Pediatric Medicine and Surgery

Summary

Pediatric medicine focuses on diagnosing and treating diseases in infants and children. Doctors in this specialty are known as pediatricians. Pediatric surgery focuses on the surgical treatment of diseases in infants and children. Sometimes the diagnosis is made by a pediatrician, who then refers the patient to a pediatric surgeon. On other occasions, the pediatric surgeon makes the diagnosis and then performs the surgery. Subspecialties exist within both the medical and surgical fields. For example, some pediatricians focus on pediatric endocrinology (endocrine glands), and some specialize in pediatric oncology (cancer treatment). Some pediatricians focus on a certain age group, such as adolescents, and others specialize in neonatology, the medical treatment of newborns.

Definition and Basic Principles

Pediatric medicine is a medical specialty focused on the diagnosis and treatment of children from infancy through adolescence. Pediatric surgery is a surgical specialty focused on surgery for children. A pediatrician receives specialized training in pediatric medicine after completing medical school; a pediatric surgeon receives training in general surgery plus additional training in pediatric surgery.

Subspecialties exist in both the medical and surgical fields. For example, a pediatrician might specialize in adolescents, and a pediatric surgeon might specialize in pediatric cardiothoracic surgery. Some medical and surgical problems are similar to those of adults (such as pneumonia and appendicitis). However, others are unique to children (such as a cardiac defect, which, if not corrected, will result in childhood death).

Preventive health care is a significant component of pediatric care. Immunizations are scheduled for diseases such as diphtheria, pertussis (whooping cough), and tetanus. The immunization is given in a combined injection known as DPT. Congenital disorders often appear at birth or within the first few years of life. Some, such as phenylketonuria, which causes cognitive disabilities, can be corrected if recognized early. Other disorders, such as cystic fibrosis, cannot be cured. However, the patient can live longer and more healthily if the disease is recognized early and treatment is initiated.

An important and often underemphasized role of the pediatrician is educating parents so that their child can develop to their full potential—mentally, physically, and emotionally.

Background and History

Pediatric medicine arose as a medical specialty in the United States (US) in 1861. Before that time, children's healthcare was included in fields such as general medicine, obstetrics, and midwifery. The German physician Abraham Jacobi emigrated to the United States in 1853 and established a training program at New York Medical College that focused on the diseases of infants and children. He published articles in medical journals and developed children's wards in several New York hospitals. In 1933, the American Board of Pediatrics was founded by a group of thirty-five pediatricians. Paralleling the United States in the development of pediatric medicine was Great Britain, where the Hospital for Sick Children was established in London in 1852.

Pediatric surgery arose as a specialty in the mid-twentieth century. Initially, it was focused on the correction of congenital disabilities. One of the innovators in this field was C. Everett Koop, surgeon-in-chief at Children's Hospital of Philadelphia for several years. Koop performed many surgical milestones. Beginning in 1946, Koop and his team developed newer general anesthesia techniques that allowed for the surgical repair of previously untreatable congenital disabilities. In 1956, he established the first neonatal surgical intensive care unit at the Children's Hospital of Philadelphia. In 1957, he and his team performed the first separation of conjoined twins. Koop went on to become US surgeon general under presidents Ronald Reagan and George H. W. Bush from 1982 to 1989.

How It Works

In the mid-twentieth century, pediatric care often began with a newborn examination shortly after birth. In the twenty-first century, pediatric care often begins before conception. Women are advised via media sources or a healthcare provider to prepare for pregnancy and improve the chances for a healthy infant. This advice includes smoking cessation and supplementing the diet with folic acid, which decreases the incidence of neural tube defects, such as spina bifida.

