Child Malnutrition / Failure to Thrive Project 2008
Final report
Project Officer - Susan Grant
1 Acknowledgements
The Project Officer wishes to acknowledge the CM/FTT Steering Committee and all the staff from government and non-government agencies who contributed their time and thought to the project. A big thank you to all the hard working staff of the Paediatric Ward at ASH. A particular thank you to Nettie Flaherty, Carmel Hattch, Valmai McDonald, Clare MacVicar, Rob Roseby and Andrew White for their expertise and kind support. Thank you also to Mick Arundell for his time and technical expertise and to Cara Malzinskas for her patient data entry. It is hoped that this project will make a contribution to efforts to improve the care for children and families experiencing CM/FTT.
Alice Springs Hospital
Ó Department of Health and Families, Northern Territory 2008.
This publication is copyright. The information in this report may be freely copied and distributed for
· non-profit purposes such as study, research, health service management and public information subject to the inclusion of an acknowledgement of the source. Reproduction for other purposes requires the written permission of the Chief Executive of the Department of Health and Families, Northern Territory.
Printed by the Government Printer of the Northern Territory, 2008.
An electronic version is available at: www.nt.gov.au/health/
General enquiries about this publication should be directed to:
CEO Alice Springs Hospital
Department of Health and Families
PO Box 2234,
Alice Springs, NT, 0871
Phone: (08) 8951 7777
2 Table of Contents
1 Acknowledgements 2
2 Table of Contents 3
1 Executive Summary 3
1.1 Background 3
1.2 The Project 3
1.3 Lessons from the literature review 3
1.4 Findings 3
1.4.1 Extent of the problem 3
1.4.2 Quality of care in ASH 3
1.4.3 Continuity of care 3
1.5 Conclusion 3
2 Recommendations 3
2.1 Development, implementation and monitoring of Clinical Guidelines for CM/FTT 3
2.2 Multidisciplinary team approach to assessment and planning 3
2.3 Cultural safety for children with CM/FTT and their families 3
2.4 Standardised documentation 3
2.5 A dedicated team response to improved service delivery 3
2.6 Review and resourcing of nutrition management and feeding practices in ASH 3
2.7 Clarification and review of roles in managing CM/FTT inpatients 3
2.8 Staff development 3
2.9 Ongoing Research and Advocacy 3
2.10 Interface between ASH and FACS 3
2.11 Interface between ASH and services continuous with ASH in CM/FTT 3
2.12 Coordinated departmental and regional response 3
Primary and secondary service system development 3
2.13 Primary Prevention 3
2.14 Early intervention and family support infrastructure 3
2.15 Investigation of other treatment contexts 3
3 Introduction 3
3.1 Background 3
3.2 Purpose and scope 3
3.3 Method 3
3.4 Terminology and definitions 3
4 History of CM/FTT initiatives in CA 3
4.1 The Child Health Unit (CHU) (1972-1998) and Mt Gillen 3
4.2 Growth Action and Assessment Program (GAA) 3
5 Results 3
5.1 Summary of quantitative findings 3
5.1.1 Nutritional status of paediatric patients in ASH 3
5.1.2 Assessment of nutritional status 3
5.1.3 File Audit 3
5.2 Quality of Care: Summary of qualitative findings 3
5.2.1 ASH Survey Results 3
5.2.2 Main themes from ASH surveys 3
5.2.3 Mapping of Patient Journey 3
5.2.4 Summary 3
5.3 Continuity of Care: Questionnaire results (see appendix 5.4.5 ) 3
5.3.1 ASH interface with Remote Communities 3
5.3.2 ASH interface with community-based organisations 3
5.3.3 Key service or systems gaps in CM/FTT 3
5.4 Appendices 3
5.4.1 Appendix 1 Steering Committee 3
5.4.2 Appendix 2 Stakeholders consulted 3
5.4.3 Appendix 3 Social Work Procedures 3
Appendix 4 File Audit Questions 3
5.4.4 Appendix 5 File Audit Report 3
5.4.4.1 Location by State 3
5.4.4.2 Location by urban/remote CA 3
5.4.4.3 Primary vs secondary diagnoses of CM/FTT 3
5.4.4.4 Weight deficits in ASH 3
5.4.4.5 Weight Gain in ASH 3
5.4.4.6 Length of stay (LOS) 3
5.4.4.7 Number of addresses 3
5.4.4.8 Months of CM/FTT before admission 3
5.4.4.9 Pre episode service provision 3
5.4.4.10 Discharge planning 3
5.4.4.11 Readmission rates 3
5.4.5 Appendix 6 Service Provider Questionnaire 3
Table of Figures
Figure 1 Episodes from Caresys 3
Figure 2 Episodes from file audit 3
Figure 3 Locality 3
Figure 4 Primary and secondary diagnoses 3
Figure 5 Wasting 3
Figure 6 Stunting 3
Figure 7 Weight for height 3
Figure 8 Weight gain during admission 3
Figure 9 Length of stay 3
Figure 10 Episodes with a discharge plan 3
Figure 11 Readmission rates 3
Acronyms
ADx Additional Diagnosis
AHW Aboriginal Health Worker
AIN Assistant in Nursing
ALO Aboriginal Liaison Officer
ARACY Australian Research Alliance for Children and Youth
ASH Alice Springs Hospital
ASYASS Alice Springs Youth Accommodation and Support Service
CA Central Australia
CFRH Centre for Remote Health
CHU Child Health Unit
CM Child Malnutrition
CM/FTT Child Malnutrition/ Failure to Thrive
