Paediatrics
And Child Health
Paediatrics is not just about the
recognition and treatment of children’s illness. It also encompasses child
health, covering all aspects of growth and development, promotion of children’s
health and the prevention of disease. It includes every aspect of life from
birth through adulthood. In many countries, such as the UK, paediatric care
extends up to the age of 18 and covers all children from the very premature infant to teenagers in the workforce.
All aspects of paediatrics are coloured by the fact that the child is
growing and developing both physically and emotionally. Anyone involved in the
medical care of children needs to have an understanding of children’s normal
development and a realization that children must not be considered as mini
adults. In paediatrics, more than in any other branch of medicine, the needs of
the family and carers must also be taken into consideration. At the end of
childhood, a smooth transition of care to adult services is needed, especially
for those with chronic conditions.
The changing face of paediatrics and child health
One hundred years ago, infection was the major cause of morbidity and
mortality in childhood. Improvements in the environment, sanitation and housing
began the trend for advancement in pop- ulation health, and this was
accelerated by the introduction of immunizations and antibiotics. Changes have
occurred in society too, many of which are beneficial to children and their
health and well-being. Children are better and more widely protected than was
the case a century ago. Educational standards, social support, medical care and
knowledge about child development have all improved, and child abuse has become
unacceptable.
However, inequalities in both wealth and health are increasing, and the
‘gap’ between the richest and poorest has a profound impact on children’s
lives. Referrals for emotional and behavioural problems are rising
dramatically, and childhood obesity is seen as the major public health problem
of our time. A relatively new aspect of paediatrics is the understanding that
many determinants of adult health have their origins antenatally, in infancy
and in the early years of childhood.
Health care has also changed in paediatrics. Over the last 40 years, we
have seen more children admitted to hospital, but the experience of
hospitalization has changed. Once visiting hours for parents were limited to 30
minutes per day, but now the normal expectation is that parents will stay with
their child. Where possible every effort is made to keep children out of
hospital, and many aspects of specialized complex care have become available in
the community. Even for the acutely ill child, short-stay observation wards now
allow serious causes of illness to be excluded and children to be discharged to
recover at home. A significant proportion of admissions are for social reasons,
for example, if there are concerns that the family is unable to cope or they
live too far away to safely send the child home.
The determinants of health
The way health is considered has also changed over the decades. In the
early part of the 20th century, health was considered to be the absence of
disease. However, in 1948, the World Health Organization changed the way we
look at health when it declared that ‘health isa state of complete physical,
mental, and social well-being, and
not merely the absence of disease and infirmity’. In paediatrics, this has been
accompanied by a more holistic approach to children, with greater emphasis on
well-being especially for those coping with chronic conditions and
disabilities.
Two major factors have changed priorities in the care of children and
their services. The first is the understanding that socioeconomic status has a
powerful influence over many aspects of children’s health. Poverty is now known
to be a significant predictor of a number of major measures of health,
including:
•
Birth weight
•
Perinatal morbidity
•
Sudden infant death syndrome (SIDS)
•
Admission to hospital
•
Obesity.
The other factor that has changed the way we view disease arises from the
‘Barker hypothesis’. Barker and his colleagues brought to light how events in
pregnancy and infancy can have a long-term effect on health. Exploring infant
growth records from the last century, they showed that babies born small for
gestational age were at significantly increased risk for hypertension,
cardiovascular dis- ease, diabetes and obesity in adult life, particularly if
they showed rapid catch-up growth in the first year of life. Their findings
demonstrated how critical the early years are in programming later health
outcomes.
Rather reassuringly, economists have shown that although the preschool
years are a vulnerable period, they are also a critical period amenable to
intervention. The evidence clearly shows that when society invests in the early
childhood years and provide support, community programmes, guidance for parents
and education, there are profound benefits on many later outcomes such as
physical health, academic achievement, mental health, antisocial behaviour and
substance abuse.
Types of paediatric problems
With the changing face of childhood disease, health professionals need to
be competent at managing a broad variety of conditions. These conditions
include the following broad categories:
•
Acute illnesses such as bronchiolitis,
respiratory infections and anaphylaxis
•
Chronic illnesses such as asthma, epilepsy,
diabetes and cancer
•
Disabilities both physical and intellectual
•
Injury: accidental and non-accidental
•
Disorders of eating and nutrition, including
weight faltering, obesity and anorexia
•
Mental health disorders such as attention
deficit disorder, challenging behaviour, depression and anxiety.
Some of the particular challenges we need to face are emotional and
behavioural problems, childhood obesity, child abuse and neglect, accidents and
injuries, sexually transmitted disease and teenage pregnancy, increase in
disabilities and chronic illness, substance misuse, suicide and self-harm and
poor vaccine uptake. By directly treating childhood conditions, by ensuring
effective screening and prevention programmes and by advocating for better
public health interventions, paediatricians and all those working in child
health have a fantastic opportunity to influence the longterm outcome of their
patients. Paediatrics is a challenging specialty but a very rewarding one.
