In 1986, the American Board of Pediatrics approved pediatric pulmonology as a separate subspecialty area with specific fellowship requirements and a board certification examination. The first examination was administered that year and within the next few years, 150 physicians were certified in pediatric pulmonology. Another group of physicians who had been primarily caring for children with cystic fibrosis (CF), complex asthma, and a variety of other related pulmonary disorders for a minimum 5 to 10 years (prior to the establishment of accredited subspecialty training programs) were “grandfathered-in,” and were eligible to take the certifying examination.
There were 1,031 board certified pediatric pulmonary specialists in the United States as of 2016; most of the clinicians practice in university-based medical schools and some are in private practice or managed care groups. Prior to the recognition of pulmonary as a separate boarded specialty, children with cough or wheezing and chronic or recurring respiratory difficulties saw their pediatrician. Pulmonary issues made up a substantial percentage of what a pediatrician saw saw on any given day or week. This is likely still the case, but in large urban areas with easy access to specialty care and ever-expanding “outreach” efforts by pediatric tertiary care institutions, specialists see many more children as a first entry to care and for subsequent follow up as well for pulmonary problems. Is this optimal and if so why?
Many would argue that the greatly expanded understanding of the pathophysiology and molecular and genetic basis of childhood lung diseases as well as the development of new therapies based on these discoveries position the specialist as the one best able to provide the optimal care for children with pulmonary problems. Parallel with this surfeit of new knowledge and expertise is the rise of the well-informed and savvy consumers—parents who are much more likely to seek a specialist for their child than they would have in the past if they think it is warranted. This leads to the dilemma that is debated by many: who should be the initial point of contact for a child with recurrent cough and wheeze, a positive newborn screen for CF, or a follow-up after a first emergency department visit for what has been called asthma, and who should provide the regular follow-up?
The issue of Pediatric Annals includes five review articles that to some extent address these issues; in particular they highlight the state of our current understanding of the child who is born prematurely and who develops chronic lung disease of infancy, the new developments in the diagnosis and care of children with CF, a review of common upper airway diseases, the presentation and management of congenital lung malformations, and an overview of some of the less common entities such as ciliary dyskinesia and interstitial lung diseases that affect the infant and older child. Asthma is a much more common pulmonary problem affecting children and the many aspects and controversies in diagnosis and management of asthma are reviewed in the first part of this two-part issue on pediatric pulmonology.1
As noted by Drs. Megan K. Tracy and Sara K. Berkelhamer in the first article, “Bronchopulmonary Dysplasia and Pulmonary Outcomes of Prematurity,” as ever-smaller and more premature infants survive the neonatal period, many have multiple problems of which pulmonary compromise is only one. These infants are often best seen until age 2 or 3 years (or at least as long as they remain on oxygen) by a neonatology follow-up clinic that works closely with pulmonary, neurology, nutritionists, and developmental specialists, but with close communication with the family's pediatrician who often provides care for the infant's siblings. In the same vein, as Drs. Danielle Goetz and Clement L. Ren indicate in the second article, “Review of Cystic Fibrosis,” the network of accredited CF centers that have a wide array of specialists have worked to provide care that has greatly improved outcomes and life expectancy, and have developed an expertise in prescribing innovative mutation-specific disease-modifying therapies. Care of children with CF is best when there is collaboration between the CF physicians and ancillary services and the pediatrician who will typically provide the well-child care, including immunizations. In the next article, “Common Pediatric Airway Disorders,” Drs. Pallavi P. Patwari and Girish D. Sharma review congenital airway lesions. In the following article, “Congenital Lung Malformations,” Drs. John Palla and Marianna M. Sockrider provide a similar review of common lung malformations that may present in the neonatal period or early infancy. These infants are often referred directly to pediatric ear, nose, throat specialists, pediatric surgeons, or pulmonary physicians, but it is important for pediatricians to be familiar with the presentation and typical course of these entities. They may well be involved in helping families make decisions as well as providing follow-up care. The final article, “Full-Term Neonatal Respiratory Distress and Chronic Lung Disease,” by Drs. Naema Chowdhury, B. Louise Giles, and Sharon D. Dell on rarer lung diseases serves to remind pediatricians that new diagnostic modalities and treatment options are available so that together with the specialist, they may help them to provide care for a child with puzzling symptoms that do not fit with more typical and familiar diagnoses.
- Giles BL, Lester LA. Pediatric pulmonology: part 1. Pediatr Ann. 2019;49(3):e101–e102. doi:. doi:10.3928/19382359-20190221-02 [CrossRef]