What are pediatrics?

Science and Profession

The practice of pediatrics begins with birth. Most babies are born healthy and
require only routine medical attention. Many hospitals, however, have a
neonatology unit for babies who are born
prematurely, who have disease conditions or birth
defects, or who have low birth weight, weighing less than
5.5 pounds (even though they may be full-term babies). All these infants may
require short-term or prolonged care by pediatricians in the neonatology unit.

The problems of premature babies usually center on the fact that they have not
fully developed physically, although other factors may also be involved, such as
the health and age of the mother, undernourishment during pregnancy, lack of
prenatal care, anemia, high blood pressure, abnormalities in the mother’s
reproductive organs, infectious disease, or physical trauma or injury to the
mother. A past record of infertility, stillbirths, abortions, and other
premature births may indicate that a pregnancy will not go to full term.

Low birth weight in both premature and full-term babies is directly related to the
incidence of disease and congenital defects. Low-birth-weight infants have a 50
percent higher chance of experiencing developmental problems, including hearing
and vision problems and chronic conditions such as heart disease later in life.
Recent studies also indicate an increase in neurological problems such as
attention-deficit hyperactivity disorder and autism spectrum disorder in these
children.

Because the lungs are among the organs that develop late in pregnancy, many
premature infants are unable to breathe on their own. Some premature babies are
born before they have developed the sucking reflex, so they cannot feed on their
own.

Hundreds of congenital diseases can be present in the neonate. Some are apparent at birth; some become evident in later years. Some may be life-threatening to the infant or become life-threatening in later years. Others may be harmless.

The child may be born with an infection passed on from the mother, such as
rubella (German measles) or human immunodeficiency
virus (HIV). Rubella may also infect the child in the womb,
causing severe physical deformities, heart defects, cognitive delays, deafness,
and other conditions. Genital herpes affects about 2,000 newborns in the United
States each year and may cause serious complications. A herpes infection during
the second or third trimester of a woman’s pregnancy may increase the chance of
preterm delivery or cesarean section. Group beta
strep (GBS) infections are another serious problem for one of
every 2,000 newborns in the United States. GBS infection may cause sepsis (blood
infection), meningitis, and pneumonia. Pregnant women are tested for GBS infection
during pregnancy, typically at thirty-five to thirty-seven weeks. With a course of
antibiotics, a woman who tested positive for GBS infection has only a 1 in 4,000
chance of delivering a baby with GBS infection, compared to a 1 in 200 chance
without antibiotics.

Among the most prevalent congenital birth defects is cleft lip and
palate. Cleft lip occurs when the upper lip does not fuse
together, leaving a visible gap that can extend from the lip to the nose. Cleft
palate occurs when the gap reaches into the roof of the mouth.

Various abnormalities may be present in the hands and feet of neonates. These can be caused by congenital defects or by medications given to the pregnant mother. Arms, legs, fingers, and toes may fail to develop fully or may be missing entirely. Some children are born with extra fingers or toes. In some children, fingers or toes may be webbed or fused together. Clubfoot is relatively common. In this condition, the foot is twisted, usually downward and inward.

Many congenital heart defects can afflict the child, including septal defects
(openings in the septum, the wall that separates the right and left sides of the
heart), the transposition of blood vessels, the constriction of blood vessels, and
valve disorders. Newborns are screened for congenital heart defects before leaving
the hospital after birth.

Congenital disorders of the central nervous system include spina bifida,
hydrocephalus, cerebral palsy, and Down syndrome. Spina bifida
is a condition in which part of a vertebra (a bone in the spinal column) fails to
fuse. As a result, nerves of the spinal cord may protrude through the spinal
column. This condition varies considerably in severity; mild forms can cause no
significant problems, while severe forms can be crippling or life-threatening. In
hydrocephalus, sometimes called “water on the brain,” fluid
accumulates in the infant’s cranium, causing the head to enlarge and putting great
pressure on the brain. This disorder, too, can be life-threatening.

