Education and documentation strategies to improve malnutrition diagnosis in hospitalized children: A quality improvement project

BACKGROUND

The Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition (AND/ASPEN) published malnutrition guidelines in 2014. In 2015, our institution implemented a quality improvement project focused on malnutrition identification with the goal to improve the diagnosis of malnutrition in hospitalized children.

METHODS

Our project included three approaches: education, nutrition assessment, and documentation initiatives. Education initiatives focused on physicians at all levels of training. Nutrition screening was completed on all patients admitted to our institution. Registered dietitians (RDs) conducted nutrition assessments and identified and documented malnutrition based on AND/ASPEN guidelines. Documentation initiatives included development of automatic text and template changes to allow import of RD-assigned malnutrition diagnosis into physician documentation. We met with members of our clinical documentation integrity team regularly to review the results of these initiatives starting in 2016.

RESULTS

The total diagnosed cases of malnutrition increased from 208 cases in 2016 at the start of our monitoring to >800 cases per year in 2020-2022. Unspecified (no severity assigned) protein calorie malnutrition as a percentage of total malnutrition diagnoses decreased from 36.9% in 2016 to <10% since 2018. Children with severe malnutrition have remained the largest portion of children with a malnutrition diagnosis, with >40% of children with malnutrition diagnosed with severe malnutrition.

CONCLUSION

Our education and documentation initiatives have led to both improved diagnosis of malnutrition and accurate identification and documentation of malnutrition severity. These initiatives could be utilized to improve malnutrition diagnosis and documentation at other institutions caring for hospitalized children.

Improving anthropometric measurements in hospitalized children: A quality-improvement project

BACKGROUND

The objective of this quality-improvement project was to increase documentation rates of anthropometrics (measured weight, length/height, and body mass index [BMI], which are critical to identify patients at malnutrition (undernutrition) risk) from <50% to 80% within 24 hours of hospital admission for pediatric patients.

METHODS

Multidisciplinary champion teams on surgical, cardiac, and intensive care (ICU) pilot units were established to identify and iteratively test interventions addressing barriers to documentation from May 2016 to June 2018. Percentage of patients with documented anthropometrics <24 h of admission was assessed monthly by statistical process control methodology. Percentage of patients at malnutrition (undernutrition) risk by anthropometrics was compared by χ2 for 4 months before and after intervention.

RESULTS

Anthropometric documentation rates significantly increased (P < 0.001 for all): BMI, from 11% to 89% (surgical), 33% to 57% (cardiac), and 16% to 51% (ICU); measured weight, from 24% to 88% (surgical), 69% to 83% (cardiac), and 51% to 67% (ICU); and length/height, from 12% to 89% (surgical), 38% to 57% (cardiac), and 26% to 63% (ICU). Improvement hospital-wide was observed (BMI, 42% to 70%, P < 0.001) with formal dissemination tactics. For pilot units, moderate/severe malnutrition (undernutrition) rates tripled (1.2% [24 of 2081] to 3.4% [81 of 2374], P < 0.001).

CONCLUSION

Documentation of anthropometrics on admission substantially improved after establishing multidisciplinary champion teams. Goal rate (80%) was achieved within 26 months for all anthropometrics in the surgical unit and for weight in the cardiac unit. Improved documentation rates led to significant increase in identification of patients at malnutrition (undernutrition) risk.

Association of handgrip strength with nutritional status and clinical outcomes in hospitalized pediatric patients

BACKGROUND & AIMS

Malnutrition in children and adolescents is prevalent at hospital admission and the incidence increases with length of stay. Malnourished patients have loss of muscle mass and strength, compromising their functionality. Handgrip strength (HGS) is a nutritional marker understudied in pediatrics although it is capable of detecting nutritional deprivation before changes in body composition are observed. Therefore, this study aimed to evaluate the association between reduced HGS at hospital admission, compromised nutritional status and worse clinical outcomes of pediatric patients.

METHODS

Cohort study conducted with patients aged 6-18 years admitted to a pediatric ward. Nutritional status was assessed in the first 48 h of hospital admission using the z-score of height for age (H/A) and body mass index for age (BMI/A), percentile of mid-arm muscle circumference for age (MAMC/A) and the pediatric global subjective nutritional assessment (SGNA). HGS was measured using a digital dynamometer and considered reduced when the maximum value of three measurements was below the 5th percentile for sex and age. The clinical outcomes analyzed were length of hospital stay and frequency of readmission within 3 months after hospital discharge.

