Jo Lawrence. Hospital in the Home, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.28959
Elise is about to have her 8th birthday and has planned a small party at home with her family and two best friends. Elise also has acute lymphoblastic leukaemia and is in the middle of chemotherapy treatment. Her next dose of methotrexate is due the day after her birthday but requires pre-hydration the day before….
Thomas is in year 3 and loves playing foursquare at lunch with his friends. He also has CF and requires regular tune-ups of 2 weeks IV antibiotics and physiotherapy…..
MaryKate is an 8 month old and the youngest of 5 children. She has poor oral feeding due to a complex medical background and requires nasogastric top-ups. Her parents have been told that she could wean from the tube if she participated in an intensive multidisciplinary program but are reluctant to attend hospital due to the significant disruption on family routine…..
Is there a way Elise could enjoy her birthday at home, Thomas stay active at school and MaryKate receive the treatment she needs without significant family disruption?
What is Hospital in the Home?
Hospital in the Home (HITH) refers to hospital level care provided in the home environment.
As we look at managing our growing population with a fixed number of hospital beds this is one area of healthcare that is set to boom!
When admitted to HITH, clinicians visit the home and provide the acute care interventions required in 1-2 visits per day. The advantages of this model of care on hospital flow and access are readily apparent. Less obvious, although equally critical, are the substantial benefits for the family and patient. Being treated in a safe place surrounded by familiar faces eases the stress and anxiety experienced by the child. Cost-savings for families obviously include not having to fork out for travel and hospital parking, but the real cost-savings occur for families because both parents no longer have to take carers leave – one for the hospitalized child, the other for the siblings. On average, HITH ends up being one-third of the cost of hospitalization for families1. In addition, HITH avoids disruption to family routines and unwanted separation.
So what can Hospital in the Home do?
Pretty much anything! As long as the patient is clinically stable (not heading for ICU) and can have their care needs delivered in up to 2 visits per day, then it can be done.
Traditionally Hospital in the Home models have centred around IV antibiotics and little else, but that has dramatically changed over the past few years.
Here are some of the common things that paediatric HITHs are currently doing2:
- Diabetes education
- Eczema dressings
- Subcutaneous infusions
- Chemotherapy
- Pre and post-hydration for chemotherapy
- TPN hook ons and hook offs
- Wound dressings
- NG feed support
- Cardiac monitoring
- CF tunes ups
- Physiotherapy
- IV antibiotics
Baseline criteria regarding distance from hospital and safety of home environment exist but solutions exist for almost situations.
Although most centres service a certain distance from hospital, care can often be outsourced for children who live more rurally. The care continues to be managed by the tertiary hospital but provided by local care teams – a superb option.
In cases where a barrier exists for staff to enter the home, creative solutions can be found by meeting children at school, in parks or family member’s homes.
What has changed with Covid-19?
Whilst paediatric hospitals in general saw a fall in patient presentations, HITH referrals have sky-rocketed. Doctors and families have experienced renewed interest in moving vulnerable patients out of hospital walls and away from the potential of cross-infection. Stricter visitor restrictions meant hospitalisation had an even greater impact on family life and the driver to manage care at home wherever possible has grown.
Most of this growth has been through increasing the proportion of eligible children referred rather than creating new pathways. A couple of children have been admitted for observation of Covid-19 infection, but these cases have been few and far between.
However, as with every area of healthcare delivery, the biggest changes for HITH have been moving with the technology. Education visits, medical and nursing reviews and physiotherapy have all been converted to telehealth where safe to do so.
Vaccination for influenza was offered to all patients admitted to HITH and was accepted by 70% of eligible patients. 65% of these were being vaccinated for the first time against flu3. In an environment where routine vaccinations have been falling4, this is a powerful demonstration of the opportunities that exist within HITH.
Infants with bronchiolitis have been managed through HITH before5 but the care pathway has never stuck due to barriers accessing cylinders on the same day and clinician confidence. A new model has been rolled out overcoming these barriers through utilising oxygen concentrators and remote monitoring.
With time, our use of remote monitoring and ability to feed vital signs directly into the Electronic Medical Record, will allow massive expansion of HITH services. Predictive modelling from large EMR datasets will allow more accurate prediction of which children are likely to be safely transferred to the home environment. Realtime data and predictive modelling will enhance clinician and family confidence and enable us to fully realise the benefits of HITH to hospitals and families.
So what about our friends Elise, Thomas and MaryKate….
