Adolescent chronic disease: transition of care

Z00.3

DESCRIPTION

Transition of care in adolescence is described as the purposeful, planned movement of a person with chronic medical conditions from a child-centred to an adult-orientated health care service.

Specialised programmes for transition improve adherence and outcomes. Careful assessment of growth and development may determine an individualised approach to transition. Chronic disease during this period impacts on growth and development.

GENERAL AND SUPPORTIVE MEASURES

  • Promote adherence to medicine and follow up.
  • Counselling and support.
  • Manage and co-ordinate treatment through a multidisciplinary team including physicians and paediatricians.

MEDICINE TREATMENT

The Tanner Staging is used to assess pubertal development.

TANNER STAGING OF PUBERTAL DEVELOPMENT

Tanner
stage 		Pubic hair Breast
development 		Testicular and
scrotal
development 		Penis
1. No hair Pre-adolescent Pre-adolescent Pre-adolescent
2. Sparse, downy
hair at base
of symphysis pubis 		Breast bud Enlargement of
scrotum and
testis
Skin of scrotum
reddens,
changes in
texture 		Little or no
penis
enlargement
3. Sparse, coarse
hair across
symphysis pubis 		Continued
growth of
breast 		Further growth
of testes and
scrotum 		Enlargement of
penis mainly
in length
4. Adult hair
quality, fills in
pubic triangle, no
spread to thighs 		Areolar and
papillae form
secondary
mound 		Testes and
scrotum larger;
scrotal skin
darkened 		Increased size
with growth
in breadth and
development
of glans
5. Adult quality and
distribution of
hair including
spread to medial
thighs 		Mature female
breast 		Adult size and
shape 		Adult size and
shape

Note: deviation from normal pubertal development may be primarily a disorder of the endocrine system, and may reflect the impact of another disease process on the endocrine system.

In 50% of children, breast stage 2 develops at 10 years, pubic hair stage 3 at 11.5 years and menarche at 12.5 years.

Titrate doses according to Tanner staging rather than strictly on basis of age.

  • Tanner 1 or 2 (early puberty): use paediatric schedules.
  • Tanner stage 5 (late puberty): use adult schedules.
  • Puberty may be delayed in children with chronic disease, adding to discrepancies between Tanner stage-based dosing and age-based dosing (consult relevant package inserts for guidance of dosage).
  • Optimise therapy of certain medicines by monitoring drug levels, adjusting doses during puberty and with weight gain.
  • Consider medicine interactions, e.g. induction of oral contraceptive metabolism by rifampicin and changes of drug disposition during puberty and use convenient medicine formulations and devices that contribute to better treatment adherence.
  • Minimise the adverse impact of medicines on cognition and brain development.

REFERRAL

  • Refer patients with cognitive impairment and mental health problems to a psychiatrist.
  • Adolescents with chronic disease for assessment by psychologist and mental health specialist for recognition of anxiety, depression, attention-deficit disorder and posttraumatic stress disorder.