hypertension, metabolic syndrome, and obesity. Improved neonatal care results in greater survival of preterm, low birthweight, or very low birthweight newborns, increasing the number of children with chronic medical conditions and developmental delays with their lifelong implications.
Landscape of Health Care for Children in the United States
Complex health, economic, and psychosocial challenges greatly influence the well-being and health outcomes of children. National reports from the Centers for Disease Control and Prevention (CDC) (e.g., http://www.cdc.gov/nchs/data/hus/hus15.pdf ) provide information about many of these issues. Some of the key issues include the following:
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Health insurance coverage. Medicaid and the State Children’s Health Insurance Program provide coverage to health care access to more than 45 million children in 2013.The slow drop in uninsured children nationally over the past decade leaves 5.5% of U.S. children lacking insurance in 2014. Despite public sector insurance, the rate of unvaccinated children remains unchanged over the past 5 years.
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Prenatal and perinatal care. Ten to 25% of women do not receive prenatal care during the first trimester. In addition, a significant percentage of women continue to smoke, use illicit drugs, and consume alcohol during pregnancy.
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Preterm births. The incidence of preterm births (<37 weeks) peaked in 2006 and has been slowly declining (9.6% in 2014). However, the rates of low birthweight infants (≤2,500 g [8% of all births]) and very low birthweight infants (≤1,500 g [1.4% of all births]) are essentially unchanged since 2006.
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Birthrate in adolescents. The national birthrate among adolescents has been steadily dropping since 1990, reaching its lowest rate (24.2 per 1000) for 15- to 19-year-old adolescents in 2014.
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Adolescent abortions. In 2010 the percent of adolescent pregnancies that ended in abortion was 30%. The rate of abortions among adolescents has been dropping since its peak in 1988 and is now at its lowest rate since abortion was legalized in 1973.
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Infant mortality. Internationally, infant mortality decreased from 63 deaths per 1000 live births in 1990 to 32 deaths per 1000 live births in 2015. In the United States, overall infant mortality rate decreased to a record low 5.96 per 1000 live births in 2013. A persistent disparity remains among ethnic groups. The infant mortality rate (in deaths per 1000 live births) is 4.96 for non-Hispanic white infant mortality, 5.27 for Hispanic infants, and 11.61 black infants. U.S. geographic variability persists with highest mortality rates in the South.
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Initiation and maintenance of breast-feeding. Seventy-nine percent of newborn infants start to breast-feed after birth. Breast-feeding rates vary by ethnicity (higher rates in non-Hispanic whites and Hispanic mothers) and education (highest in women with a bachelor’s degree or higher). Only 49% of women continue breast-feeding for 6 months, with about 27% continuing at 12 months.
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Cause of death in U.S. children. The overall causes of death in all children (1-24 years of age) in the United States in 2014, in order of frequency, were accidents (unintentional injuries), suicide, assaults (homicide), malignant neoplasms, and congenital malformations ( Table 1.1 ). There was a slight improvement in the rate of death from all causes.
