Pediatric Health Declining

Failing Them

Why Are We?

We are failing our children, the next generation.

I have been spending an inordinate amount of time studying cellular biology and mitochondrial function in order to understand worsening disease trends. Thus, I want to revisit a landmark study that is one of the most comprehensive assessments of pediatric health ever conducted in the United States. Rather than examining a single disease or health outcome, Dr. Forrest and colleagues integrated data from multiple nationally representative surveys, mortality databases, and electronic health records encompassing millions of children to evaluate whether the health of American children has changed over the past 17 years. The answer was strikingly consistent: across virtually every major health domain, children in the United States are becoming less healthy. The investigators examined mortality, chronic physical and mental health conditions, obesity, functional status, sleep, puberty, physical symptoms, and emotional well-being between 2007 and 2023. Nearly every indicator worsened over time.

"From 2007 to 2022, infants (<1 year old) were 1.78 and 1- to 19-year-old individuals were 1.80 times more likely to die in the US than in the OECD18. The 2 causes of death with the largest net difference between the US and OECD18 were prematurity and sudden unexpected infant death for infants 12 months or younger, and firearm-related incidents and motor vehicle crashes for 1- to 19-year-old individuals. From 2011 to 2023, the prevalence of 3- to 17-year-old individuals with a chronic condition rose from 39.9% to 45.7% within PEDSnet, and from 25.8% to 31.0% within the general population. Rates of obesity, early onset of menstruation, trouble sleeping, limitations in activity, physical symptoms, depressive symptoms, and loneliness all increased during the study period." (Forrest et. al. 2025)

Equally concerning was the rise in chronic illness. Depending on the data source, the prevalence of chronic conditions increased by approximately 15% to 20% over the study period. The fact that 45.7% of US children have a chronic disease is extremely sobering. "The 8 conditions with the largest increases were major depression (RR, 3.30), sleep apnea (RR, 3.22), eating disorder (RR, 3.20), anxiety (RR, 3.06), autism spectrum disorder (RR, 2.62), obesity (RR, 2.37), disorders of lipid metabolism (RR, 2.06), and developmental disorder (RR, 2.05)."(Forrest et. al. 2025)

These findings reinforce that the United States continues to underperform peer nations despite spending substantially more on health care. That fact clearly leads to an incongruent reality that money cannot fix this struggle and there is a more fundamental underlying problem at play. We have discussed the problem often here.

Food.

The study also documented deterioration in broader measures of health and function. Childhood obesity continued its steady rise, sleep problems became more common, activity limitations increased, early puberty occurred more frequently, and both depressive symptoms and loneliness worsened substantially. Importantly, these trends emerged across multiple independent data sources using different methodologies, suggesting that the findings are unlikely to be explained solely by changes in diagnostic practices or reporting bias. 

Perhaps the most important contribution of this paper is conceptual rather than statistical. Rather than viewing obesity, anxiety, autism, developmental disorders, sleep dysfunction, and chronic disease as isolated epidemics, the authors argue that they likely represent manifestations of a broader deterioration in the developmental ecosystem surrounding children. They deliberately refrain from assigning causality but instead call for research directed toward identifying common upstream drivers, including nutrition, environmental exposures, physical inactivity, sleep disruption, psychosocial stress, health care access, and broader societal influences, that simultaneously affect multiple health outcomes. 

For clinicians practicing pediatrics, the implications are profound. This paper validates what many physicians have observed in practice: increasing numbers of children with multiple chronic conditions, metabolic dysfunction, behavioral disorders, and impaired resilience. It also highlights the limitations of disease-specific approaches. Treating obesity, anxiety, ADHD, asthma, or depression individually will likely produce only modest improvements if the underlying biologic and environmental factors driving these conditions remain unchanged.

From an integrative and immunometabolic perspective, the findings are particularly compelling. Although the authors intentionally avoid mechanistic speculation, I will not. The pattern of simultaneous increases in obesity, inflammatory disorders, mental health conditions, sleep disturbances, and developmental disorders is consistent with the hypothesis that shared upstream disruptions, including metabolic dysfunction, chronic inflammation, mitochondrial stress, poor nutrition, and adverse environmental exposures, may underlie much of the observed decline.

Overall, this study should be viewed as a wake-up call for pediatric medicine. It shifts the conversation from managing isolated diseases to asking a more fundamental question: Why are American children becoming less healthy across nearly every measurable domain? It provides compelling epidemiologic evidence that the decline is real, widespread, and likely driven by systemic factors requiring equally systemic solutions. 

 WHY?

Today's children are often over nourished in calories yet undernourished in the micronutrients required for normal cellular function. Diets dominated by ultra-processed foods provide excess energy while lacking the vitamins, minerals, amino acids, and phytonutrients necessary to support mitochondrial energy production, antioxidant defense, immune regulation, and tissue repair. Emerging evidence continues to point to disrupted intestinal microbiomes feeding low level endotoxemia and increased systemic inflammation. At the same time, chronic psychological stress, sleep disruption, and relentless digital stimulation increase sympathetic nervous system activation and cortisol signaling, driving persistent low-grade inflammation worsening mental health causing a loop effect.

Modern children also experience unprecedented exposure to environmental chemicals, microplastics, endocrine disruptors, and air pollutants, all of which place additional demands on detoxification systems and mitochondrial function. Sedentary lifestyles reduce mitochondrial biogenesis, impair insulin sensitivity, and limit the profound anti-inflammatory and insulin sensitizing effects of regular physical activity. Reduced outdoor time further compounds these problems by decreasing sunlight exposure, lowering vitamin D synthesis, disrupting circadian entrainment, and weakening normal immune and metabolic regulation.

These stressors rarely occur in isolation. Rather, they converge to create a state of chronic immunometabolic dysfunction in which mitochondrial energy production becomes less efficient while oxidative stress and inflammatory signaling increase. The result is diminished physiologic resilience, making children more susceptible to obesity, asthma, neurodevelopmental disorders, autoimmune disease, mental health conditions, and other chronic illnesses highlighted in the Forrest study. Mechanistically, these trends suggest that the rising burden of pediatric disease is less the consequence of isolated genetic defects than of an environment that chronically exceeds the adaptive capacity of developing biological systems. Restoring health therefore requires addressing these upstream drivers, not merely treating their downstream manifestations.

We are at a major crossroads in Pediatric Health. Are we going to make changes for them or let this trend continue????

Dr. M

Forrest JAMA