the role of hospital rob roseby respiratory and general paediatrician senior lecturer, flinders...
TRANSCRIPT
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