What should adult rheumatology know about paediatric rheumatology?

Paediatric and adult rheumatology share many similarities in practice, patterns of disease and treatment and care of patients, but they have some important differences. Paediatric consultations emphasize family, education and developmental concerns as compared with more individualistic consultations in adult services. Young people (YP) with rheumatological disease encounter adult rheumatology during the crucial, tumultuous developmental stage of adolescence (ages 10 19 years) [1]. This may be during a move, ideally through a planned process of transition, from children’s to adult services, or as a firsttime referral. YP therefore experience the interface of paediatric and adult rheumatology at a time of profound personal change and development [2]. The process of transition is important to adult and paediatric rheumatology alike, and rheumatology leads research in this area [3]. However, from the perspective of adult rheumatologists, what is necessary to know about paediatric rheumatology to meet in the middle? Patients with rheumatic disease starting in childhood and adolescence are an important part of adult rheumatologists’ clinical work and a significant proportion require biologic therapy [4]. Therefore adult rheumatologists need to appreciate the features, spectrum and natural history of paediatric rheumatological disease. They also need to be familiar and comfortable with the specific developmental features of adolescence, such as risky behaviours and non-compliance, which impact on health care provision for YP. Adaptations that make services more YP friendly—holding specific YP’s clinics in appropriate environments, adjusting timings to reduce time off school and the innovative use of virtual resources—help engage adolescents [5]. Key in all these aspects are effective, multidisciplinary links between local adult and paediatric rheumatology services in both service delivery and training of staff. In terms of specific disease management, adult rheumatologists need to appreciate paediatric rheumatic disease phenotypes and treatments and how they differ from adult disease. JIA is an umbrella term for several different forms of arthritis, and when JIA exhibits disease activity into adulthood, it should not be seen as seronegative RA. Relabelling risks overtreating the proportion of JIA that will go into remission spontaneously, where treatment should be stopped. Relabelling may also mean patients are lost to follow-up in important registry studies of biologics in JIA. In turn, this contributes to the relative lack of knowledge and invisibility of JIA symptoms, signs and management in adult rheumatology for patients who continue to have active disease into adulthood. The window of opportunity concept in paediatric rheumatology is increasingly recognized, and this imperative to treat inflammatory disease, as well as the range of effective therapies, are very familiar to adult rheumatologists. What may be less familiar to these professionals are some specific features and complications of paediatric rheumatic disease. In JIA, the importance of temporomandibular joint disease, the use of repeated joint injections as monotherapy for oligoarticular disease and the high index of suspicion for recognition and early treatment of macrophage activation syndrome (most typically in systemic JIA) are often underrecognized in adult rheumatology. Similarly, the understanding that presentation of SLE in adolescence is associated with increased morbidity and mortality and the different phenotypes and management strategies of JDM as compared with the adult form are crucial in effective adult rheumatology care. Training programmes for health care professionals often teach either paediatric or adult rheumatology, and wider integration of adolescent rheumatology in each is required. Integration of programmes with each other and the consequent improved knowledge are likely to benefit patient care. In addition to improved training, good links with local paediatric services ensure that YP do not fall into potential knowledge gaps and that individual professionals from multidisciplinary backgrounds in both paediatric and adult rheumatology continually learn from each other. These links are particularly important for adult rheumatologists in understanding issues, such as needle phobia, that YP experience and the potential impact of loss of school time and peer contact during periods of severe illness. Both adult and paediatric rheumatologists routinely see patients with musculoskeletal symptoms and pain that do not have an inflammatory basis. Adult rheumatologists seeing YP need to adopt a paediatric perspective in understanding that such symptoms may be an important marker of psychological distress related to family dynamics or problems in education and may be associated with self-harm. YP and their families have often developed significant trust in and reliance on paediatric services, which can make engagement for YP in adult services problematic. Understanding of such issues requires adult rheumatologists to modify services accordingly. Similarly, paediatric rheumatologists benefit