CY&MH Child, Youth & Maternal Health
DHF Department of Health and Families
DMO District Medical Officer
DV Domestic Violence
EASA Employee Assistance Services Australia
ED Emergency Department
EM Explanatory Model
FACS Family and Community Services
FAS Foetal Alcohol Syndrome
FASD Foetal Alcohol Spectrum Disorder
FTT Failure to Thrive
GAA Growth Action and Assessment Program
IDA Iron Deficiency Anaemia
LBW Low Birth Weight
LOS Length of Stay
MC&YH Maternal, Child and Youth Health
MPH Medical Placement Home
MSF Medecins Sans Frontieres
NHMRC National Health and Medical Research Council
NOFTT Non Organic Failure to Thrive
NPY Ngaanyatjarra Pitjantjatjara Yankunytjatjara
NT Northern Territory
OT Occupational Therapist
PDx Primary Diagnosis
PHC Primary Health Care
PND Post Natal Depression
PSA Patient Services Assistant
RAN Remote Area Nurse
RDH Royal Darwin Hospital
RTHC Road to Health Chart
RUF Ready to Use Food
SA South Australia
SD Standard Deviation
SNAICC Secretariat of National Aboriginal and Islander Child Care
SHFA Standard Height for Age
SWFA Standard Weight for Age
SWFH Standard Weight for Height
UK United Kingdom
UNICEF United Nations International Children’s Fund
US United States
WA Western Australia
WHO World Health Organisation
1 Executive Summary
1.1 Background
· Aboriginal children in the NT have much higher rates of malnutrition and failure to thrive than their non- indigenous counterparts, with associated high burdens of disease and high hospital admission rates. This is reflected in the substantial burden of care of CM/FTT in ASH, with lengthy hospitalisations and readmissions. Even though it is generally agreed that tertiary treatment is not the best form of management in most cases, ASH continues to play a substantial role in the continuum of care for indigenous children with CM/FTT
· Dilemmas around the medicalisation of CM/FTT in the context of developmental adversity for indigenous children were leading to ongoing tensions around management and quality of care issues at ASH. It was therefore decided to conduct a project to identify the extent of the problem, clarify the issues in ASH, look at how ASH interacts with others services in the ‘patient journey’ for CM/FTT and make recommendations for change
1.2 The Project
· The CM/FTT project is a quality improvement initiative of Alice Springs Hospital (ASH). The overall aim of the CM/FTT project was to improve the quality and continuity of care for children with CM/FTT. The project officer undertook a literature review and consulted with government and non-government service providers in the field of CM/FTT. A retrospective file review of children with a diagnosis of CM/FTT was conducted. The project conducted quality improvement activities in ASH, mapped current services for CM/FTT and made recommendations
· The project looked at both failure to thrive and malnutrition in an attempt to clarify definitional and diagnostic uncertainty in ASH. For the purposes of this report ‘CM/FTT’ is used to describe the conditions of malnutrition and failure to thrive, which both refer to undernutrition in children
· Although not confined to the indigenous population, it is overwhelmingly indigenous children who are hospitalised for CM/FTT in ASH. Therefore the project focused on CM/FTT in indigenous children
1.3 Lessons from the literature review
· It is only relatively recently that the importance of maternal and child nutrition has been recognised at national and global levels. Methodological and logistical difficulties have limited the development of knowledge in this area and ultimately the quality of care
· The literature on CM/FTT is vast and complex. The literature on malnutrition derives from population-based studies in developing countries, whereas the literature on FTT tends to derive from numerous smaller hospital or community based studies in developed countries. Neither of these contexts is readily applicable to the unique Central Australian context, thus leaving clinicians to draw on philosophical and ethical decision-making frameworks for treatment interventions in the absence of ‘hard’ evidence
· There are inconsistencies in terminology in the literature, with no ‘gold standard’ definitions or diagnostic criteria, especially for FTT. Even though it is often poorly assessed, growth is the main measure of CM/FTT. Other determinants of child wellbeing are more difficult to measure. Malnutrition tends to be measured by static measurements and failure to thrive by longitudinal growth. CM/FTT can be mild, moderate or severe. It is important to address the severity of the nutritional state as this informs management