During the pregnancy, ultrasound examinations are periodically performed, which can readily identify internal anatomical features, such as a kidney abnormality or a heart defect. If an abnormality is found, healthcare professionals can prepare for any special needs at the time of birth. Furthermore, if indicated, both medical and surgical treatment can be initiated. This treatment is coordinated between the obstetrician and other specialists, such as perinatologists, neonatologists, and pediatric surgeons. A perinatologist is an obstetrician with specialized training in high-risk pregnancy. Their goal is to obtain a good outcome for both the mother and her developing infant. A neonatologist is a pediatrician with specialized training in the care of high-risk infants. A pediatric surgeon has specialized training in surgery on infants and children. In some cases, surgery is performed before birth. The uterus is incised, the surgery is performed, and the uterine incision is closed. This type of surgery is indicated when an abnormality is likely to cause the death of the fetus before birth or delivery complications.

Pediatric Medicine. From the early twentieth century through 1975, an initial pediatric physical exam was conducted shortly after birth. With the introduction of ultrasound in the 1970s, the first newborn exam was conducted via a prenatal ultrasound examination. Most women receiving prenatal care in developed nations, such as the United States, undergo one or more ultrasound examinations during their pregnancy. For many women, this may be the most thorough exam she will ever have. A pediatrician or a neonatologist attends deliveries with increased risk (such as cesarean sections or multiple births). Most infants breathe spontaneously at birth. However, sometimes resuscitation is needed. If a pediatrician or neonatologist is present, that person will conduct the resuscitation. Sometimes, an infant will unexpectedly need resuscitation. In that case, the obstetrician or delivery room nurse (usually a registered nurse) will perform the resuscitation. After birth, high-risk infants begin their pediatric care with a neonatologist. This care is given in a specialized intensive care unit known as a neonatal intensive care unit (NICU). The infant is placed in an incubator, which supplies controlled temperature and humidity and oxygen. Some infants require a ventilator, which mechanically assists their breathing and instills oxygen into the lungs.

In most cases, an infant is born healthy without any special needs. All infants born in a hospital will receive a newborn examination before they are discharged. Follow-up care will be arranged with a pediatrician or family physician. Immunizations for childhood diseases will be scheduled, and at each visit, the child's health will be assessed. Usually, a growth chart is begun, which plots weight and height. This information allows for the determination of proper growth and development and can also predict adult height. In many midsize and large hospitals, a separate section of the hospital is dedicated to pediatric patients. Metropolitan areas often have separate hospitals devoted to pediatric patients. However, some others do not offer pediatric care.

Pediatric Surgery. Since it arose as a specialty in the mid-twentieth century, a major portion of pediatric surgery is devoted to the correction of congenital malformations. Some require immediate attention after birth, and others can be delayed for months or years. Those that require immediate attention include abdominal wall defects such as gastroschisis and omphalocele. With this condition, a portion of the abdominal contents, primarily intestines, protrude through a defect in the abdominal wall. Less serious abdominal wall defects in which repair can be postponed include hernias and undescended testes. Defects of the digestive tract vary in the degree of urgency; some require prompt treatment, while others can be postponed to a time when the child is stronger and healthier. These defects include esophageal atresia (narrow or closed esophagus); pyloric stenosis (narrowing of the outlet from the stomach to the intestines); Hirschsprung's disease (blockage of the large intestine); and imperforate anus (no anal opening). Some types of malignancies typically appear in infants and children. These malignancies often require surgery. These tumors include neuroblastomas (the most common childhood brain tumor), rhabdomyosarcomas (muscle tumors), Wilms' tumors (kidney tumors), and teratomas. (Teratomas contain several types of tissue, such as bone, hair, and teeth). Although teratomas are thought to be present at birth, some are not diagnosed until adulthood. Conjoined twins require surgical correction after evaluation of shared organs and circulation. Surgery is usually postponed until a time when the twins' health permits. If an organ such as the heart is shared to some degree, separation may be difficult or impossible. In some cases, the surgical procedure focuses on the twin with a better chance of survival. A cleft lip and palate are readily diagnosed at birth, and many are diagnosed with a prenatal ultrasound. More urgent cases include those that interfere with nursing.

Applications and Products

Products for pediatrics use include infant formulas, medications, and medical office, surgical, and endoscopic equipment. Many specialized products exist for use in a neonatal intensive care unit.

