The role of hospital Rob Roseby Respiratory and General Paediatrician Senior Lecturer, Flinders University Head, Dept of Paediatrics, ASH

The role of hospitalising a child with malnutrition Rob Roseby Respiratory and General Paediatrician Senior 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 reasons only Failure to respond to adequate outpt mx Delivery of healthcare which cant be delivered in another setting

Hospitalising a child 101 (2) A childs place is at home with family Hospitals are dangerous Hospitals are expensive

Hospitalising a child 101 (3) Hospitals are full of: –Terrific h ealth 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 Cant 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 family oassessment oidentification and treatment of organic factors onutritional rehabilitation (Russell 2004, Brewster 2008) oDischarge plan and follow up oPolicy development has been difficult but is progressing

When to hospitalise an individual child Some individual variation inevitable