Hospital-acquired malnutrition in children with mild clinical conditions

Development of the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC) using a modified Delphi technique

One in three hospitalized children have disease-related malnutrition (DRM) upon admission to hospital, and all children are at risk for further nutritional deterioration during hospital stay; however, systematic approaches to detect DRM in Canada are lacking. To standardise and improve hospital care, the multidisciplinary pediatric working group of the Canadian Malnutrition Taskforce aimed to develop a pediatric, inpatient nutritional care pathway based on available evidence, feasibility of resources, and expert consensus. The working group (n = 13) undertook a total of four meetings: an in-person meeting to draft the pathway based on existing literature and modelled after the Integrated Nutrition Pathway for Acute Care (INPAC) in adults, followed by three online surveys and three rounds of online Delphi consensus meetings to achieve agreement on the draft pathway. In the first Delphi survey, 32 questions were asked, whereas in the second and third rounds 27 and 8 questions were asked, respectively. Consensus was defined as any question/issue in which at least 80% agreed. The modified Delphi process allowed the development of an evidence-informed, consensus-based pathway for inpatients, the Pediatric Integrated Nutrition Pathway for Acute Care (P-INPAC). It includes screening <24 h of admission, assessment with use of Subjective Global Nutritional Assessment (SGNA) <48 h of admission, as well as prevention, and treatment of DRM divided into standard, advanced, and specialized nutrition care plans. Research is necessary to explore feasibility of implementation and evaluate the effectiveness by integrating P-INPAC into clinical practice.

Prospective evaluation and follow-up of nutritional status of children hospitalized in secondary-care level hospitals: a multicentre study

Although disease-associated undernutrition is still an important problem in hospitalized children that is often underrecognized, follow-up studies evaluating post-discharge nutritional status of children with undernutrition are lacking. The aim of this multicentre prospective observational cohort study was to assess the rate of acute undernutrition (AU) and/or having a high nutritional risk (HR) in children on admission to seven secondary-care level Dutch hospitals and to evaluate the nutritional course of AU/HR group during admission and post-discharge. STRONGkids was used to indicate HR, and AU was based on anthropometric data (z-score < -2 for weight-for-age (WFA; <1 year) or weight-for-height (WFH; ≥1 year)). In total, 1985 patients were screened for AU/HR over a 12-month period. On admission, AU was present in 9.9% of screened children and 6.2% were classified as HR; 266 (13.4%) children comprised the AU/HR group (median age 2.4 years, median length of stay 3 days). In this group, further nutritional assessment by a dietitian during hospitalization occurred in 44% of children, whereas 38% received nutritional support. At follow-up 4-8 weeks post-discharge, 101 out of orginal 266 children in the AU/HR group (38%) had available paired anthropometric measurements to re-assess nutrition status. Significant improvement of WFA/WFH compared to admission (-2.48 vs. -1.51 SD; p < 0.001) and significant decline in AU rate from admission to outpatient follow-up (69.3% vs. 35.6%; p < 0.001) were shown. In conclusion, post-discharge nutritional status of children with undernutrition and/or high nutritional risk on admission to secondary-care level pediatric wards showed significant improvement, but about one-third remained undernourished. Findings warrant the need for a tailored post-discharge nutritional follow-up.

Evaluation of an electronic medical record-based Paediatric Nutrition Screening Tool

BACKGROUND

Nutrition screening is recommended to identify children at risk for malnutrition. A unique screening tool was developed based on American Society for Parenteral and Enteral Nutrition (ASPEN) recommendations and embedded in the electronic medical record to assess for nutrition risk.

METHODS

The components of the tool included the Paediatric Nutrition Screening Tool (PNST) and other elements recommended by ASPEN. To evaluate the screening tool, retrospective data were analysed on all patients admitted to acute care units of Children's Wisconsin in 2019. Data collected included nutrition screen results, diagnosis and nutrition status. All patients who received at least one full nutrition assessment by a registered dietitian (RD) were included in analysis.

RESULTS

One thousand five hundred seventy-five patients were included in analysis. The following screen elements were significantly associated with a diagnosis of malnutrition: any positive screen (p < 0.001), >2 food allergies (p = 0.009), intubation (p < 0.001), parenteral nutrition (p = 0.005), RD-identified risk (p < 0.001), positive risk per the PNST (p < 0.001), BMI-for-age or weight-for-length z-score (p < 0.001), intake <50% for 3 days (p = 0.012) and NPO > 3 days (p = 0.009). The current screen had a sensitivity of 93.9%, specificity of 20.3%, positive predictive value (PPV) of 30.9% and negative predictive value (NPV) of 89.8%. This is compared with the PNST which had a sensitivity of 32%, specificity of 94.2%, PPV of 71% and NPV of 75.8% in this study population.

CONCLUSION

This unique screening tool is useful for predicting nutrition risk and has a greater sensitivity than the PNST alone.

The Neutrophil-to-Lymphocyte Ratio (NLR) Can Predict Sepsis's Presence and Severity in Malnourished Infants-A Single Center Experience

Sepsis represents one of the leading causes of death in newborns and infants, and prompt diagnosis is essential for achieving favorable outcomes. Regarding malnourished children with concurrent infection, most studies have focused, besides blood culture, on C-reactive protein and procalcitonin. Because malnutrition has a deleterious effect on cellular immune competence, the present study characterized the acute-phase response, including hematological indices, in response to sepsis. Among the examined laboratory biomarkers, procalcitonin and neutrophil-to-lymphocyte ratio were the most accurate discriminators between sepsis patients and those with bacterial infection. Moreover, these two parameters showed a gradual increase between sepsis, severe sepsis, and septic shock patients (p < 0.001). Subgroup analysis of the sepsis group revealed positive correlations of NLR with prolonged ICU stay (<0.001), acute organ dysfunction (0.038), mechanical ventilation (<0.001), and fatality (<0.001). In summary, our results suggest that the neutrophil-to-lymphocyte ratio can be used as an auxiliary diagnostic index in discriminating the presence and severity of bacterial sepsis in malnourished infants.

