Home Pediatric Commentary Children are not small adults … except when they are

Children are not small adults … except when they are

June 2008

Published in the June 2008 issue of Today’s Hospitalist

“Why can’t you fly now, mother?”
“Because I am grown up, dearest. When people grow up, they forget the way”

J.M. Barrie
“Peter and Wendy”

CHILDREN ARE NOT SMALL ADULTS. This is the standard mantra during pediatrics residency training, an almost sacrosanct statement. It seems designed not to justify the specialized care that children need, but instead to assure ourselves, as pediatricians, that we will not become obsolete.

I can hear some of you reacting with a degree of outrage: “How can you say that, you Dr. Heathen? Children ARE NOT small adults! Call the pediatric inquisition!!”

I both agree and disagree.

From the points of view of anatomy (obvious) and physiology (less obvious), children are in a special category. Apart from dealing with the evident array of childhood- specific illnesses “juvenile-onset diabetes, neonatal hyperbilirubinemia and congenital heart disease “pediatric care providers have to deal with complex social, nutritional and psychological circumstances. Children behave differently than adults; they require specific testing for their specific illnesses; they need special techniques for procedures.

Pediatric hospitalists and nurses must tailor therapies to children, whether those are pain control, preventive medications and vaccinations, or radiation doses for CT scans. Even the size of the surgical equipment for children highlights the fact that they are a special group of patients.

The need for a new mantra
All of that said, I still think we need to change our mantra, maybe to something like, “Children are not small adults “¦ but sometimes they are.”

The role of the pediatric hospitalist is changing. The hospital is becoming a room in the medical home for children, especially those with illnesses like leukemia, cystic fibrosis, even asthma. Thanks to great surgical and medical advances, children with congenital heart disease and metabolic disorders are living into adulthood.

The reality is that these “children” are still coming to the children’s hospital to see pediatric nurses and physicians.

I recently overheard a conversation between a nurse and a resident regarding a 26-year-old patient with cystic fibrosis who was being admitted to the pediatric unit for a “tune-up.” The discussion went something like this:

“Why can’t she go to an adult floor?” “Well, she is a patient of Dr. So-and-So. Plus she really likes the way she’s treated here in the peds unit.” “Well, I don’t blame her for that. But she is an ADULT!”

There was this conversation about a 17-year-old girl who was pregnant and being hospitalized for pyelonephritis:

“But she is PREGNANT!! We don’t take care of pregnant patients!” “But she is still in the pediatric age group.” “But she is PREGNANT!”

Notice I don’t identify who said what. As a matter of fact, these discussions didn’t take place exactly as I report, but instead are composites of conversations I’ve heard or taken part in over the years. While the conversations aren’t real, the underlying issues are, and the question remains: When does a pediatric patient become an “adult”? And when do pediatric care providers stop taking care of them?

My answer to both questions is, “Children are not small adults”¦but sometimes they are.”

The point is that even if we are hospitalists for children, we must be willing and able to take care of patients who reach the “outer range” of what we view as “pediatric.” We must be willing and able to care for “adults” who have life-long pediatric illnesses. We must be willing and able to provide a medical home for these patients. And if we have some intellectual discomfort in taking care of them, an appropriate referral to another physician is the right thing to do.

Just as we’ve become adept at discharge planning and quality improvement, we must also become adept at dealing with older adult/pediatric patients, treating them with respect and competence. And, yes, once in a while, offering them a sugar-free lollipop (without being paternalistic)!

“But they are adults!” some may protest.

Yes, but they were kids at one point in their lives. Just like you and me.

Ruben J. Nazario, MD, is a pediatric hospitalist at Kentucky Children’s Hospital in Lexington. A guest blogger for Today’s Hospitalist, Dr. Nazario weighs in on the challenges of daily pediatric hospital medicine practice at www.todayshospitalist.com.