CURRENT CHALLENGES

CURRENT CHALLENGES

Current challenges in the care of children are access to health care; health disparities; children's social, cognitive, and emotional lives; congenital and genetic disorders; and environmental factors that affect optimal outcome of child health. Scientific advances in genetics are particularly relevant to pediatrics. With newer genetic technologies, pediatricians are able to diagnose diseases at the molecular level. Microarray genetic technology can identify the cluster of candidate genes associated with a variety of diseases; this technology is now used for the prognosis of diseases (e.g., cancer). Prenatal diagnosis of a variety of genetic diseases is now possible. Mandatory and recommended newborn screening for genetic and metabolic diseases has improved the accuracy of early diagnosis of these conditions, which, although rare, are often treatable. Giving folic acid to women of childbearing age reduces the risk of neural tube defects. The blood triple or quadruple screen during pregnancy and intrauterine ultrasound as a screening tool to detect fetal malformations and deformations provide information for diagnosis, prognosis, and clinical decision making. Functional magnetic resonance imaging allows a greater understanding of psychiatric and neurologic problems, such as dyslexia and attention-deficit/hyperactivity disorder.

The incidence of many serious bacterial and viral infections has been significantly reduced or eliminated by immunizations. Smallpox has been eliminated worldwide, and polio should be eliminated shortly. The overwhelming success of immunization programs in preventing many of the serious diseases seen in children in the last century has been associated with concerns about minor immunization side effects and rare complications. Pediatricians must continue to seek the safest vaccines possible, but they should oppose vigorously any attempts to limit the use of proven successful immunizations when the risk of complications is remote compared with the serious risk of clinical disease. The inappropriate claim of a causal association of autistic spectrum disorders and the measles vaccine has been disproved, and there have been numerous outbreaks of measles in unimmunized children.

There is increasing concern about environmental toxins in the food chain affecting children's growth and development and the ever-present problem of air pollution adversely affecting children's pulmonary function. Children are subject to physical, emotional, and sexual abuse; they also are victims of and bear witness to violence. Many immigrant families have seen death, destruction, terrorism, and war, all of which affect children's emotional development. Since the September 11, 2001, destruction of the World Trade Center, fear of terrorism has increased the level of anxiety for many families and children.

Pediatricians need to practice as part of an expanded healthcare team. Nurse practitioners provide well-child care and, in collaboration with pediatricians, care for common illnesses. Many pediatricians practice collaboratively with psychiatrists, psychologists, nurses, lawyers, and social workers. School health and school-based health clinics have improved access and outcomes for many common childhood and adolescent conditions.

Childhood antecedents of adult health conditions, such as alcoholism, depression, obesity, hypertension, and hyperlipidemias, are increasingly being recognized. There is an increase in the diagnosis of obesity and type 2 diabetes and a possible increase in the incidence of autistic spectrum disorders, although the latter may be secondary to improved diagnosis. Because of improved neonatal care, a greater percentage of preterm, low birth weight, or very low birth weight newborns are surviving, increasing the number of children with chronic medical conditions and developmental delays. Death from congenital malformations and malignant neoplasms is less common than previously, but these conditions remain the second and third most important causes of death after injuries in the 1- to 4-year-old population.