Nutritional Risk and Malnutrition in Paediatrics: From Anthropometric Assessment to Strongkids® Screening Tool

INTRODUCTION

The prevalence of malnutrition in hospitalized children is high and is associated with negative health impact. The aim of this study was to characterize the nutritional status of hospitalized children as well as comparing nutritional risk stratification using the STRONGkids® tool and anthropometric assessment.

MATERIAL AND METHODS

A prospective study was conducted between March and June 2019 in a paediatric unit of a district hospital. Children with ages between one month and 17 years were included. Nutritional screening (STRONGkids®) was performed, and demographic and anthropometric variables were assessed by trained doctors and nurses (z-scores for height-for-age, weight-for-age, weight-for-height and body mass index were compared to the World Health Organization reference values) and related to the underlying condition (cause of hospitalization; hospital stay; the presence of chronic disease).

RESULTS

A total of 209 children were evaluated, 188 of whom were included. Median age was 4.6 years and median hospital length of stay was four days. Fifty-four per cent were classified with "moderate risk" and 2% with "high risk" of developing malnutrition; 25% were effectively malnourished. Of the 105 children for which it was possible to calculate the z-scores, 6% presented acute malnutrition and nearly 14% presented chronic malnutrition. The STRONGkids® score correlated positively with nutritional status on admission, disease type on admission, and presence of previous underlying disease (p < 0.05).

CONCLUSION

STRONGkids® is a simple, quick nutritional screening tool for hospitalized children that is related to nutritional status on admission. Given that a considerably high percentage of children were identified as being at risk for malnutrition, it is essential to identify this early and provide nutritional intervention during hospitalization.

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.

A Practical Approach to Identifying Pediatric Disease-Associated Undernutrition: A Position Statement from the ESPGHAN Special Interest Group on Clinical Malnutrition

ABSTRACT

Disease-associated undernutrition (DAU) is still common in hospitalized children and is generally accepted to be associated with adverse effects on disease outcomes; hence making proper identification and assessment essential in the management of the sick child. There are however several barriers to routine screening, assessment, and treatment of sick children with poor nutritional status or DAU, including limited resources, lack of nutritional awareness, and lack of agreed nutrition policies. We recommend all pediatric facilities to 1) implement procedures for identification of children with (risk of) DAU, including nutritional screening, criteria for further assessment to establish diagnosis of DAU, and follow-up, 2) assess weight and height in all children asa minimum, and 3) have the opportunity for children at risk to be assessed by a hospital dietitian. An updated descriptive definition of pediatric DAU is proposed as "Undernutrition is a condition resulting from imbalanced nutrition or abnormal utilization of nutrients which causes clinically meaningful adverse effects on tissue function and/or body size/composition with subsequent impact on health outcomes." To facilitate comparison of undernutrition data, it is advised that in addition to commonly used criteria for undernutrition such as z score < -2 for weight-for-age, weight-for-length, or body mass index <-2, an unintentional decline of >1inthese z scores over time should be considered as an indicator requiring further assessment to establish DAU diagnosis. Since the etiology of DAU is multifactorial, clinical evaluation and anthropometry should ideally be complemented by measurements of body composition, assessment of nutritional intake, requirements, and losses, and considering disease specific factors.

Hospital-acquired malnutrition in paediatric patients: a multicentre trial focusing on prevalence, risk factors, and impact on clinical outcomes

Alteration of nutrient metabolism during hospital stay may cause a deterioration in patients' nutritional status. The aim of this study was to determine the prevalence and possible risk factors for nutritional deterioration in hospitalized children. A multicentre prospective study was conducted among the patients aged 1 month to 18 years in tertiary-care hospitals, between December 2018 and May 2019. Demographic data, illness, and nutritional assessment on the first and the last day of admission were collected. There were 623 patients enrolled in this study with the median age of 4.3 years. Two thirds of the patients had at least one underlying disease. Eighty-eight percent of the patients were admitted with mild medical conditions including a scheduled cycle of chemotherapy or immunosuppressive drugs, minor infection, and non-invasive procedures. The prevalence of nutritional deterioration (reduction in body mass index ≥ 0.25 Z-score) was 24% and was associated with a significantly higher rate of nosocomial infection (24% vs. 11%, p < 0.001) compared to patients without hospital-acquired malnutrition. Risk factors included moderate to severe medical conditions (AOR 1.90, 95% CI 1.09-3.31, p = 0.024), pneumonia (AOR 1.85, 95% CI 1.05-3.28, p = 0.034), seizure (AOR 2.82, 95% CI 1.28-6.19, p = 0.01), and surgery (AOR 2.98, 95% CI 1.60-5.56, p = 0.001). Nutritional management showed a significant reduction in the incidence of hospital-acquired malnutrition and a trend towards a 60% decrease in infectious complications in patients with moderate to severe medical conditions.Conclusions: Approximately one fourth of paediatric patients developed malnutrition during hospitalization. Nutritional screening, assessment, and treatment should be implemented to improve the outcomes of hospitalized paediatric patients. What is Known: • Malnutrition at admission has a negative impact on outcomes of patients, including prolonged hospitalization, increased costs of care, and a higher rate of nosocomial infection. What is New: • Hospital-acquired malnutrition can occur regardless of prior nutritional status and is predominantly related to illness severity. • Malnourished patients with nutritional intervention experience an improvement in their nutritional status as well as a lower risk of developing hospital morbidity during hospitalization.

