Andrew Kennedy

Transition from pediatric to adult services: are we getting it right?

Purpose of review The transition of healthcare from pediatric to adult settings has become more significant over the past 20 years as the survival of young people with chronic illness and disability has increased and healthcare delivery has become more complex. This review examines the evidence from recent studies and position statements to determine the current issues relating to transition. Recent findings Although there are many examples of excellent transition processes, these are mostly confined to individual clinics (often subspecialist), with little evidence of hospital-wide or regional planning. The notion of transition to adult healthcare has now spread from its roots in adolescent medicine to influence many subspecialty areas of practice. However, it remains largely confined to a pediatric paradigm and risks becoming disconnected from the principles and practice of adolescent medicine from which it emerged. Summary More systematic investment in regional clinical service planning is indicated, as is investment in more systematic approaches to training both pediatric and adult healthcare providers around the importance of transition to adult healthcare. Collaboration is urged in relationship to clinical service developments, training and research initiatives.

Iron status and haematological changes in adolescent female inpatients with anorexia nervosa.

Objectives:  (i) To investigate the incidence of iron deficiency (both latent iron deficiency and iron deficiency anaemia) in post menarchal female adolescent patients hospitalized with anorexia nervosa. (ii) To observe changes in iron status during refeeding.

Higher Caloric Refeeding Is Safe in Hospitalised Adolescent Patients with Restrictive Eating Disorders.

Introduction. This study examines weight gain and assesses complications associated with refeeding hospitalised adolescents with restrictive eating disorders (EDs) prescribed initial calories above current recommendations. Methods. Patients admitted to an adolescent ED structured “rapid refeeding” program for >48 hours and receiving ≥2400 kcal/day were included in a 3-year retrospective chart review. Results. The mean (SD) age of the 162 adolescents was 16.7 years (0.9), admission % median BMI was 80.1% (10.2), and discharge % median BMI was 93.1% (7.0). The mean (SD) starting caloric intake was 2611.7 kcal/day (261.5) equating to 58.4 kcal/kg (10.2). Most patients (92.6%) were treated with nasogastric tube feeding. The mean (SD) length of stay was 3.6 weeks (1.9), and average weekly weight gain was 2.1 kg (0.8). No patients developed cardiac signs of RFS or delirium; complications included 4% peripheral oedema, 1% hypophosphatemia (<0.75 mmol/L), 7% hypomagnesaemia (<0.70 mmol/L), and 2% hypokalaemia (<3.2 mmol/L). Caloric prescription on admission was associated with developing oedema (95% CI 1.001 to 1.047; p = 0.039). No statistical significance was found between electrolytes and calories provided during refeeding. Conclusion. A rapid refeeding protocol with the inclusion of phosphate supplementation can safely achieve rapid weight restoration without increased complications associated with refeeding syndrome.

Effect of warfarin on menstruation and menstrual management of the adolescent on warfarin

Aim:  The aim of this study was to review a consecutive cohort of adolescent females on warfarin to determine the effect of warfarin on menstruation, management options and their perceived efficacy.

Adolescent and young adult medicine in Australia and New Zealand: towards specialist accreditation.

Abstract In Australia and New Zealand, a critical mass of academic and clinical leadership in Adolescent Medicine has helped advance models of clinical services, drive investments in teaching and training, and strengthen research capacity over the past 30 years. There is growing recognition of the importance of influencing the training of adult physicians as well as paediatricians. The Royal Australasian College of Physicians (RACP) is responsible for overseeing all aspects of specialist physician training across the two countries. Following advocacy from adolescent physicians, the RACP is advancing a three-tier strategy to build greater specialist capacity and sustain leadership in adolescent and young adult medicine (AYAM). The first tier of the strategy supports universal training in adolescent and young adult health and medicine for all basic trainees in paediatric and adult medicine through an online training resource. The second and third tiers support advanced training in AYAM for specialist practice, based on an advanced training curriculum that has been approved by the RACP. The second tier is dual training; advanced trainees can undertake 2 years training in AYAM and 2 years training in another area of specialist practice. The third tier consists of 3 years of advanced training in AYAM. The RACP is currently seeking formal recognition from the Australian Government to have AYAM accredited, a process that will be subsequently undertaken in New Zealand. The RACP is expectant that the accreditation of specialist AYAM physicians will promote sustained academic and clinical leadership in AYAM to the benefit of future generations of young Australasians.

