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Malnutrition in hospitalized children: prevalence, impact, and management.

INTRODUCTION

Studies (1-5) from numerous countries show that acute malnutrition occurs frequently in hospitalized children, but the definition of malnutrition varies from one study to another (Table 1) (6). The prevalence of acute malnutrition in infants and children with multiple diagnoses can be as high as 31.8% (7). In the current study, acute malnutrition was defined as being underweight or wasting, while chronic malnutrition was defined as stunting. In only a handful of studies have investigators examined both chronic and acute malnutrition in children. According to many reports (4,8-11), malnutrition has a considerable impact on prognosis and duration of hospitalization, and therefore on health care costs. Some research has shown progressive weight loss during hospitalization (2,12), which alerts us to the importance of preventing malnutrition. Assessing risk is essential because 85% of hospitalized children have been reported to be at risk for malnutrition (2).

PURPOSE

The prevalence of malnutrition in children was explored and the risk for malnutrition was assessed upon their admission to the general pediatric unit of a university hospital. The secondary objectives were to study the children's change in nutritional status throughout hospitalization and the association between nutritional status and duration of hospitalization.

METHODS

Study population

Study participants aged zero to 18 years were recruited from the general pediatric unit of Sherbrooke University Hospital Centre, Sherbrooke, Quebec. This study was approved by Sherbrooke University Hospital Centre Institutional Review Board (ethics file number #07-040). The inclusion criterion for all children was hospitalization at some point during two consecutive summer months, from June 1 to July 31, 2007. Exclusion criteria were hospitalization for less than 24 hours, a diagnosis of anorexia nervosa, or the inability to meet legal guardians to obtain consent.

Data collection

A parent or a legal guardian gave informed consent, and children able to participate gave assent. Each child's nutritional risk was assessed with Sermet-Gaudelus et al.'s (2) pediatric nutritional risk score (NRS). This well-validated instrument (13) relies on the severity of the diagnosis (mild = 0, moderate = 1, severe = 3), the pain (absent = 0, present = 1), and energy intake (normal = 0, [greater than or equal to] 50% decrease = 1 point). The sum of these three components provides the final NRS (low = 0, moderate = 1 to 2, severe = 3 to 5). This NRS was obtained through a research assistant's interview with the parent upon the child's admission to the general pediatric unit. Specifically, the parent was asked about the child's energy intake over the past 48 hours; whether the child was in pain was determined.

Nutritional status (NS) was assessed using the Canadian collaborative statement from Dietitians of Canada, the Canadian Paediatric Society, and other organizations (14). These criteria were used to define acute malnutrition as underweight (weight for age below the third percentile), severe underweight (weight for age below the 0.1 percentile), wasting (birth to two years: weight for height [WFH] below the third percentile; two to 19 years: body mass index [BMI] for age below the third percentile), or severe wasting (birth to two years: WFH below the 0.1 percentile; two to 19 years: BMI for age below the 0.1 percentile). Chronic malnutrition was defined as stunting (height for age below the third percentile) or severe stunting (height for age below the 0.1 percentile).

For research purposes, the NS was monitored by a research assistant who performed weight, height, and subcutaneous fold measurements within 24 hours of each child's admission and every three days thereafter. Weight was quantified using an Olympic Smart Scale (Natus Medical Incorporated, San Carlos, CA) with accuracy to 0.01 kg for infants. For older children, we used a Detecto medical scale (Detecto Scale, Webb City, MO) with accuracy to 0.1 kg. Height was measured using a pediatric height scale (model 116-890, AMG Medical Inc., Montreal, QC), using millimetres for infants shorter than 90 cm. A Detecto-Medic stadiometer with an accuracy of [+ or -] 2 mm (Detecto Scale, Webb City, MO) was used for children who were able to stand. The same research assistant measured bicipital, tricipital, subscapular, and suprailiac subcutaneous folds with a skinfold caliper (Caliper Deluxe 116-780, AMG Medical Inc., Montreal, QC) to the nearest millimetre; measurements were taken three times at each site, and the average of the three measurements was used for analyses. The sum of the four skinfolds was studied over time (15).

For all children hospitalized for three or more days, energy intake by all routes (oral, enteral, and parenteral) was assessed with a chart review and a food diary recorded by the parent every day during the child's hospital stay. The research assistant (who had been trained by a dietitian) explained and reviewed the food records with the families. Energy intake was assessed with Nutrific software (version 0.99, Department of Nutrition and Food Sciences, Universite Laval, Quebec, QC, 2008) and compared with daily requirements as a function of age, weight, physical activity level, and degree of illness (16,17).

