Much has been written about team-based care in the adult literature, but
there is a paucity of information on
what this should look like for children. A new AAP policy statement addresses how
team-based care should incorporate what is unique
about children and outlines what is optimally needed
to support children and families.
The policy, Guiding Principles for Team-Based Pediatric Care, is available at https://doi.org/10.1542/
peds.2017-1489 and is published in the August issue
Team-based care for children is different from that
for adults for three key reasons:
• Early environment and experiences have crucial
effects on lifelong health.
• Resources targeted toward health promotion
and disease prevention have significant societal
• Pediatrics fundamentally incorporates the dynamic nature of childhood.
Medical home ‘plus’
The policy recommends a team that continually
works to keep children and their families or caregivers
at the center. In addition, it’s important to think of
the team as one that extends beyond and enhances the
medical home, and is dynamic as the child grows/de-velops and is responsive to his or her changing needs.
For example, an infant’s team may include the pediatrician, a lactation consultant, the obstetrician-gy-
Team-based care for children:
Who should be included and who should lead?
Module on team-based care in pediatric primary care
offices, AAP practice transformation site, http://bit.ly/
Don’t ‘define’ pediatric metabolic syndrome;
treat risk factors, report advises
necologist if the parent is depressed and a community
home-visiting program. A troubled teen’s team might
include the pediatrician, foster parents, a child psy-
chiatrist, a school psychologist and a wrap-around
While team-based statements produced by other
entities do not specifically state that teams should be
led by a physician, this policy clearly articulates that
pediatricians are the ideal leaders of team-based care
for children. The locus of leadership may shift over
time, residing with the primary pediatric provider or
the pediatric medical or surgical subspecialist, or it
may be shared among them when appropriate. Also,
the team’s composition and pediatrician leadership
will change as the needs of the child and family change.
Does this mean the pediatrician must do everything? Absolutely not.
From an operational viewpoint, other members
with child and/or adolescent expertise may be the
most appropriate team leaders to oversee and pro-
vide details of care delivery. However, as the policy
states, “A pediatrician (general pediatrician, pediatric
medical subspecialist or pediatric surgical subspecial-
ist) is uniquely qualified, on the basis of training and
expertise, to oversee the team, provide administrative
oversight and serve as a resource to promote optimal
functioning while meeting the needs of the patient
and family, given available resources.”
No single person or entity can meet the needs of a
child and family throughout their growth and devel-
opment. Team-based care asks us all to reflect on what
we do best and identify opportunities where others
can contribute, then work together toward a shared
goal: to better meet the needs of children and families
and help them achieve their potential.
Much work is to be done if every child is given the
opportunity to be served by a high-functioning team.
These include the following, according to the policy:
• Payment models are needed to support appropriate payment for implementation, ongoing infrastructure, collaboration and continuous improvement to sustain team-based care for children and
• Medical school, residency training and continuing
medical education need to incorporate principles
and practice of team-based care and development
of team leadership skills for pediatricians. Pediatricians will need education, implementation
toolkits, technical assistance and infrastructure
support to transform their practices.
• Implementation of technology-enabled communication is needed to establish, support and
strengthen communication across the care team.
Electronic platforms are needed to share medical records and key information in an accessible
format so that all team members — including
children and families — can communicate in real
time, while respecting confidentiality.
• Children and families should be confident that
they are at the center of the team. Shared decision-making skills are key to strengthening
collaboration among team members, physicians
• Communities need information and incentives to
partner with pediatricians and others dedicated
to the health of children in a more comprehensive
and collaborative team-based approach to care.
All stakeholders should examine how effectively
they reach families and children who need services and work together to close gaps in resources.
As the evidence mounts toward better understanding of the influences of social determinants of health
on outcomes, as well as the interdependence on mental and physical health, it’s becoming increasingly apparent that pediatricians cannot do this work alone.
We are an integral part of, and uniquely qualified to
serve as leaders of team-based care, but we must look
at the broader landscape to work with others to give
children and families what they need
Dr. Kressly is a lead author of the policy and a member of the AAP Task Force
on Pediatric Practice Change.
Clinicians should screen for and
treat the individual risk factor components of “metabolic syndrome”
(MetS) and avoid trying to define
what the syndrome means in pediatric care, according to a new AAP clinical report.
In adults, the term MetS is used to identify those
at risk of diabetes and cardiovascular disease when
they have at least three of five cardiometabolic risk
factors: hyperglycemia, increased central adiposity,
elevated triglycerides, decreased high-density lipoprotein cholesterol and elevated blood pressure.
In children, however, MetS “is difficult to define and has unclear implications for clinical care,”
according to The Metabolic Syndrome in Children
and Adolescents: Shifting the Focus to Cardiometabolic
Risk Factor Clustering. The report from the AAP
Committee on Nutrition, Section on Endocrinology and Section on Obesity is available at https://
doi.org/10.1542/peds.2017-1603 and is published
in the August issue of Pediatrics.
The report discusses the pathophysiology, the nuances of the definitions of MetS, the determinants
of metabolic risk factor clustering, comorbidities,
screening and treatment.
Following are key points:
• The focus for clinical screening and treatment
should be on cardiometabolic risk factors,
many of which cluster together and are associ-
ated with obesity.
• Pediatricians should not focus on the specific
levels of cardiometabolic risk factors from the
multitude of MetS definitions because the risk
lies on a continuum and in the context of the
• To address the major MetS-associated cardiometabolic risks in pediatric populations,
follow recommendations for screening and
treatment of obesity, glucose abnormalities,
hypertension and dyslipidemia.
• By identifying children with multiple component risks, pediatricians can apply the most
intensive intervention efforts to the patients in
greatest need of risk reduction.
• Increase awareness of comorbid conditions —
such as nonalcoholic fatty liver disease, mental health disorders, polycystic ovary syndrome
and obstructive sleep apnea — to address
these issues and refer patients to specialists as