RESULTS

A total of 135 patients were evaluated (median age 10.9 years, 55.6% male) and 17.8% had reduced HGS. Patients with reduced HGS had lower H/A z-score (-0.50 vs 0.22, p = 0.012) and a higher frequency of reduced MAMC when compared to those with normal HGS (8% vs 13%, p = 0.007). Reduced HGS was not associated with malnutrition (OR = 0.63; 95%CI 0.23-1.77), prolonged hospital stay (OR = 1.89; 95%CI 0.72-4.92) or readmission to hospital 3 months after hospital discharge (OR = 1.82; 95%CI 0.67-4.93), in a model adjusted for the clinical condition.

CONCLUSION

Reduced HGS was not a predictor of malnutrition and clinical outcomes. However, it was associated with lower H/A Z-score and MAMC/A percentile values and can be used as a complementary measure in the nutritional status assessment of hospitalized pediatric patients.

Evaluation of malnutrition and screening tools in hospitalized children

BACKGROUND & AIMS

Detecting malnutrition and its related risk factors are crucial, in hospitalized children. Anthropometric z scores are used to assess malnutrition. Screening tools also aim to detect the presence of malnutrition and the developing risk of malnutrition in hospitalized children to determine who may benefit from nutritional support. Therefore, the aims of the study are to detect malnutrition and its related demographic and clinical risk factors in hospitalized children and determining the sensitivity of Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) and Pediatric Yorkhill Malnutrition Score (PYMS) screening tools.

METHODS

A total of 130 hospitalized children aged between 0 and 18 years were included in to study. A survey including demographic and clinical characteristics, STAMP and PYMS were applied to parents of the children. Patients were classified into nutritional risk groups through screening tools. Anthropometric measurements (body weight, length/height, and middle upper arm circumference (MUAC) of the children were taken. Body mass index-for-age and height-for-age z scores were calculated to assess acute and chronic malnutrition prevalence. MUAC-for-age z scores were calculated as well. To detect independent risk factors for acute and chronic malnutrition multivariable logistic regression models were constructed.

RESULTS

A total of 14.6% of hospitalized children had acute malnutrition, 21.5% of children had chronic malnutrition and 27.7% of them had low MUAC standard deviation score (SDS) (less than -2). The independent risk factors for acute malnutrition were younger maternal age at birth and long length of stay (p < 0.05). The independent risk factors for chronic malnutrition were being female, younger maternal age at birth, longer illness duration and having urological or allergy and immunological diseases (p < 0.05). However, MUAC for age SDS groups were not related to any demographic and clinical factors, in children of all ages (p > 0.05). Regarding the screening tools, PYMS displayed 100% sensitivity against acute malnutrition. While PYMS displayed better sensitivity to identify acute malnutrition than STAMP, STAMP was more sensitive than PYMS to detect chronic malnutrition and low MUAC SDS.

CONCLUSIONS

Low MUAC for age SDS was not related to any demographic and clinical factors, in hospitalized children of all ages, unlike acute and chronic malnutrition, in this study. Pediatric screening tools mainly PYMS did not have high sensitivity to detect chronic malnutrition and low MUAC SDS, in hospitalized children. Therefore, the tools have to be used along with z scores of anthropometric parameters.

Healthcare Burden Associated with Malnutrition Diagnoses in Hospitalized Children with Critical Illnesses