Elise is able to receive her pre-hydration at home on her birthday. She celebrates her birthday in her parent’s bed with her sister beside her, both building her new lego sets. Her best friends visit and her mother prepares a special meal and bakes a special cake. She is able to go to bed that night, knowing the HITH nurses will visit every day over the following week to administer her chemotherapy and post-hydration and she has avoided another week in hospital.
The HITH nurses visit Thomas daily before school to connect his longline to a Baxter antibiotic infusion. Before and after school he performs physiotherapy via telehealth. At school, he wears his antibiotic in a backpack and can continue to play 4 square at lunch.
MaryKate is visited by the HITH dietitian and speech therapy who provide feeding advice and a regime that fits around the family routine. They can see where MaryKate sits for meals and how her meals are prepared first hand and are able to offer some helpful suggestions. The team are also able to visit MaryKate at her daycare and ensure her routine is consistent. In between visits, MaryKate is reviewed via telehealth by the allied health team. She makes significant oral progress and by the end of 2 weeks, her tube is no longer required.
Managing Gastro-Oesophageal Reflux Disease
Sarah Davies. Managing Gastro-Oesophageal Reflux Disease, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.29563
Isobel is a 10 week old, exclusively breast-fed, baby girl. She is brought into the Emergency Department with a history of frequent vomiting and poor weight gain. Her examination is normal, but when you ask Isobel’s exhausted-looking mother to put her to the breast, she becomes fractious and fussy, pulling away, arching her back, and taking very little feed at all.
What are you going to do?
At face value, this familiar presentation sounds like gastro-oesophageal reflux disease (GORD), although the differential for a ten-week old with vomiting and weight loss is wide.
Gastro-oesophageal reflux (GOR) is …the effortless retrograde passage of gastric contents into the oesophagus, with or without overt regurgitation.
It is:
Gastro-oesophageal reflux disease (GORD) can be diagnosed clinically when GOR is accompanied by troublesome symptoms that affect everyday functioning (eg crying, back-arching, food refusal) and may lead to complications (eg failure to thrive).
Alternative diagnoses should be considered when there are additional red flag features (see below) indicative of a different pathology and under these circumstances, investigations should be tailored to rule these in or out.
As Isobel has symptoms of GORD with faltering growth you check her head circumference (which is appropriate), dip a urine (which is negative), and send some bloods for a faltering growth screen (although you strongly suspect they will come back as normal). You explain to Isobel’s mother that there is a stepwise approach to the management of GORD starting with non-pharmacological measures.
So, in the absence of red flag symptoms, do I need to prove its GORD?
In short, no. There is no single gold standard test for the diagnosis of GORD, hence the emphasis on clinical diagnosis.
Invasive testing does have a place, though it is rarely the job of an ED clinician to be considering this.
Endoscopy is used under the guidance of a Paediatric Gastroenterologist, for infants who fail to respond to optimal medical management. This will diagnose erosions and eosinophilic oesophagitis.
pH MII (multi-channel intraluminal impedance) monitoring is used in children whose symptoms persist despite optimal medical therapy with normal endoscopy. For a great explanation of this technique this previous DFTB post on reflux from 2016.
Barium is out. Reliable biomarkers don’t yet exist. Scintigraphy, ultrasound and trial of a proton-pump inhibitor (PPI) are not useful in babies.
OK, so I only need to investigate if I think there may be another cause for the symptom. But what should be my initial approach to treatment?
Positional management – keeping the baby upright after feeds and elevating the head of the cot to sleep – is often advised for reflux. However, a study by Loots and colleagues in 2014 showed that regurgitation was only reduced through the use of side-lying positions which should NEVER be recommended due to the increased risk of SIDS. Head elevation made no difference at all despite some evidence that it can be beneficial in adults.
And whilst a common-sense approach would support a move to smaller more frequent feedings and keeping a baby upright for 20-30 minutes after a feed, there isn’t any good quality evidence that confirms this.
Feed thickeners have been shown repeatedly to reduce the frequency of visible regurgitation episodes in babies with reflux and in some studies to decrease cry/fuss behaviour too. They are safe and come highly recommended as a first-line intervention for babies with troublesome reflux. If you are going to advise a thickener for a breastfed infant, it’s important to suggest a carob bean-based product, such as Carobel, because the amylase in breast milk will digest the rice cereal-based thickeners such as Cerelac.
Acupuncture, probiotics, massage, hypnotherapy have not yet been adequately studied for us to say one way or another if they are of any benefit. And alginates, probably the most familiar to us being Gaviscon? We’ll cover those shortly.
