Role of the Pediatrician

Thomas G. DeWitt and Neal Halfon

As pediatrics and the delivery of children’s health care enter the 21st century, the role of the pediatrician continues to evolve and change. Guided by the knowledge, skills, and tools that the profession has accumulated over many decades, pediatricians must strategically respond to changing conditions, health determinants, and epidemiology of childhood as well as to shifting social and cultural norms of what constitutes healthy child development. Our knowledge of the pathophysiology of many diseases has evolved from simple causal models based on germ theory to more complex notions of gene-environment interactions. As pediatric care has triumphed over many infectious diseases and made significant strides in the management of chronic disease, newer morbidities have emerged, including a growing prevalence of developmental, behavioral, and mental health conditions. To impact child health, 21st-century pediatricians must provide care with an expanded concept of healthy child development and must acquire skills to effectively practice in collaboration with other individuals and entities involved in promoting and supporting that development.

Societal expectations for healthy child development are a reflection of our collective hopes for what our children should achieve and what challenges they must successfully face in their transition to adulthood. These expectations are being transformed by an expanded understanding of what constitutes a healthy child as well as by a globalized economy that places a higher value on cognitive and emotional performance in the workplace, especially within developed nations.

The 2004 Institute of Medicine’s landmark report, Children’s Health, The Nation’s Wealth,¹ presents a new definition of child health and three associated, measurable domains:

“Children’s health should be defined as the extent to which individual children or groups of children are able or enabled to (a) develop and realize their potential, (b) satisfy their needs, and (c) develop the capacities to allow them to interact successfully with their biological, physical, and social environments.”

The domains include health conditions, capturing the traditional notions of health measured by disorders or illnesses of body systems; functioning, assessing how health affects an individual’s daily life; and health potential, identifying the assets and positive aspects of health, such as competence, capacity, and developmental potential.

The new definition and domains help establish the goals of child health care, which go beyond diagnosing and treating disease and preventing and managing chronic health conditions. They include promoting the health capacities of each child and optimizing the health potential of all children. Underlying this definition and these goals is a new and more dynamic conceptual model of how health develops; the model can be represented by a health trajectory that is influenced by a range of biopsychosocial and environmental risks, as well as by protective and promoting factors (Fig. 1-1).²

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