G, B.K. S. Impact of COVID-19 on the mental health among children in China with specific reference to emotional and behavioral disorders

Purpose

This paper aims to investigate impact of coronavirus COVID-19 on children’s mental health specifically emotional and behavioral disorders. It aims at identifying the main disorders faced by children during epidemics and suggests recommendations to nurture resilience among children and involving them in various positive activities.

Design/methodology/approach

This study is based on review of literature focused on COVID-19. Recent articles related to coronavirus or COVID-19 and psychological distress among children were included to draw conclusion and impact of COVID-19 on mental health of children. Due to the limited availability of studies on CONID-19 impact on mental health of children, studies focused on recent pandemic were focused.

Findings

The identified literature reports a negative impact of COVID-19 on individual’s mental health. Relatives’ health, poor appetite, fear of asking questions about epidemics, agitation, clinginess, physical discomfort, nightmares and poor sleep, inattention and separation issues were among the major psychological conditions analyzed. Personal attributes such as resilience, should be nurtured so that children will be empowered to manage difficult situations such as traumas and disappointments. Several measures were suggested by pediatricians in China to family members and parents such as playing games with children to reduce feeling of loneliness, increased communication to address their concerns and fears, promoting and encouraging physical activities and involving in musical activities to reduce fear, worry and stress among children.

Originality/value

Coronavirus is new pandemic and growing rapidly. most of the research studies are focused on physical health of individuals, but mental health concept has bene overlooked. This study helps to broaden the scope of research on children's mental health by examining the impact of COVID-19.

Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) in the Electronic Health Record: A Validation Study

BACKGROUND

The impact of malnutrition on pediatric patients in the acute care setting is significant. Hospitalized patients with malnutrition have been shown to have poor clinical outcomes. Nutrition screening is the first critical step in identifying and treating malnutrition. Although several pediatric nutrition screening tools exist, none incorporate both electronic health record (EHR) compatibility and the recommended indicators of pediatric malnutrition, a gap recently identified in a systematic review by the Academy of Nutrition and Dietetics. The aim of this study was to prove the validity of a new version of Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), EHR-STAMP, modified for incorporation into the EHR and inclusion of updated pediatric malnutrition indicators.

METHODS

An interprofessional team modified the existing STAMP for integration into the EHR. Audits were performed by the research dietitian to assess accuracy and provide feedback for continuous improvement of the tool design.

RESULTS

A total of 3553 pediatric inpatients were studied from August 2017 to May 2019. Accuracy, sensitivity, and specificity improved with each modification to the EHR-STAMP. The final version of the EHR-STAMP found 85% accuracy, 89% sensitivity, and 97% specificity, with a positive predictive value of 60% and a negative predictive value of 94%.

CONCLUSION

The EHR-STAMP is a highly reliable tool in the screening of nutrition risk for pediatric hospitalized patients. The tool is easy to use, EHR compatible, and incorporates the current indicators recommended for assessing pediatric malnutrition.

Statistical Risk Characteristics and Risk Scoring of Hospital-Acquired Malnutrition for Pediatric Patients

Background

Malnutrition is a global health problem and challenge for every country. It may occur in any form and affect all levels of age including children. We pay particular attention to the so-called hospital-acquired malnutrition (HaM) for pediatric patients. Our aim was to explore statistical risk factors or characteristics as well as to forecast risk scoring for such malnutrition.

Methods

This study employed a cross-sectional design involving children from 1 month to 18 years of age who were hospitalized for at least 72 hours. We used secondary data from 308 medical records of pediatric patients who were admitted to the hospital in 2017. We excluded the data if the patient had tumors or organomegaly, fluid retention, and dehydration. HaM was determined based on a weight loss each day during hospitalization until the day of discharge. Statistical data analysis is carried out for both descriptive and inferential statistics. Our predictive model is yielded by linear regression, and risk scoring is obtained through logistic regression.

Results

The findings showed several risk factors or characteristics for HaM prevalence: sex, age, medical diagnosis, diet, nutrition route, and NEWS score. The early warning system to pediatric patients is conducted by calculating malnutrition-at-risk in which a value beyond 100.5 is considered as having high potential risk for HaM.

Conclusion

Nurses are expected to monitor pediatric patients' condition, including measuring the anthropometry regularly, in order to identify the initial signs of HaM.

Validity and reliability analysis of the Turkish version of pediatric nutritional risk score scale

BACKGROUND/AIMS

We aimed to perform the validity and reliability analysis of the Turkish version of the Pediatric Nutritional Risk Score (PNRS).

MATERIALS AND METHODS

The study group consisted of 149 patients aged between 1 month and 18 years who were admitted to the hospital for at least 48 h. The patients' age, gender, anthropometric measurements, length of stay, admission diagnosis, daily body weights, food consumption, and pain status were recorded. Backward and forward translations into Turkish were done. PNRS was performed by two different physicians. The consistency of the PNRS results was evaluated to determine the validity of PNRS. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated.

RESULTS

Of all patients, 69 (46.3%) were female and 80 (53.7%) were male. The mean length of the stay was 7.3±4.0 days. The mean age of the patients was 51.9±63.6 months. The Kappa coefficient between the two physicians was 0.66. Weight loss was observed in 65.2% of the patients in the high-risk group and 25.4% in the low-risk group. The hospital malnutrition rate was 31.5%. A higher risk was identified in those with <50% food intake and more severe disease. The specificity, sensitivity, NPV, and PPV of PNRS were 82.1%, 77.8%, 92.0%, and 58.3%, respectively.

CONCLUSION

A good consistency suggests that the Turkish validation was achieved successfully. The power of PNRS to discriminate the patients with moderate-low risk of developing malnutrition is higher than the patients with high risk. PNRS is considered a valid and reliable tool to establish the risk of malnutrition in the hospitalized patients.