Infant Formulas. A wide variety of infant formulas are marketed that all attempt to approximate the composition of breast milk. Some are based on soy or other proteins for infants who are lactose intolerant or allergic to milk products. None of the products are identical to breast milk, a species-specific formulation for human babies. Each animal species has a unique milk formulation for its young. Also, breast milk can supply maternal antibodies, protecting the infant from infection. For the foregoing reasons and others, many women choose to breastfeed. Some of these women will rely on breast pumps for regular or occasional use.

Medications. Pediatric medications include over-the-counter products such as vitamins and analgesics (painkillers). They also include a wide variety of prescription medications. Both prescription and over-the-counter medications are usually in a liquid or chewable formulation. They are often flavored to make them more palatable to the child. Dosage must be based on the child's weight and age.

Medical Office Equipment. Medical equipment for a pediatric office is similar to adult equipment—it is modified for “smaller people.” Pediatric stethoscopes and otoscopes (earscopes) are found in a pediatrician's office. The ophthalmoscope, which visualizes the inner eye, is identical to that used for adults, as the eye is adult size at birth. A scale and tape measure are used at each visit to record the child's height and weight.

Surgical Equipment. As in adult surgery, laparoscopic procedures are increasing in pediatric surgery. Laparoscopy, sometimes termed minimally invasive surgery, involves inserting a scope into the abdominal cavity through a small incision and then performing surgical procedures with specialized instruments. These instruments perform various tasks, including manipulating, cauterizing, and suturing. Some equipment is similar to that used on adults, while others are scaled down. Scaled-down or adult-size equipment is also used for traditional surgical procedures.

Endoscopic Equipment.Endoscopy involves endoscopes, which are small scopes that can be passed in the body to visualize internal structures. This equipment includes devices which can biopsy, cauterize, and grasp internal structures. Endoscopes are designed for passage into the intestinal tract (esophagus, stomach, small intestines, large intestines, and the anus), the bronchi (lung tubes), and joints. It is not uncommon for a child to swallow an object that inadvertently finds its way into the bronchi. After the object (medically described as a foreign body) is located via a radiologic procedure, an endoscope can be passed to retrieve it.

Neonatal Intensive Care Unit Equipment. The neonatal intensive care unit (NICU) contains a great deal of high-tech equipment to facilitate the growth and survival of high-risk infants. Many are premature, others have serious infections, and some have a combination of the foregoing problems. Common NICU equipment includes resuscitation equipment, ventilators, radiant warmers, incubators, cardiorespiratory monitors, pulse oximeters, and scales.

A cardiorespiratory monitor is attached to sensors on the infant and provides a continuous readout of heart rate and rhythm, respiratory rate, arterial or central venous pressure, as well as other useful information. Alarms can be adjusted to alert NICU staff when any of the vital signs go above or below a set limit. Some incorporate computer systems, which can filter out false alarms, record data over an extended period, and perform analysis of vital signs.

Incubators supply a controlled temperature and humidity to infants who are more stable than those requiring a radiant warmer. They also maintain a clean environment for the infant and protect it from drafts, noise, infection, and excessive handling.

The pulse oximeter monitors the oxygen saturation of the blood. This is accomplished by shining light through the infant's skin and measuring the color of the transmitted light. It works on the principle that blood which is redder the higher oxygen content it possesses.

Radiant warmers supply warmth to unstable or extremely premature infants. Infants have a large surface area compared to their size and often possess little body fat; thus, they are unable to maintain their body temperature. Heat is radiated to the infant from an overhead element. Sensors on the baby's abdomen are attached to a thermostat, which adjusts the necessary amount of heat. The open design of the radiant warmer allows NICU personnel ready access to the infant from all sides.

A cardiac arrest is not an uncommon occurrence in a NICU. The unit is equipped with defibrillators, ventilators, and medication necessary for resuscitation.

The basic scale is an essential piece of NICU equipment. All feedings, intravenous-fluid administration, and medication administration is based on the infant's weight, so the weight must be accurate and current. The weight is carefully adjusted for the weight of the diaper and attached medical equipment. The weight is entered into a flow sheet on a daily basis.

