Pediatrics is the medical specialty concerned with the health of infants, children, and adolescents; their growth and development; and their opportunity to achieve full potential as adults. This includes the age group from newborn to age 16–21, depending on the country. The word pediatrics is derived from two Greek words, paidi which means “child” and iatros which means “doctor.” Pediatricians are physicians who assume a responsibility for children’s physical, mental, and emotional progress from conception to maturity. Hence, pediatricians must be concerned with social and environmental influences, which have a major impact on the health and well-being of children and their families, as well as with particular organ systems and biologic processes. The young are often among the most vulnerable or disadvantaged in society, and thus their needs require special attention.
In the United States, pediatricians are considered to be primary care doctors, along with family practice, internal medicine, and obstetrics. Much of the rest of the world considers them specialists, and parents are only referred to pediatricians for special care not handled by the generalists. Most pediatricians are members of a national body, such as the American Academy of Pediatrics, the Canadian Paediatric Society, and the British Association of Paediatric Surgeons.
Pediatrics emerged as a medical specialty over a century ago in response to increasing awareness that the health problems of children differ from those of adults and that a child’s response to illness and stress varies with age. The obvious body size differences are paralleled by maturational changes. The smaller body of an infant or neonate is substantially different physiologically from that of an adult. Congenital defects, genetic variance, immunology, oncology, and a host of other issues are unique to the realm of pediatrics. Increasingly effective healthcare also means that diseases such as sickle cell anemia and cystic fibrosis are more often treated by pediatricians, although many or most patients grow into adulthood. Issues revolving around infectious diseases and immunizations are also dealt with primarily by pediatricians.
Another major difference between pediatrics and adult medicine is that children are minors and, in most jurisdictions, cannot make decisions for themselves. The issue of guardianship, legal responsibility, and informed consent must always be considered in every pediatric procedure. In a sense, pediatricians often have to treat the parents and, sometimes, the family, rather than just the child. Adolescents are in their own legal class, having rights to their own healthcare decisions in only certain circumstances, although this is in legal flux and varies by region.
Moreover, today it is widely recognized that the health problems of children and youth vary widely among the nations of the world depending on a number of factors, which are often interrelated. These factors include the prevalence and ecology of infectious agents and their hosts; climate and geography; agricultural resources and practices; educational, economic, social, and cultural considerations; stage of industrialization and urbanization; and, in many instances, the gene frequencies for some disorders.
Assessment of the state of health of any community must begin with a description of the incidence of illness and must continue with studies that show the changes that occur with time and in response to programs of prevention, case finding, therapy, and adequate surveillance.
According to current United Nations Children’s Fund (UNICEF) data, there are 71 million children younger than 18 years in the United States and 2.1 billion children younger than 18 years in the rest of the world. Ninety percent of children in the early 21st century are born into the developing or Third World. The mortality rate of children younger than 5 years is eight per 1,000 in the United States and 86 per 1,000 for the overall child population of the world. One thousand infants die each hour; 970 of these deaths occur in developing countries. Causes of death were attributed to malnutrition (54 percent), perinatal conditions (20 percent), pneumonia (19 percent), diarrhea (15 percent), measles (8 percent), malaria (7 percent), HIV/AIDS (3 percent), and other (28 percent).
One-third of births in the developing world are not registered. Population projections to 2025 show continuing rapid growth in Africa, Western Asia, south central Asia, southeast Asia, west Asia, South America, and Latin America, with modest or slowing growth rates in east Asia, North America, and Europe. Hundreds of thousands of children born in developing countries move into Europe and into North America as refugees, immigrants, or international adoptees.
Between 1980 and 2000, there were dramatic increases in the percentage of children immunized in developing countries and, as a result, diseases such as poliomyelitis and measles are much less common. However, immunizations for diseases such as hepatitis, haemophilus influenza b, and varicella are rarely available in the developing world. The number of children infected with HIV has increased dramatically, as has the number of children suffering from malnutrition associated with disasters. Malaria and tuberculosis also affect greater numbers of children than they did a decade ago.
Malaria is the leading cause of hospitalization, mortality, and morbidity in children younger than 5 years who live in sub-Saharan Africa. Malnutrition, including both calorie and micronutrient deprivation, causes acute and chronic morbidity, contributes to reduced immunity, and increases the likelihood of mortality and morbidity in association with infectious diseases.
Physicians caring for children have been increasingly called on to advise in the management of disturbed behavior of children and youth or problematic relationships between child and parent, child and school, or child and community. They are increasingly concerned with problems of mental, social, and societal health.