Cerebral
palsy is caused by damage to brain cells that control motor
function in the body. This damage can occur before, during, or after birth. It may
or may not be accompanied by mental disability. Many children with cerebral palsy
appear to have below-average intelligence because they have difficulty speaking,
but, in fact, their intelligence may be normal or above normal. Down syndrome
(trisomy 21) is one of the most common chromosomal anomalies detected at birth,
affecting 1 in 691 infants born to mothers. It is caused by an extra chromosome
passed on to the child. The distinct physical characteristics of Down syndrome
include a small body, a small and rounded head, oval ears, and an enlarged tongue.
Mortality is high in the first year of life because of infection or other
disease.

Cystic
fibrosis is one of the most serious genetic disorders of
Caucasian children. Because the lungs of children with this disease cannot expel
mucus efficiently, it thickens and collects, clogging air passages. The mucus also
becomes a breeding ground for bacteria and infection. Other parts of the body,
such as the pancreas, the digestive system, and sweat glands, can also be
impaired. A common congenital disorder among African
American children is sickle cell disease. It causes
deformities in red blood cells that clog blood vessels, impair circulation, and
increase susceptibility to infection.

One of the major problems of infancy is sudden infant death syndrome (SIDS), in
which a baby that is perfectly healthy, or only slightly ill, is discovered dead
in its crib. In 2011 in the United States, over 2,200 infant deaths were reported
as SIDS, according to the US Centers for Disease Control and Prevention. The cause
is not known. The child usually shows no symptoms of disease, and autopsies
reveal no evidence of smothering, choking, or strangulation. Research indicates
that rebreathing of carbon dioxide as well as exposure to secondhand cigarette
smoke and other forms of indoor air pollution may greatly
increase the risk of SIDS.

Infectious diseases are more prevalent in childhood than in later years. Among the
major diseases of children (and often adults) throughout the centuries have been
smallpox, malaria, diphtheria, typhus, typhoid fever,
tuberculosis, measles, mumps, rubella, varicella
(chickenpox), scarlet fever, pneumonia,
meningitis, and pertussis (whooping cough). In more recent years,
HIV and hepatitis infection have also become significant threats to the young.

Certain skin diseases are common in infants and young children, such as
diaper
rash, impetigo, neonatal acne, and seborrheic
dermatitis, among a wide variety of disorders. Fungal diseases of the skin occur
often in the young, usually because of close contact with other youngsters. For
example, tinea pedis (athlete’s foot), tinea cruris
(jock
itch), and tinea corporis (a fungal infection that
occurs on nonhairy areas of the body) are spread by contact with an infected
playmate or by the touching of surfaces that harbor the organism. Similarly,
parasitic diseases such as head lice, body lice,
crabs, or scabies are easily spread among
playmates. Some skin conditions are congenital. Between 20 and 40 percent of
infants are born with, or soon develop, skin lesions called hemangiomas.
They may be barely perceptible or quite unsightly; they generally resolve by the
age of seven.

One form of diabetes mellitus arises in childhood, insulin-dependent
diabetes mellitus (IDDM) or type 1. In the healthy individual, the pancreas
produces insulin, a hormone that is responsible for the metabolism of blood sugar,
or glucose. In some children, the pancreas loses the ability to produce insulin,
causing blood sugar to rise. When this happens, a cascade of events causes harmful
effects throughout the body. In the short term, these symptoms include rapid
breathing, rapid heartbeat, extreme thirst, vomiting, fever, chemical imbalances
in the blood, and coma. In the long term, diabetes mellitus contributes to heart
disease, atherosclerosis, kidney damage, blindness, gangrene, and a host of other
conditions.

Cancer can afflict children. One of the most serious forms is acute lymphocytic
leukemia. Its peak incidence is between three and five years
of age, although it can also occur later in life. Leukemia is
characterized by the overproduction of white blood cells (leukocytes). In acute
lymphocytic leukemia, the production of lymphoblasts, immature cells that
ordinarily would develop into infection-fighting lymphocytes, is greatly
increased. This abnormal proliferation of immature cells interferes with the
normal production of blood cells, increasing the child’s susceptibility to
infection.

In addition to the wide range of diseases that can beset the infant and growing
child, there are many other problems of childhood that the parent and the
pediatrician must face. These problems may involve physical
and behavioral development, nutrition, and relationships with
parents and other children.

