Catch kids’ problems when they’re young

Israeli pediatricians will have to relearn profession, as leading Australian expert spearheads holistic, more scientific approach.

By JUDY SIEGEL-ITZKOVICH
Pediatrician child doctor cartoon 390 (photo credit: MCT)
Pediatrician child doctor cartoon 390
(photo credit: MCT)
Pediatricians have been so busy in hospitals and clinics that they haven’t noticed the essence of their work has largely shifted from treating children for infections, congenital diseases, injuries and other conventional care to subjects they never learned in medical school.
There is a “new morbidity” – a fresh collection of conditions that can make children miserable and perform at less than their natural potential, says Australian Prof.
Frank Oberklaid, director of the Center for Community Child Health at the Royal Children’s Hospital and a professor of pediatrics at the University of Melbourne. Oberklaid is also deputy chairman of the Victorian Children’s Council, which advises the government on policy involving children’s health. He has received numerous research grants and awards, been invited to give lectures and granted visiting professorships in a number of countries.
A highly developed commonwealth with the world’s 13th-largest economy and fifth-highest per-capita income, his country is ahead of Israel in this new emphasis on children’s behavioral, developmental and psychosocial disorders, says Oberklaid. A Kazakhstan-born Jew and staunch supporter of Israel, Oberklaid was taken by his parents at the age of three to Australia after World War II. The Polish couple had lost almost all their relatives in the Holocaust and, arriving on an ramshackle freighter from Europe with only their clothes on their backs, they set off on a new life.
“My father worked in a knitting factory, and my mother helped him,” says one of his country’s leading pediatricians in an interview during a visit to Israel with The Jerusalem Post. “My brother and I both studied medicine. I wasn’t sure what I wanted to do, but I liked the atmosphere in a children’s hospital, with the caring staff and the kids’ toys. I always liked children.”
He completed a specialty in pediatrics and received a fellowship at Harvard Medical School, even serving on the staff while he trained in child development and behavior. Then, returning to Australia, he established a new department of ambulatory pediatrics at Royal Children’s Hospital and is now director of the center, which has 200 staffers.
“In the last 40 years, so many children’s disorders have been solved with immunization and improved medications and techniques. But children’s problems involving sleep, obesity, parental stress, endlessly crying babies, speech delays, Asperger’s syndrome and many others have created the new diseases,” the Australian says.
“These problems don’t suddenly crawl out of the woodwork. If the baby cries incessantly, is aggressive, has a lag in toilet training and speech, there may be a problem that has to be fixed.”
The brain is not mature at birth. Different areas of the brain develop, organize and become fully functional at different stages during childhood, he explains. “While genes provide the initial map for brain development, it is an infant’s early experiences and relationships that literally sculpt the brain. Little can be done to change a child’s genes, but there is much we can do to change the environment in which young children grow and develop. The evidence is startling. One can’t continue business as usual if you are exposed to child development research based on biology, epigenetics, economics and neuroscience. Dispassionate data has been accumulated.”
“This holistic approach relates to the interface between pediatrics and psychology,” he says. “Many pediatricians may not like these changes in their field, because it is much more complicated than treating an ear infection, for example. The pediatrics of the future aims at prevention of multi-factorial conditions. We have to immunize children against future failure.”
At his Melbourne hospital, which has served as a model around the world, Oberklaid and his team offer special intervention programs, work in translational research that reaches the young patients quickly and provide parents and decision makers with information (at www.raisingchildren.net).
Children are particularly vulnerable developmentally in the earliest years of their life, he continues. Having low socio-economic status has a major effect on early childhood development. Poverty used to be regarded as having less money for material possessions, but today, it is regarded as a complex, multifactorial experience that extends beyond insufficient income.
“It incorporates the wider effects of social exclusion, shame and reduced self-esteem and self-respect that result from a lack of access to material and cultural resources,” he explains. “The personal and social consequences of poverty are then more likely to affect a child’s future prospects and quality of life.”
Children are hurt by prolonged stress. If the parents suffer severe stress themselves, it can lead to substance abuse, alcoholism and family violence, and the kids are hurt, he says.
Mothers don’t have to avoid outside employment and stay home with their young children to raise their chances for healthy development.
Quality really matters.
“If Israel institutes free education from age three, it will [be making] a mistake if the nursery and kindergarten teachers and caretakers are not trained properly. You pay a huge price if children do not get quality educations.”
Aware of the Finance Ministry’s decision about seven years ago to privatize the Health Ministry’s School Health Service as a “cost saving” measure – which has been deplored by everyone from the State Comptroller to parents’ organizations – Oberklaid is furious.
