The costs of disease related malnutrition in hospitalized children

Nutritional Support Best Practices in Pediatric Blood and Marrow Transplant Patients: An Integrative Review

Nutrition is vital to the long-term survival of children undergoing blood and marrow transplantation (BMT), but there is no standardization on how to optimize the nutritional status of these patients. A literature search was performed to evaluate nutritional support approaches currently in practice for pediatric patients who are undergoing BMT. CINAHL, Embase, and Cochrane databases were searched for peer-reviewed articles evaluating nutritional interventions for BMT recipients aged 20 or younger. Nine articles published between 2019 and 2023 were found and reviewed. The nutritional support varied between enteral nutrition, parenteral nutrition, a combination of both, and prophylactic feeding tube placement. The post-transplant outcomes identified as associated with alterations in nutritional regimens included length of stay, date of platelet engraftment, incidence of acute graft-versus-host disease, infection rate, and overall survival. The use of any amount of enteral nutrition compared to parenteral alone was beneficial. Complications during BMT can potentially be decreased via prioritizing enteral nutrition over parenteral. The paucity of literature on this topic highlights an unmet need in the field. Future research should focus on ways to optimize the nutritional support of transplant recipients, including increasing the likelihood of enteral feeding tube placement and utilization.

Effect of oral nutritional supplements on outcomes in children presenting with, or at risk of, faltering growth in clinical settings: A systematic review and meta-analysis

This systematic review summarises evidence regarding oral nutritional supplement (ONS) use in children with, or at risk of, faltering growth (FG). Ten randomised controlled trials (RCTs), compared changes in outcomes amongst children receiving ONS versus control were included. Overall, 1116 children (weighted mean (WM) age 5 years; n658 (59%) male) were recruited, of which 585 (52%) received ONS (WM intake contribution 412 kcal, 16.3 g protein, 395 ml) for 116 days (WM). ONS use was associated with significantly greater gains in weight (mean difference (MD) 0.4 kg, 95% CI [0.36, 0.44]) and height (MD 0.3 cm, 95% CI [0.03, 0.57]), likely related to improvements in nutritional intake. Mean compliance to prescribed dose was 98%. Data suggested an association between ONS use and reduced infections. Further research is warranted to establish ONS dosage and effects upon other outcomes. This review provides evidence to support use of ONS in the management of children with, or at risk of, FG.

Prevalence and economic cost of malnutrition in Italy: A systematic review and metanalysis from the Italian Society of Artificial Nutrition and Metabolism (SINPE)

OBJECTIVES

Disease-related malnutrition (DRM) is a major public health issue with dramatic consequences on outcomes. However, in Italy a comprehensive and updated overview on national prevalence, in both the adult and pediatric populations, and its burden on the health care environment, is missing. The aim of this systematic literature review and meta-analysis was to identify and summarize the available evidence regarding the prevalence of DRM in Italy from pediatric to adult and older ages, and to project its global costs on the health care system.

METHODS

We performed a systematic literature search for articles on epidemiology of DRM in Italy published up to June 2021. Studies reporting data on the prevalence of DRM in community-dwelling individuals with chronic diseases, nursing home patients, and hospitalized patients (medical, surgery, and oncology patients), were selected for inclusion. Methodological quality of the studies was assessed by two independent reviewers using published criteria. An epidemiologic meta-analysis to obtain an aggregate estimate of prevalence of DRM was performed and a model for estimating the cost of illness, based on the application of epidemiologic results to official national hospitalization data, and attribution of relevant unit costs in the national context was constructed.

RESULTS

Sixty-seven studies reporting on the prevalence of DRM in Italian populations were included in the final selection; meta-analytical pooling yields mean prevalence estimates of about 50% and 30% in adult and pediatric hospitalized populations, respectively, with even higher findings for residents of long-term care facilities. Modeled projections of DRM-attributable yearly economic effects on the Italian health care system exceed 10 billion € in base case analysis, with the most optimistic estimate still exceeding 2.5 billion €.

