Paediatric Chronic Medical Conditions Require Comprehensive Annual Paediatrician Review

APS Position Paper

September 2025

Introduction:

Children with chronic and complex health conditions require more than episodic care. Their developmental trajectory, the evolving nature of multi-morbidities, and the rapid pace of medical innovation demand a structured, comprehensive review at least once per year by a consultant paediatrician. Such reviews ensure care is clinically appropriate, developmentally responsive, and family centred.

1. Complexity and Evolving Needs

Many children present with multiple comorbidities (e.g., Type 1 Diabetes with ADHD, Eczema and Coeliac Disease), requiring multidisciplinary input and integrated planning. Chronic diseases in children often evolve with age: puberty, growth spurts, cognitive development, and mental health challenges all affect treatment tolerance, adherence, and risk profiles. There is a very high percentage (up to 80%) of marriage failure and family disruption / mental health issues in families with a child with chronic disease. Annual reviews provide an opportunity to adapt treatment plans to reflect the changing profile of the child and to prevent complications.

2. Developmental Milestones and Transitions

Each stage of childhood and adolescence introduces new medical, psychological, and social challenges. Comprehensive reviews allow the paediatrician to adjust treatment to meet developmentally appropriate needs, including mental health, school participation, and social inclusion. Structured review at least annually ensures smoother transitions between stages of care, including moving from paediatric to adult services.

3. Updating Treatment with Emerging Evidence and Technology

Chronic conditions such as diabetes, epilepsy, developmental disorders and allergies are affected by rapidly evolving technologies and investigations (e.g., automated insulin delivery, gene-based diagnostics, immunotherapy). Annual reviews ensure children gain access to latest evidence-based innovations that may significantly improve outcomes. Family support and social media may raise the possibilities of new interventions that may or may not be appropriate for that individual child.

4. Acknowledging Workforce and System Gaps

There is a shortage of general, subspecialist and allied health paediatric services in parts of regional and suburban Australia. When present, those services may be costly. This often leaves children at risk of fragmented or delayed care. The paediatrician therefore must develop a comprehensive clinical skills toolbox to fill in those gaps. Regional families face inferior health outcomes and greater disruption due to travel burden, school absences, and family stress. Annual reviews by consultant paediatricians help bridge these gaps by coordinating care, guiding local providers, and preventing clinical deterioration and promoting best health outcomes. Regular medication and technology reviews also improve safety, adherence, and cost-effectiveness.

5. Family-Centred Care and Consumer Confidence

Annual reviews support shared decision making with families, empowering them to actively participate in care planning. Schools and preschool facilities often required updated comprehensive treatment and management plans. Clear, consistent communication improves adherence, family satisfaction, and children’s quality of life. For families in regional areas, consultant-led reviews reinforce confidence in local services and reduce inequities.

6. Consultation and Communication

Paediatricians should schedule annual review consultation time to a minimum 45 minutes and encourage participation of both parents if possible. It is imperative that clear and timely communication on the outcomes and plans of the annual review consultation be relayed to the child’s general practitioner.

7. Collaboration with General Practitioners

APS recognises that several complex paediatric conditions are beyond the scope of practice and expertise of general practitioners and the need to support, not burden those practitioners through ongoing collaboration and communication. Similarly, APS supports indefinite referrals when the condition is clearly not within the scope of practice of the referring general practitioner to minimise inefficiency, reduce burden to the family and general practitioner and cost to Medicare and the patient. Where an indefinite referral exists, the responsibility continues for the paediatrician to maintain efficient and comprehensive communication and updates on the comprehensive treatment and management plan.

8. Remuneration of Annual review.

APS recognises that the fee charged for annual review of the 45 to 60 minutes consultation should recognise the skill of the consultant paediatrician as it does for the general practitioner. APS recognises that utilising the MBS Item 132 on annual basis for all children with complex chronic conditions involving two or more comorbidities is with consistent with PBS regulations and intentions. APS has developed a separate Position Statement (2025) on the importance of paediatrician involvement in severe complex developmental disorders.

Conclusion

Annual comprehensive reviews by consultant paediatricians are best practice, clinically justified, developmentally appropriate, and equity-promoting.
Annual comprehensive reviews enable proactive planning, timely adaptation to developmental and technological change, and effective integration of services across health, education, and community sectors.
This structured approach improves outcomes for children with chronic disease and ensures continuity, quality, and safety of care, especially for those living with multiple comorbidities and in regional or disadvantaged communities.

Download APS Position Paper here:

APS Position Statement: Annual Review Chronic Disease Children175.6 KB