Neonatal and paediatric parenteral nutrition prescription practices in South Africa : a cross-sectional survey

Flint, Cristen Sarah (2018-03)

Thesis (MNutr)--Stellenbosch University, 2018.

Thesis

ENGLISH SUMMARY : Objectives: The objective of this study was to describe the current parenteral nutrition (PN) prescription practices and knowledge of prescribers (paediatric doctors and dietitians) for their neonatal and paediatric patients, in South Africa, and to establish the factors which influence usage and adherence to the available guidelines. Methods: A descriptive cross-sectional survey was conducted from November 2016 to March 2017 through a self-administered online questionnaire. PN prescription factors were assessed in terms of timing, patient type and diagnosis, use of macronutrients, and fluid allocations. Prescriber knowledge of the ESPGHAN international guidelines was assessed, as well as access to information. Knowledge and practice score competency levels were set, a priori, at 60% and 80% respectively. Respondents were stratified according to work sector (state / private) or professional group (dietitian / paediatric doctor) for statistical comparison. Summary statistics, chi-squared tests and correlation coefficients were used to describe and analyse the data. Results: A total of 72 survey respondents were included, 58% dietitians and 42% paediatric doctors; 47% private sector and 53% state sector based. The primary indications for PN use were gut abnormalities and intolerances, prematurity and critical illness. Doctors prioritised fluid calculation in determining their PN prescription. Dietitians were significantly more likely to calculate the patient-specific protein requirements (p < 0.001). Only 36% of prescribers commenced PN feeding within the first 24 hours of admission, but the majority (67%) introduced intravenous lipid emulsion (IVLE) from day 1 of PN. The main reasons given for IVLE delay were habit, liver function concerns, and PN bag availability. The mean practice score was 75% (SD ± 17). There was no significant difference in mean score between the work sector subgroups (75 ± 20% state versus 76 ± 15% private; p = 0.82). The dietitians, however, scored significantly higher for practice outcomes compared with the doctors (82 ± 12% versus 65 ± 19 %; p < 0.001). The main potential factors that influenced the delay or non-use of PN when it was indicated included concerns regarding infectious complications and financial resource constraints. Inadequate access to PN, and a lack of trained staff to administer the PN, also impacted on its use. Only 64 of the respondents completed the knowledge section of the questionnaire. The mean knowledge score was 74% (SD ± 12), range 50 – 100%. There was no significant difference in mean score between the work sector subgroups (73 ± 13% for state versus 76 ± 12 % for private; p = 0.32). The mean knowledge score for the dietitians (77 ± 13%) was however significantly higher than that of the doctors (71 ± 11%); (p = 0.04). Conclusion: PN prescribing practices in South Africa for neonatal and paediatric patients are not yet optimal in many respects. Prescribers require access to clear PN therapy guidelines, as well as guidance on how to implement these recommendations effectively in daily clinical practice. A multidisciplinary approach to PN feeding is paramount. Our findings emphasise the role of the dietitian as part of the multidisciplinary team in achieving optimal feeding. Additional research is warranted to further assess the PN feeding practices in this vulnerable patient group.

AFRIKAANSE OPSOMMING : Doelwitte: Die doel van hierdie studie was om pediatriese dokters en dieetkundiges se huidige voorskrifpraktyke en kennis van parenterale voeding (PV) vir neonatale en pediatriese pasiënte in Suid-Afrika te bepaal; asook die faktore wat die gebruik en nakoming van beskikbare riglyne beïnvloed vas te stel. Metodes: ‘n Dwarssnit beskrywende studie is uitgevoer vanaf November 2016 – Maart 2017 deur middel van ‘n self-geadministeerde aanlyn vraelys. Faktore wat PV voorskrifte beïnvloed soos tyd geïnisieer, pasiënt tipe en diagnose, gebruik van makronutriënte en vloeistofbehoeftes is bepaal. Kennis van die ESPGHAN internasionale riglyne en toegang tot inligting is bepaal onder die voorskrywers. Die vaardigheidsvlakke vir kennis en praktyke is onderskeidelik vooraf vasgestel op 60% en 80%. Vir statistiese vergelykings is respondente stratifiseer volgens werksektor (staat / privaat) en professionale groep (dieetkundiges / pediatriese dokters). Beskywende statistiek, chi-kwadraat toetse en korrelasie koëfisiente is gebruik om data te beskryf en analiseer. Results: ‘n Totaal van 72 respondente is ingesluit, 58% dieetkundiges en 42% pediatriese dokters; 47% private sektor en 53% staatssektor gebasseer. Die hoof indikasies vir PV gebruik was dermkanaal abnormaliteite en intoleransies, prematuriteit en kritieke siekte. Dokters het vloeistof berekeninge geprioriseer in die berekening van hul PV voorskrifte. Dieetkundiges was beduidend meer geneig om pasiënt-spesifieke proteïen behoeftes te bereken (p < 0.001). Slegs 36% van respondente het PV beginbinne die eerste 24 uur na toelating. Die meerderheid (67%) het egter intraveneuse lipied emulsies begin op dag 1 van PV. Die hoofredes verskaf vir die vertraging van lipied toediening was gewoonte, lewerfunksie bekommernisse en beskikbaarheid van die PV sakke. Die gemiddelde praktyktelling was 75% (SD ±17). Daar was geen beduidende verskil in die gemiddelde telling tussen werksektor subgroepe (75±20% staat versus 76±15% privaat; p= 0.82). Die dieetkundiges het egter beduidende hoër tellings verkry teenoor die dokters (82 ± 12% versus 65 ± 19 %; p < 0.001). Bekommernisse oor infektiewe komplikasies en finansiële beperkings was die hoof potensiële faktor vir die vertraging of nie-gebruik van PV in gevalle waar dit aangedui was. Onvoldoende toegang tot PV en ‘n tekort aan opgeleide personeel om PV te kan toedien het ook die gebruik beïnvloed. Slegs 64 van die respondente het die kennisdeel van die vraelys voltooi. Die gemiddelde kennistelling van 74% (SD±12), reikwydte 50-100%. Daar was geen beduidende verskil in die gemiddelde telling tussen werksektor subgroepe nie (73 ± 13% staat versus 76 ± 12 % privaat; p = 0.32). Die gemiddelde kennistelling van die dieetkundiges (77 ± 13%) was egter beduidend hoër as die van die dokters (71 ± 11%); (p = 0.04). Gevolgtrekking: PV voorskrifpraktyke in Suid-Afrikavir neonatale en pediatriese pasiënte is nie optimaal in baie aspekte. Diegene wat PV voorskryf benodig toegang tot duidelike PV terapeutiese riglyne, asook raadgewing oor hoe om die riglyne effektief te implementeer in daaglikse kliniese praktyke. ‘n Multidissiplinêre benadering tot PV praktyk is noodsaaklik. Ons bevindinge het die rol van die dieetkundige om optimale voeding te bereik as deel van die multidissiplinêre span beklemtoon. Addisionele navorsing is nodig om die PV voedingpraktyke van hierdie kwesbare pasiëntgroep te bepaal.

Please refer to this item in SUNScholar by using the following persistent URL: http://hdl.handle.net/10019.1/103892
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