Our primary study objectives were to (i) determine the proportion of children admitted to the Pediatric Intensive Care Unit (PICU) with malnutrition diagnoses, (ii) compare healthcare utilization by malnourished and non-malnourished PICU patients, and (iii) examine the impact of implementing malnutrition screening and coding practices at a major academic urban tertiary care medical center. Using patient records, we conducted a retrospective analysis of 4106 children admitted to the PICU for severe illnesses between 2011 and 2019. Patients were identified as malnourished if records showed an ICD-9 or ICD-10 code for malnutrition. We compared malnourished and non-malnourished patients by age, admitting diagnoses, number of comorbid conditions, and clinical outcomes (length of stay, hospital readmission). About 1 of every 5 PICU-admitted patients (783/4106) had a malnutrition diagnosis. Patients with malnutrition were younger (mean age 6.2 vs. 6.9 years, p < 0.01) and had more comorbid conditions (14.3 vs. 7.9, p < 0.01) than those without. Malnourished patients had longer hospital stays (26.1 vs. 10.0 days, p < 0.01) and higher 30-day readmission rates (10% vs. 7%, p = 0.03). Implementation of malnutrition screening and coding practices was associated with an increase in malnutrition diagnosis. In this study of children admitted to the PICU, malnourished patients had more comorbid diagnoses and used more healthcare resources (prolonged hospitalizations and higher 30-day readmission rates), leading to higher healthcare costs. Such findings underscore the need for policies, training, and programs emphasizing identification and treatment of malnutrition at hospitals caring for critically ill children.

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.

Key Strategies for Optimizing Pediatric Perioperative Nutrition-Insight from a Multidisciplinary Expert Panel

Adequate nutrition is an essential factor in healing and immune support in pediatric patients undergoing surgery, but its importance in this setting is not consistently recognized. Standardized institutional nutrition protocols are rarely available, and some clinicians may be unaware of the importance of assessing and optimizing nutritional status. Moreover, some clinicians may be unaware of updated recommendations that call for limited perioperative fasting. Enhanced recovery protocols have been used in adult patients undergoing surgery to ensure consistent attention to nutrition and other support strategies in adult patients before and after surgery, and these are now under evaluation for use in pediatric patients as well. To support better adoption of ideal nutrition delivery, a multidisciplinary panel of experts in the fields of pediatric anesthesiology, surgery, gastroenterology, cardiology, nutrition, and research have gathered and reviewed current evidence and best practices to support nutrition goals in this setting.

Malnutrition among Hospitalized Children in the United States: A 2012-2019 Update of Annual Trends

BACKGROUND

Malnutrition is associated with adverse clinical outcomes and increased health care utilization for hospitalized children. Yet pediatric malnutrition often goes undiagnosed and national prevalence research in this population is scarce.

OBJECTIVE

The aim was to assess change in the coded diagnosis of malnutrition (CDM) among US hospitalized children given increased awareness of the need for improved recognition and standardized diagnosis.

DESIGN

Retrospective, cross-sectional analysis using nationally representative data from the Nationwide Inpatient Sample.

PARTICIPANTS/SETTING

Our sample was 13.2 million hospitalizations from 2012 to 2019 among pediatric patients between age 1 month and 17 years.

MAIN OUTCOME MEASURE

CDM using International Classification of Diseases Ninth and 10th Revision-Clinical Modification diagnosis codes.

STATISTICAL ANALYSES

Descriptive statistics and sampling weights were used to estimate the national frequency and prevalence of CDM. Temporal trends in CDM overall and stratified by age, race/ethnicity, and hospital type were analyzed using joinpoint regression.

RESULTS

CDM prevalence increased from 3.9% in 2012 to 6.4% in 2019. During this period, failure to thrive decreased from 40.6% to 23.3% of all cases with concomitant increases in the diagnosis of protein-calorie malnutrition and children identified with more than one malnutrition subtype. Differences in CDM diagnoses are evident by hospital type, race/ethnicity, and age of the patient.

CONCLUSIONS

Although pediatric malnutrition continues to be underdiagnosed in hospital settings, this study demonstrates improvement over time. There continues to be a need for continued professional education regarding best practices for diagnosis to improve health care provider knowledge and self-efficacy on this topic, especially in nonteaching hospitals.

Are We Ready for a New Approach to Comparing Coverage and Reimbursement Policies for Medical Nutrition in Key Markets: An ISPOR Special Interest Group Report

OBJECTIVES

Healthcare policy makers should ensure optimal patient access to medical nutrition (MN) as part of the management of nutrition-related disorders and conditions. Questions remain whether current healthcare policies reflect the clinical and economic benefits of MN. The objective of this article is to characterize coverage and reimbursement of MN, defined as food for special medical purposes/medical food for a diverse set of countries, including Australia, Belgium, Brazil, Canada, China, France, Germany, Hong Kong, Italy, Japan, The Netherlands, Singapore, Spain, United Kingdom, and United States.

