ESPE Yearbook of Paediatric Endocrinology

To read the full abstract: Lancet Child Adolesc Health 2019; 3: 822–30. doi: 10.1016/S2352-4642(19)30266-4

• The upper age limit of paediatric care varies markedly from country to country.• The authors surveyed 1372 paediatricians in 115 countries and found that, based on their personal experience, the upper age limit of pediatric services had increased over the last 20 years of their practice, reflecting greater awareness of adolescent health.• A greater focus on adolescent health during training is recommended.

Between September and December 2018, the authors sent an invitation to participate in an online survey to multiple regional pediatric organisations, asking them to distribute it to their members. The survey focused on the upper age limit of pediatric services in their country and on the respondents’ perceptions of the upper age limits of pediatric services 10 years and 20 years ago. The survey was completed by 1372 pediatricians in 115 countries. The highest mean upper age limit of pediatric patients was 19.5 years in the USA. The lowest mean upper age limit was 11.5 years in South Africa. Within a country, replies from pediatricians vary and in 14 countries, the upper age limit varied by more than 10 years. The 600 pediatricians who had practiced for over 20 years reported that the mean upper age limit of inpatients had increased from 16.2 years two decades ago, to 17.4 years now. The main reason for the rising age over time was felt to be a greater awareness of adolescent health and leadership by professional associations. The authors suggest that a greater focus on adolescent health is required within pediatrics to ensure that the future pediatric workforce is appropriately equipped to respond to the changing disease pattern across childhood and adolescence.

Overall, the study shows that there is little agreement on the upper age limit for pediatric care. But should there be an international consensus on the age range of young patients seen by a pediatrician? Interestingly, WHO does not presently have a common definition for the upper age limit of pediatrics. For instance, the Essential Medicine List for children (EMLc) defines a child as younger than 12 years. This means that contraceptives are listed only in the adult EML, not in the EMLc. In the HIV/AIDS section of the WHO website (www.who.int/hiv/pub/guidelines/arv2013/intro/keyterms/en/ adolescence), an adult is a person older than 19 years of age while a child and an adolescent are defined as persons aged <10 and <19 years, respectively. For the WHO growth curves, an adult is a person older than 20 years of age, children as <5 years and school age children + adolescents as 5–19 years. Practically, younger children are commonly seen by a pediatrician, and young adults (after high school) are commonly seen by an adult physician. It can be argued that an international age limit is not realistic and that the age of adolescence should be based on maturation (puberty, independence): age at which adolescents leave home to go to college, work independently or marry; age at which pubertal development and adult height are achieved (for instance, in British Columbia, Canada, the age of transition from pediatric to adult care is officially flexible, from 17 up to 21 years). There may also be practical reasons that influence the age at which a pediatric patient is cared for by a pediatrician or by an adult physician, such as the availability of pediatric in- and outpatient care (for instance, in francophone Africa, the lack of pediatric endocrinologists means that most children and adolescents are followed by adult endocrinologists). Overall, an important message is that physicians who care for adolescents, whatever the definition is, should receive appropriate specialty and sub-specialty training.