An Overview of Pediatrics

 

                                    

                                          Figure taken from Nelson Textbook of Pediatrics, 21 edition

Introduction

Pediatrics stands as the sole discipline entirely dedicated to the comprehensive care and well-being of infants, children, and adolescents. This encompasses not only their physical health but also their mental, social, and psychological growth and development. Moreover, it pertains to their potential to attain full adulthood. Pediatricians possess the responsibility to focus not solely on specific organ systems, genetics, and biological processes, but also on environmental, psychosocial, cultural, and political influences. These various factors can significantly impact the health and wellness of children and their families.

Advocacy for children is essential, as they are not entirely capable of advocating for themselves. Serving as professionals committed to enhancing children's well-being, pediatricians must champion the cause of each individual child and all children as a whole. This advocacy transcends cultural, religious, gender, sexual orientation, racial, or ethnic boundaries, as well as local, state, or national divisions. The importance of advocacy becomes even more pronounced when dealing with populations that are politically, economically, or socially marginalized. These groups require strong advocacy efforts for their children and those who support them. Given their vulnerability, youth necessitate special attention.

As the lines between nations become increasingly blurred due to advancements in media, transportation, technology, communication, and economics, a global perspective becomes indispensable for the field of pediatrics. This shift is both a reality and a necessity. The interconnectedness of health issues worldwide has become evident through events like the Zika, Ebola, SARS, and AIDS epidemics, conflicts, bioterrorism, natural disasters such as the 2004 tsunami and the 2010 Haiti earthquake, and the displacement of families during the Syrian refugee crisis in 2016–2018. Additionally, the growing severity of droughts, hurricanes, and cyclones, consequences of climate change further highlight the global nature of health challenges.

Over a century ago, pediatrics emerged as a distinct medical specialty due to the growing recognition that children's health problems differ from those of adults. The response to disease and stress in children varies with age and development. In 1959, the United Nations issued the Declaration of the Rights of the Child, establishing the universal presumption that children everywhere possess fundamental needs and rights. Presently, the affirmation of these rights and the commitment to fulfilling these needs hold more significance than ever before.

 

Key Insights Regarding Children's Health on a Global Scale

From 1990 to 2010, the global population experienced a yearly growth rate of 1.3%, a decline from the 1.8% rate over the preceding two decades. This rate of growth has continued to decrease, reaching 1.13% in 2016. Globally, the population under 18 years old stands at 2.34 billion individuals, which constitutes around a third (32%) of the total world population of 7.4 billion. In 2016, the average birth rate across the world was 18.5 births per 1,000 people, with Niger having the highest rate at 44.8 births per 1,000 and Monaco the lowest at 6.6 births per 1,000. The most populous countries, namely China, India, and the United States, exhibit rates of 12.4,19.3, and 12.5 births per 1,000 population, respectively.

Despite the increasing global interconnectedness, the health status of children and youth displays considerable variation both between and within different regions and nations. This variation is influenced by an array of interconnected factors: economic circumstances, educational, social, and cultural considerations, healthcare infrastructure, climate, and geographical elements, agricultural practices influencing nutritional resources, stages of industrialization and urbanization, gene frequencies related to specific disorders, the interplay between infectious agents and their hosts, social stability, and political priorities and stability. While genetics, biology, and access to affordable and high-quality healthcare hold significance, it is evident that social determinants of health, encompassing the physical environment, political and economic conditions, social and cultural aspects, and behavioral psychology, exert an equally if not greater impact on health outcomes.

In 2000, to ensure that the needs of both children and adults on a global scale were adequately addressed, the international community established 8 Millennium Development Goals (MDGs) aimed at achieving tangible outcomes by 2015. While all 8 MDGs have an impact on child well-being, MDG 4 was exclusively dedicated to children: reducing the under-five mortality rate (U5MR) by two-thirds between 1990 and 2015. It was observed that poor nutrition accounted for over a third of deaths worldwide among children under the age of 5. Many initiatives to achieve this goal focused on enhancing household food security. Additionally, increasing measles vaccination, particularly in sub-Saharan Africa, was a strategy to mitigate U5MR. Progress was made towards MDG 4, with a 50% reduction in worldwide U5MR between 1990 and 2015. Although the goal of a two-thirds reduction was not entirely reached, child deaths under the age of 5 decreased from 12.7 million in 1990 to approximately 6 million in 2015, even as the world population grew during the same period.

The U5MR can be further categorized into neonatal (<1 month of age), infant (<1 year of age), and post-infancy (1-5 years of age) periods. The leading causes of global U5MR are complications arising from preterm birth, pneumonia, perinatal asphyxia, diarrheal diseases, and malaria. Many of these causes are intricately linked to malnutrition. Notably, children in sub-Saharan Africa are 14 times more likely to experience mortality before the age of 5 compared to their counterparts in more developed regions of the world.

 

Disparities in Under-5 Mortality Causes Between Developed and Developing Nations

The causes of mortality among children under the age of 5 exhibit significant variations between developed and developing countries. In developing nations, a staggering 66% of deaths in this age group are attributed to infectious and parasitic diseases. Among the 42 countries accounting for 90% of childhood fatalities, diarrheal disease accounts for 22% of deaths, pneumonia for 21%, malaria for 9%, AIDS for 3%, and measles for 1%. Neonatal causes contribute to 33% of the mortality.

Contrastingly, in the United States, pneumonia (including influenza) contributes to only 2% of under-5 deaths. Negligible contributions are observed from diarrheal diseases and malaria. Among U.S. children aged 1-4 years, unintentional injuries stand as the leading cause of death, comprising approximately 33% of fatalities. This is followed by congenital anomalies at 11%, homicides at 9%, and malignant neoplasms at 8%. Other factors contribute to less than 5% of the overall mortality within this age group. Notably, violence plays a significant role in injury-related mortality across all age groups of children. While unintentional injuries hold a relatively smaller role in the causes of mortality within developing countries, the absolute rates and contributions of these injuries to morbidity are considerably higher compared to developed countries.

 

Distribution of Child Mortality Rates: Insights and Disparities

In developed nations, the infant mortality rate, which encompasses deaths of children under 1 year old, constitutes 85% of the under-5 mortality rate (U5MR). However, this percentage is slightly lower at 70% in the least developed countries. Neonatal deaths, occurring within the first month of life, also hold significant importance, particularly as the U5MR decreases. Globally, the neonatal mortality rate, at 19 deaths per 1,000 live births, accounts for 60% of the infant mortality rate and 45% of the U5MR. Notably, the neonatal mortality rate contributes to 56% of the U5MR in industrialized nations, 45% in developing countries, and 38% in the least-developed countries. It's noteworthy that in developing nations, a greater number of children under 5 years old succumb to non-birth-related causes.

Child mortality rates exhibit substantial variations on a global scale, differing by nation, region, economic status, and level of industrial development, as categorized by the World Bank). By 2015, eight nations, all situated in the WHO African region, reported a U5MR of ≥100 per 1,000 live births. The average U5MR in low-income countries stood at 76 per 1,000 live births, while in high-income countries, it was 6 per 1,000. However, it's important to note that income and wealth alone do not solely determine mortality rates. For instance, the United States ranks 10th highest in gross national income per capita but held the 57th position in terms of the lowest infant mortality rate as of 2016.

In addition to mortality rates, the causes of death also vary based on a nation's developmental status. In the United States, the three leading causes of death among children under 5 years old were congenital anomalies, disorders related to gestation and low birth weight, and unintentional injuries. Conversely, in developing countries, the majority of infant deaths stem from pneumonia, diarrheal diseases, and malaria.