METHODS

Data sources included published literature and online sources. ISPOR's Nutrition Economics Special Interest Group developed a data collection form to guide data extraction that included reimbursement coverage, years that reimbursement policies were established, and presence of a formal health technology assessment (HTA) for MN technologies.

RESULTS

Reimbursement coverage of MN technologies varied across the countries that were reviewed. All but 3 countries limited coverage to specific formulations of products, regardless of demonstrated clinical benefit. The year that reimbursement policies were established varied across countries (ranging from 1984 to 2017), and only 4 countries regularly update policies. France and Brazil are the only countries with a formal HTA process for MN technologies.

CONCLUSIONS

Most countries have limited MN reimbursement, have not updated reimbursement policies, and lack HTA for MN technologies. These limitations may lead to suboptimal access to MN technologies where they are indicated to manage nutrition-related disorders and conditions, with the potential of negatively affecting patient and healthcare system outcomes.

Malnutrition identification and management variability: An administrative database study of children with solid tumors

Background

Malnutrition during cancer treatment increases treatment‐related morbidity and mortality. Our study better characterizes variability in malnutrition identification and treatment by examining nutrition‐related diagnoses and support for children with central nervous system (CNS) and non‐CNS solid tumors during therapy. We examined diagnosis of malnutrition, use of tube feeding or parenteral nutrition (PN), and appetite stimulants.

Methods

We retrospectively reviewed 0 to 21‐year‐old patients in the Pediatric Health Information System from 2015 to 2019. Patients were classified as having (1) billed malnutrition diagnosis, (2) malnutrition diagnosis or using PN and enteral nutrition (“functional malnutrition”), and (3) any previous criteria or prescribed appetite stimulants (“possible malnutrition”), as well as associated risk factors.

Results

Among 13,375 unique patients, CNS tumors were most common (24.4%). Overall, 26.5% of patients had malnutrition diagnoses, 45.4% met functional malnutrition criteria, and 56.0% had possible malnutrition. Patients with adrenal tumors had highest billed, functional, and possible malnutrition (36.6%, 64.1%, and 69.4%, respectively) followed by CNS tumors (29.1%, 52.4%, and 64.1%). Patients with adrenal tumors had highest rates of PN use (47.4%) and those with CNS tumors had the highest tube feeding use (26.8%). Hospital admissions with malnutrition had a longer hospital length of stay (LOS) (6 vs 3 days, P < 0.0001), more emergency department admissions (24.4% vs 21.8%, P < 0.0001), and more opioid use (58.6% vs 41.4%, P < 0.0001).

Conclusions

Variability in malnutrition diagnoses hinders clinical care and nutrition research in pediatric oncology. Improving disease‐specific recognition and treatment of malnutrition can target nutrition support, ensure appropriate reimbursement, and potentially improve outcomes for children with solid tumors.

Update on use of enteral and parenteral nutrition in hospitalized patients with a diagnosis of malnutrition in the United States

BACKGROUND

Malnutrition continues to be associated with outcomes in hospitalized patients.

METHODS

An updated review of national data in patients with a coded diagnosis of malnutrition (CDM) and the use of nutrition support (enteral nutrition [EN] and parenteral nutrition [PN]) was conducted using the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project and Medicare Claims data.

RESULTS

Results demonstrated a growing trend in CDM accompanied by continued low utilization of PN and EN.

CONCLUSION

Underutilization of nutrition support may be due to product shortages, reluctance of clinicians to use these therapies, undercoding of nutrition support, strict adherence to published guidelines, and other factors.

Malnutrition diagnoses and associated outcomes in hospitalized patients: United States, 2018

In the US, malnutrition is prevalent among hospitalized patients and is associated with higher morbidity, mortality, and healthcare costs when compared with those without malnutrition. Over time, national data have indicated the rate of coded malnutrition diagnoses among hospital discharges rising over time, and more current data on demographic and clinical characteristics of these patients are needed. Data on malnutrition discharges from the 2018 Healthcare Cost and Utilization Project (HCUP)-the most recent nationally representative data-were examined and compared with earlier HCUP findings. Based on International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes, 8.9% of all US non-maternal, non-neonatal hospital discharges in 2018 had a coded diagnosis of malnutrition (CDM). From this 2018 data, those with a CDM were older, had longer lengths of stay, and incurred higher costs, as compared with those without a CDM. Higher readmission rates and higher inpatient mortality were also observed in this group. These findings provide more recent demographic and clinical evidence for standardized malnutrition diagnostic and interventional programs to treat and/or prevent this condition.

