Obesity and under-nutrition in a tertiary paediatric hospital

Quality Improvement Project to Promote Identification and Treatment of Children With Obesity Admitted to Hospital

Among children hospitalized for acute problems, comorbid obesity is commonly unaddressed. The objective was to improve identification and initial management of obesity among hospitalized children. In collaboration with nurses and dietitians, pediatric hospitalists of 2 children's hospitals conducted a quality improvement project to improve body mass index (BMI) documentation, obesity diagnosis, diet, and nutrition consultation through clinician education, development of computerized clinical decision-support system tools, and workflow modifications. Participants received monthly performance feedback. Among those with elevated BMI, diagnosis rose to 70.2%; a documented obesity diagnosis was associated with being 35 times more likely (P < .001) to receive at least 1 intervention while hospitalized. Participants reported an increase in skill in (27%), comfort with (27%), and knowledge of (33%) obesity management. Improvement in health care provider recognition and management of obesity in the inpatient setting is achievable. Additional work is needed to identify how best to sustain desired practice patterns.

Factors Associated With Documentation of Obesity in the Inpatient Setting

OBJECTIVES

Childhood obesity is rarely identified in hospitalized pediatric patients despite the high prevalence of obesity and potential for associated morbidity. The purpose of this study was to identify specific patient characteristics associated with the documentation of obesity and related weight management recommendations in the inpatient setting.

METHODS

Retrospective chart review was conducted on all pediatric patients ages 2 to 18 years old and discharged between January 1, 2012, and December 31, 2014, to determine the following: (1) if obesity was noted in the clinical documentation of those with a BMI ≥95th percentile; and (2) if those with documented obesity had evidence of an obesity-specific management plan. Using χ2 and multivariable logistic regression, we determined patient characteristics associated with the documentation of obesity and presence of a management plan.

RESULTS

Only 26% (214 of 809) of inpatients with obesity had documentation of weight status. The odds of obesity documentation were higher in patients with comorbid cholelithiasis, severe obesity, and older age. Of those with obesity documentation, 23% (49 of 214) had an obesity management plan. Comorbid sleep apnea and admission to a surgical service with a pediatric hospital medicine consult were significantly associated with the presence of an obesity management plan.

CONCLUSIONS

Increased efforts are necessary to improve obesity diagnosis and management in younger children who have not yet developed comorbidities. Additionally, the role of pediatric hospitalists as consultants for surgical patients should be further explored as a tool for addressing obesity during inpatient hospitalization.

Prevalence of child malnutrition at a university hospital using the World Health Organization criteria and bioelectrical impedance data

Malnutrition constitutes a major public health concern worldwide and serves as an indicator of hospitalized patients’ prognosis. Although various methods with which to conduct nutritional assessments exist, large hospitals seldom employ them to diagnose malnutrition. The aim of this study was to understand the prevalence of child malnutrition at the University Hospital of the Ribeirão Preto Medical School, University of São, Brazil. A cross-sectional descriptive study was conducted to compare the nutritional status of 292 hospitalized children with that of a healthy control group (n=234). Information regarding patients’ weight, height, and bioelectrical impedance (i.e., bioelectrical impedance vector analysis) was obtained, and the phase angle was calculated. Using the World Health Organization (WHO) criteria, 35.27% of the patients presented with malnutrition; specifically, 16.10% had undernutrition and 19.17% were overweight. Classification according to the bioelectrical impedance results of nutritional status was more sensitive than the WHO criteria: of the 55.45% of patients with malnutrition, 51.25% exhibited undernutrition and 4.20% were overweight. After applying the WHO criteria in the unpaired control group (n=234), we observed that 100.00% of the subjects were eutrophic; however, 23.34% of the controls were malnourished according to impedance analysis. The phase angle was significantly lower in the hospitalized group than in the control group (P<0.05). Therefore, this study suggests that a protocol to obtain patients’ weight and height must be followed, and bioimpedance data must be examined upon hospital admission of all children.

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.

Improving delivery of health care to Aboriginal and Torres Strait Islander children

AIM

To identify opportunities to improve health-care delivery for urban Aboriginal and Torres Strait Islander children requiring hospital admission and to determine their characteristics.

METHODS

We analysed all documentation of admissions of Aboriginal and/or Torres Strait Islander children to a tertiary paediatric hospital in 2010. We reviewed the medical records to determine whether the Aboriginal status of patients was known, whether Aboriginal and/or Torres Strait Islander children and their families were reviewed by Aboriginal staff during admission and whether basic health-care quality indicators were met, including documentation of anthropometry, ear examination findings, immunisation status and catch-up immunisation delivery.

