Role of Pediatricians, Pediatric Associations, and Academic Departments in Ensuring Optimal Early Childhood Development Globally: Position Paper of the International Pediatric Association

ABSTRACT

Early childhood (birth-8 years), particularly the first 3 years, is the most critical time in development because of the highly sensitive developing brain. Providing appropriate developmental care (i.e., nurturing care, as defined by the World Health Organization [WHO]) during early childhood is key to ensuring a child's holistic development. Pediatricians are expected to play a critical role in supporting early childhood development (ECD) through providing developmental services such as developmental monitoring, anticipatory guidance, screening, and referral to medical and/or community-based services when delay is identified. Pediatricians are also expected to serve as advocates within their clinics and communities for improved delivery of ECD services, such as advocating for increasing funding for ECD initiatives, increasing insurance coverage of ECD services, and working to increase other pediatricians' awareness of the principles of ECD and how to deliver developmental services. However, this does not always occur. Typically, pediatricians' training and practice emphasizes treating disease rather than enhancing ECD. Pediatricians are further hindered by a lack of uniformity across nations in guidelines for developmental monitoring and screening. In this article, we present the vision of the International Pediatric Association (IPA) of the roles that pediatricians, academic departments, medical training programs, and pediatric associations should fulfill to help support ECD, including raising ECD to higher levels of priority in routine pediatric care. First, we present the challenges that face these goals in supporting ECD. We then propose, with supportive literature, strategies and resources to overcome these challenges in collaboration with local and international stakeholders, including the IPA, the WHO, UNICEF, and the World Bank.

The Rights of Children for Optimal Development and Nurturing Care

Millions of children are subjected to abuse, neglect, and displacement, and millions more are at risk for not achieving their developmental potential. Although there is a global movement to change this, driven by children's rights, progress is slow and impeded by political considerations. The United Nations Convention on the Rights of the Child, a global comprehensive commitment to children's rights ratified by all countries in the world except the United States (because of concerns about impingement on sovereignty and parental authority), has a special General Comment on "Implementing Child Rights in Early Childhood." More recently, the World Health Organization and United Nations Children's Fund have launched the Nurturing Care Framework for Early Childhood Development (ECD), which calls for public policies that promote nurturing care interventions and addresses 5 interrelated components that are necessary for optimal ECD. This move is also complemented by the Human Capital Project of the World Bank, providing a focus on the need for investments in child health and nutrition and their long-term benefits. In this article, we outline children's rights under international law, the underlying scientific evidence supporting attention to ECD, and the philosophy of nurturing care that ensures that children's rights are respected, protected, and fulfilled. We also provide pediatricians anywhere with the policy and rights-based frameworks that are essential for them to care for and advocate for children and families to ensure optimal developmental, health, and socioemotional outcomes. These recommendations do not necessarily reflect American Academy of Pediatrics policy.

Global health training for pediatric residents

The FOPO Global Health Working Group concludes that global health experiences are important for pediatric residency training and offers five recommendations: 1) There is a need to articulate clearly the rationale supporting the creation of global health experiences in pediatric residency programs. 2) A core curriculum needs to be established for a consistent and meaningful educational experience. The curriculum should include the underlying principles discussed above and should engage representatives from potential host countries in the development of the curriculum. 3) Promoting the opportunity for a global health experience in all residency programs will require a collaborative effort across programs, perhaps at the national level through the Association of Pediatric Program Directors or through the already established Global Health Education Consortium (GHEC).34 A clearinghouse for curricula and for host organizations/institutions both abroad and within the United States and Canada should be established. 4) Global health training needs to be studied rigorously, and lessons learned should be shared. 5) Pediatric residency programs should respect the rights, autonomy, and confidentiality of patients and families in clinical care, research, and operational programs. The FOPO Global Health Working Group looks forward to serving as a focal point to promote discussion on this important issue to the health of our world's children.

Lack of association between measles virus vaccine and autism with enteropathy: a case-control study

Background

The presence of measles virus (MV) RNA in bowel tissue from children with autism spectrum disorders (ASD) and gastrointestinal (GI) disturbances was reported in 1998. Subsequent investigations found no associations between MV exposure and ASD but did not test for the presence of MV RNA in bowel or focus on children with ASD and GI disturbances. Failure to replicate the original study design may contribute to continued public concern with respect to the safety of the measles, mumps, and rubella (MMR) vaccine.

Methodology/Principal Findings

The objective of this case-control study was to determine whether children with GI disturbances and autism are more likely than children with GI disturbances alone to have MV RNA and/or inflammation in bowel tissues and if autism and/or GI episode onset relate temporally to receipt of MMR. The sample was an age-matched group of US children undergoing clinically-indicated ileocolonoscopy. Ileal and cecal tissues from 25 children with autism and GI disturbances and 13 children with GI disturbances alone (controls) were evaluated by real-time reverse transcription (RT)-PCR for presence of MV RNA in three laboratories blinded to diagnosis, including one wherein the original findings suggesting a link between MV and ASD were reported. The temporal order of onset of GI episodes and autism relative to timing of MMR administration was examined. We found no differences between case and control groups in the presence of MV RNA in ileum and cecum. Results were consistent across the three laboratory sites. GI symptom and autism onset were unrelated to MMR timing. Eighty-eight percent of ASD cases had behavioral regression.

Conclusions/Significance

This study provides strong evidence against association of autism with persistent MV RNA in the GI tract or MMR exposure. Autism with GI disturbances is associated with elevated rates of regression in language or other skills and may represent an endophenotype distinct from other ASD.

Accreditation for learning and change: quality and improvement as the outcome

Increased accountability for facilitating and demonstrating the continued competence of physicians and improvements in the quality of health care are being called for by government, the public, and organized medicine. Areas of critical skills have been identified by the Institute of Medicine, the Accreditation Council for Graduate Medical Education, and the American Board of Medical Specialties. These "competencies" serve as the framework around which medical school curricula, residency programs, and continuing medical education (CME) can be built. Much discussion revolves around the reform of CME, and the organizations most involved have developed innovative plans and initiatives to ensure that CME is optimally positioned to support physicians in learning and change. The Accreditation Council for Continuing Medical Education (ACCME) supports a new and expanded role for the CME provider in physicians' lifelong learning, including periodic self-assessment and practice performance improvement. CME providers can assist in the determination of need (self-assessment) by the physician, the delivery of education to meet that need, and the evaluation of education used to meet the need, especially as it relates to the practice performance of the physician. The ACCME, working with accredited providers, has embraced these expectations and believes that CME can meet these challenges with an approach that also expects independence from commercial interests and freedom from commercial bias. The CME enterprise is uniquely positioned to deliver effective education for learning and change.