Preoperative and operation-related risk factors for postoperative nosocomial infections in pediatric patients: A retrospective cohort study

Background

Pediatric patients undergoing invasive operations bear extra risk of developing nosocomial infections (NIs). However, epidemiological evidence of the underlying risk factors, which is needed for early prevention, remains limited.

Methods

Using data from the electronic medical records and the NI reporting system of a tertiary pediatric hospital, we conducted a retrospective analysis to identify preoperative and operation-related risk factors for postoperative NIs. Multivariable accelerated failure time models were fitted to select independent risk factors. The performance of these factors in risk stratification was examined by comparing the empirical risks between the model-defined low- and high-risk groups.

Results

A total of 18,314 children undergoing invasive operations were included for analysis. After a follow-up period of 154,700 patient-days, 847 postoperative NIs were diagnosed. The highest postoperative NI rate was observed for operations on hemic and lymphatic system. Surgical site infections were the NI type showing the highest overall risk; however, patients were more likely to develop urinary tract infections in the first postoperative week. Older age, higher weight-for-height z-score, longer preoperative ICU stay, preoperative enteral nutrition, same-day antibiotic prophylaxis, and higher hemoglobin level were associated with delayed occurrence of postoperative NIs, while longer preoperative hospitalization, longer operative duration, and higher American Society of Anesthesiologists score showed acceleration effects. Risk stratification based on these factors in an independent patient population was moderate, resulting in a high-risk group in which 72% of the postoperative NIs were included.

Conclusions

Our findings suggest that pediatric patients undergoing invasive operations and at high risk of developing postoperative NIs are likely to be identified using basic preoperative and operation-related risk factors, which together might lead to moderately accurate risk stratification but still provide valuable information to guide early and judicious prevention.

Barriers to Oral Food Intake for Children Admitted to Hospital

Children are at risk for malnutrition in hospital, and a contributing factor may be poor oral intake. Barriers to intake have been studied in adults, but there is a lack of research in children. The purpose of this study was to identify the potential barriers to oral intake for children in hospital. Patients and families (n = 58) admitted to surgery and medicine units at the Stollery Children’s Hospital completed a survey on barriers to oral food intake. Barriers were classified into 6 domains and major barriers were those identified by at least 30% of the population. On average each patient was affected by 22% of the barriers. Within each domain, the proportion of patients identifying at least 1 barrier was as follows: organization (74%), hunger (67%), quality (60%), effects of illness (53%), choice (38%), and physical limitations (29%). Having food brought in from home due to hunger, not wanting what was ordered once it arrives, food quality, decreased appetite, sickness, fatigue, and pain were identified as major barriers. Children have unique barriers to oral food intake in hospital which have not been previously identified. Food service models should consider these barriers to better meet the needs of this population.

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.

Screening and assessment tools for early detection of malnutrition in hospitalised children: a systematic review of validation studies

OBJECTIVE

The aim of the present study was to identify all currently available screening and assessment tools for detection of malnutrition in hospitalised children, and to identify the most useful tools on the basis of published validation studies.

DESIGN

Systematic review.

DATA SOURCES

PubMed, CINAHL and MEDLINE were searched up to October 2017.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Studies in English that reported sensitivity, specificity and positive/negative predictive values (PPVs/NPVs) in the paediatric population were eligible for inclusion.

DATA EXTRACTION AND SYNTHESIS

Two authors independently screened all of the studies identified, and extracted the data. The methodological qualities of the studies included were assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool.

RESULTS

The 26 validation studies that met the inclusion criteria for this systematic review used eight screening and three assessment tools. The number of participants varied from 32 to 14 477. There was considerable variability in the chosen reference standards, which prevented direct comparisons of the predictive performances of the tools. Anthropometric measurements were used as reference standards in 16 of the identified studies, and full nutritional assessment in 5. The Pediatric Yorkhill Malnutrition Score (PYMS) screening tool performed better than Screening Tool for the Assessment of Malnutrition and Screening Tool for Risk On Nutritional status and Growth when compared in terms of anthropometric measurements, especially for body mass index (Se=90.9, Sp=81.9) and triceps skinfold thickness (Se=80.0, Sp=75.0). However, low PPVs indicated the problem of overprediction of positive cases, which was typical for all of the studies that used anthropometric measurements as the reference standard.

CONCLUSIONS

This systematic review identifies the need for definition of the gold standard for validation of screening tools. Anthropometry measurements using WHO or Centers for Disease Control and Prevention growth charts should be considered as the possible reference standard in future validation studies. We would recommend the use of PYMS for hospitalised paediatric patients without chronic conditions, in combination with full nutritional assessment.

PROSPERO REGISTRATION NUMBER

CRD42017077477.

Validation and impact of paediatric malnutrition screening tool in hospitalised children on awareness of medical staff and health-related outcomes

AIMS

This study aimed to evaluate the use of the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) among children admitted in a paediatric hospital, and assess its impact on the nutritional status awareness among the medical staff and on health outcomes at discharge.

METHODS

STAMP performed by nurses on admission was compared with full nutritional assessment performed by a dietitian. Area under the receiving operating characteristic (AUROC) curve was used to evaluate validity of the tool. To assess how the tool affected awareness among the staff, information on nutritional status was compared prior to and following the intervention period. Therewith, health outcomes at discharge were compared for the children who had been screened by STAMP and the children who had not.

RESULTS

The analysis was performed for a total of 60 children (38 boys, 63%). The mean age was 7.8 ± 4.7 years. Malnutrition was found in 16% of patients, segregating equally between acute and chronic malnutrition. Sensitivity, specificity, positive predictive value and negative predictive value were 95.7% (95% confidence interval, CI = 85.75-98.83%), 76.9% (95% CI = 49.74-91.82%), 93.7 and 83.3, respectively. AUROC was 0.863 (95% CI = 0.72-1). There was no difference either in malnutrition awareness among the medical staff before and after the intervention period or in health outcomes at discharge.

