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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