The key thing to remember for any intervention, is to reserve these for your patients with GORD. Happy, thriving, refluxy babies, typically outgrow their symptoms as they transition to solid food and should be left well alone.
OK, but what if my patient has tried these already? What should I advise next?
First, check how long they have persisted with the intervention.
One of the biggest reasons for the simpler interventions not to help with GORD is that they are not given enough time to make a difference. Having said that, if a tired parent is repeatedly confronted with a grizzly, uncomfortable baby who is refusing to feed, asking them to persevere for two weeks with an intervention they don’t think is helping, may be practically difficult to achieve.
In the UK, we have a choice of two key guidelines to help us with the next steps in reflux management.
OR
Except that these guidelines differ a little on the advice they give for when simple measures don’t help…
NICE recommend a trial of Gaviscon first, and if that doesn’t work 4-8 weeks of a PPI such as omeprazole, and only then suggest a trial of cow’s milk protein exclusion (either through use of a hydrolysed formula or maternal dairy exclusion in breastfed infants) as a last resort, if reflux does not improve after ‘optimal medical management’.
NASPGHAN/ESPGHAN on the other hand, suggest that ALL infants undergo an initial trial of cow’s milk protein exclusion, and only if this fails do they suggest the use of a PPI or hydrogen receptor antagonist (H2RA) such as Ranitidine. The bottom line is, that no-one has looked at the efficacy of a cow’s milk protein-free diet for symptom relief in babies presenting with reflux as the single symptom of cow’s milk protein intolerance (CMPI).
The NASPGHAN team argues, that whilst there is no evidence on the topic, there are a number of babies with CMPI manifesting as reflux only who will benefit from this approach. They suggest eliminating cow’s milk protein from an infant’s diet for a minimum of 2 weeks, ideally four. If symptoms resolve and reappear on reintroduction then the diagnosis is clear.
NASPGHAN then suggest babies who do not respond should be referred to secondary care services and started on a time-limited trial of PPI.
This is largely so that infants are not left struggling on inadequate therapy for long periods of time, but also because their review found conflicting evidence around the benefit and side effect profile of these medications for young children.
In six studies looking at PPI versus placebo, four studies showed no difference in regurgitation or other reflux associated symptoms between intervention and control groups. Three studies comparing H2RAs to placebo did show some benefit of the intervention, however, these studies were all in older children with biopsy-proven erosive oesophagitis up to 8 years of age. Two studies showed endoscopic and histological and clinical features of GORD were reduced with H2RA over placebo, but these were in mixed-age groups including children up to 8 years old.
All studies showed a similar profile of side effects and between drug and placebo arms, however, one study demonstrated an increased rate of infection, in particular lower respiratory tract infection and diarrhoea in the PPI group.
Given these findings, NASPGHAN cautiously recommends PPI or H2RA therapy in babies who have troublesome reflux despite trying a number of other non-pharmacological management options.
Their key message is around early referral to secondary care, giving sufficient time for any one intervention to work, and making sure children are appropriately followed up.
So, what should I do?
Given the somewhat conflicting advice outlined by these two well-respected groups, you could be left feeling unsure how to manage your next case. However, the genuine gap in the evidence market here does mean you are free to exercise your own clinical judgment and tailor your decision making to each individual refluxy baby, whilst empathetically taking on board the thoughts and preferences of the family. This could, for some babies and parents, be medicine in itself.
And what about alginates?
Two studies in the large literature review by the NASPGHAN/ESPAGHN group, compare Gavsicon to placebo. They show a reduction in visible regurgitation but no difference in reflux-associated symptoms. Furthermore, infants treated with alginate and then undergoing pH MII for 24 hours, showed no difference in the frequency of regurgitation events between groups.
Chronic use of alginates causes constipation and poses a theoretical risk of milk-alkali syndrome, which is perhaps why the authors suggest use is limited to short term therapy. NICE do recommend a trial of Gaviscon therapy at an early stage in their pathway, as an alternative to feed thickener, but again on a time-limited basis with a planned review.
Isobel’s mother had already tried two weeks of feed thickener on recommendation from the GP with no improvement. She was keen to avoid medication if possible so you agreed to a trial of dietary cow’s milk elimination for Mum who would continue to breastfeed and give top-ups with a hydrolysed formula if there was still no weight gain in a week. You gave her a sheet of dietary advice to ensure she maintained her own calcium intake and asked her to see the GP in 2 weeks for a review.
Take home message
References