CONCLUSION

Although comparable in magnitude to data from previous studies in analogous international settings, the diffusion and effects of DRM in the Italian setting is impressive. Increased awareness of these data and proactive fostering of clinical nutrition services are warranted, as prompt identification and treatment of malnutrition have been shown to effectively improve clinical and economic results.

Good nutrition across the lifespan is foundational for healthy aging and sustainable development

Ensuring healthy lives and promoting wellbeing across the age spectrum are essential to sustainable development. Nutrition is at the heart of the World Health Organization (WHO) Sustainable Development Goals, particularly for Sustainable Development Goal 2/Subgoal 2, which is to End all forms of malnutrition by 2030. This subgoal addresses people of all ages, including targeted groups like young children and older adults. In recent decades, there have been marked advances in the tools and methods used to screen for risk of malnutrition and to conduct nutritional assessments. There have also been innovations in nutritional interventions and outcome measures related to malnutrition. What has been less common is research on how nutritional interventions can impact healthy aging. Our Perspective article thus takes a life-course approach to consider what is needed to address risk of malnutrition and why, and to examine how good nutrition across the lifespan can contribute to healthy aging. We discuss broad-ranging yet interdependent ways to improve nutritional status worldwide-development of nutritional programs and policies, incorporation of the best nutrition-care tools and methods into practice, provision of professional training for quality nutritional care, and monitoring health and economic benefits of such changes. Taken together, our Perspective aims to (i) identify current challenges to meeting these ideals of nutritional care, and to (ii) discover enabling strategies for the improvement of nutrition care across the lifespan. In harmony with the WHO goal of sustainable development, we underscore roles of nutrition to foster healthy human development and healthy aging worldwide.

Development and Validation of a New Screening Tool with Non-Invasive Indicators for Assessment of Malnutrition Risk in Hospitalised Children

There is no evidence of the most effective nutritional screening tool for hospitalized children. The present study aimed to develop a quick, simple, and valid screening tool for identifying malnutrition risk of hospital admission with non-invasive indicators. A cross-sectional study was conducted. Children`s nutritional baseline using a questionnaire, subjective malnutritional risk, and Subjective Global Nutritional Assessment were assessed on admission. Concurrent validity was assessed using American Society for Parenteral and Enteral Nutrition (ASPEN)and Academy of Nutrition and Dietetics assessment and Subjective Global Nutritional Assessment tool. A new screening tool Simple Pediatric Nutritional risk Screening tool (SPENS) was developed, and sensitivity, specificity and reliability were evaluated. A total of 180 children aged from 1 month to 18 years were included (142 in the development phase and 38 in the validation phase). SPENS consist of four variables and shows almost perfect agreement with subjective malnutritional risk assessment (κ = 0.837) with high sensitivity and specificity (93.3% and 91.3% respectively). Compared with Subjective Global Nutritional Assessment and ASPEN and Academy of Nutrition and Dietetics assessment, SPENS had sensitivity 92.9% and 86.7%, a specificity of 87.5% and 87.0%, and an overall agreement of 0.78 and 0.728, respectively. Due to the fast, simple, easy, and practical to use, screening the SPENS can be performed by nurses, physicians, and dieticians.

Nutrition considerations in pediatric surgical patients

Children who require surgical interventions are subject to physiologic stress, necessitating a period of healing when nutrition needs may temporarily change. Providing appropriate nutrition to children before and after surgery is an important part of minimizing surgical morbidity. There is a clear link between poor nutrition and surgical outcomes, therefore providing good reason for ensuring an appropriate nutrition plan is in place for children requiring surgery. This review will address recent research investigating nutrition considerations for pediatric surgical patients with a focus on practical tools to guide decision making in the preoperative, intraoperative, and postoperative periods.

Pediatric malnutrition screening and assessment tools: Analyzing the gaps

Pediatric healthcare professionals know that children who are malnourished have worse clinical outcomes than do their well-nourished peers. The body of evidence in the literature on the topic of pediatric malnutrition (PMN) is growing and supports this conclusion. The goal of this article is to present the current state of practice related to PMN screening, the use of malnutrition risk screening (MNRS) tools, malnutrition assessment, and the use of malnutrition assessment tools. The purpose is also to discuss best practice for MNRS and assessment and to consider the gaps in practice where additional work is needed.