RESULTS

In 2010, 543 (2%) patients admitted to the institution were identified as Aboriginal and/or Torres Strait Islander: 140/538 (26.0%) were from the first decile (most disadvantaged) on Socio-Economic Indexes for Areas index. Of all admitted children, 148/543 (27.3%) were referred to Aboriginal health professionals during admission, more when length of stay was greater than 7 days (61% vs. 23%, P < 0.001). There was documentation of weight in 533/543 (98.2%), ear examinations in 64/543 (11.8%), immunisations being not up to date in 126/543 (23%), catch-up immunisation given in 7/126 (5.6%), Aboriginal and/or Torres Strait Islander status in 8/543 (1.5%) medical and 1/543 (0.2%) nursing discharge summaries.

CONCLUSIONS

We have identified several opportunities to improve culturally appropriate health-care delivery for Aboriginal and Torres Strait Islander children admitted to hospital, including improved recognition of Aboriginal and/or Torres Strait Islander status of patients, improved access to Aboriginal health professionals and increased performance and documentation of basic anthropometry, ear examination and immunisation catch-up.

Prevalence of malnutrition, obesity and nutritional risk of Australian paediatric inpatients: a national one-day snapshot

AIM

Low prevalence rates of malnutrition at 2.5% to 4% have previously been reported in two tertiary paediatric Australian hospitals. The current study is the first to measure the prevalence of malnutrition, obesity and nutritional risk of paediatric inpatients in multiple hospitals throughout Australia.

METHODS

Malnutrition, obesity and nutritional risk prevalence were investigated in 832 and 570 paediatric inpatients, respectively, in eight tertiary paediatric hospitals and eight regional hospitals across Australia on a single day. Malnutrition and obesity prevalence was determined using z-scores and body mass index (BMI) percentiles. High nutritional risk was determined as a Paediatric Yorkhill Malnutrition Score of 2 or more.

RESULTS

The prevalence rates of malnourished, wasted, stunted, overweight and obese paediatric patients were 15%, 13.8%, 11.9%, 8.8% and 9.9%, respectively. Patients who identified as Aboriginal and Torres Strait Islander were more likely to have lower height-for-age z-scores (P < 0.01); however, BMI and weight-for-age z-scores were not significantly different. Children who were younger, from regional hospitals or with a primary diagnosis of cardiac disease or cystic fibrosis had significantly lower anthropometric z-scores (P = 0.05). Forty-four per cent of patients were identified as at high nutritional risk and requiring further nutritional assessment.

CONCLUSIONS

The prevalence of malnutrition and nutritional risk of Australian paediatric inpatients on a given day was much higher when compared with the healthy population. In contrast, the proportion of overweight and obese patients was less.

Excess body weight in children may increase the length of hospital stay

OBJECTIVES

To investigate the prevalence of excess body weight in the pediatric ward of University Hospital and to test both the association between initial nutritional diagnosis and the length of stay and the in-hospital variation in nutritional status.

METHODS

Retrospective cohort study based on information entered in clinical records from University Hospital. The data were collected from a convenience sample of 91 cases among children aged one to 10 years admitted to the hospital in 2009. The data that characterize the sample are presented in a descriptive manner. Additionally, we performed a multivariate linear regression analysis adjusted for age and gender.

RESULTS

Nutritional classification at baseline showed that 87.8% of the children had a normal weight and that 8.9% had excess weight. The linear regression models showed that the average weight loss z-score of the children with excess weight compared with the group with normal weight was -0.48 (p = 0.018) and that their length of stay was 2.37 days longer on average compared with that of the normal-weight group (p = 0.047).

CONCLUSIONS

The length of stay and loss of weight at the hospital may be greater among children with excess weight than among children with normal weight.

Pediatric obesity and safety in inpatient settings: a systematic literature review

OBJECTIVE

Pediatric obesity affects more than 16% of American children and is associated with worse outcomes in hospitalized patients. A systematic literature review was performed to identify studies of adverse care events affecting obese pediatric patients in the emergency room, operating room, or inpatient wards.

EVIDENCE REVIEW

We systematically searched Medline for articles published from 1970 to 2013 regarding obesity and patient safety events in pediatric acute care settings. We determined the study design, number of patients studied, definition and prevalence of obesity, the relevant acute care setting, the specific association with obesity addressed, and the results of each study.

RESULTS AND CONCLUSION

Thirty-four studies documented both procedural complications and issues with general hospital care. Most were retrospective and focused on surgery or anesthesia. Obese patients may have increased risk for a variety of adverse events. Further study could improve institutional patient safety guidelines to enhance care for obese children.

