On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.98 n.11 Cape Town Nov. 2008
Tony WestwoodI; George SwinglerII; Maureen RossIII; Bhavna PatelIII; Bongani M MayosiIII
IPaediatric and Child Health, Western Cape Department of Health. firstname.lastname@example.org
IISchool of Child and Adolescent Health, University of Cape Town, and Department of Paediatrics, Red Cross War Memorial Children's Hospital, Cape Town
IIIGroote Schuur Hospital, Cape Town
To the Editor: Stephan and Van der Merwe's call for adolescent medicine units1 is timely. They highlight the special needs of adolescents, and the folly of using 13 years as an upper age limit for children to be managed by paediatric services, especially for those with long-term health conditions ('chronic illness'). In South Africa, the number of adolescents with long-term health conditions is rising as a result of much improved medical and surgical care for children with conditions such as congenital heart disease; additionally, the advent of antiretroviral therapy for children with perinatally acquired HIV infection is producing a new population of such adolescents.2
The authors suggest that paediatricians are best suited to continue clinical care through the transition process to adult-orientated care. We suggest that, while paediatricians in South Africa may be better suited in this area than most of their physician colleagues, a partnership is needed across the disciplines of paediatrics, medicine, surgery and mental health to bring about a successful interdisciplinary service. Furthermore, there is much that paediatricians, physicians and surgeons need to learn in order to promote optimal transition care. Pseudo-parental infantilising and poor understanding of the needs of adolescents with longer-term health conditions are recognised faults of well-meaning child health practitioners.
In the 1990s, a survey of staff at Red Cross War Memorial Children's Hospital (RCH) and Groote Schuur Hospital (GSH) in Cape Town showed that, in general, paediatricians felt inclined to take on the care of adolescents, while physicians preferred to take over care of the more mature (A Westwood and L Henley, unpublished data). Specialised surgeons (such as neurosurgeons) found it relatively easy to span the transition to adult-orientated care for the few adolescents in their services, largely because the same staff served the child and adult services. At the time of the survey, formal transition services existed for adolescents with diabetes mellitus and cystic fibrosis.3 The survey found that significant numbers of teenagers received care at RCH, varying from yearly follow-up of young people who had survived cancer, through intensive management of those who had had renal transplants, to end-of-life care for young adults with genetic muscular disorders.
From the survey, a policy on the care of adolescents with long-term health conditions was developed at RCH to 'regularise' the continuing attendance at the hospital of children over the age of 13 years. The policy also encouraged transition plans in all services. The establishment of an inpatient adolescent ward at GSH was mooted, was supported by most people surveyed and, within a few years, had become part of the GSH strategic planning process.
Plans for a 15 - 18-bed adolescent inpatient unit (which is due to open in 2009) include:
• appointment of a specialist with a special interest in adolescent health to oversee the ward (in this case, a paediatrician)
• promotion of shared care between paediatricians and physicians for adolescents with long-term health conditions
• access for most adolescents with an acute non-psychiatric disorder who require specialised care
• nurses with skills in adolescent care
• admission rights for paediatricians, physicians and surgeons from RCH and GSH
• support from mental health professionals such as social workers
• an associated outpatient service
• space for schooling
• space for relaxation.
It will be important to audit and evaluate this pioneer project to further develop the service and to provide a blueprint for similar units in other hospitals (not only public ones) in South Africa. The authors undertake to do this.
1. Stephan C, Van der Merwe P-L. Treating adolescents in South Africa: time for adolescent medicine units? S Afr Med J 2008; 98: 184-187. [ Links ]
2. Examining the past, seeing the future. Mail & Guardian 2006; 28 July - 3 August: 36-37.
3. Westwood ATR, Henley LD, Willcox P. The transition from paediatric to adult care for persons with cystic fibrosis: patient and parent perspectives. J Paediatr Child Health 1999; 35: 442-445. [ Links ]