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.

Undernutrition and Obesity Are Associated with Adverse Clinical Outcomes in Hospitalized Children and Adolescents with Acute Pancreatitis

Background: Adult studies demonstrated that extremes of nutritional status adversely impact clinical outcomes in acute pancreatitis (AP). With rising prevalence of undernutrition/obesity in children, we analyzed the effect of nutritional status on the clinical outcomes in children and adolescents with acute pancreatitis. Methodology: We analyzed the Kids’ Inpatient Database (KID) between 2003 and 2016 to include all patients with a primary diagnosis of AP using specific International Classification of Diseases (ICD) codes. We classified into (1) undernutrition, (2) obesity and (3) control groups, based on ICD codes, and we compared severe acute pancreatitis and healthcare utilization (length of stay and hospitalization costs). Results: Total number of AP admissions was 39,805. The prevalence of severe AP was higher in the undernutrition and obesity groups than the control group (15.7% vs. 5.8% vs. 3.5% respectively, p < 0.001). Multivariate analyses demonstrated that undernutrition and obesity were associated with 2.5 and 1.6 times increased risk of severe AP, p < 0.001. Undernutrition was associated with an additional six days of hospitalization and almost $16,000 in hospitalization costs. Obesity was associated with an additional 0.5 day and almost $2000 in hospitalization costs, p < 0.001. Conclusion: Undernutrition and obesity were associated with greater severity of AP, as well as prolonged hospitalization stay and costs. It is imperative for treating clinicians to be aware of these high-risk groups to tailor management and strive for improved outcomes.

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.

General practitioners' practices for malnutrition screening in paediatric populations: a survey in one French department

BACKGROUND

Malnutrition remains a public health problem in Europe, not only in adults, but also in paediatrics. The aim of this study was to evaluate general practitioners (GPs) practices in paediatric malnutrition screening.

METHODS

An anonymised questionnaire was sent to GPs in one French area. We analysed GPs' data: sociodemographic, knowledge of malnutrition screening, practices, tools, and trainings.

RESULTS

Overall, 102 of 174 GPs replied to the questionnaire (58.6%). 79.4% of GPs routinely measured weight, but only 33.3% measured both height and BMI, despite having tools (98,6%). 43.6% of GPs systematically reviewed growth charts. 71.3% were familiar with dietary recommendations, 30.7% with blood tests for nutritional status assessment, and 13.7% with dietary supplements. GPs who routinely measured BMI reviewed significantly more growth charts (p = 0.001) and prescribed more dietary supplements (p = 0.001).

CONCLUSIONS

GPs do not sufficiently measure children's height and BMI, despite the increasing availability of software. Failure to analyse growth charts can induce delays in malnutrition screening.

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.

NASPGHAN Nutrition University (N2U): A Survey of its Efficacy as Continuing Nutrition Education for North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition

The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) developed NASPGHAN Nutrition University (N2U) in 2012 to improve nutrition education for pediatric gastroenterology providers. A total of 543 providers (physicians, registered dietitians, and advanced practice nurses) have applied to N2U and 285 have attended this 2-day course. We used survey methodology to compare attendees to applicants who did not attend. Course attendees reported more confidence than nonattendees in the nutritional management of patients with short bowel syndrome, feeding disorders, and gastrointestinal allergies, even though they were seen at similar frequency in both groups. Eighty-eight percent of attendees disseminated the information they learned at N2U through venues such as grand rounds or guideline/policy development. These results demonstrate the benefit of N2U in enhancing nutrition education for pediatric gastroenterology practitioners.

Prevalence, trends, and correlates of malnutrition among hospitalized children with cerebral palsy

AIM

This cross-sectional study characterized the prevalence, trends, sociodemographic factors, and clinical factors that are associated with a coded diagnosis of malnutrition (CDM) among hospitalized children with cerebral palsy (CP) in the USA.

METHOD

We used data from the 2002 to 2015 National Inpatient Sample database and restricted the analysis to hospitalized children with CP between 2 and 17 years of age. International Classification of Diseases, Ninth Edition, Clinical Modification diagnosis codes for CP, malnutrition, and comorbidities associated with CP were used to characterize hospitalizations for this population. Logistic regression models were conducted to identify the sociodemographic factors and comorbidities associated with a diagnosis of malnutrition.

