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A LEADING expert in adolescent health is calling for the age cut-off for paediatric care in Australia to be lifted to at least 19 years.
Professor Susan Sawyer, Geoff and Helen Handbury Chair of Adolescent Health at the University of Melbourne and Murdoch Children’s Research Institute, is lead author of a recent global survey of paediatricians that found that the mean upper age limit of paediatric inpatients in Australia was 17.8 years.
The survey of 1372 paediatricians – which was published on 18 September 2019 in The Lancet Child and Adolescent Health – found great variability in the age cut-offs for paediatric care in the 115 countries surveyed.
In more than a third of the countries surveyed, paediatrics did not extend beyond early adolescence (10–14 years), while in more than a half of countries surveyed paediatrics extended into young adulthood (up to 24 years).
The US was home to the highest mean upper age limit for paediatric inpatients at 19.5 years, while South Africa had the lowest upper age limit at 11.5 years.
Professor Sawyer, who is also Director of the Royal Children’s Hospital’s Centre for Adolescent Health, said the World Health Organization first defined adolescence as extending from age 10 to 19 years back in the mid-1960s.
However, in an article published in The Lancet Child and Adolescent Health in January 2018, Professor Sawyer and her colleagues argued that extending the definition of adolescence to up to 24 years corresponded “more closely to adolescent growth and popular understandings of this life phase”.
In an exclusive InSight+ podcast, Professor Sawyer said the past few decades had seen significant social changes with a marked increase in the age at which people participated in education, married and had children. Also, she said, brain imaging had provided greater understanding of the biological endpoints of adolescence, which did not end with completion of pubertal maturation.
“We [now have a] much greater appreciation that the adolescent brain is an incredibly active brain which is continuing to be remodelled across not just the second decade but into the mid-20s as well,” she said. “We can think of adolescence as a period of major biological growth and development not simply in terms of the pubertal cascade that tends to complete by the mid-teens, but that it continues with brain maturation extending across the teenage years and into the 20s.”
In the 2019 survey, two-thirds of responding paediatricians from Australia and New Zealand suggested that paediatric practice should extend beyond the age of 18 years, and a quarter suggested that it should extend beyond the age of 20 years.
“Yet, we know the mean age [of paediatric inpatients] in Australia currently is 17.8 years, with it being much lower in New Zealand at 15.6 [years],” Professor Sawyer told InSight+.
Professor Sawyer said several specialist paediatric services in Australia provided paediatric care only up to the age of 16 years.
“It’s inappropriate for a 16-year-old who is newly diagnosed with type 1 diabetes to be managed in an adult service,” she said.
Paediatricians who had been trained to work with adolescents were better placed to understand the importance of supporting young people’s engagement in education and their developmental trajectory in the context of new onset of a significant chronic illness such as type 1 diabetes, she said.
Professor Sawyer also noted that many young people had their 18th birthday in their final year of high school, which can be a challenging time to transfer from paediatric to adult services.
“In Australia, we have very different age cut-points in different children’s services,” she said, noting that in many parts of Australia child and youth mental health services now provided care up to age 24 years.
She said it would not be appropriate for paediatric services – “the way they are currently configured” – to provide care up to an age of 24 years.
“But I certainly do believe that paediatric services in Australia should at least extend up to 19 years … and the majority of paediatric services … do not extend up to that age,” she said, adding that specialist training in adolescent medicine was crucial in providing high quality care for this age group.
“The good news in Australia is the recognition that these developmental years actually require not just paediatricians’ leadership but adult specialist leadership as well. This is being embodied in the [Royal Australasian College of Physicians’ (RACP)] specialist recognition of Adolescent and Young Adult Medicine [branch], which accredits specialty training for paediatricians and adult physicians.”
In response to this research, the International Pediatric Association has developed a new policy that supports the discipline of paediatrics extending at least up to 19 years, she said. The RACP also has plans to develop a minimum upper age policy.
My 17 year old has experienced brilliant care from their paediatric specialists verses condescending, patronising and dismissive ‘care’ from ‘adult’ specialists. There is a very real need for extending paediatric specialist care beyond 18 years if age in Australia.