Subacute combined degeneration of the spinal cord in an adolescent male with avoidant/restrictive food intake disorder: A clinical case report.

Avoidant/restrictive food intake disorder (ARFID) is a potentially lethal eating disorder. This case example of a male, G, aged 17 years with ARFID illustrates the multiplicity of health problems related to nutritional deficiencies which may develop in an adolescent of normal weight. Of particular concern was the diagnosis of subacute combined degeneration (SCD) of the spinal cord and the real possibility that G may have irreversible damage to his spinal cord. To our knowledge, this is the first reported case of a patient with SCD of the spinal cord due to ARFID. The adolescent was found to be deficient in Vitamin A, E, K, D, B12, and folate. Management required vitamin replacement, initial nasogastric feeding and the slow introduction of a varied diet. This patient will require long term rehabilitation. Medical practitioners need to be attuned to abnormal eating patterns in children and adolescents and refer for specialist care early.Avoidant/restrictive food intake disorder (ARFID) is a potentially lethal eating disorder. This case example of a male, G, aged 17 years with ARFID illustrates the multiplicity of health problems related to nutritional deficiencies which may develop in an adolescent of normal weight. Of particular concern was the diagnosis of subacute combined degeneration (SCD) of the spinal cord and the real possibility that G may have irreversible damage to his spinal cord. To our knowledge, this is the first reported case of a patient with SCD of the spinal cord due to ARFID. The adolescent was found to be deficient in Vitamin A, E, K, D, B12, and folate. Management required vitamin replacement, initial nasogastric feeding and the slow introduction of a varied diet. This patient will require long term rehabilitation. Medical practitioners need to be attuned to abnormal eating patterns in children and adolescents and refer for specialist care early.

Opportunistic adolescent health assessment in the child protection unit

Adolescent health assessments are recommended to identify health‐risk behaviours. Adolescents who experience maltreatment are more likely to engage in such behaviours. This study (i) describes the frequency of health‐risk behaviours amongst adolescents attending a hospital‐based child protection unit (CPU) and (ii) determines whether use of a health assessment questionnaire increases the identification of these behaviours.

Making the most of an admission: the safety and efficacy of higher caloric refeeding in hospitalised adolescents with restrictive eating disorders

Results The mean (SD) age of the 184 adolescents was 16.7 years (0.9). Mean (SD) admission BMI was 16.9kg/m2 (2.3) and discharge BMI was 19.5kg/m2 (1.5). The mean (SD) starting caloric intake was 2523.6kcal/day (383.5) equating to 56kcal/kg (12). Most patients (87.5%) were treated with nasogastric tube feeding. Mean (SD) length of stay was 3.5 weeks (1.9) with a weekly weight gain of 2.1kg (0.9). No patients developed cardiac signs of refeeding syndrome or delirium; complications included peripheral oedema (3.8%), hypophosphatemia (1.1%), hypomagnesaemia (6%), and hypokalaemia (1.6%). Caloric prescription on admission was not associated with developing hypophosphatemia (p=0.15), hypokalaemia (p=0.40) and hypomagnesaemia (p=0.96). Conclusion Results demonstrated the efficacy of treating adolescent inpatients with restrictive EDs safely with higher initial caloric intakes, resulting in rapid weight restoration without major refeeding complications; which challenges current conservative calorie prescriptions advocated in clinical guidelines.

An audit of a high caloric refeeding regimen used for medically unstable adolescent inpatients with severe restrictive eating disorders

Results Median age 16.6 years (range: 14.7 19.9), median BMI 16.2 kg/m2 (12.4 18.5) on admission. Median weight gain in first week 4.0 kg (1.2 – 6.9), median total weight gain 7.8 kg (3.3 18.3). Median BMI on discharge 19.1 kg/m2 (16.4 21.0). Median length of stay 24.4 days (6.0 – 82.3 days). No admissions resulted in refeeding syndrome. Peripheral oedema and/or mild electrolyte abnormality occurred in 20.4% of admissions.