gateway.aap.org From 2008-’ 10, I participated in the
Vision of Pediatrics 2020 project. Eight
transformational drivers of pediatrics were
identified, No. 1 being the changing so-
cial and clinical demographics of the child
population. The Vision of Pediatrics 2020
report postulated increasing rises of health
problems related to social determinants of
health and chronic illness.
I believe the changing demographics and epidemiology of
morbidity and mortality in childhood and adolescence are
both challenging and transforming the practice of pediatrics.
During the early 1900s, pediatricians concentrated on educating parents about child-rearing, treating infectious diseases
(for which neither antibiotics nor vaccines were available), respiratory and diarrheal illnesses, and the care of minor trauma.
With the advent of antibiotics, vaccines and infection control
and the explosion of scientific knowledge regarding health
and disease toward the middle of the 20th century, pediatricians were able to diagnose and treat diseases in a consistent,
Mortality in children under 5 has decreased by more than
75% in the last 50 years. Mortality in the pediatric intensive
care unit dropped from nearly 30% in the early 1970s to 3%
The absolute number of children living with congenital and
genetic disorders, the decrease in morbidity and mortality from
infectious diseases, and the increase in survival rates in neonatal
and pediatric intensive care units have contributed to a shift
in the nature of diseases encountered in everyday pediatrics.
This shift has been in the direction of greater complexity, with
increasingly frequent visits from children with neurodevelop-mental disorders and sequalae correlated to social determinants
After age 5, the majority of the burden of disease in children
now is from noncommunicable diseases (NCDs). Traumatic
injuries, malignant neoplasms, diabetes related to obesity, suicide and homicide lead the list.
Life expectancy at birth has been increasing every year in
the U.S. for the last 50 years — until 2015 when it decreased.
The World Health Organization makes a compelling case for
the difference between life expectancy at birth and healthy
life expectancy. The U.S. is seeing an increase in the number
of years lost due to disability, and we saw with concern the
absolute decrease in life expectancy in 2015. In 2016, our
country ranked 42nd in the world for life expectancy at birth
at 79.6 years. At the top are Monaco and Singapore with 89.6
and 84.8 years, respectively. The top three causes of mortality
are cardiovascular diseases, malignant neoplasms and chronic
lower respiratory diseases.
What also should concern us is that the premature death
rate (dying before the average life expectancy) is on the rise.
Even more alarming is the fact that according to the Population
Reference Bureau, half of premature deaths in the U.S. are
preventable. The keys to prevention are modifiable behaviors
known so well by all pediatricians, including poor diet, lack of
exercise and tobacco use, according to the National Research
Council and the Institute of Medicine.
When looking at NCDs in order of prevalence and as a
cause of death, we draw the inevitable conclusion that work
must start during the pediatric ages to prevent them. But our
patients grow up and leave us. One thing we can do is engage
our adult medicine colleagues in disease prevention efforts that
continue for a lifetime.
While the pediatrician clearly plays a pivotal role, along with
all physicians, we know these challenges cannot be solved in the
doctor’s office alone. To win the battle against NCDs, there has
to be a convergence of physicians, medical scientists, educators,
legislators, government, business and industry.
The pediatrician’s office already is a cross-section of the so-
cial, economic and political problems manifesting themselves
in a variety of forms. The social determinants of health are
raising their claws more and more every day. Is the pediatrician
capable of solving this in the 15 minutes per patient expected
by the health plan? Hardly.
We as pediatricians are witnesses to the consequences of
policies being decided elsewhere. Now more the ever before,
we have to raise our voices in defense of children and families.
We must play a leadership role and articulate the important
difference between life expectancy at birth and years lost due
The challenge for the pediatrician is the tension between
wanting to do what is right for the patient and family and
the sense that the problems are too big, too complex or both.
This is a known factor contributing to pediatrician burnout.
I believe it is too heavy a lift for pediatrics alone. To me, the
answer is clear. We must follow the call of past AAP leaders
and double our efforts to engage new partners to work with
us in innovative ways.
Pediatricians must partner with others
on disease prevention
Fernando Stein, M.D., FAAP
President, American Academy of Pediatrics
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• Recalled children’s products,
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