The National Association of Pediatric Nurse Practitioners (NAPNAP) is the professional organization that advocates for children, (infants through young adults), and provides leadership for Pediatric Nurse Practitioners who deliver primary health care in a variety of settings. NAPNAP was founded in 1973 as a non-profit specialty nursing organization devoted to improving the quality of infant and child health care. NAPNAP promotes high standards of child health care through education, research, and legislative action involving over 6,200 members in 48 chapters across the country. NAPNAP collaborates with several organizations and entities engaged in activities that support improvements in children's health. NAPNAP has a unique relationship with the Association of Faculty of Pediatric Nurse Practitioners (AFPNP). This relationship provides the essential foundation to ensure the highest standards of practice, education, and regulation for PNPs. The two organizations, each separate entities, work together in common areas to foster the development of standards of care for PNPs, to recognize graduate PNP educational programs that adhere to national PNP educational standards and to establish national position statements related to PNP education, practice, and certification. The AFPNP is a national organization of nursing educators who teach in pediatric, family and school nurse practitioner programs, and who work together on relevant practice and educational issues. The organization began in 1972 to establish curriculum guidelines for pediatric nurse practitioner programs. The organization has clear goals and purposes, which have evolved with the continuing challenges that PNP educators face. The group has been meeting annually since 1978, holding its meeting in conjunction with the yearly NAPNAP conference. The AFPNP has authored and updated the document, Philosophy, Conceptual Model and Terminal Competencies for the Education of Pediatric Nurse Practitioners. The organizations work together with the common goals of ensuring children and families receive quality health care and ensuring that PNPs are educated and prepared to provide that care. The organizations collaboratively used an evidence-based approach to ensure congruency among PNP educational programs, national certification standards, and PNP practice. A recent study (Brady, M, and Neal, A. (2000). Role delineation study of pediatric nurse practitioners: a national study of practice responsibilities and trends in role functions. Journal of Pediatric Health Care, 14(4), pages 149-59) was completed to examine current practice parameters for PNPs. This study validates the diverse and expanding role of the PNP in providing healthcare to children of all ages. Additionally, a survey of PNP graduates was recently completed to examine implications for education of PNPS (Jackson, P. et al, 2002, Professional practice of pediatric nurse practitioners Implications for education and training of PNPs, Journal of Pediatric Health Care (in press). Both studies exemplify the three organizations' integrated approach to meeting the shared objective of supporting the role of PNPs to provide quality care to children and families and the shared goal of excellence in practice and avoidance of barriers to providing accessible, consistent health care. Although, the organizations do not have a position statement that specifically delineates age parameters for patients of PNPs, all organizations broadly define the patient population seen by PNPs as "infants through young adults." The criteria were established to ensure that PNPs' scope of practice was not limited to only birth to 21 years of age, but to allow the PNP to care for a broad range of patients. There are situations in which the PNP is appropriately qualified to care for a child older than age 21 years, and we do not limit the scope to a specific age-range. Two common textbooks used by PNP educational programs and by the practicing PNPs are: Fox, J. (1997). Primary Health Care of Children and Burns, C.E., Brady, M.A., Dunn, A.M., and Starr, N.B. (2000). Pediatric Primary Care: A Handbook for Nurse Practitioners (2nd Ed.). Each of the textbooks is written for advanced practice nurses providing health care to infants through young adults. Care of the adolescent and young adult is included in both texts. Additionally, the American Academy of Pediatrics has a widely accepted, comprehensive resource used for physician education, training, and reference. This manual, Guidelines for Health Supervision III, outlines primary care provider health supervision schedules for each year, from infancy through age 21 years. Other textbooks used by PNPs and PNP educational programs that include the health care for children through young adulthood are: Dixon, S. D. & Stein, M. T. (2000) Encounters with children: Pediatric behavior and development (3rd ed.), Hoekelman, R, et al. (2000). Primary pediatric care. (4th ed.) and Neinstein, L. (1996) Adolescent health care: A practical guide (3rd ed.). The field of pediatrics universally focuses on a patient population of newborns through young adults. Since 1988, the American Academy of Pediatrics (AAP), has had a position statement titled Age Limits of Pediatrics (Available online at: www.aap.org/policy/02031.html). The statement, written by