“I would love to to get my hands on the Treasury officials who made this terrible decision. It surely has caused long-term damage. In a growing number of countries, including Australia, officials have accepted the philosophy of valuing early child care, development and education. More and more education ministries around the world have expanded their names to Ministry of Education and Child Development.”
Every two minutes a baby is born in Australia. The structure of government in Australia is “as good as it gets. The decision makers really understand investing in the child,” he says.
Israel needs to mobilize all the resources it can for this target, recommended Oberklaid.
“The Treasury has to understand it is either pay now or pay later, and later it will be much more expensive. Any minister who understands science will – in a second – decide against privatization of such vital services. If cabinet ministers really care about children, they would base their policies on scientific research. Policy must be informed by research and not by politics.”
“In Israel, the eventual risk of ignoring these facts is the disintegration of social infrastructure. For every Nobel Prize Israeli scientists receive, there are huge numbers of children here who are not reaching their potential,” declares Oberklaid, who speaks some Hebrew and visits the country frequently. “If your finance ministry doesn’t understand this, it is pure ignorance.”
Poverty, for example, can corrode family relationships – parents with children, parents between themselves – creating a great deal of harmful stress. Poverty also directly affects children’s health by increasing the prevalence of low birthweight, infections, cerebral palsy and even obesity later on. Parents living in poverty have higher rates of smoking, including during pregnancy, and their children are more at risk for asthma due to passive smoking, he says.
Mothers, points out Oberklain, are less likely to breastfeed, which can lead to health complications. Even if they are caring and well meaning, the poor are more likely to have poor parenting skills and suffer from chronic stress – which is toxic – and youngsters are at higher risk for child abuse and neglect.
The Australian physician stresses that brain development research in the past decade has clearly shown that during a child’s first two or three years of life, he or she is “exquisitely sensitive to the environment, nutrition, infection and the quality of parenthood. This period sets the foundations for the rest of their lives.”
It isn’t inevitable that lives will be troublesome if children are improperly raised during these early years; they can usually be repaired – but it is much more difficult and takes much time, he says.
“Brain research shows that biologically, it is better to get it right the first time rather than fix it. Today, we know exactly what young children need to thrive and prosper,” stresses Oberklaid, who has written over 150 scientific journal articles on these subjects and some books including Health in Early Childhood Settings: From Emergencies To the Common Cold.
The pediatrician from Australia, where there are 120,000 Jews – 70,000 in Melbourne – is not just giving free Israel advice; he is also actively involved in making changes here.
On a February night a few years ago, Oberklaid went to dinner in a kosher Tel Aviv restaurant called Goshen to brainstorm with colleagues from Israel and abroad. One was Ron Finkel, president of the Hadassah Australia Project, which raised money for a program that would revolutionize Israeli pediatrics.
Finkel discussed how to bring to fruition Oberklaid’s vision of a comprehensive community pediatrics program.
Influential Israelis also present were Prof. Mati Berkovitch, head of the Israel Pediatrics Association, and Prof. Basil (Boaz) Porter, international coordinator of the Israel Ambulatory Pediatrics Association.
The first step was selecting a young Hadassah pediatrician for a two-year training fellowship, who would work with Oberklaid in Australia.
Dr. Hava Gedassi, a physician and modern Orthodox mother of four and married to an engineer, was chosen, and she is now completing her training. Upon her return this summer, she will set up an academic and community child health unit at Hadassah in Ein Kerem to implement what she learned.
The program was called the Goshen project, named for the restaurant, with the connotation of the ancient Israelites leaving the part of Nile basin where they were in Egyptian bondage and going to freedom.
The Goshen Project, Oberklaid says, will raise pediaticians’ awareness about the importance of the early years of childhood in affecting health throughout one’s life and of heading off poor literacy, obesity, criminality, substance abuse, welfare dependency, mental health problems and others.
“Pediatricians and other health professionals have an unparalleled opportunity to participate in programs of prevention and intervention early in the life course, before problems become entrenched,” he says.
As Prof. Porter comments, “We all felt sure that this time things were starting to come together for child health.”
“The Health Ministry is weak, and I’d like to see more Israeli pediatricians step up to the plate and show leadership,” says Oberklaid. “But the resources are here, if the medical system were properly organized. A national steering committee will be set up to spread the Goshen Project nationally. Other hospitals and the medical faculties are very interested, and the health funds are also very interested in joining.”
Prof. Eitan Kerem, head of Hadassah’s pediatric branch, and his predecessor Prof. David Bransky, have also been very supportive.
“In my country, we have anonymous data on health and vulnerability on 98 percent of the children. It’s all public domain,” he concludes. For him and his Australian colleagues, “Israel is like a laboratory for us. Our methods have to be adapted and translated, but the principles – of one-stop, integrated services for young children – are universal.”