What’s next for pediatrics? Here’s the world according to Alan Guttmacher, MD, Director of the National Institute of Child Health and Human Development. Guttmacher did his internship, residency and fellowship in clinical genetics at Children’s Hospital Boston during the 1980s. At a recent Medical Grand Rounds at Children’s, he outlined what’s changed for the better in child health since his training and what new threats are looming. I was struck by how pediatrics has changed (at least in the U.S.) since I was a kid.
On the plus side:
- Sudden Infant Death Syndrome — a.k.a. “crib death” — has receded, starting with new pediatric practice guidelines in 1985 and continuing with the Back to Sleep Campaign. (We’ve since learned that some infants are especially vulnerable to SIDS when sleeping face down because of low production of serotonin in the brainstem.
- Acute lymphoblastic leukemia (ALL), which accounts for up to a quarter of all childhood cancers, now has a cure rate of more than 90 percent, in large part from the work of institutions like Children’s and Dana-Farber Cancer Institute that have steadily refined treatment.
- Invasive Haemophilus influenzae disease, a major cause of bacteremia, pneumonia and meningitis in infants and young children, has dropped sharply, thanks to a vaccine that became available in the early 1990s. “In the ‘80s we saw multiple cases,” Guttmacher said. “I’d be curious if any house officer today knows of a single case.”
- Reye’s syndrome, a common neurologic disease in the 1970s, has been virtually eliminated with increased awareness of the dangers of giving aspirin to children. (In 1986, Robert Tasker, Children’s new Director of Neurocritical Care, started a fellowship to study the acute brain swelling caused by Reye’s syndrome. “Within 3 months of me taking the job, the condition disappeared,” he recounts.
- Many more children are surviving prematurity and serious conditions like cystic fibrosis and congenital disease.
But new challenges have taken the place of these successes:
- Unintentional injuries, congenital anomalies, cancer and homicide have become the top killers of children.
- As infectious diseases recede,“immune” disorders are becoming more common: Asthma, multiple sclerosis, type 1 diabetes and Crohn’s disease are up. “I would argue that many of these have their roots in childhood,” Guttmacher said.
- New “epidemics” are emerging: Autism, obesity, childhood-onset type 2 diabetes, asthma.
And children and their environment have changed, too:
- Studies indicate that puberty is getting earlier and earlier, possibly fueled by rising child obesity and other environmental factors.
- Children are more likely to be born through assisted reproductive technology, to be part of a multiple birth, and to be delivered by C-section.
- Preterm birth rates are higher, for reasons that aren’t fully known – 1 in 8 children born in the U.S. each year are born preterm — so more infants have low birth weights. Even late preterm infants (born at 34-36 weeks’ gestation) are at increased risk for health problems.
- Data suggest that fewer U.S. children now live in a household with two married parents than live in a household with a pet.
- Cyber-bullying has become an epidemic.
But pediatric success stories — improved medical and surgical care — have created new challenges. Children surviving prematurity often have developmental and health problems as they get older. More children are living into adulthood with chronic disease or disability – only to find that adult practitioners often aren’t trained to handle diseases like cystic fibrosis and congenital heart disease, because they never used to see them.
But Guttmacher also sketched an optimistic vision of the future of pediatric medicine, one driven by new technologies, particularly in genetics and genomics. That’ll be the topic of my next post.