CONCLUSIONS

STAMP is a valid tool for malnutrition screening in hospitalised children; however, its use does not influence admitted patients' nutritional status awareness among the medical staff nor their outcomes at discharge.

Malnutrition and medical nutrition therapy in hospitalized children: a case study of using national malnutrition screening tools in northeastern Iran

Background

Nationwide studies have focused only on prevalence of malnutrition in hospitalized children, while medical nutrition therapies and assessing nutritional interventions is neglected.

Methods

This research was conducted in tertiary level children hospitals in the NorthEastern region of Iran for 1 year from 2016 to 2017. Five questions were included in the initial assessment form and, if there was even one positive response, nutritional interventions were prescribed for the patients.

Results

A total of 65 children aged ≥ 5 years and hospitalized for ≥ two days were included. 24.6% of patients had 2 >BMI Z-score>-2 at time of admission. At the beginning of the study, weight loss more than 10%, and appetite loss or decreased food intake was observed in 10.8% and 20% of the study population, respectively. Median BMI percentile of patients with nutritional intervention was 8.9 (0.1–98.7) at the beginning of the study and 12.7 (0.1–98.4) at discharge time which shows a significant difference (P=0.01).

Conclusion

Medical nutrition therapy employed in this study prevented deterioration of nutritional status of children during hospitalization and was effective in stabilizing indices of nutritional status.

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.

Evaluation of malnutrition development risk in hospitalized children

OBJECTIVES

Many screening methods, such as the Screening Tool Risk on Nutritional Status and Growth (STRONGkids) and the Pediatric Yorkhill Malnutrition Score (PYMS), have been developed to detect malnutrition in pediatric patients. We aimed to explore the prevalence of malnutrition risk in hospitalized children via symptoms and identification of contributing factors, and to examine the efficacy of malnutrition screening tools for hospitalized children.

METHODS

STRONGkids and PYMS were applied to 1513 inpatients at 37 hospitals in 26 cities from different regions of Turkey. Physical measurements were collected at hospital admission and at discharge. z-Scores of height-for-age, weight-for-age, weight-for-height, and body mass index-for-age were calculated.

RESULTS

Overall, 1513 patients were included in the study. A body mass index standard deviation score of less than -2 was present in 9.5% of the study population at hospital admission, whereas 11.2% of the participants had a weight-for-length/height score of less than -2 at hospital admission. According to STRONGkids results, the proportion of the patients with an underlying chronic disease was higher for the patients at high risk of malnutrition than for the patients at medium or low risk (91% compared with 47% or 45%, respectively). PYMS results indicated that patients at high risk of malnutrition have more chronic diseases (75%) than the patients at medium or low risk of malnutrition (55% and 44%, respectively).

CONCLUSIONS

Use of anthropometric measurements in addition to screening tools to identify hospital malnutrition (such as PYMS, STRONGkids) will prevent some nutritional risk patients from being overlooked.

Frequency and risk factors for malnutrition in children undergoing general anaesthesia in a French university hospital: A cross-sectional observational study

BACKGROUND

Malnutrition is often underdiagnosed in hospitalised children, although it is associated with postoperative complications, longer hospital lengths of stay and increased healthcare-related costs.

OBJECTIVE

We aimed to estimate the frequency of, and identify factors associated with, malnutrition in children undergoing anaesthesia.

DESIGN

Cross-sectional observational study.

SETTING

Paediatric anaesthesia department at the University Children's Hospital, Bordeaux, France.

PARTICIPANTS

A total of 985 patients aged less than 18 years.

MAIN OUTCOME MEASURES

Anthropometric measurements, American Society of Anesthesiologists physical status classification score and the Pediatric Nutritional Risk Score (PNRS) recorded at the pre-anaesthesia evaluation.

RESULTS

When assessed as a Waterlow index less than 80%, malnutrition was present in 7.6% children. This increased to 8.1% of children assessed by clinical signs and to 11% of children when defined by a BMI less than the third percentile. In a univariate analysis, children with a BMI less than the third percentile were more often born prematurely (22.4 vs 10.4%; P = 0.0008), were small for gestational age at birth (18.4 vs 4.5%; P < 0.0001), were admitted from the emergency department (12.0 vs 5.6%; P = 0.02), had a high American Society of Anesthesiologists score (P < 0.0001), or had a high Pediatric Nutritional Risk Score (P < 0.0001). Presence (P = 0.01) and type (P = 0.002) of chronic disease were also associated with malnutrition. In the multivariate analysis, a premature birth, a lower birth weight and a higher Pediatric Nutritional Risk Score were significantly associated with a higher odds of malnutrition when defined by BMI.

CONCLUSION

All children should be screened routinely for malnutrition or the risk of malnutrition at the pre-anaesthesia visit, allowing a programme of preoperative and/or postoperative nutritional support to be initiated. We suggest that as well as weight and height, BMI and a pediatric nutritional risk score such as PNRS should be recorded routinely at the pre-anaesthesia visit.

Handgrip Strength and Malnutrition (Undernutrition) in Hospitalized Versus Nonhospitalized Children Aged 6-14 Years

BACKGROUND

Diagnosing undernutrition in hospitalized pediatric populations is crucial to provide timely nutrition interventions. Handgrip strength (HGS), a measurement of muscle function, is a reliable indicator of undernutrition. However, limited research exists on HGS in hospitalized pediatric patients. The primary aim of this study was to determine if HGS differed between hospitalized children within 48 hours of admission and nonhospitalized children. A secondary purpose was to describe the association of HGS with height, weight, body mass index (BMI), mid upper arm circumference (MUAC), activity level, disease severity, nutrition risk, and nutrition intervention.

