Saying that “the death of any child is a tragedy and the death of any child from preventable causes is always unjust,” Paul Wise, MD, MPH, FAAP, urged pediatricians attending Friday’s Pediatrics for the 21st Century Symposium to rethink pediatric practice in light of rapid changes that are taking place in the epidemiology of childhood disease and the impact of those changes on everyday practice.

“Modern pediatrics has been characterized by remarkable expansion in clinical capability,” said Dr Wise, the Richard E. Behrman Professor of Child Health and Society, and director of the Center for Policy Outcomes and Prevention at Stanford University School of Medicine.

“The development of a host of new vaccines, highly effective antibiotics, medications for learning and psychiatric disorders, and advances in intensive care and pediatric surgery have all served to profoundly enhance the capacity to provide pediatric services over the past 50 years,” he began.

However, he expressed some concern about the future of pediatric practice.

“Inherent in this record of remarkable success are the seeds of obsolescence from transforming the threats to child health so dramatically that the traditional practice of pediatrics itself becomes increasingly outmoded,” he said.

Dr Wise pointed to a dramatic reduction in acute childhood diseases, and in particular infectious diseases such as pneumoccocal disease, and a steady rise in chronic conditions as major trends in child health care.

“We’ve seen an evaporation of much of the traditional acute infectious disease in this country. At the same time, we’ve seen a slow but steady rise in the prevalence of serious chronic conditions,” he said. “Kids with genetic and neuro-developmental problems, many of whom would have died 20 or 30 years ago, are now surviving and going on to live happy lives, integrating into school, family, and community life.”

He added that rates of asthma have gone up, as has the prevalence of autism. Another chronic problem, obesity, has become far more prevalent among children in America. As a result, hospitals are taking care of more chronic childhood diseases than acute diseases.

“These days, the likelihood that a well child is going to get seriously ill, wind up hospitalized and go on to die is extremely small, much smaller than it’s ever been,” Dr Wise said. “The name of the game more than ever before is serious chronic illness.”

“We are now increasingly expected in pediatrics to confront what I would call precursor conditions to adult-onset disease. Obesity is really a precursor condition,” he said. “It sets kids up for a lifetime of enhanced risk for a series of adult-onset diseases.”

One impact of these trends on pediatric practice is an increased need for ongoing chronic disease management for children. Another impact is the emergence of new well-child care structures, such as retail-based pediatric clinics that represent a challenge to traditional pediatric theory and practice, Dr Wise said.

Other impacts on practice include the growth of the specialty of hospitalists to address the increased complexity of hospital care to treat chronic diseases and the possibility that pediatricians will be less able to take care of chronically ill children in the hospital.

“Kids can be in an outpatient setting, wind up in an ER, go to the ICU, back to the ward and back into primary care practice within 36 hours. So the distinction between outpatient, inpatient and ED care is becoming increasingly blurred. That will put pressure on pediatric practices and hospitals to be far more nimble in their ability to confront complex problems,” Dr Wise.

“The last is what I think is the most troubling. Pediatric practice is increasingly being forced to treat higher and higher volumes of pediatric patients to maintain incomes at the same time that the epidemiology of childhood disease is suggesting that the real action for serious morbidity and mortality is in treating kids with serious chronic illness,” he said.

Dr Wise noted that some pediatricians are turning away children with serious chronic illnesses because they cannot take care of them. “Something is fundamentally wrong with pediatric practice if that is going to happen,” he added.

Dr Wise urged a rethinking of pediatric training, saying, “Such that the trainees spend more and more time in community settings learning how to structure pediatric practices to provide high-quality clinical care for that group of chronically ill kids who need it most.”