Data analysis

Normally distributed interval data are presented as means [+ or -] standard deviations. Non-normally distributed variables are presented as medians with an interquartile range (IQR: 25th to 75th percentiles). Associations between NS and length of hospital stay and between NRS and duration of hospitalization were assessed with Pearson correlations. The evolution of weight and skinfold measurements over time was analyzed using repeated-measures analysis of variance (ANOVA). Sphericity for ANOVA was evaluated with Mauchly's test, and whenever the assumption of sphericity was not met, the repeated-measure ANOVA was corrected using the Greenhouse-Geisser method (for epsilon smaller than 0.75) or the Huynh-Feldt method (for epsilon greater than or equal to 0.75). Post hoc analyses comparing initial (admission) parameters with parameters at each subsequent measurement were performed using Student's f-test for paired samples and adjusted using the Bonferroni correction for multiple comparisons. Statistical significance was defined as P<0.05.

RESULTS

The characteristics of the 173 patients (median age three years, 88 girls) hospitalized in the general pediatric unit are presented in Table 2. Figure 1 shows the numbers of potential participants and participants at various points in the study. The mean duration of hospitalization was 3.9 [+ or -] 3.3 days (median 3, IQR 1 to 5 days). Ten patients received bolus gavages, three received central parenteral nutrition, 10 received nutritional supplements, and 102 received substantial (more than the minimal amount to keep the vein open) peripheral intravenous (IV) fluids containing 5% dextrose.

According to the NRS, 79.8% of patients had a moderate to severe risk of malnutrition (NRS 0: 20.2%; NRS 1: 29.5%; NRS 2: 30.1%; NRS 3: 13.3%; NRS 4: 1.7%; NRS 5: 5.2%). Only 11% were acutely malnourished and 6.3% chronically malnourished, while 13.3% were acutely and/or chronically malnourished. Malnutition was most prevalent in surgical patients; 11 of 21 children were malnourished (Fisher's exact test, P<0.05).

The NRS was associated with longer hospitalization in children older than three years (n=79, Pearson coefficient = 0.226, P<0.05), while the only parameter of NS associated with a longer stay was the WFH percentile in children younger than three years (n=80, Pearson coefficient = -0.268, P<0.05).

Close monitoring of weight showed no change between values observed on admission and those taken three and six days later (Table 3). However, total skinfold measurements tended to decrease (P=0.08) during hospitalization by repeated-measures ANOVA. Pairwise analysis showed that skinfolds decreased in thickness after three days (n=43, P<0.05) and six days (n=13, P<0.01) in comparison with values recorded on admission.

The overall mean energy intake during hospitalization was 64.6 [+ or -]31.9 kcal/kg/day, which corresponded to 73.3% of recommended intake, and the mean protein intake was 1.7 [+ or -] 1.0 g/kg/day. Subjects with moderate and severe NRS had a lower energy intake than those not at risk (66.9 [+ or -] 26.5% versus 88.0 [+ or -] 37.0% of recommended intake, P<0.01), while children categorized as malnourished had a higher energy intake than well-nourished children (92.5 [+ or -] 38.7% versus 67.7 [+ or -] 27.0% of recommended intake, P<0.05). The energy intake was also higher (P<0.01) in children receiving IV fluids containing 5% dextrose than in those without IV fluids. Only 16 participants had a consultation with the dietitian during the study.

DISCUSSION

Malnutrition incidence and risk

In this prospective study, 13.3% of children were acutely and/or chronically malnourished, while 79.8% had an NRS indicating a moderate to severe risk of malnutrition. The NRS on admission was a good predictor of the duration of hospitalization in children older than three years. In younger children, the WFH percentile was inversely associated with the length of hospital stay. Although only 16 subjects had an NS assessment on day 6, a deterioration of NS is suspected with a progressive decrease in the thickness of total skinfolds during hospitalization. Management was suboptimal for children identified as at risk for malnutrition on admission: they received only 66.9% of recommended energy intake. However, management was acceptable for malnourished children, with energy intake averaging 92.5% of recommended intake.

Few data are available on chronic malnutrition in industrialized countries (18,19), but the prevalence of acute malnutrition in the current study is consistent with findings from studies listed in Table 1 (6). As other investigators (4,8,9,13) have pointed out, an adverse NS may be predictive of an extended hospital stay. In our sample, poor NS had an impact on the length of hospital stay only for infants and toddlers. This was also the case in Campanozzi et al.'s study (20), in which malnourished younger patients were more likely to have a prolonged hospital stay.

