Health care issues as the child with chronic illness transitions to adulthood. (Editorial).

In this continuing medical education section, I have invited experts in pediatric newborn medicine, hematology/oncology, behavioral developmental pediatrics, and pediatric endocrinology to contribute articles centered on the transition of the youngster with a chronic health care need from pediatric-centered to adult-centered care. Our therapeutic successes in newborn medicine and hematology/oncology have resulted in an increased proportion of young adults with the medical consequences of either prematurity or a childhood malignancy. By contrast, in behavioral developmental pediatrics and endocrinology, changes in lifestyle have resulted in an epidemic of youngsters and adolescents with attention-deficit/hyperactivity disorder (ADHD) and a rise in the incidence of childhood obesity and subsequent type 2 diabetes mellitus. The articles in this section provide guidelines for the practitioner who cares for these youngsters as they progress from pediatric care to adult care.

In the past 30 years, dramatic improvements have been made in the cure rate for childhood cancers, with 75% to 80% of youngsters with acute lymphocytic leukemia now cured. (1) Since the estimated cure rate for all childhood cancer exceeds 60%, 1 of 1,000 young adults in the age range of 20 to 29 years is now a survivor of a childhood malignancy. (2,3) In the article by Castellino and Hudson (elsewhere in this issue), a review of late effects of specific treatment modalities serves as an instruction module for long-term follow-up by the internist and family physician of young adults who have survived intensive chemotherapy, radiation, and/or surgery for a childhood malignancy. Anticipatory guidance for reducing risk behavior, including efforts at smoking cessation, increased physical activity, and improvements in nutrition, seems especially important in this group.

Recommendations for specific emphasis on endocrine, cardiac, and pulmonary late effects are predicated by the type of previous treatment. Accelerated atherosclerotic cardiovascular disease and the increased incidence of breast cancer now seen after thoracic radiation therapy should alter routine surveillance for young adults who survive chest wall malignancies or Hodgkin's disease. The authors' overall emphasis on ideal habits of nutrition, exercise, weight control, and smoking cessation are integral to the long-term obviation of late effects in these young adults.

In newborn medicine, the limits of viability of the premature infant have been significantly lowered over the past 3 decades with improved perinatal care, advances in neonatal intensive care management, and the development of surfactant replacement therapies. (4,5) Elsewhere in this issue, York et al review the neurocognitive, cardiopulmonary, gastrointestinal, ophthalmologic, and audiologic late effects on survivors of prematurity, and highlight areas of increased emphasis for surveillance by the primary care physician.

Attention-deficit/hyperactivity disorder is among the most commonly recognized behavioral disorders of childhood and results in immediate health care costs that mirror the costs of treating a child with asthma. (6) The prevalence of ADHD in adolescents has been underestimated, and this is a difficult primary diagnosis in the adolescent or young adult with comorbidities that frequently mask this diagnosis. (7) It has now been documented that a higher proportion of youngsters with ADHD grow into adulthood with persistent ADHD symptoms, often associated with suboptimal social function, poor occupational achievement, and increased potential for abusing drugs. (7,8) Stern et al, in this special section, review the difficulties inherent in making the diagnosis of ADHD, not only in the child or adolescent, but also in the young adult. Although there are consensus guidelines for both the diagnosis and treatment of the school-aged child with ADHD, (9,10) the long-term role of drug, behavioral, or combination intervent ions for the adolescent or young adult has not been firmly established. (7,8,11) For the primary care parctitioner challenged by the young adult with a previous ADHD diagnosis, we probably have more questions than we have answers.

Finally, Beck et al (elsewhere in this issue) have addressed the management of another emerging social morbidity, childhood obesity with type 2 diabetes. As a consequence of the rise of the fast-food industry and of changes in family dynamics dictating that both parents work, childhood obesity has risen to epidemic proportions, with a concomitant increase in the incidence of childhood type 2 diabetes. (12,13) As pediatricians and as primary care providers, we must find effective means for better nutrition and weight control, not only for the overweight child, but also for the entire family. Beck et al (elsewhere in this issue) review the specific therapeutic options for the adolescent/young adult with type 2 diabetes. Whether our medical interventions will impact on the renal, ophthalmologic, and cardiovascular complications of long-term type 2 diabetes will require extended, prospective follow-up studies. To prevent this disease, we need to engage our entire community to emphasize increased physical activity and healthy nutrition for all children. (13)

David K. Kalwinsky, MD FAAP 

Department of Pediatrics

East Tennessee State University College of Medicine

PO Box 70578

Johnson City, TN 37614-1708

References

(1.) Pui C-H, Evans WE: Acute lymphoblastic leukemia. N Engl Med 1998; 339:605-615

(2.) Marina N: Long-term survivors of childhood cancer. Pediatr Clin North Am 1997; 44:1021-1042

(3.) Meadows AJ, Hobbie WL: The medical consequences of cure. Cancer 1986; 58:524-528

(4.) Richardson DK, Gray JE, Gortmaker SL, et al: Declining severity adjusted mortality: evidence of improving neonatal intensive care. Pediatrics 1998; 102:893-899

(5.) Lee K-S. Khoshnood BK, Wall SN, et al: Trend in mortality from respiratory distress syndrome in the United States. J Pediatr 1999; 134:434-440

(6.) Chan E, Zhan C, Homer CJ: Health care use and costs for children with attention-deficit/hyperactivity disorder. Arch Pediatr Adolesc Med 2002; 156:504-511

(7.) Baren M: ADI-ID in adolescents: will you know it when you see it? Contem Pediatr 2002; 19:124-143

(8.) Elia J, Ambrosini PJ, Rapoport JL: Treatment of attention-deficit/hyperactivity disorder. N Engl J Med 1999; 340:780-788

(9.) Homer CJ, Boltz RD, Hickson GB, et al: Clinical practice guidelines diagnosis and evaluation of the child with attention-deficit/hyperactivity disorder: Pediatrics 2000; 105:1158-1170

(10.) American Academy of Pediatrics: Clinical practice guideline: treatment of the school-aged child with attention-deficit! hyperactivity disorder. Pediatrics 2001; 108:1033-1044

(11.) Zametkin AJ, Ernst M: Problems in the management of attention-deficit/hyperactivity disorder. N Engi] Med 1999; 340:4046

(12.) Schlossea E: Fast Food Nation. Boston, Houghton Mifflin Co, 2001, pp 239-243

(13.) Rocchini AP: Childhood obesity and a diabetes epidemic. N Engl J Med 2002; 346:854-855

(14.) Rosenbloom A, Arslanian S, Brink S: Type 2 diabetes in children and adolescents. Pediatrics 2000; 105:671-680