METHODS

One hundred nine hospitalized and 110 nonhospitalized patients aged 6-14 years participated in this cross-sectional nonequivalent control group design study. Weight, height, MUAC, and HGS were measured within 48 hours of hospital admission for the hospitalized group or immediately following a well-child visit for the control group.

RESULTS

Based on analysis of covariance, the HGS was estimated to be 12.4 ± 0.37 kgF (mean ± SE) for hospitalized subjects and 13.1 ± 0.37 for nonhospitalized subjects ( P = .2053). HGS was associated with age ( P < .0001), height ( P < .0001), dominant hand ( P < .0001), and MUAC z scores ( P = .0462).

CONCLUSION

HGS was not significantly different between hospitalized and nonhospitalized participants, although anthropometric measurements were similar between groups. A strong relationship was demonstrated between HGS and BMI and MUAC z scores. Further research is needed that examines serial HGS measurements, feasibility in hospitalized patients, and the association of HGS measurements and nutrition risk.

Proposal for An Algorithm for Screening for Undernutrition in Hospitalized Children

The prevalence of disease-related undernutrition in hospitalized children has not decreased significantly in the last decades in Europe. A recent large multicentric European study reported a percentage of underweight children ranging across countries from 4.0% to 9.3%. Nutritional screening has been put forward as a strategy to detect and prevent undernutrition in hospitalized children. It allows timely implementation of adequate nutritional support and prevents further nutritional deterioration of hospitalized children. In this article, a hands-on practical guideline for the implementation of a nutritional care program in hospitalized children is provided. The difference between nutritional status (anthropometry with or without additional technical investigations) at admission and nutritional risk (the risk of the need for a nutritional intervention or the risk for nutritional deterioration during hospital stay) is the focus of this article. Based on the quality control circle principle of Deming, a nutritional care algorithm, with detailed instructions specific for the pediatric population was developed and implementation in daily practice is proposed. Further research is required to prove the applicability and the merit of this algorithm. It can, however, serve as a basis to provide European or even wider guidelines.

Nutritional status, metabolic state and nutrient intake in children with bronchiolitis

Nutrition has a coadjuvant role in the management of children with acute diseases. We aimed to examine nutritional status, macronutrient requirements and actual macronutrient delivery in bronchiolitis. The nutritional status was classified according to WHO criteria and resting energy expenditure (MREE) was measured using an indirect calorimeter. Bland-Altman analysis was used to examine the agreement between MREE and estimated energy expenditure (EEE) with standard equations. Based on the ratio MREE/EEE in relation to Schofield equation on admission, we defined the subjects' metabolic status. A total of 35 patients were enrolled and 46% were malnourished on admission, and 25.8% were hypermetabolic, 37.1% hypometabolic and 37.1% normometabolic. We performed a 24-h recall in 10 children and 80% were overfed (AEI: MREE >120%). Mean bias (limits of agreement) with MREE was 8.9 (-73.9 to 91.8%) for Schofield; 61.0 (-41 to 163%) for Harris-Benedict; and 9.9 (-74.4 to 94.2%) for FAO-WHO equation. Metabolism of infants with bronchiolitis is not accurately estimated by equations.

[Nutritional assessment in hospitalized children in a Paediatric service]

INTRODUCTION

Malnutrition in hospitalized children is associated with increased morbidity and mortality.

OBJECTIVE

To determine the nutritional status in children admitted to the Hospital Clínico de la Universidad Católica de Chile.

PATIENTS AND METHOD

A retrospective, cross-sectional study was conducted on hospital patients less than 17 years old within the period from November 2010 to April 2011. A record was made of the demographic data, admission diagnosis, biochemistry results (albumin, haemoglobin, haematocrit), hospital stay, and anthropometry data. Nutritional diagnosis was expressed as standard deviation (SD) for weight-for-height (WFH) by WHO in children younger than 5 y, and body mass index (BMI) by CDC-NCHS in older children. Height-for-age (HFA) ≤-2SD indicated stunted growth.

RESULTS

A total of 365 children, including 201 boys (55.1%), were evaluated. The median age was 3.35 years (IQR: 1.2-8.2). The most frequent reason for admission was heart disease (30.4%). The median hospital stay was 2 days (IQR: 2.0-4.0). Undernutrition was observed in 3.3% of the children, 8% were nutritionally at risk, 15% were overweight, and 10.9% were obese. As regards HFA, short stature was reported in 12.9%. There was a significant relationship between lower age and heart disease, and higher age with gastrointestinal and neurological diseases. By ordinal logistic regression for each year of age, the weight/height ratio (ZP/T) increases by 6.9% (OR=1.07). The biochemistry results (albumin, haemoglobin and haematocrit levels) were not associated with nutritional status.

CONCLUSIONS

A high percentage of children at risk of undernutrition was found. The percentage overweight was similar to the general Chilean paediatric population. Early detection will allow an opportune intervention, and nutritional monitoring at discharge.

Malnutrition risk in hospitalized children: use of 3 screening tools in a large European population

BACKGROUND

Several malnutrition screening tools have been advocated for use in pediatric inpatients.

OBJECTIVE

We evaluated how 3 popular pediatric nutrition screening tools [i.e., the Pediatric Yorkhill Malnutrition Score (PYMS), the Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP), and the Screening Tool for Risk of Impaired Nutritional Status and Growth (STRONGKIDS)] compared with and were related to anthropometric measures, body composition, and clinical variables in patients who were admitted to tertiary hospitals across Europe.

DESIGN

The 3 screening tools were applied in 2567 inpatients at 14 hospitals across 12 European countries. The classification of patients into different nutritional risk groups was compared between tools and related to anthropometric measures and clinical variables [e.g., length of hospital stay (LOS) and infection rates].

