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A shared community means a critical step forward for pediatrics
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We’ve got to save the world/Someone’s children they may need it — George Harrison, “Save the World,” 1981
Last electric Sunday mornin’ waitin’ in the park for the dawn/Listenin’ to all the animals in the park and in the city beyond/Flashin’ with my lady. Sky goin’ black to blue/She said I got a surprise for you /A child is coming/A child is coming /A child is coming to you — Paul Kantner, Grace Slick, David Crosby, “A Child is Coming,” 1970
Medicine is about as big or as little in any community, large or small, as the physicians make it. — Charles H. Mayo, MD, 1928, physician and co-founder of The Mayo Clinic
Somewhere between saving the world and preparing for the coming of a child lies a message for pediatric and obstetric communities alike.
As we look for partners in our search to improve the well-being of the children under our care, let us not overlook our obstetric colleagues. I know these are often the same people who pronounce universal Apgar scores of 8 and 9; insensitively walk into mother’s postpartum room and begin to examine the mother’s incision in the midst of our newborn exams; and refer all questions of maternal drug interactions with breast-feeding to our offices. However, if we are ever to design a better health delivery model, there is an undeniable logic to linking primary care providers of mothers and children.
William T. Gerson
There are hurdles to be overcome to be sure, not only those listed above, but also true gaps in our knowledge and experience sets. Beginning with the division of career tracks between medical and surgical specialties, the circle back to connect us as primary care providers is not an easy one. Current training models make it even more difficult. In our institution, obstetricians no longer examine infants after birth. The claim is made that it does not reflect current practice and it is no longer an expectation of training programs. I simply find it hard to believe that the curiosity invested in what has been going on in the uterus doesn’t extend to the newborn.
From the pediatric side of the street, our interest in the physiology of pregnancy is also not an imperative. However, our training continues to emphasize interviews with mothers in the acute prenatal period when called on to discuss implications for the newborn, and our residents are taught the obstetric evaluation of the status of the fetus in the labor and delivery ward. Unfortunately, the longitudinal care aspects of maternal health are not shared across specialties, and for those of us who are not called to the delivery room anymore, even the acute care of the newborn has been passed off to others.
Improvement opportunities
Opportunities for improvement abound. Practical exchanges of information, even agreeing on common language, would be an improvement. With increased attention on identifying risks for the newborn based on maternal health data, the importance of the transfer not only of data but also meaning is intensified. Agreeing on a shared definition of chorioamnionitis would be a start.
Coupling our own data sets, but more importantly the reasons for defining certain data points, would enhance the opportunities for better care and outcomes. Why we continue to pretend that the mother and the infant have not been intimately connected during pregnancy and that results of physiologic testing on either side once the umbilical cord has been cut is only reflective of separate systems is foolish.
If our future patients are to benefit from reasonable attempts to improve the welfare of mothers and infants, we must not passively accept the status quo. I understand changing practice within any one medical community is difficult and view the remarkable delay in the acceptance of prenatal steroids to mothers in preterm labor, despite excellent data, as a real-world reminder of how hard it is to change both of our professional practices despite shared goals.
Challenges to change
How then to integrate changes coming forward? We can build on success. Obstetricians have done a better job with immunizing mothers for influenza and pertussis, but we both still falter with wider family members and often miss out on the opportunity provided in the postpartum ward because of institutional bureaucratic restraints. We can support future attempts to mitigate infant morbidity and mortality by cooperating with future trials to vaccinate mothers for respiratory syncytial virus and group B streptococcus. Think of the impact of focused maternal nutrition — which means targeting our female young adult patients — could have on infant well-being or even premature labor. Redoubling our efforts on smoking cessation could pay dividends on many levels. Only if we as pediatricians are more closely linked to the obstetric community, can we better answer these questions.
Our primary care relationships with our OB/GYN colleagues seem to me to be too distant. Prevention of premature births is clearly not just an obstetric issue. Equally clear is that late-onset group B streptococcal disease is not just a pediatric problem. The implications of maternal addiction, referenced in one of the allegories above, clearly cross both of our practices. Developing a shared community is a critical step forward. At a minimum, that would require a unified database but more essentially a commitment to communicate. Without such capability, networks cannot foster better practice. Longitudinal care of children linked to maternal health data is a powerful tool in shaping an improved tomorrow for all of our children.
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William T. Gerson, MD, is Clinical Professor of Pediatrics at the University of Vermont College of Medicine and a member of the Infectious Diseases in Children Editorial Board. He can be reached at 52 Timber Lane, S. Burlington, VT 05403; email: William.Gerson@uvm.edu.
Disclosure: Gerson reports no relevant financial disclosures.