· The causes of CM/FTT are multiple and complex. Childhood nutritional health outcomes are a function of direct and indirect causes manifested at the child, family, community and socio political levels. In CA, the high level of disadvantage of indigenous families is well documented. The final cause of CM/FTT is lack of nutrition, but poor growth in utero, problems with the transition to complimentary foods, inadequate quality and quantity of food, acute and chronic infections, poor living conditions, overcrowding, poor socioeconomic status, family and community dysfunction, poor access to early intervention and social support services, social exclusion and poverty can all be contributors
· There is increasing recognition that child growth and development in the first few years of life sets the foundation for future learning, behaviour and health over the life cycle. It is now known that undernutrition in utero and early childhood has serious short and long term consequences, including increased morbidity and mortality, chronic disease in adulthood (diabetes, heart disease, kidney disease) and long term cognitive deficits. Internationally, investment in early childhood growth and development is now seen as an investment in society
· The literature highlights an overall lack of good evidence for interventions for CM/FTT. Hospitalisation was historically the treatment for both malnutrition and FTT. However there has been a policy shift internationally from tertiary treatment towards primary and secondary interventions. Hospitalisation is no longer recommended except for cases of severe CM/FTT, complex cases or where there is a failure of community based intervention. In Australia, undernutrition has been shown to be highly correlated with readmission rates and longer LOS. Hospital admission rates and LOS have also been shown to be affected by degree of remoteness and access to local health services
· The importance of individualised multidisciplinary assessment incorporating medical, nutritional and psychosocial factors is highlighted in the literature. Assessment can be used to develop a shared understanding of the problem with the family. The approach should be tailored to the family’s strengths and needs. A thorough assessment itself can be seen as effective in provoking change. The literature highlights that deficiencies in assessment, consistency and interdisciplinarity can lead to a potentially dangerous lack of continuity of care
· There is a dearth of evidence for best practice responses and solutions to CM/FTT in the NT context. There is a diversity of community-based interventions but poor evidence for their effectiveness. A recent NT review found that growth faltering may be prevented by community-based nutrition education/counselling interventions using a range of strategies and involving carers, community health workers and representatives, as well as addressing the underlying causes of growth faltering. It was recommended that other interventions should only be considered in the context of a broad primary health care approach and/or based on identified local needs
· A set of broad principles that underpin good practice can be identified from the literature. These are the importance of primary prevention and secondary interventions, early intervention, thorough individualised assessments, a multidisciplinary team approach, the significance of the introduction of complementary foods period, empowerment of women, the importance of parenting interventions and combined interventions addressing both nutrition and nurture. Principles for engagement with families around CM/FTT include non-judgemental, holistic and strengths based approaches, developing a shared understanding with Aboriginal families about growth and development, and indigenous participation and control in identifying problems and solutions. The importance of the continuum of care is highlighted in the literature
(see full literature review for references)
1.4 Findings
· The project identified that there are a number of significant issues affecting the management of CM/FTT in ASH. The project also found that current primary and secondary interventions for CM/FTT in the NT are insufficient and appear to be failing to decrease the dependency on hospitalisation for these children
1.4.1 Extent of the problem
· It is difficult to get an idea of the real extent of the problem, as overall data is not collected. Although growth rates are slowly improving, GAA data indicates that indigenous children in remote CA communities still experience high levels of underweight, stunting and wasting. Indigenous infants are also still twice as likely to be born with LBW as non-indigenous infants
· The 2 periods of highest vulnerability for growth faltering are in-utero and the introduction of complementary foods period (6 - 24 months of age), with children’s transition to foods that are often inadequate in quality and quantity in a context of structural disadvantage. Although living in a first world country, this pattern is similar to that identified in children in developing countries, with a prevalence of stunting in the NT also similar to that in developing countries. There has been little change in the last 4 years in rates of stunting, wasting and underweight in the Alice Springs remote region