Educational Case: Understanding Kwashiorkor and Marasmus: Disease Mechanisms and Pathologic Consequences

The following fictional case is intended as a learning tool within the Pathology Competencies for Medical Education (PCME), a set of national standards for teaching pathology. These are divided into three basic competencies: Disease Mechanisms and Processes, Organ System Pathology, and Diagnostic Medicine and Therapeutic Pathology. For additional information, and a full list of learning objectives for all three competencies, seehttp://journals.sagepub.com/doi/10.1177/2374289517715040.1.

Catch-up growth is a better indicator of undernutrition than thresholds for stunting

Objective:

Stunting (height-for-age < −2 sd) is one of the forms of undernutrition and is frequent among children of low- and middle-income countries. But stunting perse is not a synonym of undernutrition. We investigated association between body height and indicators of energetic undernutrition at three critical thresholds for thinness used in public health: (1) BMI SDS < −2; (2) mid-upper arm circumference divided by height (MUAC (mm) × 10/height (cm) < 1·36) and (3) mean skinfold thickness (SF) < 7 mm and to question the reliability of thresholds as indicators of undernutrition.

Design:

Cross-sectional study; breakpoint analysis.

Setting:

Rural and urban regions of Indonesia and Guatemala – different socio-economic status (SES).

Participants:

1716 Indonesian children (6·0–13·2 years) and 3838 Guatemalan children (4·0–18·9 years) with up to 50 % stunted children.

Results:

When separating the regression of BMI, MUAC or SF, on height into distinguishable segments (breakpoint analysis), we failed to detect relevant associations between height, and BMI, MUAC or SF, even in the thinnest and shortest children. For BMI and SF, the breakpoint analysis either failed to reach statistical significance or distinguished at breakpoints above critical thresholds. For MUAC, the breakpoint analysis yielded negative associations between MUAC/h and height in thin individuals. Only in high SES Guatemalan children, SF and height appeared mildly associated with R² = 0·017.

Conclusions:

Currently used lower thresholds of height-for-age (stunting) do not show relevant associations with anthropometric indicators of energetic undernutrition. We recommend using the catch-up growth spurt during early re-feeding instead as immediate and sensitive indicator of past undernourishment. We discuss the primacy of education and social-economic-political-emotional circumstances as responsible factors for stunting.

Utilization of Current Diagnostic Indicators to Characterize Pediatric Undernutrition among US Children

The purpose of this study was to estimate the prevalence of pediatric undernutrition in the US general population using the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition consensus statement on identification of pediatric malnutrition (undernutrition). National Health and Nutrition Examination Survey (NHANES) data for years 2005–2014 was analyzed for children ages 1–13 years (n = 13,950) with valid anthropometric data. The prevalence of undernutrition was assessed through z-scores for weight-for-height, body mass index (BMI)-for-age, height-for-age, and mid-upper-arm circumference-for-age generated from the 2000 Centers for Disease Control and Prevention growth charts. Children were stratified into: no undernutrition, mild undernutrition, and moderate or severe undernutrition. Descriptive statistics were used to identify the prevalence of undernutrition. Differences in Z-scores across growth chart metrics were compared across undernutrition categories using analysis of variance. The total prevalence of pediatric undernutrition in this sample was 0.4% (severe undernutrition), 2.0% (moderate undernutrition), and 10.9% (mild undernutrition) for all ages. Z-scores differed significantly across all levels of undernutrition for all anthropometrics, showing poorer mean growth metrics in those with undernutrition. Pediatric undernutrition is a prevalent condition that transcends the prior focus on <5th percentile of growth curves and impacts children across different demographic categories.

Physical fitness and nutritional status in female adolescents with anorexia nervosa