Changes in skinfold measurements

During the current study, a progressive decrease in the thickness of skinfolds was observed. Most children were hospitalized for three or fewer days, and this may explain why no change in weight was observed; this observation contrasts with those in other studies (2,7,12).

Nutritional screening tool

Some previous studies (2,10,21-25) have shown the effectiveness of different nutritional screening tools. In the current study, a high prevalence of moderate to severe NRS was observed and NRS was correlated with the length of hospital stay in children older than three years. To our knowledge, minimal literature is available on the predictive value of the NRS for the duration of hospitalization. Some concerns may be raised about the validity of the NRS in children younger than three years because of the difficulty of assessing pain in this group.

Energy intake

In our study, patients at risk according to the NRS had only about two-thirds of recommended energy intake. This finding indicates the usefulness of a nutritional risk screening tool during admission, so that appropriate nutritional interventions can be initiated promptly for those at risk. On the other hand, malnourished children had an energy intake close to recommended levels, which suggests that pediatric health professionals are attuned to the subjective evaluation of NS and respond appropriately, perhaps because of previous studies (26-28).

Study limitations

This study has some limitations. A potential selection bias exists because the 50 children who did not participate may have been better nourished than the 173 participants; however, we did not collect baseline data from those who declined to participate, and therefore we cannot compare these characteristics. In addition, the stay was very short, and consequently the sample size over time was small. Because previous studies (28,29) have shown a decrease in skinfold thickness over about seven days and because children in a general pediatric unit tend to have a stay shorter than seven days, skinfolds were monitored every three days; this is a shorter interval than usual. A longer study with a larger group should be conducted to confirm the findings.

This is the second Canadian pediatric study on the prevalence, impact, and management of NRS and malnutrition in an inpatient service (10). A great need exists for future pediatric studies that are part of the Canadian Malnutrition Task Force and can be used to investigate malnutrition and its impact in a network of Canadian hospitals. The results of such studies may lead to better recognition and management of this problem.

RELEVANCE TO PRACTICE

This prospective study in a general pediatric unit permitted documentation of the importance of assessing both NS and NRS on admission; current nutritional management may be suboptimal for hospitalized children. Few participants had a consultation with the dietitian. Best practice should require early multidisciplinary nutritional intervention, with dietitians playing a key role.

Acknowledgements

Funding for this research was provided by Fondation des Etoiles.

References

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VERONIQUE GROLEAU, MD, FRCPC, Department of Pediatrics, Sherbrooke University Hospital Centre, Sherbrooke, QC, Division of Gastroenterology, Hepatology and Nutrition, Ste-Justine University Hospital Centre, Montreal, QC; MAXIME THIBAULT, BPharm, MSc, Department of Pharmacy, Ste-Justine University Hospital Centre, Montreal, QC; MYRIAM DOYON, MSc, Department of Pediatrics, Sherbrooke University Hospital Centre, Sherbrooke, QC; EVE-EMMANUELLE BROCHU, PDt, Department of Nutrition, Sherbrooke University Hospital Centre, Sherbrooke, QC; CLAUDE C. ROY, MD, FRCPC, Division of Gastroenterology, Hepatology and Nutrition, Ste-Justine University Hospital Centre, Montreal, QC; CORENTIN BABAKISSA, MD, Department of Pediatrics, Sherbrooke University Hospital Centre, Sherbrooke, QC

Table 1 Prevalence of acute malnutrition in hospitalized children (a)

Reference                     Country              Age           n

Pawellek et al.             Germany             0-18 years       475

Rocha et al.                Brazil              <5 years         186

Marteletti et al.           France            2 months-16 year   280

Dogan et al.                Turkey            1 month-23 years   528

Ozturk et al.               Turkey              2-6 years        170

Hankard et al.              France              >6 months         58

Hendricks et al.            USA                 0-18 years       268

Hendrikse et al.            UK                7 months-16 year   226

Moy et al.                  UK                3 months-18 year   255

Marino et al.               South Africa        0-18 years       227

Sermet-Gaudelus et al.      France              0-18 years       296

De Moraes Silveira et al.   Brazil            1 month-10 years   426
                                              and 10-12 years
Sarni et al.                Brazil               <5 years        907

