great achievements in paediatric health in the last 40 ... · great achievements in paediatric...

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Great Achievements in Paediatric

Health in the Last 40 Years:

Building a Healthier Future

Tina L. Cheng, MD, MPH

“the birthplace of modern pediatrics

and the future of health.”

Disclosures

Acknowledgements

• The conference is funded by the USAID

Maternal and Child Survival Program.

• In the past 12 months, I have no relevant

financial relationships with the

manufacturer(s) of any commercial product(s)

and/or provider(s) of commercial services

discussed in this CME activity.

• I do not intend to discuss an

unapproved/investigative use of a commercial

product/device in this presentation.2

“We live in extraordinary

times...thanks to medical

and scientific advances

that even a generation

ago would have sounded

like science fiction…An

American born today has

a projected average

lifespan 20 full years

longer than one born in

1925…”

TIME Magazine Feb 12, 2015

Mortality in Children < 5 years by

Region, 1990-2017

May 28, 2019 4

Global Mortality Rates and Deaths

by Age, UN-IGME-Child-Mortality-Report-2018.pdf

May 28, 2019 5

Objectives

• Describe great achievements in global

child health

• Discuss future threats and opportunities

7 Great Achievements

in Pediatric Research in the Last 40 Years

• Preventing Disease

with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer

• Saving Premature

Babies

• Preventing HIV Maternal

Transmission

• Increasing Life

Expectancy for Children

with Chronic Diseases

• Saving Lives with Car

Seats and Seat belts

Aap.org/7achievementsCheng, et al. Pediatric Res Sept 2016;80:330-07




with Immunizations

Vaccine Development Timeline 1910-2013

Pickering LK, Peter G, Shulman ST. Pediatrics 2013; 132;898-908.

Recommended Childhood and Adolescent Immunization Schedule, US 2019




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer

American Cancer Society, http://www.cancer.org/research/cancerfactsstatistics/cancerfactsfigures2014/




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies

The Surfactant Story

http://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0CAcQjRw&url=http://www.nlm.nih.gov/changingthefaceofmedicine/physicians/biography_17.html&ei=kUc6Vdq7NsGaNpOIgegH&bvm=bv.91427555,d.eXY&psig=AFQjCNFv0Ss1SBRK6vKp2pT8gxuD1WgWew&ust=1429969078352770

Estimated Mortality Decline After

Use of Surfactant by Gestational Age

0

5

10

15

20

25

30

35

40

45

50

24 26 28 30 32

Pe

rce

nt

De

cli

ne

Gestational Age




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies


Transmission

FDA Approval

of Zidovudine

Use

MMMR 2006;55(21):592-597

Estimated Cases of Perinatally

Acquired AIDS,* by year of Diagnosis - US




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies


Transmission

• Increasing Life



Increases in Life Expectancy in

Patients with Cystic Fibrosis

European Lung

white book.

http://www.ersw

hitebook.org/ch

apters/cystic-

fibrosis/

Increases in Life Expectancy in Patients

with Sickle Cell Anemia in the U.S.




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies


Transmission

• Increasing Life





0

10

20

30

40

50

60

1975 1980 1985 1990 1995 2000 2005 2010

<1 year

1-3 years

4-8 years

9-12years

U.S. Department of Transportation’s Fatality Analysis Reporting System

Passenger Vehicle Child Occupant

Deaths/Million Children by Age




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies


Transmission

• Increasing Life





Objectives

• Describe great achievements in global

child health

• Discuss future threats and opportunities

Future of Pediatrics

Pediatrics

Child & Family Health Needs

Cutting Edge

Scientific Advances

Health System

Changes

Leading Causes of Child

Mortality, WHO

• <5 years: preterm birth, pneumonia,

birth asphyxia, diarrhoea and malaria

• Children in sub-Saharan Africa are

more than 15 times more likely to die

before the age of 5 than children in high

income countries.

World Health Organization

10 Threats to Global Health in 2019

1. Air pollution and climate change

2. Non communicable diseases

3. Global Influenza pandemic

4. Fragile and vulnerable settings

5. Antimicrobial resistance

6. Ebola and other high-threat pathogens

7. Weak primary health care

8. Vaccine hesitancy

9. Dengue

10. HIV

NRC IOM Model of

Children’s Health

and Its Influences

Children’s Health,

the Nation’s

Wealth. DC:

National Academies

Press, 2004.

Multiple

Influences

Life Course

World Health Organization

10 Threats to Global Health in 2019

1. Air pollution and climate change

2. Non communicable diseases

3. Global Influenza pandemic

4. Fragile and vulnerable settings

5. Antimicrobial resistance

6. Ebola and other high-threat pathogens

7. Weak primary health care

8. Vaccine hesitancy

9. Dengue

10. HIV

Millennial Morbidity Epidemics

• Poverty, obesity, drugs, violence, toxic

stress, adverse childhood experiences,

mental health, injuries

• Appreciation of the interaction of biology

and the environment

• Continued racial/ethnic & SES disparities

• First generation to have lower life

expectancy than their parents?Palfrey JS et al.