I doubt many rural settings have the capacity to extend their care beyond 18 years. The vast majority of this group will be teens with ADHD on stimulants. In NSW that means they need a script every 6 months from a Paed or Psychiatrist. Consequently, these clinics fill up over time (many of this group are seen every 6 months from 5-18 years) and the rate of new referrals far out-strips discharges and natural attrition. We presently face a stark choice, in the absence of any increased capacity: continue seeing until 18 and refuse all new referrals of younger children who would likely benefit from a Paediatric review/treatment. Or, we discharge all those over 16 to free up space to see those younger children, who – if not seen – will undoubtedly suffer significantly, both in terms of their mental health, but also their education. The result will be a potentially avoidable, but life-long handicap.
As a musician once said, “ age ain’t nothing but a number”. It’s curious therefore that we decide that at some point to choose to move people across sectors based solely on this requirement. Would it therefore be a good idea to look at cut offs that are based on other features such as Gillick competence? This would mean having a clear idea about the needs and capabilities of our clients would make the difference in these transitions and how we facilitate this.
yeah and at the same time we can still send paediatric trauma to the proper grown up EDs instead of kiddie EDs on the basis that they can’t cope with trauma…but keep them in resp clinic until 19…seriously people used to fly spitfires in defence of the realm and free world at 18 but we can’t have them in adult hospitals now. What a change.
Sounds like you are interested in working with young people and have the skills to do so, which is great. Sadly not all of your colleagues do – and not all of my paediatric colleagues do either. The point of the paper was not to set up paediatricians against adult physicians. But rather, to ask the question about when does paediatrics currently end in different countries, is it increasing in age, and if so why? The main concern is not about minor differences in upper age in Australia but about the 8 years of difference between when paediatrics ends in the US and when it ends in South Africa, for example. That paediatrics hardly extends into the second decade in a number of countries in sub-Saharan Africa suggests that it is failing to embrace the challenge of adolescent health. Many countries are rapidly lifting their upper age of paediatrics – in the paper, we give the example of Ghana that a few months back lifted their upper age from 13 to 19. Prior to that, paediatrics services could continue to manage older adolescents but as they no longer were eligible for financial reimbursement, it functioned as an effective ‘end’ of paediatrics. The key point about the changes in Ghana is not that adult services can no longer consult with adolescents under 19 (they can), but that both paediatric and adult services need training to care for adolescents. The need for paediatric training in adolescent health will be most critical in countries with a high population proportion of adolescents, a high adolescent burden of disease, and a rapidly rising upper age. There is growing evidence that adolescents do less well than adults with receive the same quality of care, which presumably reflects many different factors. The good thing is that Australia is one of few countries with accredited training in Adolescent and Young Adult Medicine for both paediatric and adult trainees. In Australia, having suggested that paediatrics should at least extend up to 19 by no means precludes adult medicine starting earlier, as long as physicians are trained to care for this age group. Indeed, there should be overlap.
Having said this, most 15 year olds I care for are pretty different developmentally from 21 year olds. let alone 24 year olds
Interesting viewpoint and the conflict of interest (more paediatric work & expanded career opportunities) should also be acknowledged.
I would like to propose that rather than talking about whether care is “paediatric” or not we would serve patients better by focussing on whether it is appropriate for them – whatever their age.
As an “adult” Gastroenterologist with an IBD focus, I would even go so far as to say that a newly presenting young person with IBD for example, (anyone over 15-16 years) should always come to “adult” care rather than a childrens’ setting. To propose adult services are incapable of understanding and responding to the needs of 16-19 year olds (yet are fine to suddenly manage people at 18, 20, 25 or whenever) is hard to take seriously. Starting care for complex chronic disease management with a team who can stay with you as you grow and help you take decisions for the long term (not just until you leave their service) has a lot to recommend it. Transition is known to be a time of risk and in the IBD field there are data showing paeds services are not so comfortable discussing issues relevant to adolescents/young adults such as sex, contraception, drugs and alcohol…..
There would also be huge cost implications of the proposal – and to ensure tax payers’ money is wisely spent, there would need to be cost-efficacy proof in extending paediatric care
The proposal is very good. I agree that children still at school should not be cared for in adult services.
I suppose it would still be best for an 18 year old to have her baby delivered in an adult setting.