Sensitivity and specificity test of alarm malnutrition for hospital-acquired malnutrition among pediatric patients

Detecting the risks for hospital-acquired malnutrition in children can be performed by using nutritional screening tools. One of the screening tools that has been created is Alarm Malnutrition. This study aimed to test the sensitivity and specificity of Alarm Malnutrition in detecting the risks for hospitalacquired malnutrition in comparison to Screening Tool for the Risk on Nutritional status and Growth (STRONGkids). This study employed cross sectional design and involved 168 hospitalized children (1 month to 18 years) at pediatric ward. The data were analyzed using diagnostic approach which resulted in sensitivity and specificity values. The statistical tests showed that the sensitivity and specificity values of Alarm Malnutrition and STRONGKids were 32,2% and 81,6% respectively. These results indicated that this screening tool was not better than STRONGkids which has been previously used in Indonesia. Alarm Malnutrition needs to be developed and improved in order to achieve better performance in detecting the risks for hospital-acquired malnutrition.

Malnutrition in Hospitalised Children-An Evaluation of the Efficacy of Two Nutritional Screening Tools

Nutritional risk screening (NRS) is not yet established in many clinical settings. This study aimed to evaluate the efficacy of two NRS tools; the Paediatric Yorkhill Malnutrition Score (PYMS) and the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP), compared to the global dietitians’ clinical judgment. The goal of this study was also to estimate the prevalence of nutritional risk in Greek paediatric patients. Overall, 1506 children, 1–16 years, from paediatric and surgical wards of two Greek hospitals were included. NRS was performed using PYMS and STAMP based either on World Health Organization (WHOGC) or Hellenic growth charts (HGC). The first 907 children were also referred to dietitians who categorized children in low, medium and high nutritional risk according to their global clinical judgment. PYMS, either based on WHOGC or HGC, showed better agreement with dietitians’ feedback (k_{PYMS_WHO} = 0.47; 95%CI: 0.41–0.52, k_{PYMS_HGC} = 0.48; 95%CI: 0.43–0.53) compared to STAMP (k_{STAMP_WHO} = 0.28; 95%CI: 0.23–0.33, k_{STAMP_HGC} = 0.26; 95%CI: 0.21–0.32). PYMS also showed the best diagnostic accuracy compared to STAMP in paediatrics and surgical wards separately. Moreover, the PYMS showed similar sensitivity to the STAMP (WHOGC: 82% vs. 84.4%), but a higher positive predictive value (WHOGC: 58.2 vs. 38.7). Using PYMS, high and medium malnutrition risk was observed at 14.9%, and 13.1% of children, respectively. Almost 28% of hospitalised children were at nutritional risk. Children in hospitals should be screened with effective and feasible NRS tools such as PYMS.

Nutrition risk profile of 62 408 inpatients based on electronic health records in a tertiary children's hospital

OBJECTIVES

This study aimed to evaluate the nutrition risk profile of hospitalized children with electronic health record-based nutrition risk screening. Additionally, this study analyzed the association between high nutrition risk and clinical outcomes.

METHODS

Children discharged from Shanghai Children's Medical Center between 2017 and 2018 were enrolled and nutritionally screened. Nutrition risk scores using the Screening Tool for Assessment of Malnutrition in Pediatrics (STAMP), length of stay (LOS), and costs of hospitalization were recorded. Enrolled patients were categorized into two groups: the low and medium nutrition risk (LMNR) group, with scores ranging from 0 to 3, and the high nutrition risk (HNR) group, with scores ≥4.