Pediatrics. 2005

Apr;115(4 Suppl):1121-3

“Unless effective population-level interventions

to reduce obesity are developed, the steady

rise in life expectancy observed in the modern

era may soon come to an end and the youth of

today may, on average, live less healthy and

possibly even shorter lives than their parents.”

N Engl J Med. 2005;17;352(11):1138-45


Pediatrics


Cutting Edge

Scientific Advances

Health System

Changes

• Leading Causes of M & M

• Continued Infectious Diseases

• Millennial Morbidities




with Immunizations

• Reducing Sudden

Infant Death with

Back to Sleep

• Curing a Common

Childhood Cancer


Babies


Transmission

• Increasing Life





Aap.org/7achievementsCheng, et al. Pediatric Res Sept 2016;80:330-07

The NEXT 7 Great Achievements

in Pediatric Research?

• More immunizations save lives

• Pediatric cancer immunotherapy improves survival

• Genomic discoveries predict, prevent and more effectively treat disease starting early

• Big life course data recognizes early antecedents of adult disease leading to early intervention

• Understanding the interaction of biology, physical and social environment leads to individual and population health prevention

• Quality improvement science creates safer systems of care

• Implementation and dissemination research to achieve health equity

Cheng, Bogue, Dover.

Pediatrics May 2017;136

History of Medical Progress

Adapted from E. Zerhouni, A Vision for

Transforming Medicine in the 21st Century, 9/13/06, http://www.nih.gov/about/director/slides/vision.pdf

19th

Century

20th

Century21st Century

Treat

symptoms

Treat

diseases

Predictive

Preemptive

Participatory

Personalized

Cost of Sequencing a Human

Genome 9/01–7/15

$1 000

$10 000

$100 000

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$10 000 000

$100 000 000S

ep

-01

Ma

r-02

Sep

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Sep

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Disorders with

Known Molecular Basis

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

5500

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Source: Online Mendelian Inheritance in Man

The Future Paradigm: 4 P’sTolerable

Into

lera

ble

Preclinical

Time

Co

st

Molecular preemption

Curativetreatment

Symptommanagement

Dis

eas

eB

urd

en

CostSavings

Zerhouni, EA. Annual Mtg of NIH Roadmap

Multidisciplinary Clinical Research Career

Dev Program, 2007

History of Medical Progress:

8 P’s

19th

Century

20th

Century21st Century

Treat

symptoms

Treat

diseases

Predictive

Preemptive

Participatory

Personalized

Pediatrics, Prenatal,

Population Health,

Policy

Cheng, Cohn & Dover. JAMA 2008:299:451-3Zerhouni, EA. NIH Roadmap, 2007

Precision Medicine


Pediatrics


Cutting Edge

Scientific Advances

Health System

Changes




• Genomics, Epigenetics

• Microbiome

• New Vaccines

• Dev Origins of Disease

The single most effective way to improve

health and reduce disparities is to invest

in helping young people reach their full

academic potential.

—World Health Organization

Children’s health and educational

success are highly interconnected

Educational Outcomes

Health Outcomes

VISION: To improve the health, education

and future productivity of children and

adolescents, their families, and their

communities.

Full service school clinic

to meet physical & mental health needs

Chronic illness programs

to promote disease self-management

& reduce absenteeism

School health curriculum

to promote healthy behaviors

Nutrition and physical activity programs

to promote healthy schoolenvironment Parent and Teacher

health education & wellness to support parents & educators to

support children

Wellness programs, screening & school health

campaigns to improve readiness

to learn

AcademicAchievement &

Healthfor healthy futures

Health & Education Outcomes:

2 schools, 1500 students, over 3 years

• Reduced chronic absenteeism– 49% drop for children with asthma, 50% drop for

children with ADHD

• Reduced emergency department

utilization

• Increased immunization rates

• 90% screened for vision, dental, BMI

• Cost effectiveness– Despite higher staffing costs, every $1.00 invested in the Rales

Health Center returns more than $4.20 of social benefit


Pediatrics


Cutting Edge

Scientific Advances

Health System

Changes




• New Models of Care

• Telehealth

• Genomics, Epigenetics

• Microbiome

• New Vaccines

• Dev Origins of Disease

The NEXT 7 Great Achievements

in Pediatric Research?

• More immunizations save lives

• Pediatric cancer immunotherapy improves survival

• Genomic discoveries predict, prevent and more effectively treat disease starting early

• Big life course data recognizes early antecedents of adult disease leading to early intervention

• Understanding the interaction of biology, physical and social environment leads to individual and population health prevention

• Quality improvement science creates safer systems of care

• Implementation and dissemination research to achieve health equity

Cheng, Bogue, Dover.

Pediatrics May 2017;136

Jose’ Luis Bayer, Chile

Children are

the message

we send to

the future.

“Our children are our greatest

treasure. They are our future.”Nelson Mandela

Probability of Child Death 1990-2017

Probability of Death, %

% Change from 1990 to 2000 in Observed to

Expected Disability Adjusted Life Years Ratio in

Children 0-19 years

60

% Change from 2000 to 2017 in Observed to

Expected Disability Adjusted Life Years Ratio in

Children 0-19 years

61

Trends in Disability-Adjusted Life Years 1990-

2017 by Socio-Demographic Index, 0-20 years

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