Primary Care Pediatrics and Public Health: Meeting the Needs of Today’s Children

摘要

The proportion of children suffering from chronic illnesses—such as asthma and obesity, which have significant environmental components—is increasing. Chronic disease states previously seen only in adulthood are emerging during childhood, and health inequalities by social class are increasing. Advocacy to ensure environmental health and to protect from the biological embedding of toxic stress has become a fundamental part of pediatrics. We have presented the rationale for addressing environmental and social determinants of children’s health, the epidemiology of issues facing children’s health, recent innovations in pediatric medical education that have incorporated public health principles, and policy opportunities that have arisen with the passage of the 2010 Patient Protection and Affordable Care Act. In pediatrics, the acknowledgment of child development as a transactional process and ultimate determinant of adult capacity has important implications for the development of systems, practice models, and training. If we are to ensure children’s health and, ultimately, overall population well-being, childhood service systems must become responsive and coordinated on many levels; practitioners must develop multiple skills outside the traditional medical model; and training strategies must become innovative. Promoting access to effective health and health-related services is essential for achieving Healthy People 2020 objectives (the US Department of Health and Human Services’ set of health-promotion and disease-prevention goals to be achieved nationwide by 2020). There are many examples of shortfalls in adequacy of available services, effectiveness of care provided, organization of services, and focus on primary prevention. Up to 50% of developmental problems in children are not identified until school entry, 1 more than 8 million children remain without health care coverage in the United States, and a much larger number have no regular source of health care except in emergencies. 2 In addition to inadequate funding for appropriate services, the network of programs serving children is increasingly fragmented, difficult to navigate, and unresponsive. A major challenge for children’s and youths’ services is to develop more effective and efficient service integration models. In the present system, pediatricians tend to avoid asking parents about matters for which they feel inadequately trained and for which they are not aware of patient resources, including child development, obesity, breastfeeding, family violence, environmental health, and mental health. The system will not respond without adequately prepared clinician–advocates who recognize and understand these issues and their relationship to ultimate outcomes.