Advances in Pediatrics

Life Goes On: Health Care Systems, Complex Medical Conditions, and Newer Trends in Health Care: Post Pandemic

      Overarching health care and health care systems are addressed in several articles in this latest issue of Advances in Pediatrics. Leading off is a discussion of Health Systems Science, the third branch of medicine along with Basic Science and Clinical Medicine. Health Systems Science evaluates the evolution of medicine from solo practice and small medical groups to large complex health systems, and the economics of health care and the medical home. Also included is the impact of COVID-19 on health care and resources and the effect the large-scale social unrest that our society witnessed during the pandemic had. In a similar vein, “When Less Is More: The Role of Overdiagnosis in Pediatric Patient Safety” details how overuse, including overdiagnosis and overtreatment, contributes to the high cost of health care, waste, and patient harm in the form of adverse effects. Avoidance of the inappropriate use of antibiotics is provided through antibiotic stewardship, allowing infectious disease experts to monitor the prescribing of antibiotics and advise medical staff on the appropriate choice and duration of therapy. The involvement of pediatric patients in medical decisions related to their care often requires acknowledging the balance between children as vulnerable individuals requiring protection and their need to be autonomous. Use of the Chenneville protection-autonomy model provides a framework for how best to involve minors in treatment and research. In caring for children, clinicians must remain cognizant of the many antecedent factors that affect a child’s life and their health, and how parental adverse childhood experiences as well as the child’s traumatic experiences have lasting effects.
      On a positive note, improved medical care has allowed children with chronic medical conditions to survive well into adulthood. These children are often followed in complex care clinics by multidisciplinary teams that provide options for addressing challenges that children and families face. When children are admitted to the hospital, care is facilitated not just by the skilled surgical teams but also by the hospitalists who assess the risk for conditions like respiratory problems, venous thromboembolism, and pain management. Although the list of these complex medical conditions is long, we provide an update on inflammatory bowel disease and juvenile idiopathic arthritis.
      Controversies exist around vitamin D, and these resurfaced during COVID. Vitamin D in pediatrics also has unresolved questions, including the lack of a standard definition of optimal vitamin D status. Less controversial is the importance of a breast exam in pediatric patients, particularly teens. While most breast masses are benign, patients as well as their parents are often concerned. When to observe, when to do an ultrasound, and when to do a fine needle biopsy are some of the issues to consider when a patient complains of a breast lump. While breast masses may be detected by physical examination, tumors in other areas, such as the pituitary or the adrenal gland, may present with an array of symptoms, including alterations in growth and development, or as an incidental finding when imaging studies are done for unrelated reasons. The assessment and management of endocrine tumors depend on the associated studies and findings that are detailed in their respective articles.
      As is always the case, Advances in Pediatrics reports on children across the entire age spectrum from infancy through late adolescence. We are able to see the latest approach to esophageal atresia, including diagnosing any associated syndromes. We also learn about the “Trends in Recreational Drug Use and Ingestion” and the wide sometimes perplexing picture with which these patients present. This year, as in the past, there remain new developments in how health care is delivered and, in the diagnosis and management of the many conditions that affect the pediatric population.