The role of hospital

Rob RosebyRespiratory and General

PaediatricianSenior Lecturer, Flinders University

Head, Dept of Paediatrics, ASH

The role of hospitalising a child with malnutrition

Rob RosebyRespiratory and General

PaediatricianSenior Lecturer, Flinders University

Head, Dept of Paediatrics, ASH

Photo: Liz Mowatt

15 mins• Hospitals 101• Role of doctor wrt CM/ FTT• Role of inpatient stay

Hospitalising a child 101

2 reasons only• Failure to respond to adequate outpt

mx• Delivery of healthcare which can’t be

delivered in another setting

Hospitalising a child 101 (2)

• A child’s place is at home with family

• Hospitals are dangerous• Hospitals are expensive

Hospitalising a child 101 (3)

• Hospitals are full of:– Terrific health professionals

across disciplines with access to information

– Beds– Drugs, fluids and other goodies

Hospitalising a child 101 (4)

• Conflict!– Beneficence– Non-Maleficence– Justice– Autonomy

Role of doctor re: CM/FTT

• Assessment of a diagnostic problem

Medical assessment of anthropometry

• Weight, height/ length, Head circumference

• Growth trajectory

Medical assessment of cause

• Inadequate intake, eg:– Milk supply issue– Incorrect milk powder– Food deficiency– Anatomical or

neurological problem– etc

• Excessive losses, eg:– Chronic Diarrhoea– Vomiting– Pancreatic disease– Malabsorption syndromes

• Giardia, coeliac dis.– etc

• Increased energy requirement, eg:– Most Chronic Diseases– UTI– Chronic chest disease– etc

• Can’t grow, eg:– Genetic/ chromosomal

abn– FASD & other

syndromes– Endocrine/ metabolic d/o

Medical assessment of effect

• Complications

Role of inpatient stay

• Assessment of the above is easier as an inpt- – access to mother/ carer, child,

observers, specimen collection and transport, tests and results

Role of hospitalisation for CM

• Advantages – Assessment– Nutritional rehab, multidisciplinary team– Discharge and follow up plans

(Schwartz 2000)

• Disadvantages– Separation from home, family– Stressful environment– Staffing pressures– Nosocomial infection

(Oates 2001)

Role of hospitalisation for CM (2)

Influences• Constraints on health system->

decisions re competing priorities– Primary prevention vs Secondary prevention

vs Tertiary care (Black 1999, Brewster 2008)

• Access to community based services, incl skill of staff; distance; perceived level of compliance

(Lee 2003)

Role of hospitalisation for CM (3)

Outcome?• Limited evidence • ASH study 2002 of hospitalision for FTT

– effective in re-establishing weight gain

– effective in identifying organic contributors to malnutrition, but • 38% hospital acquired infection • 53% readmitted within 6 months• Children did not sustain ‘catch-up’ growth

(Russell et al, 2004)

When to hospitalise children for CM

Little disagreement • severe wasting• dehydration and/or infection or other intercurrent

illness • when community-based interventions have failed• where there are other serious risk factors (incl.

psychosocial) for the child and familyo assessmento identification and treatment of organic factorso nutritional rehabilitation

(Russell 2004 , Brewster 2008)o Discharge plan and follow upo Policy development has been difficult but is

progressing

When to hospitalise an individual child

• Some individual variation inevitable