RESULTS

The average documented rate of CDM among hospitalized children with CP was 7.9% and nearly doubled during the study period. The model suggests that younger age, non-white ethnicity, lower income, and non-private insurance/payer status were associated with increased odds of documented malnutrition. Concomitant inpatient diagnoses of epilepsy, dysphagia, scoliosis, reflux, and constipation were associated with higher rates of CDM.

INTERPRETATION

The rate of CDM in hospitalized patients with CP is well under the estimated clinical prevalence of 30% to 40%. Multiple sociodemographic, hospital, and clinical factors are associated with higher rates of CDM.

WHAT THIS PAPER ADDS

The documented rate of malnutrition in hospitalized children with cerebral palsy (CP) averaged 7.9% yearly. For hospitalized children with CP, documentation of malnutrition nearly doubled between 2002 and 2015. Economically disadvantaged and minority ethnic groups had a greater likelihood of malnutrition documentation. Inpatient malnutrition documentation was more likely with some comorbidities indicative of greater impairments. Gastrointestinal disorders increased the likelihood of an inpatient-documented diagnosis of malnutrition.

Examining Mid-Upper Arm Circumference Malnutrition z-Score Thresholds

BACKGROUND

Anthropometric z-scores used commonly for diagnosis and determining degree of malnutrition, specifically body mass index (BMIz), weight-for-length (WLz), and mid-upper arm circumference (MUACz), are not wholly concordant, yet the proposed thresholds for classification are identical. This study was designed to critically examine MUACz thresholds and their ability to correctly classify nutrition status.

METHODS

This was a 2-year, prospective single-center study of children ≤18 years seen by registered dietitians within a large pediatric institution. The sensitivity, specificity, and predictive performance of the malnutrition classification thresholds were estimated against clinician-based classification.

RESULTS

Sixty-one dietitians enrolled 10,401 patients with distributions of z-scores for weight (-0.5 ± 1.9), length (-0.8 ± 1.6), BMI or WL (-0.1 ± 1.8), and MUAC (-0.4 ± 1.5), suggesting participants were smaller and shorter than the reference U.S.

POPULATION

Distributions of MUACz were broad and overlapped between nutrition classification groups, an observation that extended to BMIz and WLz as well. Consequently, existing thresholds do not accurately classify 100% of children. Misclassification rates increase, with increasing severity ranging from 8% in children with no malnutrition to 71% in children with severe malnutrition. Algorithm- and manually-based refinement of thresholds result in mixed improvements and can be explored by the reader with the associated supplement.

CONCLUSION

The sensitivity of proposed MUACz thresholds systematically decreases with increasing severity of malnutrition and will require optimization if we aim to limit the number of children at risk of misclassification. Indicators for overnutrition remain to be addressed but are explored herein.

STRONGkids: Predictive Validation in Brazilian Children

OBJECTIVES

The aim of the study is to assess STRONGkids as a tool for predicting weight loss and length of hospital stay in children and to determine whether the anthropometric diagnosis of nutritional status at the time of admission was associated with weight loss and length of hospital stay.

METHODS

A methodological study recruiting 245 children age between 1 and 10 years of age admitted to a tertiary hospital. The participants were weighed daily until discharge. Validation of the STRONGkids tool for the identification of patients sustaining weight loss at the end of hospitalization involved the calculation of sensitivity, specificity, and positive and negative predictive values, and anthropometric assessment.

RESULTS

A total of 129 (52.7%) children lost weight at the end of hospitalization. Of these, 73 (56.6%) lost over 2% of their weight on admission. The tool had a sensitivity of 55.8%, a specificity of 38.8% and a positive predictive value of 50.3% in identifying children who lost weight. The anthropometric assessment had a sensitivity of 26.5%, a specificity of 75.9%, and a positive predictive value of 49.1%.

CONCLUSIONS

The model used to develop the STRONGkids tool incorporated clinical evaluation to a greater extent than the assessment of nutritional status. The tool, however, had a low sensitivity and a high percentage of false positives. Therefore, it should be considered as a preliminary evaluation tool and its use should be complemented with clinical data.