their Council on Child and Adolescent Health states: "The purview of pediatrics includes the physical and psychosocial growth, development, and health of the individual. This commitment begins prior to birth when conception is apparent and continues throughout infancy, childhood, adolescence, and early adulthood, when the growth and developmental processes are generally completed. The responsibility of pediatrics may therefore begin with the fetus and continue through 21 years of age. There are special circumstances (e.g., a chronic illness and/or disability) in which, if mutually agreeable to the pediatrician, the patient, and when appropriate the patient's family, the services of the pediatrician may continue to be the optimal source of health care past the age of 21 years. The AAP also has a position statement titled: Scope of Health Care Benefits for Newborns, Infants, Children, Adolescents, and Young Adults Through Age 21 Years (Available online at: www.aap.org/policy/re9730.html). This statement emphasizes that the optimal health of children can best be achieved by providing access to comprehensive health care benefits. The statement focuses on the needed services and procedures specific to the delivery of comprehensive preventive, prenatal, postnatal, and mental health care for all children through age 21 years. The statement emphasizes that the care should be delivered by appropriately trained and board-eligible/certified pediatric providers, including primary care pediatricians, pediatric medical sub-specialists, and pediatric surgical specialists. This statement certainly defines pediatrics to at least 21 years of age, and does not put any specific restrictions on pediatric health care providers treating children older than 21 years. The Pediatric Nurse Practitioner is one such provider. The American Medical Association also has a comprehensive program called Guidelines for Adolescent Preventive Services (GAPS). This program defines health care needs of adolescents through age 21 years. Again, the age is defined until at least 21 years, with no specific restrictions on providing this care to children older than 21 years. Based on the above definitions, the PNP scope of practice most assuredly includes adolescence and young adults. Again, there are several definitions of adolescence, but universally, all definitions include children through age 21 years, and often up to 24 years, or even 25 years. The Society of Adolescent Medicine defines adolescent medicine as: "Adolescent Medicine" applies to health care, professional training, health research, and advocacy related to persons age 10 to 25 years. (Available online at: www.adolescenthealth.org/html/adolescent_medicine.html). In most medical and nursing literature, the standard method for categorizing adolescents is to divide it into three psychosocial phases. The subgroups of adolescents are: early (11-14 years), middle (15-17 years), and late (18-21 years) adolescents. The goals of Healthy People 2010 delineate specific objectives related to reductions of deaths in adolescents and young adults. The categories used for the population are: Adolescents aged 10 - 14 years, Adolescents aged 15 - 19 years, and Young Adults aged 20 - 24 years. In the Healthy People 2010 document, many objectives related to decreasing tobacco use and substance abuse in adolescents are identified. The specific focus is on the school-aged population, with grades 9 - 12 clearly identified. Many PNPs work in the school health setting. Often high school children are 18, 19, or even up to twenty-one years of age. The pediatric health care provider is adequately prepared to deal with health and psychosocial needs of the high school student of all ages. Additionally, the PNP is trained in school sports physical examinations for the adolescent and young adults in the high school setting. The evolving health care status of children makes it increasingly difficult to specifically define pediatrics. There is a growing population of adolescent and young adults with special health care needs, chronic conditions, and disabilities who need transition care from pediatric to adult health care settings. These adolescents and young adults face unique challenges in accessing adult health care providers who can provide adequate primary and specialized health care services. Until recently, efforts to facilitate successful transitions for these children have been limited. Pediatric health care providers have an extensive knowledge base regarding development issues and a unique awareness of some of the pertinent concerns pertaining to adolescent and young adult transitions, especially those pertaining to health care, and are qualified to assist these patients during the transition phase. Establishing exclusive upper age limits to PNPs' practice creates a significant barrier for PNPs and limits access to health care for this population. In summary, the PNP is highly qualified to provide care to children all ages. NAPNAP and the AFPNP firmly support PNPs scope of practice to be inclusive of newborns, infants, children, adolescents, young adults, and special care needs children of all ages. Julie C. Novak, DNSc, RN, CPNP President, NAPNAP Michelle Beauchesne, DNSc, RN, CPNP President, AFPNP

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