RESULTS

A similar rate of completion of the screening tools for each tool was achieved (PYMS: 86%; STAMP: 84%; and STRONGKIDS: 81%). Risk classification differed markedly by tool, with an overall agreement of 41% between tools. Children categorized as high risk (PYMS: 25%; STAMP: 23%; and STRONGKIDS: 10%) had a longer LOS than that of children at low risk (1.4, 1.4, and 1.8 d longer, respectively; P < 0.001). In high-risk patients identified with the PYMS, 22% of them had low (<-2) body mass index (BMI) SD-scores (SDSs), and 8% of them had low height-for-age SDSs. For the STAMP, the percentages were 19% and 14%, respectively, and for the STRONGKIDS, the percentages were 23% and 19%, respectively.

CONCLUSIONS

The identification and classification of malnutrition risk varied across the pediatric tools used. A considerable portion of children with subnormal anthropometric measures were not identified with all of the tools. The data obtained do not allow recommending the use of any of these screening tools for clinical practice. This study was registered at clinicaltrials.gov as NCT01132742.

[Nutritional status in pediatric intermediate care: Assessment at admission, progression during the stay and after discharge]

INTRODUCTION

Malnutrition, known as a cause of morbidity, has not been studied in children admitted to pediatric intermediate care units. This study aimed to describe the association between patients' nutritional status and the relative severity of illness that characterizes this population.

PATIENTS AND METHODS

In this prospective longitudinal study, a dedicated nutrition support team assessed the nutritional status of all children, aged 5 days to 18 years, admitted to our university pediatric intermediate care unit (Hôpital Femme-Mère-Enfants, Lyon, France) over one year (2012-2013). Weight, height, body mass index, weight-for-age ratio, height-for-age ratio, and the analysis of growth curves were collected at admission. We monitored patients' weight, which allowed us to detect malnutrition occurrence during the stay, and its progression up to 3 months after discharge.

RESULTS

A total of 459 patients were enrolled. Based on the analysis integrating all nutritional indices and the progression of growth curves, malnutrition at admission was detected in 23.8% of children (20.5% and 6.8% suffered from acute and chronic malnutrition, respectively). Based only on the body mass index, malnutrition was detected in 15.5% of children. Chronic disease appeared as a risk factor for malnutrition at admission (P=0.0001) and young age for acute malnutrition (P=0.04). The incidence of acquired malnutrition during the stay (in children with a length of stay > 5 days) was up to 26%, and dyspnea was the only risk factor identified. This population recovered with a normal nutritional status late (66% after 2 months and 16% after 3 months).

CONCLUSIONS

The prevalence of malnutrition is high in our pediatric intermediate care unit. The occurrence of acquired malnutrition during the stay is frequent. All children should benefit from systematic nutritional assessment at admission as well as careful monitoring during the stay and after discharge, to adapt early and individualized nutritional support.

Malnutrition in Hospitalized Pediatric Patients: Assessment, Prevalence, and Association to Adverse Outcomes

Malnutrition is a frequent finding in pediatric health care settings in the form of undernutrition or excess body weight. Its increasing prevalence and impact on overall health status, which is reflected in the adverse outcomes, renders imperative the application of commonly accepted and evidence-based practices and tools by health care providers. Nutrition risk screening on admission and nutrition status evaluation are key points during clinical management of hospitalized pediatric patients, in order to prevent health deterioration that can lead to serious complications and growth consequences. In addition, anthropometric data based on commonly accepted universal growth standards can give accurate results for nutrition status. Both nutrition risk screening and nutrition status assessment are techniques that should be routinely implemented, based on commonly accepted growth standards and methodology, and linked to clinical outcomes. The aim of the present review was to address the issue of hospital malnutrition in pediatric settings in terms of prevalence, outline nutrition status evaluation and nutrition screening process using different criteria and available tools, and present its relationship with outcome measures. Key teaching points • Malnutrition-underweight or excess body weight-is a frequent imbalance in pediatric settings that affects physical growth and results in undesirable clinical outcomes. • Anthropometry interpretation through growth charts and nutrition screening are cornerstones for the assessment of malnutrition.To date no commonly accepted anthropometric criteria or nutrition screening tools are used in hospitalized pediatric patients. • Commonly accepted nutrition status and screening processes based on the World Health Organization's growth standards can contribute to the overall hospital nutrition care of pediatric patients.

Accuracy of Nutritional Screening Tools in Assessing the Risk of Undernutrition in Hospitalized Children

OBJECTIVE

The aim of the present study was to evaluate the predictive accuracy of screening tools for assessing nutritional risk in hospitalized children in developed countries.

METHODS

The study involved a systematic review of literature (MEDLINE, EMBASE, and Cochrane Central databases up to January 17, 2014) of studies on the diagnostic performance of pediatric nutritional screening tools. Methodological quality was assessed using a modified QUADAS tool. Sensitivity and specificity were calculated for each screening tool per validation method. A meta-analysis was performed to estimate the risk ratio of different screening result categories of being truly at nutritional risk.

RESULTS

A total of 11 studies were included on ≥1 of the following screening tools: Pediatric Nutritional Risk Score, Screening Tool for the Assessment of Malnutrition in Paediatrics, Paediatric Yorkhill Malnutrition Score, and Screening Tool for Risk on Nutritional Status and Growth. Because of variation in reference standards, a direct comparison of the predictive accuracy of the screening tools was not possible. A meta-analysis was performed on 1629 children from 7 different studies. The risk ratio of being truly at nutritional risk was 0.349 (95% confidence interval [CI] 0.16-0.78) for children in the low versus moderate screening category and 0.292 (95% CI 0.19-0.44) in the moderate versus high screening category.