RESULTS

Out of 62 408 subjects, 17.4% were at HNR. Patients with congenital heart diseases (83.9%), hematology-oncology diseases (26.0%) and gastroenterological diseases (21.4%) were affected most. Infants had the highest HNR rates (35.5%) of any age group. Surgical patients (20.7%) had a higher rate of HNR than non-surgical patients (9.5%). The HNR group had longer LOS (10.0 d versus 3.0 d, P < 0.001), higher total hospital costs (53 680.1 Chinese yuan [CNY] versus 8810.1 CNY, P < 0.001), and higher costs of antibiotics (441.0 CNY versus 0.0 CNY, P < 0.001) compared to the LMNR group. As STAMP score values increased, growing LOS and costs of hospitalization, medications, and antibiotics were observed.

CONCLUSIONS

A high prevalence of HNR was found in patients of Shanghai Children's Medical Center. Surgeries, specific disease, and infancy were important HNR risk factors. HNR scores using STAMP might predict prolonged LOS and higher medical costs.

Assessing the Effect of Nutrition Therapy on Rehospitalization Rate in Malnourished Pediatric Patients With Chronic Diseases

BACKGROUND

Malnutrition is common among hospitalized children with chronic diseases and increases hospital care needs. The aim of this study is to estimate the clinical consequences of nutrition therapy (NT) after discharge.

METHODS

A retrospective analysis of all pediatric inpatients with diagnosis of malnutrition hospitalized at our center from January 2017 to February 2018 was conducted. Malnutrition was assessed according to body mass index (BMI) z-score, routinely recorded in patient's files. The treatment group consists of all patients referred to nutrition assessment and treated by the clinical nutrition team; all the other patients not receiving NT are selected as the control group. The effect of NT on rehospitalization rates, length of stay (LOS), and emergency room (ER) visits was estimated for the total cohort and in a propensity score (PS) matched sample.

RESULTS

277 malnourished pediatric inpatients were enrolled and analyzed. NT was prescribed in 111 patients (40%). Rehospitalization rate was lower in the treated group (rate ratio [RR] = 0.797; 95% CI, 0.630-1.009); particularly, nonelective hospital admissions are considerably lower (RR = 0.556; 95% CI, 0.325-0.952). The strength of this association increased in the PS-matched sample. There is no clear evidence of NT's effect on ER visits (RR = 0.892; 95% CI, 0.580-1.373) or LOS per episode (Δ = 1.46 days; 95% CI, -3.39 to 6.31).

CONCLUSIONS

Detecting and treating malnutrition seems to promptly improve the patients' clinical course after discharge, reducing the number of subsequent hospitalizations, particularly nonelective ones, probably caused by unresolved, ongoing malnutrition.

Risk of malnutrition in orthopedic trauma patients with surgical site infections is associated with increased morbidity and mortality - a 3-year follow-up study

BACKGROUND

Malnutrition is a worldwide problem which can result in prolonged hospitalization from complications such as poor wound healing and increased morbidity. There is increasing evidence of the effect of risk of malnutrition (ROM) on outcomes in orthopedic surgical patients. However, there is little data on the effect of nutritional status on clinical outcomes in orthopedic trauma patients with surgical site infections (SSI). Therefore, our aim was to investigate how malnutrition risk affects clinical outcomes in a prospective cohort of orthopedic trauma patients with SSI.

METHODS

The study included 345 patients who underwent surgery due to SSI at a level 1 trauma center. All patients were evaluated on their nutritional status as assessed by the Nutritional Risk Screening in 2014/15 and 2017/18. 238 (69.0%) datasets were available for the follow-up analysis. Twenty patients (8.4%) had died, resulting in 218 patients. Outcomes investigated included comorbidities, medication intake, destination of discharge, degree of mobility, support for procuring food, mortality risk and quality of life.

RESULTS

32.8% were at risk of malnutrition (ROM) at EXAM1. Female patients had a higher ROM than males (p < 0.05). Patients with ROM had more comorbidities (p < 0.001), an increased need for medication intake (p < 0.001), a decreased level of mobility (p < 0.001) and increased need of support in procuring food (p < 0.001). The destination of discharge was independent of the nutritional status (p = 0.641). Twenty (8.4%) of the available 238 patients had died during follow-up time period, resulting in a 6.2-times higher risk of mortality in patients with ROM. EQ-5D revealed that mobility, self-supply and usual activities of daily living were increased in well-nourished patients (p < 0.001).

