One of the reasons we love pediatrics as a focus is the joy of seeing our patients grow before our eyes. Their waiting room experience is very telling. First, there are the babies that can sit in the car seat while parents read a magazine. Then come the toddler years when drawing them away from the fish or toys to go see the doctor literally is a feat of strength. The school-aged children are sometimes working on homework or reading a book. (Although let’s be real, they are usually utilizing some electronic device to bide their time.) But there is an age when most patients look around the waiting room and think: What am I doing in this room filled with babies?
Pediatric care encompasses physical, developmental health, as well as mental and psychosocial health, and can extend from the time of conception through early adulthood. The decision to transition to an adult provider can be complicated, especially in the presence of a chronic medical condition. The American Academy of Pediatrics has published guidelines outlining the age of 21 as the time to transition, but recognizes exceptions to consider on a case-by-case basis. Following are considerations for deciding when to transition away from a pediatrician to an adult physician.
What to Expect From Your Child’s Pediatrician
Pediatric providers help prepare your child a transition to an adult physician. Pediatricians should begin talking to patients in private sometime in the early teen years. Just like learning to pay bills or pump gas, an adolescent needs to learn to tell their own story and start to practice advocating for himself or herself. The provider can also help guide you, as the parent, if there are any considerations as described below.
The pre-college exam is a nice time to start the discussion of other resources if it has not already been addressed. Whether it is the student health options on campus, or mental health support provided by their school, college students need to know that they have other avenues open to them. We recommend starting the dialogue with your child and pediatrician in late high school to see what fits your specific child’s needs.
Most pediatric primary care and specialty groups have general, but not absolute, age cut-offs. For instance, Charlotte Pediatric Clinic sees its patients through college or until the age of 22. All the surgeons at Pediatric Surgical Associates are double boarded in both pediatric and adult general surgery. PSA sees patients through college or age 22, but this depends on the specific need. On the other end, internal medicine groups may not see patients younger than 18.
Chronic Medical Conditions
When chronic conditions are present from birth or at a very early age, they are managed by pediatricians and pediatric specialists. Examples would be congenital heart disease or cystic fibrosis. Once a child is older, finding an adult specialist can be difficult. For this reason, the pediatric specialist may continue to manage care beyond 18 or 21 years of age. They often, however, can help find a physician to transition your care to when they time is appropriate.
For some other diagnoses, the opposite is true. Chronic conditions that arise during early adulthood may be better managed by an adult specialist and possibly an adult primary care physician sooner than 18 to 21. If this is the case, it may be beneficial to transition care for this newly diagnosed disease to an adult specialist rather than starting care with a pediatric specialist and needing to change doctors in a year or two.
Changing Needs of the Patient and Sexual Health
Situations such as the need for gynecologic resources is a good example of transitioning earlier to streamline care. Individual pediatric groups have different approaches when it comes to contraception or management of sexual health. If patients need care in these areas, especially if they are close to the age the practice generally transitions, that could be a turning point. It may be more useful to transition to an adult primary care physician who can pick up the role of health maintenance, but also address the specific issues that are more likely to arise in the older patients.
Consent for Treatment
Age of consent is another issue to consider. Once 18, a child can legally sign consent for treatment and surgical procedures. For instance, after turning 18, the patient is asked to sign the forms for vaccines or procedures despite still being with a pediatric practice.
As children grow up, they have more adult feelings and needs from a mental health standpoint. Despite a pediatrician being perfectly capable and qualified to address these concerns, your child may not feel comfortable discussing these certain topics with the provider who has seen him or her throughout childhood. If a referral needs to be made to a psychologist or psychiatrist, there may be more availability with the providers who see primarily adults if the patient meets the minimum age requirements.
There are some instances when insurance does not cover visits to a pediatrician or pediatric subspecialist when the patient is over age 21. This is policy-specific and worth a look as your child gets older.
The timing of transitioning from pediatric to adult care varies slightly depending on the needs of the individual patient, as well as the general age set out by the pediatrician. From day one, a pediatrician’s goal is the same as yours: to help set babies up to be the healthiest adults possible, even when they have “outgrown” pediatric care.
Anna Schmelzer, MD, is a board-certified pediatrician at the SouthPark office of Atrium Health Levine Children’s Charlotte Pediatric Clinic, and Thomas Schmelzer, MD, is a board-certified pediatric surgeon at Pediatric Surgical Associates. They are married and have two children.