ABSTRACT Objective This study aimed to determine whether physical fitness is related to nutritional status in a sample of female adolescents with anorexia nervosa, to contrast the nourished and undernourished patients, and to compare the physical fitness in these patients with normative data of healthy subjects stratified by age and gender. Methods Nutritional status was determined using the body mass index Z-score, fat mass, fat-free mass (bioelectrical impedance analysis), and the Controlling Nutritional Status score in 15 anorexic adolescents with 14.3±1.6 years. Physical fitness was assessed using the ALPHA-Fitness Battery (handgrip strength, standing broad jump, 4x10m shuttle run, and 20m shuttle run tests). Results Handgrip strength was significantly associated with all variables of nutritional status, except with the three blood components of the Controlling Nutritional Status score. The undernourished anorexic patients showed significantly worse physical fitness than the nourished anorexic patients in all tests, except in the standing broad jump and the 4x10m shuttle run tests. The physical fitness tests of the female anorexic adolescents showed scores significantly worse than those of the normative European female adolescent population. Conclusion The observation of female adolescents with anorexia nervosa showed associations between higher physical fitness levels and better nutritional statuses. Handgrip strength and 20m shuttle run tests may be options of additional indicators of undernutrition in anorexic female adolescents. The undernourished anorexic patients showed worse physical fitness than the nourished ones. According to normative data for healthy sex- and agematched adolescents, physical fitness is severely impaired in anorexic female adolescents.

Poor nutrition for under-five children from poor households in Ethiopia: Evidence from 2016 Demographic and Health Survey

Background

Ethiopia is commonly affected by drought and famine, and this has taken quite a toll on citizens of the country, particularly the under-five children. Undernutrition among under-five children in Ethiopia is a prominent public health concern, and it lacked attention for decades. However, the government of Ethiopia, together with other stakeholders, committed to overcoming the impact of malnutrition through the transformational plan. Here we show the magnitude of undernutrition among under-five children and the factors predicting the achievement of global nutrition targets set for 2025 at the World Health Assembly.

Methods

Ethiopian Demographic and Health Survey (EDHS) 2016 was used for this study. A total of 9494 child-mother pairs were included in this analysis. The nutritional status indicators (Height-for-age, Weight-for-height and Weight-for-age) of children were measured and categorized based on the World Health Organization child growth standards. A multilevel logistic regression model adjusted for clusters and sampling weights were used to identify factors associated with stunting, underweight, and wasting. The independent variables were assessed by calculating the odds ratios with 95% confidence interval (CI).

Result

The prevalence of stunting was 38.3% (95% CI: 36.4% to 40.2%), under-weight 23.3% (95%CI: 21.9% to 24.9%) and wasting 10.1% (95%, CI: 9.1% to 11.2%). Sex of the child (male), children older than 24 months, recent experience of diarrhea, household wealth index (poorest), and administrative regions (Tigray, Amhara and developing regions) had a higher risk of undernutrition. On the other hand, children born from overweight mothers and educated mother (primary, secondary or higher) had a lower risk of undernutrition.

Conclusion

The burden of undernutrition is still considerably high in Ethiopia. Implimentation of strategies and policies that focus on improving the socioeconomic educatiional status of the community need to be sustained. Generally, actions targeted on factors contributing to undernutrition among under-five children demands immediate attention to achieve national and global nutrition target.

Nutritional Status Deterioration Occurs Frequently During Children's ICU Stay

OBJECTIVES

Malnutrition and faltering growth at PICU admission have been related to suboptimal outcomes. However, little is known about nutritional status deterioration during PICU stay, as critical illness is characterized by a profound and complex metabolism shift, which affects energy requirements and protein turnover. We aim to describe faltering growth occurrence during PICU stay.

DESIGN

Single-center prospective observational study.

SETTING

Twenty-three-bed general PICU, Lyon, France.

PATIENTS

All critically ill children 0-18 years old with length of stay longer than 5 days were included (September 2013-December 2015).

INTERVENTIONS

Weight and height/length were measured at admission, and weight was monitored during PICU stay, in order to calculate body mass index for age z score. Faltering growth was defined as body mass index z score decline over PICU stay. Children admitted during the first year of the study and who presented with faltering growth were followed after PICU discharge for 3 months.

MEASUREMENTS AND MAIN RESULTS

We analyzed 579 admissions. Of them, 10.2% presented a body mass index z score decline greater than 1 SD and 27.8% greater than 0.5. Admission severity risk scores and prolonged PICU stay accounted for 4% of the variability in nutritional status deterioration. Follow-up of post-PICU discharge nutritional status showed recovery within 3 months in most patients.

CONCLUSIONS

Nutritional deterioration is frequent and often intense in critically ill children with length of stay greater than 5 days. Future research should focus on how targeted nutritional therapies can minimize PICU faltering growth and improve post-PICU rehabilitation.