CONCLUSION

ROM in orthopedic trauma patients with SSI is associated with an increased number of comorbidities and need for medication intake, a decrease in mobility and a higher dependency for food acquisition. Patients at ROM exhibited a 6.2-times higher mortality rate than well-nourished patients. EQ-5D evaluation showed better mobility, self-supply, and activity of daily living in well-nourished patients. We therefore strongly recommend supplementing patients with ROM with a specific diet during and after discharge from the hospital in order to reduce postoperative complications and long-term mortality.

Nationwide "Pediatric Nutrition Day" survey on the nutritional status of hospitalized children in South Korea

BACKGROUND/OBJECTIVES

To evaluate the nutritional status and prevalence of malnutrition in hospitalized children at admission and during hospitalization in South Korea.

SUBJECTS/METHODS

This first cross-sectional nationwide “Pediatric Nutrition Day (pNday)” survey was conducted among 872 hospitalized children (504 boys, 368 girls; 686 medical, 186 surgical) from 23 hospitals in South Korea. Malnutrition risk was screened using the Pediatric Yorkhill Malnutrition Score (PYMS) and the Screening Tool Risk on Nutritional status and Growth. Nutritional status was assessed by z-scores of weight-for-age for underweight, weight-for-height for wasting, and height-for-age for stunting as well as laboratory tests.

RESULTS

At admission, of the 872 hospitalized children, 17.2% were underweight, and the prevalence of wasting and stunting was 20.2% and 17.3%, respectively. During hospitalization till pNday, 10.8% and 19.6% experienced weight loss and decreased oral intake, respectively. During the aforementioned period, fasting was more prevalent in surgical patients (7.5%) than in medical patients (1.6%) (P < 0.001). According to the PYMS, 34.3% and 30% of the children at admission and on pNday, respectively, had a high-risk of malnutrition, requiring consultation with the nutritional support team (NST). However, only 4% were actually referred to the NST during hospitalization.

CONCLUSIONS

Malnutrition was prevalent at admission and during hospitalization in pediatric patients, with many children experiencing weight loss and poor oral intake. To improve the nutritional status of hospitalized children, it is important to screen and identify all children at risk of malnutrition and refer malnourished patients to the multidisciplinary NST for proper nutritional interventions.

Impact of Nutritional Deficiencies on Children and Young Adults with Crohn's Disease Undergoing Intraabdominal Surgery

PURPOSE

We examined the impact of comorbidities on length of stay and total hospital charges for children and young adults with Crohn's Disease (CD) undergoing surgery.

METHODS

Patients (<21 years) were identified with a diagnosis of CD and an intraabdominal surgery in the Kids' Inpatient Database for the years 2006, 2009 and 2012. Length of stay (LOS) and total hospital charges (THC; USD$) were stratified by anemia, anxiety, depression and nutritional deficiency. National estimates were obtained using case weighting and multivariable linear regression was performed.

RESULTS

We identified 3224 CD admissions with an intraabdominal surgery. The population was predominantly male, non-Hispanic white, and high school aged. There was an increase in LOS and THC for nutritional deficiency in all study years, and for depression and anemia in specific years. Multivariable linear regression revealed a 3.3-5.5 day increase in LOS associated with a comorbid diagnosis of nutritional deficiency. However, no increase in THC was seen for any comorbidity under evaluation.

CONCLUSIONS

Behavioral health and, particularly, nutritional status have a significant impact on the care of children and young adults with CD. Nutritional deficiency, anemia, and depression resulted in increased LOS for those undergoing surgery. Improved presurgical management of comorbidities may reduce LOS for these patients.

LEVEL OF EVIDENCE

III.

Undernutrition in childhood: Clinically based assessment tools and biological markers: Where are we and where should we go?