There is also an increasing concern about disparities in how the benefits of what we know about child health reach various groups of children. Just as in many developing countries, so in the United States does the health of children lag far behind what it could be if the means and will to apply current knowledge were focused on the health of children.
The medical problems of children are often intimately related to problems of mental and social health. The children most at risk are disproportionately represented among ethnic minority groups. Pediatricians have a responsibility to aggressively address problems such as these.
Approximately one-third of children younger than 15 years in developing countries either have or are at risk for impaired learning. Major hazards to early brain development include malnutrition, infectious diseases (e.g., meningitis), prematurity and newborn asphyxia, in utero exposure to alcohol and drugs, lead poisoning, genetic disorders, head injuries, and institutionalization. Malnutrition experienced during the critical periods of brain development from the second trimester of pregnancy until 2 years of age is most likely to be associated with subsequent cognitive impairment. Iron deficiency, very common among infants in the developing world, is associated with continuing learning problems a decade later. Iodine deficiency is also common, especially in large areas of China, central Africa, and South America, and is associated with mental impairment in children.
The number of children institutionalized in developing countries is unknown, but the number of institutions for orphan children has increased in countries of the former Soviet Union, eastern Europe, sub-Saharan Africa, India, and China in the past decade. Reasons include death of parents from AIDS, poverty in families who might ordinarily adopt child relatives, political upheavals, and community chaos. A small percentage of institutionalized children are adopted by North American or European families. Eighteen thousand children from abroad are adopted into American families each year. About half of children adopted from orphanages abroad are malnourished. Rickets is common, as are intestinal parasites. Many children have been infected with tuberculosis, hepatitis B, hepatitis C, or syphilis. Of great concern are the frequent developmental delays and attachment problems, which increase after the first year of life of these orphan children.
Traditionally, efforts to improve child health in the developing world have focused on primary healthcare. This approach concentrates on improving public health and basic healthcare at the community level, usually by training village health workers to recognize and manage childhood illnesses such as diarrhea and pneumonia. The primary healthcare approach is essential in developing countries where access to basic medical facilities and trained healthcare professionals is often lacking and where the majority of childhood diseases are preventable. However, the primary healthcare approach includes teaching village health workers to recognize and refer sick patients to acute healthcare facilities. Currently, there are inadequate resources devoted to training health professionals and establishing such referral centers in most developing countries; they often do not exist and, therefore, sicker children suffer or die.
However, as the public health infrastructure improves in a developing country, it becomes increasingly important to train local child health specialists. These child health specialists provide referral care to individual children and serve as the backbone for long-term improvements in child health by providing local expertise and knowledge for the formulation of child health policy in their own countries.
In most settings, it is difficult to separate the health of the child from that of the family and the broader social context in which the child lives. This is particularly true in the developing world. Maternal health practices strongly impact child health, particularly in the perinatal period. Prenatal care, neonatal resuscitation, maternal nutrition, breast-feeding and weaning practices, and maternal depression all may have profound effects on a child’s well-being. Economic conditions and family resources drive healthcare decision making. Environmental conditions limit the effective treatment of preventable illnesses such as diarrhea and malaria. Much of the childhood disease burden in developing countries may rightfully be seen as the medical manifestations of social illnesses, such as lack of education, poverty, and other forms of injustice.
Pediatric research in developing countries has lagged behind that in Western countries. As a result, there is a lack of knowledge in many areas, including, for example, the long-term effects of medications used to treat many parasitic infections, the interactions between traditional herbal therapies and antibiotics, the extent of genetic diseases, the prevalence of iron deficiency, and the neurodevelopmental effects of cerebral malaria. It is appropriate for child health specialists and institutions from wealthier nations to assist colleagues in developing countries to develop research skills, design appropriate projects, find financial support, and implement the research project.
It is important that child health professionals do their best for individual child patients and also participate in the broader public health and community planning on behalf of children. The 1990 United Nations World Summit for Children recommended a 10-year program to achieve basic health and social goals for children. With the exception of the immunization goals, they were not met. Probably the highest priority for the world should be the prevention of childhood learning problems. Health and human service professionals around the world must foster a global awareness about the impact of early events on the developing brain of a child, on his or her life, on the community, and on the world.
Adolescent Development; Adolescent Health; American Academy of Pediatrics (AAP); Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN); Breast Feeding; Cerebral Palsy; Child Abuse; Child Behavior Disorders; Child Dental Health; Child Development; Child Mental Health; Child Safety; Childhood Cancers; Childhood Immunization; Infant and Newborn Care; Neonatology; Neonatologist; Prenatal Care.