Ventilators supply air to the infant's lungs when they are too ill or too weak to breathe on their own. Recent models of infant ventilators are highly computerized and feature diverse modes of operation, including “assist control,” which allows for the infant to participate in the respiratory process. Some models incorporate real-time data on the infant's pulmonary function.

Careers and Course Work

To become a pediatrician or to practice some aspects of pediatrics, one must complete a Bachelor's degree and a four-year course of medical training. Initial specialty training is in one of the following fields: pediatrics, surgery, family medicine, or psychiatry. This is typically a three- or four-year residency program. A pediatrics residency is the last training step for many pediatricians. However, some pediatricians will receive further training in neonatology or the following pediatric subspecialties: neurology, endocrinology, nephrology (kidney disease), neurology, oncology (cancer treatment), cardiology, or gastroenterology. It is also possible for a physician trained in a subspecialty who did not begin with a pediatrics residency program to transition to a pediatric subspecialty. In some cases, a physician will practice general pediatrics before receiving additional training in a subspecialty. A surgeon who completes a surgical residency must then complete two or more years of training in pediatric surgery. Other areas of surgery also encompass pediatric specialties of their own, which require further training: pediatric cardiothoracic surgery, pediatric neurosurgery, pediatric orthopedic surgery, and pediatric urological surgery. For physicians desiring to practice child psychiatry, specific child-psychiatry residency programs exist, as well as programs for general psychiatrists who wish to refocus on children.

Most pediatricians will become members of one or more professional organizations. In addition to the benefits they supply, such as forums and continuing education meetings to physician members, these organizations also provide educational material to the general public. In the United States, the main professional organization for pediatricians is the American Academy of Pediatrics. Pediatric surgeons and pediatric subspecialists often belong to professional organizations pertinent to their specialty.

Social Context and Future Prospects

Two segments of the population consume the major portion of healthcare costs: infants and children with serious medical conditions and older adults with serious medical conditions. For premature or seriously ill infants, a wealth of technology is available. Unfortunately, this therapy comes with a high price tag. The healthcare costs for an infant with a serious condition can often exceed millions of dollars. In undeveloped and developing nations, a treatment dilemma does not exist—high-tech care is not available. In developed countries, very premature infants or infants with severe congenital abnormalities incompatible with life are given “comfort care.” This involves family members or hospital personnel cradling the infant while life ebbs away. Many infants are born between the two extremes of perfectly healthy and gravely ill. It is an emotionally difficult decision on where to draw the line and predict which infants merit state-of-the-art treatment. In the twenty-first century, healthcare remained a highly debated topic in American public discourse, with many frustrated by the US healthcare system. This topic is increasingly emotional when it concerns children. 

Medical technology, specifically assisted reproductive technology (ART), has created novel problems in the pediatric field. Prior practice had surgeons implanting several embryos in the uterus to ensure that at least one survived. As the technology improved, the rate of multiple births rose. Multiple births—even twins—have a much higher incidence of complications, which may be severe. Some doctors switched to implanting a single embryo to reduce complications. In some cases of multiple births, the health of all the infants and sometimes the mother are threatened. This technology has created medical, moral, and religious dilemmas.

Most women strive for a healthy lifestyle when they become pregnant. However, some are nutritionally deprived, do not receive prenatal care, smoke cigarettes, or abuse alcohol or drugs. This results in a large number of infants with serious health problems as well as death. For example, a child born to an alcoholic mother can be born with fetal alcohol syndrome, which is characterized by cognitive disabilities and physical deformities. Women who smoke cigarettes have an increased risk of delivering an infant who is premature, underweight, stillborn, or succumbs in infancy to sudden infant death syndrome (SIDS).

Still, in the twenty-first century, advances continued to be made in the pediatric field to increase the health of babies and children and decrease healthcare costs. Advances in gene editing hoped to prevent many childhood health issues. Artificial intelligence was developed for use in neonatal care applications. Research into rare childhood diseases proceeded with great success. Greater attention was paid to mental health in childhood, and telemedicine, greatly expanded during the COVID-19 pandemic, allowed for increased access to pediatric health care.

Bibliography

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