Joosten at al.              The Netherlands   1 month-18 years   424

Reference                   Prevalence     Definition
                               (%)b
Pawellek et al.                  6.1            WFH <80%
Rocha et al.                     6.9           WFH <-2 SD
Marteletti et al.                11            WFH <-2 SD
Dogan et al.                    27.7           WFH <-2 SD
Ozturk et al.                   31.8     % ideal BW/H <80%
Hankard et al.                   21             BMI <-2 SD
Hendricks et al.                 7.1            WFH <80%
Hendrikse et al.                  8             WFH <80%
Moy et al.                       14            WFH <-2 SD
Marino et al.                   25.9           WFH <-2 SD
Sermet-Gaudelus et al.          19.6     % ideal BW/H <80%
De Moraes Silveira et al.        10            WFH <-2 SD
                                14.7            BMI <-2 SD
Sarni et al.                    16.3           WFH <-2 SD
Joosten at al.                   11            WFH <-2 SD

BMI = body mass index; BW/H = body weight for height; SD = standard
deviation; WFH = weight for height

(a) Adapted from: Joosten KFM, Hulst JM. Prevalence of malnutrition
in pediatric hospital patients. Curr Opin Pediatr. 2008;20:590-6.

(b) Prevalence (%) derived from the original studies, using
equivalent criteria

Table 2

Characteristics of hospitalized children (n=173)

                                                  IQR
Characteristic                      Median     [25th-75th]

Age, in years                          3           0.4-9

Weight percentile                     50           25-82

Height percentile                     63           26-90

BMI percentile                        53           31-79

Length of hospital stay, in days       3             1-5
                                   Frequency        %

Sex

  Females                             88            50.9

  Males                               85            49.1

Diagnosis category

  Infection                           78            45.1

  Minor surgery                       17             9.8

  Major surgery                        4             2.3

  Trauma                              18            10.4

  Neurologic                          17             9.8

  Respiratory                         15             8.7

  Gastrointestinal                    11             6.4

  Endocrine                            8             4.6

  Cardiac                              2             1.2

  Other                                3             1.8

Nutritional risk score

  Low                                 35            20.2

  Moderate                           103            59.6

  High                                35            20.2

Malnutrition

  Acute                               19            11

  Chronic (n=160)                     10             6.3

BMI = body mass index; IQR = interquartile range

Table 3 Changes in body composition and weight status during
hospitalization in the 43 children who were assessed at visits 1
and 2 and in the 16 children who were assessed at visits 1 and 3

Skinfolds and     n          Visit 1              Visit 2
weight

Total skinfolds   43    30.3 [+ or -] 12.6   28.7 [+ or -] 11.0 (a)
 (mm)
Bicipital                6.1 [+ or -] 3.2     6.0 [+ or -] 2.4
Tricipital               9.4 [+ or -] 3.6     8.8 [+ or -] 3.4 (b)
Subscapular              7.2 [+ or -] 3.0     6.8 [+ or -] 2.3
Suprailiac               7.2 [+ or -] 3.9     6.7 [+ or -] 3.8
Weight (kg)       350   21.3 [+ or -] 19.9   21.1 [+ or -] 19.5
                  (c)
                             Visit 1              Visit 3
Total skinfolds   13    28.2 [+ or -] 9.9    24.7 [+ or -] 7.8 (b)
 (mm)             (d)
Bicipital                6.0 [+ or -] 2.9     4.9 [+ or -] 1.9 (a)
Tricipital               8.9 [+ or -] 3.0     7.8 [+ or -] 2.6
Subscapular              6.6 [+ or -] 2.2     6.3 [+ or -] 1.7
Suprailiac               6.4 [+ or -] 2.8     5.9 [+ or -] 2.1
Weight (kg)       16    12.7 [+ or -] 10.4   13.3 [+ or -] 10.1

(a) Change compared with visit 1 at P<0.05

(b) Change compared with visit 1 at P<0.01

(c) Out of 43, only 35 children had weight measurements at visits
1 and 2.

(d) Out of 16, only 13 children had skinfold measurements at visits
1 and 3.
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Article Details
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Title Annotation:Research/Recherche
Author:Groleau, Veronique; Thibault, Maxime; Doyon, Myriam; Brochu, Eve-Emmanuelle; Roy, Claude C.; Babakis
Publication:Canadian Journal of Dietetic Practice and Research
Article Type:Report
Geographic Code:1CANA
Date:Mar 22, 2014
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