Both parents and pediatricians must be alert to a child’s rate of growth and
mental development. Failure to thrive in infancy may
indicate a range of physical problems, such as gastrointestinal, endocrine, and
other internal disorders. In three-quarters of these cases, however, the cause is
not a physical disorder. The child may simply be underfed because of neglect.
Failure to thrive is seen often in babies who are reared in institutions where the
nursing staff does not have time to caress and comfort infants individually.

Similarly, later in childhood, failure to grow at a normal rate can be caused by
malnutrition or psychological factors. It could also be attributable to a
deficiency in a hormone that is the body’s natural regulator of growth. If this
hormone is not released in adequate supply, the child’s growth is stunted. An
excess of this hormone may cause the child to grow too rapidly. Failure to grow
normally may also indicate an underlying disease condition, such as heart
dysfunction and malabsorption problems, in which the child does not get the
necessary nutrition from food.

The parent and pediatrician must also ensure that the child is developing
acceptably in other areas. Speech and language skills, teething, bone development,
walking and other motor skills, toilet habits, sleep patterns, eye development,
vision, and hearing have to be evaluated regularly.

Profound intellectual disability is usually evident early in life, but mild to
moderate disability may not be apparent until the child starts school. Slowness in
learning may be indicative of intellectual disability, but this judgment should be
carefully weighed, because the real reason may be impaired hearing or vision,
neglect, or an underlying disease condition. The diagnosis of developmental
disabilities and neurological disorders, such as autism
spectrum disorder and attention-deficit hyperactivity
disorder (ADHD), has greatly increased in recent years and
poses a special challenge to both parents and pediatricians.

The battery of diseases and other disorders that may beset a child remains more or
less constant throughout childhood. Puberty, however, begins hormonal
changes that trigger new disease threats and vast psychological upheaval. As early
as eight years of age in girls and after ten or eleven years of age in boys, the
body begins a prolonged series of changes that changes the child into an adult.
Hormones that were previously released in minimal amounts course throughout the
body in great quantities.

In boys, the sex hormones are called androgens. Chief among them is testosterone,
which is secreted primarily by the testicles. It causes the sexual organs to
mature and promotes the growth of hair in the genital area and armpits and on the
chest. Testosterone also enlarges the larynx (voicebox), causing the voice to
deepen.

Girls also produce some testosterone, but estrogens and other female sex hormones
are the major hormones involved in puberty. They cause the sexual organs to
mature, the hips to enlarge and become rounded, hair to grow in the genital area
and armpits, the breasts to enlarge, and menstruation
to begin.

Many disease conditions can arise in association with the hormonal changes that
occur during puberty, such as breast abnormalities and genital infections. Far and
away the most common medical disorder at this time, however, is acne. Acne is
a direct result of the rise in testosterone that occurs during puberty. About 85
percent of teenagers experience some degree of acne, and about 12 percent of these
will develop severe, deep acne, a serious condition that can leave lifelong
scars.

Important psychological changes also occur during puberty. The personality can be
altered as the developing child begins to crave independence. Ties to the family
weaken, and the teenager becomes closer to his or her peer group. Sexual feelings
can be strong and difficult to repress. In modern society, this can be the time
when the teenager begins to experiment with tobacco, alcohol, drugs, or other
means of achieving a “high,” although in some groups the use of these substances
begins much earlier. Substance abuse is a major problem
throughout society, but it is particularly devastating among young people.

Sexual activity among teenagers is widespread and, combined with inadequate
education about health issues and limited access to care, has led to significant
medical problems. The incidence of sexually transmitted infections (STIs)
is higher among teenagers than any other group. Teenage
pregnancy is also a challenging issue in modern society.

If the pregnant teenager who continues her pregnancy is from a disadvantaged
family background, she is even more likely than other teen mothers to receive
little or no prenatal care. Risks of delayed or absent prenatal care can include a
fetus that is not properly nourished. Additional risks can arise from a mother who
smokes, drinks alcohol, or takes drugs throughout the pregnancy. In these cases,
the child often may be born prematurely, with all the physical problems that
premature
birth involves. Hospital care of these infants is extremely
costly.

Diagnostic and Treatment Techniques

Pediatrics is one of the widest-ranging medical specialties, embracing virtually
all major medical disciplines. Some pediatricians are generalists, and others
specialize in pediatric cardiology, pediatric
endocrinology, pediatric gastroenterology,
pediatric
oncology and hematology, pediatric
dermatology, pediatric emergency medicine, or
pediatric
surgery.