CONCLUSIONS

There is insufficient evidence to choose 1 nutritional screening tool over another based on their predictive accuracy. The estimated risk of being at "true nutritional risk" increases with each category of screening test result. Each screening category should be linked to a specific course of action, although further research is needed.

Implementation of a computerized system in pediatric wards to improve nutritional care: a cluster randomized trial

BACKGROUND/OBJECTIVES

Malnutrition occurs frequently in hospitalized children. We aimed to assess whether a computerized system could lead to improved clinical practices in malnourished children.

SUBJECTS/METHODS

Healthcare workers (242) from six departments in a pediatric university hospital participated in a cluster randomized trial, studying 1457 malnourished children hospitalized from September 2009 to August 2011. Following a baseline observational pre-intervention period, all departments were randomized into either intervention or control arms. A computerized malnutrition-screening system was implemented in the intervention group to automatically trigger a dietetic referral in real time. Furthermore, the nutrition support team conducted an awareness campaign with healthcare workers and a leadership-based strategy to reinforce the message during the entire study period. Adherence to practice guidelines (daily weights, investigation of etiology for malnutrition, management by a dietitian and application of refeeding protocols) was compared between pre- and post-intervention periods in both the intervention and trial arms.

RESULTS

When compared with the pre-intervention period, the clinical practices were significantly improved within the intervention arm for every outcome (P<0.01), whereas remained unchanged in the control arm. In addition, during the post-intervention period, malnutrition etiology investigation by physicians (adjusted odds ratio (OR) of 4.4, 95% confidence interval (CI) 1.7-11.8, P=0.003) and management by a dietitian (OR 2.7, 95% CI 1.0-6.9, P=0.046) occurred more frequently in the intervention clusters.

CONCLUSIONS

Implementation of an electronic system to detect malnutrition in real time was associated with a rapid improvement in clinical practices for better care of hospitalized children.

Back to basics: an audit of measurement of infant growth at presentation to hospital

Objectives Infants who present or are admitted to hospital with illness or with inadequate growth and development are those most at risk of decreased nutritional status. However, not all infants who present or are admitted to hospital have their growth assessed. The aim of the present study was to identify how frequently anthropometric measurements were documented in charts of infants presenting and/or admitted to a tertiary paediatric hospital. Methods A systematic random sample of hospital charts of infants who had presented to the emergency department between 1 July 2011 and 30 June 2012 was audited retrospectively for the presence of appropriate documentation of measurement. Results In all, 465 charts were audited, representing 10% of infants who presented to the emergency department in the year. The frequency of anthropometric measures was: birthweight 103 (22%), presentation weight 275 (59%), length 8 (2%), head circumference 15 (3%), percentiles 27 (6%) and body mass index score 1 (0%). Age of the infant was significantly associated with recording of birthweight. There were no significant relationships found between gender, socioeconomic status, gestational age, delivery type and recording of diagnosis and birthweight. Conclusions Infant measurements were not recorded on many occasions. Assessment of growth as a marker of illness or nutritional deficit has been poorly assessed in this group. This is a missed opportunity to assess infant growth in this population, which has been found to be at risk of decreased nutritional status. Identification and treatment of growth deficits are a cost-effective method of optimising infant health worldwide. What is known about this topic? Infants who present or are admitted to hospital with illness or with inadequate growth and development are those most at risk of decreased nutritional status. What does this paper add? Not all infants who present or are admitted to hospital have their growth assessed. What are the implications for practitioners? It is important in a paediatric setting to identify who is responsible for measuring and recording infant growth. Measurement of weight, height and head circumference is a basic, low-cost method of measuring infant growth in the hospital setting.

Methods to evaluate the nutrition risk in hospitalized patients

The rate of malnutrition is substantially high both in the population and in chronic patients hospitalized because of different reasons. The rate of patients with no marked malnutrition at the time of hospitalization who develop malnutrition during hospitalization is also substantially high. Therefore, there are currently different screening methods with different targets to prevent malnutrition and its overlook. These methods should be simple and reliable and should not be time-consuming in order to be used in daily practice. Seven nutrition risk screening methods used in children have been established until the present time. However, no consensus has been made on any method as in adults. It should be accepted that interrogation of nutrition is a part of normal examination to increase awareness on this issue and to draw attention to this issue.

Prevalence of malnutrition at the time of admission among patients admitted to a Canadian tertiary-care paediatric hospital

BACKGROUND

Malnutrition among hospitalized children is known to negatively influence their response to therapy and to prolong their admission. It also has short- and long-term consequences for growth, development and well-being. It is commonly regarded as a condition affecting children in low-income countries; however, malnutrition has been found to be variably prevalent among hospitalized children in higher-income countries. At the time the present study was conducted, it had been >30 years since the nutritional status of Canadian hospitalized children was last published.

OBJECTIVES

To determine and communicate the prevalence of malnutrition among children in a Canadian tertiary-care paediatric hospital at the time of their admission.

METHODS

In the present cross-sectional study, anthropometric measures were obtained from 322 children admitted to The Hospital for Sick Children in Toronto, Ontario. Nutritional indexes (BMI for age, weight for age, weight for length/height and length/height for age) were generated from anthropometric measures using the WHO igrowup software, and summarized according to WHO definitions.

RESULTS

The overall prevalence of malnutrition using BMI for age was 39.6% (95% CI 33% to 46%), of which 8.8% and 30.8% of participants were under- and overnourished, respectively. Furthermore, 6.9% (95% CI 3% to 13%) were determined to be acutely malnourished (weight for length/height <-2 SD) and 13.4% (95% CI 10% to 18%) chronically malnourished (length/height for age <-2 SD).

CONCLUSION

The high prevalence of overall malnutrition observed among study participants suggests that initial screening using simple anthropometric measures should be conducted on hospital admission so that patients can receive appropriate nutrition-specific care.