Screening for Pediatric Malnutrition at Hospital Admission: Which Screening Tool Is Best?

Background

Identifying children at malnutrition risk on admission to hospital is considered best practice; however, nutrition screening in pediatric populations is not common. The aim of this study was to determine which screening tool is able to identify children with malnutrition on admission to hospital.

Methods

A nurse administered 2 pediatric nutrition screening tools, Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) and Pediatric Nutrition Screening Tool (PNST) to patients admitted to medicine and surgery units (n = 165). The Subjective Global Nutritional Assessment (SGNA) was then completed by a dietitian, blinded to the results of the screens. Sensitivity, specificity, and κ were calculated for both screening tools against the SGNA. A receiver operating characteristic (ROC) curve assessed alternate cutoffs for each tool. Length of hospital stay (LOS) was used to assess prospective validity.

Results

Using the recommended cutoffs, the sensitivity of STRONGkids was 89%, specificity 35%, and κ 0.483. The sensitivity of PNST was 58%, specificity 88%, and κ 0.601. Using adjusted cutoffs, PNST's sensitivity improved to 87%, specificity 71%, and κ 0.681, and STRONGkids specificity improved to 61%, sensitivity 80%, and κ 0.5. Children identified at nutrition risk had significantly longer LOS (P < 0.05).

Conclusion

This study showed neither tool was appropriate for clinical use based on published cutoffs. By adjusting the cutoffs using ROC curve analysis, both tools improved overall agreement with the SGNA without significantly impacting the prospective validity. PNST with adjusted cutoffs is the most appropriate for clinical use in this population.

Revised antiemetics guidelines and the impact on nutritional status during induction chemotherapy in children with high-risk neuroblastoma

BACKGROUND

High-risk neuroblastoma (HR NBL) treatment requires intensive induction chemotherapy. The profoundly emetogenic agents used can compromise nutritional status. Our institution introduced a new antiemetic guideline in 2010 incorporating regular dexamethasone, in addition to ondansetron, for all highly emetogenic protocols.

PROCEDURE

A retrospective comparative review of pediatric patients diagnosed with HR NBL who received rapid COJEC induction chemotherapy as per HR-SIOPEN NBL trial. Prophylactic antiemetics were prescribed regardless of chemotherapy emetogenicity in group A (2004-2010) but for defined time periods considering chemotherapy emetogenicity in group B (2010-2017).

RESULTS

Sixty-three children were eligible for inclusion (median age, 31 months; range, 1-88 months). Group A had more episodes of emesis than group B (189 vs. 116, P < 0.0001). There was a significant difference in weight-for-age Z score change between the groups by induction end (P = 0.0027). Four children (13%) in group A lost >10% body weight versus none in group B. Nutrition support (NS) was utilized by 29 children (94%) in group A and 22 children (69%) in group B. Group A had a median of 3 (range, 1-7) admissions for febrile neutropenia (FN) versus a median of 1.5 (range, 0-4) for group B (P = 0.003) during induction.

CONCLUSION

The review of our guidelines led to reduced emesis frequency for group B. They also required less NS, followed expected growth trajectories more closely and had fewer FN admissions. We propose that this may have occurred due to better emesis control resulting in improved nutritional status and associated enhanced immune function.

Determination of Renal Nutrition Training and Education Need for Pediatric-Focused and Adult-Focused Clinicians: The North American Pediatric Renal Nutrition Education Survey (NAPRNES)

OBJECTIVE

The purpose of the study was to ascertain pediatric-focused and adult-focused renal dietitians' perspectives on need for pediatric specific training and education materials.

DESIGN

This study has a descriptive, survey research design using a cross-sectional electronic survey. Subjects included North American dietitians of all ages and experience levels in either pediatric or adult-focused renal nutrition care per self-report. Inclusion criteria were access to renal listservs and/or membership within a Council on Renal Nutrition (CRN) group.

METHODS

Individuals were recruited to participate in the survey via email correspondence disseminated through the pediatric renal listserv hosted by the University of Alberta, Canada, and through the NKF online list of CRN contacts. Surveys were conducted between April 14 and May 2, 2016, and between December 5, 2016 and January 9, 2017. A quantitative and qualitative survey/questionnaire was used to gather information. The main outcome measure of this study was to determine the need for pediatric specific renal nutrition training and education.