Doctors and nurses specializing in neonatology, including advanced practice nurse
practitioners with specialty certification in pediatrics or neonatology, have
radically improved the survival rates of premature and low-weight babies. In
neonatal care of the premature newborn, the infant may have to be helped to
breathe, fed through tubes, and otherwise maintained to allow it to develop.

Infectious diseases passed from the mother to the newborn child are a particular challenge. In some cases, such as with GBS and herpes infections, appropriate antibiotics and antiviral agents can be given. In others, such as with babies born with HIV, support measures and medications that help prevent the progress of the disease are the only procedures available.

Many birth defects and deformities can be repaired or ameliorated. Disorders such
as cleft lip or palate, deformities of the skeletal system, heart defects, and
other physical abnormalities often can be remedied by surgery. Certain structural
malformations may require prosthetic devices and/or physical therapy.

The treatment of spina bifida depends on the seriousness of the condition; surgery
may be required. With hydrocephalus, medication may be helpful, but most often a
permanent shunt is implanted to drain fluids from the cranium. Before
this technique was developed, the prognosis for babies with hydrocephalus was
poor: More than half died, and a great many suffered from mental disability and
physical impairment. Today, 70 percent or more live through infancy. Of these,
about 40 percent have normal intelligence.

There are no cures for cerebral palsy, but various procedures can improve the
child’s quality of life, exercise and counseling among them. Neither is there a
cure for Down syndrome. If intellectual disability is profound, the child may
require institutionalized care. When a child with Down syndrome can be cared for
at home in a loving family, his or her life can be improved.

SIDS continues to be a problem both in hospitals and in the home. The American Academy of Pediatrics’ Back to Sleep campaign, in which parents are encouraged to place babies on their backs for sleeping, has been extremely successful, however, and has resulted in a decrease in the incidence of SIDS by 70 to 80 percent.

Managing the infectious diseases of childhood is one of the major concerns of
pediatric providers, who are often called on to treat infections, for which they
have a wide variety of antibiotics and other agents. Pediatric providers also seek
to prevent infectious diseases through immunization and vaccination. Medical
authorities now recommend routine vaccination of all children in the United States
against diphtheria, tetanus, pertussis, measles, mumps, rubella, poliomyelitis,
pneumococcal pneumonia, Hemophilus influenzae, varicella,
hepatitis A and B, and human papillomavirus. Vaccines are also available against
rabies, influenza, cholera, typhoid fever, plague, and yellow fever; these
vaccines can be given to the child if there is a danger of infection. Vaccines for
diphtheria, tetanus, and pertussis are generally given together in a combination
called the DTaP
vaccine. Measles, mumps, and rubella vaccines are also given
together as the MMR vaccine. Repeated doses of some vaccines are necessary
to ensure and maintain immunity.

Skin disorders of childhood, including teenage acne, are usually treated successfully at home with over-the-counter remedies. As with any disease, however, a severe skin disorder requires the attention of a trained provider.

Patients with diabetes mellitus type 1 are dependent on insulin throughout life. It is necessary for the pediatrician or attending nurse to teach both the parent and the patient how to inject insulin regularly, often several times a day. Furthermore, patients must monitor their blood and urine constantly to determine blood sugar levels. They must also adhere to stringent dietary regulations. This regimen of diet, insulin, and constant monitoring is often difficult for the child to learn and accept, but strict adherence is vital if the patient is to fare well and avoid the wide range of complications associated with diabetes.

Other serious conditions are now considered to be treatable. Modern pharmacology
has greatly improved the prognosis of children with leukemia. Similarly, many
children with growth disorders can be helped by treatments of growth
hormone.

Medications and other treatment modalities for the mental disorders of childhood
have improved in recent years. Children with intellectual disabilities can often
be taught to care for themselves, and some even grow up to live independently.
Children with behavioral problems may be helped by clinicians specializing in
child
psychology or psychiatry.

The problems of sexuality, sexually transmitted infections, and pregnancy among
teenagers have provoked a nationwide response in the United States among medical
and sociological professionals. Safe-sex programs have been launched,
and clinics specializing in counseling for teenage girls are in operation to stem
the rise in teenage pregnancies.

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