The State of Pediatrics

by | Aug 1, 2017 | Pediatrics

We Live in Interesting Times

I imagine that every generation of pediatricians has felt they were living in a time of unique promise and perils, and I suspect that they have all been right. Our own time is no different except that perhaps change is moving even faster than before. At any rate, I echo my colleagues through the ages when I say that there’s never been a more exciting or more frightening time to care for children’s health and well-being.

Childhood Illness and Medical AdvancementsWe don’t have to reach back to days of widespread polio or measles to appreciate how much vaccines have altered the landscape of pediatric disease. In just the last decade I’ve seen the amount of time I spend treating ear infections, once the bread and butter of my practice, shrink to nearly nothing. Successful vaccines against Haemophilus influenza B and Pneumococcus can take much of the credit, helped by increased rates of breast feeding and falling rates of parental smoking. Even better, the sorts of life-altering, often deadly meningitis that we were constantly vigilant for as residents are vanishingly rare, again as a result of successful vaccinations. My kids can look forward to being the first generation to wipe out cervical cancer and many head and neck cancers thanks to the HPV vaccine, and just in the last decade we’ve seen hospitalizations from rotavirus infections plummet thanks to appropriate vaccination.

At the same time, we still face pockets of vaccine resistance and denial that threaten to halt and even reverse some of this progress. Every year we witness needless hospitalizations and worse from measles, influenza, and whooping cough due to parents being bombarded by misleading and frightening information about vaccines. As a pediatrician I strive to meet my parents where they are, to really hear their concerns, and then to give them the best answers I can so that they understand why I’m so relieved that all of my own children are vaccinated fully and on time.

Evidence Based Medicine

“Evidence based medicine (EBM)” was a fairly new concept when I was training, and it met with substantial resistance from some doctors for reasons that still baffle me. At its most basic, EBM means figuring out what works for patients and doing more of that while doing less of what doesn’t work. As our ability to collect and process data about patient outcomes improves new opportunities are opening up daily.

Evidence Based Medicine for childrens healthSerious questions that used to be mainly a matter of guesswork — does this little boy have appendicitis, does this baby need a spinal tap — can increasingly be answered with great precision using clinical algorithms. Often these formulas save kids from unnecessary testing and treatment, for example decreasing how often we give antibiotics for ear infections or cutting the risk of brain cancer by reducing how many CT scans we order for head injuries. Some critics call this “cookbook medicine,” but as far as I’m concerned if the recipes work then I love a good cookbook.

On the other hand there’s the very real risk that doctors will become glorified data entry technicians, spending so much of our time typing and swiping at our computers that we’ll forget to look up and play with our patients. So far there is no computer that can catch that fleeting expression on a child’s face that means she’s not telling us the whole story or that can hold a parent’s hand in a moment of fear. Big data are great, but they’re of no use unless paired with a warm smile, receptive ears, and a compassionate heart.

Stress is Toxic to Children

Every now and then a new concept comes along that revolutionizes how we think about a whole discipline. In pediatrics that idea is “toxic stress,” the fact that severe stresses during childhood — hunger, neglect, poverty, parental drug or alcohol abuse, parental absence or mental illness — can irreversibly impact a child’s health and development through adulthood and into old age. We’ve come to understand that toxic stress is the Rosetta Stone that holds the key to life outcomes that we previously did not understand. As parents and as a society our future will depend largely on what we do with this newfound truth.

What we cannot do is to protect our children from all stresses all the time (even though as a parent I’ve often wished for a magic wand that would do just that). In fact mild stresses are how a child learns and masters new skills. Trying broccoli for the first time, jumping into the deep end, falling off a bicycle, these are all the sorts of stresses that build great childhoods.

Children’s Health Overview

What we can do is to provide a supportive environment for our children, one where plenty of praise and hugs are paired with appropriate limit-setting and high expectations. The trick of course is that you’ll never know as a parent whether you’re getting it quite right. As a society, however, we have a better idea. If kids have nutritious food, stable housing, high-quality child care, and safe air to breathe and water to drink, we will have gone a long way toward insuring that the next generation is healthy and prepared for whatever challenges arise.

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