RESULTS

The majority of both pediatric-focused and adult-focused renal dietitians indicated that more pediatric renal nutrition training and education materials (100% and 87.8%, respectively) than what is currently available would be at least somewhat beneficial. In addition, the survey results showed that 22.1% of adult-focused practitioners work with pediatric individuals (≤21 years) at least monthly. Those practitioners also indicated a need for pediatric training resources and education materials.

CONCLUSION

More pediatric training and education resources need to be made available to meet the needs of both adult-focused and pediatric-focused dietitians to ensure optimal care of children with renal disease.

Optimizing Enteral Nutrition for Growth in Pediatric Chronic Kidney Disease (CKD)

Growth in pediatric Chronic Kidney Disease is important for long-term outcomes including final adult height and cognitive function. However, there are many barriers for children with chronic kidney disease to achieve adequate nutritional intake to optimize growth. This review highlights these unique concerns, including route of nutrition, dialysis contributions and biochemical indices. Fitting the enteral feeding to the patients' needs involves choosing an appropriate product or products, limiting harmful nutrients in excess, notably aluminum, and altering for electrolyte and micronutrient needs. Unique adjustments to the enteral regimen include accommodating volume needs, optimizing macronutrient ratios, specific electrolyte adjustments, the blending of products together, and adjustments made to consider patient and family psychosocial needs. When a holistic approach to medical nutrition therapy is applied, taking the above factors into consideration, adequate intake for growth of the child with CKD is achievable.

Screening tools for paediatric malnutrition: are we there yet?

PURPOSE OF REVIEW

The development of nutritional screening tools has done much to raise the profile of nutrition and encourage healthcare practitioners to consider how to identify children at nutritional risk. However, the next challenge is to ensure nutritional screening accurately identifies those who have immediate and ongoing risk and therefore the potential to impact on it.

RECENT FINDINGS

In this article, we review recent evidence which suggests that the large-scale use of these tools outside of a research setting is not always helpful. Most are highly sensitive but not particularly specific and therefore cases may be 'overdiagnosed' but also missed. It may therefore be time for nutritional screening to evolve into a process which is able to better consider the cause of risk and requirements for nutrition support with referral criteria, defined goals and outcome measures and exit criteria using a 'measure, plot, think, act' approach embedded into physician rounds. Key challenges relate to improving compliance around nutritional screening within the hospital setting and comparison of nutrition risk between centres, as well as an understanding of the barriers which prevent nutritional screening and assessment from occurring.

SUMMARY

It remains to be elucidated as to whether returning to a process which embeds nutritional assessment within the medical review rather than relying on a 'nutrition score' from a screening tool is a more effective way in which to identifying those patients that are malnourished or at risk of malnutrition during their hospital stay.

Associations of seasonal patterns and vitamin D levels with onset and flares of pediatric inflammatory bowel disease

BACKGROUND

As inflammatory bowel disease (IBD) might be associated with environmental factors such as seasonal patterns and low vitamin D levels we aimed to assess their association with IBD onset and flares in a large cohort of children.

METHODS

The records of 623 pediatric onset IBD patients were reviewed retrospectively including age at onset, gender, severity indices, month of first symptom, and vitamin D levels at diagnosis. For a subgroup of patients, data included date of first flare and vitamin D levels during flare and remission.

RESULTS

Median age at diagnosis was 14 years (IQR 11.66-15.58). Disease onset did not vary significantly between either month (P=0.367) or seasons (P=0.460). Vitamin D deficiency at the time of diagnosis was prevalent in 21% of patients with no significant association with month, season or disease's type. Vitamin D deficiency was significantly more prevalent in patients with malnutrition (P<0.001) and was associated with hypoalbuminemia (P=0.02) but did not correlate with low bone mineral density. Analysis of 169 first flares showed that flares were more common in June and less common in April (P=0.016). Mean vitamin D level was significantly lower during flares compared with remission (55.25±19.28 vs. 64.16±26.6, respectively, P=0.012).

CONCLUSIONS

IBD onset in school aged children is not associated with seasonal patterns whereas flares may follow a specific monthly pattern. Disease flares are associated with low vitamin D blood levels. Vitamin D deficiency is associated with malnutrition and hypoalbuminemia.