What We Don't See
Authors: Margaret Kendrick Hostetter
Journal: New England Journal of Medicine (2012)

of Medicine and Surgery, Sir William Osler introduced the term "pediatrics." 1 Although "diseases peculiar to children" had figured in Benjamin Rush's lectures at the University of Pennsylvania since 1789, most physicians in the early 19th century did not recognize children as a distinct population with particular medical needs.Indeed, in most medical journals of this period, the words "infant," "child," and "children" figured only in case reports of obstetrical complications or in accounts of epidemic-related mortality.Osler's use of the term "pediatrics" not only differentiated physicians "specially connected with pediatrics" from other physicians 1 but also drew attention to the creation of a "special" discipline.After Osler's introduction of the term, articles entitled "Progress in Pediatrics" began to appear sporadically in the Journal from 1904 forward, and the specialty of pediatrics was accorded its own section in the Journal in 1954.However, charting the influence of the Journal on two centuries of pediatric medicine is perhaps more thoughtfully addressed by means of a computational algorithm 2 to search the Journal's archives for Osler's designation -pediatrics -so as to gain insight into the increasing emphasis on childhood health over the past 200 years (Fig. 1).This approach allows us to demarcate four periods, albeit somewhat arbitrarily defined, that reflect the emergence and discoveries of pediatrics in the pages of the Journal -the recognition of children as a particular population benefiting from medical practice (1812 through 1880), the introduction of public health programs to reduce childhood mortality (1881 through 1930), the development of vaccines (1931 through 1980), and the global dissemination of pediatric practice (1981 through 2012) (see timeline, available with the full text of this article at NEJM.org).Each of these periods also coincides with particular advances against infectious disease -the single leading cause of childhood death yesterday and today (Fig. 2) 3 -that were heralded in the pages of the New England Journal of Medicine: the concept of social intervention, the battle against summer gastroenteritis, the defeat of smallpox, and the drive to reduce childhood mortality from diarrhea and the human immunodeficiency virus (HIV).Seminal articles in the Journal have also advanced the fields of pediatric surgery, oncology, neonatology, and a host of other pediatric disciplines over the past two centuries.Transformative approaches to noninfectious causes of childhood death -congenital heart disease and leukemia -appeared first in the Journal. 4,5Landmark articles describing functional asplenia in sickle cell disease, 6 legal redress for the battered child, 7 the genetic foundations of population-based screening for phenylketonuria and cystic fibrosis, 8,9 molecular and therapeutic advances in surfactant deficiency, 10,11 and the relationship between prone sleeping position and the sudden infant death syndrome 12 have blazed the trail of progress in pediatrics.But the fact remains that infectious diseases were the predominant cause of childhood death at the time of the Journal's inception and remain so, globally, today (Fig. 2). 3 Therefore, this review emphasizes how articles in the New England Journal of Medicine have directed and illuminated the course of progress against the infec-A timeline is available at NEJM.org