Despite its association with poor clinical outcomes and increased hospital costs, as of today undernutrition still goes undetected in paediatric hospitals. The reported prevalence of undernutrition in paediatric patients varies considerably. This disparity is partly due to the diversity of methods for its detection and assessment, as well as to the lack of consensus regarding its definition. Several methods, based on varied combinations of morphology characteristics, estimated nutritional intakes and medical conditions have been developed during the last 25 years. However, these tools suffer from poor sensitivity and selectivity particularly in acute conditions. Also while having their own merit, these tools mainly view malnutrition from the energy standpoint, disregarding assessment of specific micronutrients such as minerals and vitamins. In this position paper we make the point that in the era of personalized medicine, present technology offers the possibility of going beyond the traditional nutritional tools for assessing patients' status, and propose the measurement of selected micronutrients and allied metabolic markers in nutritional workup schemes adapted to each clinical condition.

Prevalence of Malnutrition in Pediatric Hospitals in Developed and In-Transition Countries: The Impact of Hospital Practices

Presently, undernutrition still goes undetected in pediatric hospitals despite its association with poor clinical outcomes and increased annual hospital costs, thus affecting both the patient and the health care system. The reported prevalence of undernutrition in pediatric patients seeking care or hospitalized varies considerably, ranging from 2.5 to 51%. This disparity is mostly due to the diversity of the origin of populations studied, methods used to detect and assess nutritional status, as well as the lack of consensus for defining pediatric undernutrition. The prevalence among inpatients is likely to be higher than that observed for the community at large, since malnourished children are likely to have a pre-existent disease or to develop medical complications. Meanwhile, growing evidence indicates that the nutritional status of sick children deteriorates during the course of hospitalization. Moreover, the absence of systematic nutritional screening in this environment may lead to an underestimation of this condition. The present review aims to critically discuss studies documenting the prevalence of malnutrition in pediatric hospitals in developed and in-transition countries and identifying hospital practices that may jeopardize the nutritional status of hospitalized children.

Prevalence and outcome of malnutrition in pediatric patients with chronic diseases: Focus on the settings of care

BACKGROUND

Information on disease-related malnutrition and related outcomes in pediatric patients with chronic diseases in different settings of care is not available.

METHODS

Consecutive eligible patients attending the out-patient clinic (n = 177) or admitted to the day-hospital clinic (n = 163) or to hospital (n = 201) were screened for the presence of malnutrition (BMI and/or height/length for age z-scores < -2). We recorded data on emergency care admissions to hospital that occurred during the 3 years before screening and related total days of stay, as well as data on emergency care admissions to hospital occurring within 6 months after screening.

RESULTS

Prevalence of malnutrition was 2-fold higher (P < 0.001) in in-patients (56.7% [95% CI, 49.6-63.7]) than in patients assessed at the out-patient (33.3% [95% CI, 26.4-40.8]) and day-hospital (28.3% [95% CI, 21.5-35.8]) clinics. Estimates were heterogeneous across diagnostic groups with higher rates in patients with neurologic (61%) and cardiac (56%) diseases. Stunting was more frequent among in-patients, who also had more evident nutritional derangements. Multivariate logistic regression (covariates: age, gender, healthcare setting and disease group), showed that malnutrition (OR = 1.86 [95% CI, 1.21-2.88]; P = 0.005) was significantly associated with prolonged hospitalization (≥15 days) in the 3 years before screening. In-patients were also more likely to have been hospitalized ≥15 days (using out-patients as reference category, OR = 2.24 [95% CI, 1.39-3.63], P = 0.001), but we did not find any modifying effect (interaction) of the setting of care on the association between malnutrition and prolonged hospitalization.

DISCUSSION

The rates of malnutrition in children with chronic diseases are very high and increase hospital care needs, especially when they are admitted to hospital. Nutritional care in this patient population is recommended.

Nutritional Screening Tools among Hospitalized Children: from Past and to Present

Increased awareness of the importance of nutrition among hospitalized children has increased the use of nutrition screening tool (NST). However, it is not well known the NST for hospitalized children. Therefore, the purpose of this study is to understand the past and present state of adult and child NST and discuss the pros and cons of each NST.