Introduction

In many health care institutions in India, sick children up to 12 or 13 years are registered under Pediatric service and older children under adult Medicine service. This age cut-off has been traditional. Some 3 to 4 decades ago, sick children were treated by physicians who were primarily responsible for adult medical service. Children were considered miniature adults and the main concern was only to scale down the doses of medicines according to the body weights of children. It did not matter very much where a child was admitted for treatment, because the same physicians treated children and adults. The children's wards had short beds and only children below about 12 or 13 would fit in them. Taller children, who were usually older, were admitted in adult wards. Even after Pediatrics came of age as discipline, somehow the traditional age cut off remained. Even today, when sick persons are registered at the hospital reception desk, those under 12-13 years are sent to Pediatric clinic and older children are sent to Medical clinic.

Adult Medicine (or Internal Medicine as it is often called) is usually preoccupied with the diagnosis and treatment of physical illnesses. Symptoms without disruption of functions of organs or issues are often attributed to 'functional' illness, usually without going into further details. The strength of Internal Medicine is this ability to dissect out deviations from normal physiology and we must agree that such diagnostic expertise is absolutely essential for us to understand disease processes and to be able to treat them according to pathology and/or etiology.

Pediatrics is also concerned with such diagnostic accuracy of physical illness. Since the patterns of illnesses vary very much between adults and children, the same principles as those used by Internists are necessary for Pediatricians also to diagnose and under- stand disease processes and to treat diseases rationally. But Pediatrics goes beyond disease. Childhood is the formative stage of life towards adulthood and we are concerned about growth, development and disease prevention, both physical and otherwise. This process or growth, development and vulnerability to deviation from the normal or optimal path of growth and development do not cease with age 12 or 13 years, but proceeds up to the late teen age, that is, until a person is an adult. For this and other reasons, there are many advantages for teenagers td cone under the purview of Pediatric care. Obviously, it does not matter as to who, the Internist or the Pediatrician, treats a teenager with typhoid fever or thyroid nodule. But, special skills are necessary to counsel a teenager who faces the stress of rapid body changes and the consequent confusion of self image and relationships.

Policy Statement

Policy on Age of Children for Pediatric Care (1999)

For fulfilling the professional obligations of pediatricians to the society at large, the purview of pediatrics commences with the fetus and continues through newborn, infancy, preschool and school age including adolescence up to and including 18 years of age.

An Explanatory Note

This policy has been adopted by the Academy by unanimous approval both at the Executive Board and General Body, during the Annual Conference at Jaipur, in February, 1999. It must be pointed out that we were guided very much by the 'Convention on the Rights of the Child', adopted by the United Nations General Assembly on 20 November, 1989. Article 1, of the Conventions states: "For the purposes of the present Convention; a child means every human being below the age of 18 years unless, under the law applicable to the child, majority is attained earlier". In India, the right to vote in political elections is attained at the age of 18. In the United States of America, Pediatrics covers up to 21 years of age. Thus, we could have defined the age as below 18, or up to 21 or till the last year of the teens (nineteen), but our collective wisdom has accepted it as up to and including 18 years. There is little to gain by hair-splitting.

It is generally accepted that children with chronic illnesses and who are under the continuous care of a pediatrician will continue to be cared for by the same doctor for a while longer, and not just up to the age defined here.

What Actions Do We Need to Take?

By stating a policy, it does not mean that all pediatricians have the training, aptitude, knowledge or skills necessary to care for adolescents. We must learn them, and we must teach and train. For this purpose an ad hoc Committee has been appointed and we will be guided by their recommendation about the modalities and range of contents for training Pediatricians in Adolescent Medicine and Care. Once these are decided upon, the Academy will establish a process by which training opportunities will be made available widely.

In the newly published lAP Textbook of Pediatrics, a whole section has been included on Adolescent Care. If Medical Colleges will adopt the new curriculum on Pediatric teaching as described by the Medical Council of India; this .section will become essential, and thus, future Physicians and Pediatricians will have already learned the foundations of Pediatrics including Adolescent Care.

We have amidst us a number of Pediatricians with special interest and skills in Adolescent Care. It will be in order for us to include topics of adolescent issues in our seminars, conferences and Continuing Education programs.

The Government of India is establishing a major program under the title, 'Reproductive and Child Health'. The WHO has created a new Department called 'Child and Adolescent Health and Development'. Both these developments are indicative of the changing world view on the needs and opportunities for care in the adolescent period of development. The Academy is not far behind them.

The purpose of the new policy is not to gain any advantage from anyone, not for new departments or beds for admission, but to voluntarily take upon ourselves the responsibility to provided a service that no one else has been giving. Some of us have acted as Pediatricians for many children from birth up to 12 or 13 years. So, we become naturally the doctors with whom they are comfortable, and whom they trust. But we have to learn to listen care- fully and to understand them and their situations with professional competence. We have to provide the adolescent-friendly atmosphere in our clinics and make it known that they are welcome to come and speak to us. We must develop a realistic approach about consultation charges for teenagers. Adolescent Care should not become another gimmick for income generation. For this reason, perhaps public sector clinics must come forward readily to establish Adolescent Clinics. We must be sensitive to their gender perceptions and we must carefully plan our physical examination routine when it is required. We have to get help from psychologists, counsel- ling experts, endocrinologists and even gynecologists. To a certain extent we might be treading unchartered territory but there is a lot of expertise already available in the country. Any constructive suggestions will be very welcome. Let us put the policy into practice.
 

T. Jacob John,
President,
Indian Academy of Pediatrics,
Thekkekare,
2/91 E2, Kamalakshipuram,
Vellore 632 002, Tamil Nadu, India.