Hospital-related undernutrition in children: still an often unrecognized and undertreated problem

AIM

To evaluate the nutritional status of hospitalized children in Belgian hospitals and to analyse the impact of undernutrition on the degree of weight loss and duration of hospitalization.

METHODS

In each hospital (one tertiary and three secondary hospitals), 100 consecutively hospitalized children were eligible for inclusion. Of these, 379 were included for analysis. Body weight, length and mid-upper arm circumference were measured at admission and body weight also at discharge.

RESULTS

The median (range) age was 2.1 (0.8-17) years. On admission, 29 (7.7%) children were chronically malnourished and, depending on the parameter, between 2.4% and 9.8% acutely undernourished, while 12.1% had at least one subnormal parameter. Median (range) duration of hospitalization was four (1-64) days. Median (range) weight change was 0.0% (-15.6% - +13.9%). Weight loss of >2% was significantly (p < 0.05) more prevalent in tertiary (20.0%) than in secondary (10.2%) hospitals. Median hospital duration was 50% longer for chronically malnourished children (6.0 vs 4.0 days; p < 0.01). Only 36 children received a nutritional intervention.

CONCLUSION

Acute undernutrition and chronic undernutrition remain frequent findings in hospitalized children in Belgium. Children with chronic undernutrition had a 50% longer hospital stay. Hospital-related undernutrition is an often unrecognized problem, because only one-third of the acutely malnourished children received nutritional support.

Nutritional status and nutrition risk screening in hospitalized children in New Zealand

AIM

Children requiring hospitalization are at risk of malnutrition. This study aimed to define the nutritional status of paediatric inpatients in comparison with healthy children and to compare and contrast the feasibility and validity of three nutritional risk screening (NRS) tools in the hospitalized children.

METHODS

A total of 162 children admitted to Christchurch Hospital were assessed along with a similar group of healthy children. Their nutritional state was assessed and classified using standard criteria. The NRS tools were applied, and patients were classified into low-, medium- and high-risk groups. The feasibility and validity of the tools were assessed.

RESULTS

Under-nutrition was more frequent in the inpatient group (9.9% vs. 3.7%; p = 0.04), whereas both groups had similar rates of overweight/obesity. NRS tools were able to identify between 81% and 100% of the malnourished patients in the medium- to high-risk groups. Undernourished patients had longer hospital stay than well-nourished patients.

CONCLUSION

Hospitalized children have higher rates of under-nutrition than healthy children in NZ. The three NRS tools were able to identify children at nutritional risk with differing utility. In this setting, STRONGkids was the most reliable tool.

Obesity in pediatric specialty clinics: an underestimated comorbidity

OBJECTIVES

(a) To examine the prevalence of obesity across 31 subspecialties in a tertiary care children's hospital and (b) to examine the percentage of obesity-specified diagnosis codes used for obese patient visits.

METHODS

We analyzed 48 479 youth aged 2 to 18 years in 31 outpatient subspecialty clinics at Seattle Children's Hospital between 2005 and 2007. Body mass index (BMI) percentiles were determined by age- and gender-adjusted BMI calculated from height/weight obtained at clinic visits. For obese patients, the percentage of diagnoses coded as obesity-specific (278.11, 278.01, 272.02, 783.1) were determined by evaluation of standard diagnostic codes.

RESULTS

Twenty-two of the 31 clinics had patient obesity rates greater than 15%. Analysis of International Classification of Diseases, 9th Revision, codes for obese patient visits as defined by BMI revealed only 2 clinics used obesity-specific codes for >5% of all diagnoses.

CONCLUSIONS

Given the prevalence of obesity across all subspecialties, more recognition and resources are needed to screen, diagnosis, and provide coordinated services for healthy weight management.

Malnutrition screening tools for hospitalized children

PURPOSE OF REVIEW

Malnutrition is highly prevalent in hospitalized children and has been associated with relevant clinical outcomes. The scope of this review is to describe the five screening tools and the recent European Society for Parenteral and Enteral Nutrition (ESPEN) research project aimed at establishing agreed, evidence-based criteria for malnutrition and screening tools for its diagnosis in hospitalized children.

RECENT FINDINGS

Five nutrition screening tools have recently been developed to identify the risk of malnutrition in hospitalized children. These tools have been tested to a limited extent by their authors in the original published studies but have not been validated by other independent studies. So far, such screening tools have not been established widely as part of standard pediatric care.

SUMMARY

Although nutrition screening and assessment are recommended by European Society for Parenteral and Enteral Nutrition and the European Society for Pediatric Gastroenterology Hepatology and Nutrition and are often accepted to be required by healthcare facilities, there is no standardized approach to nutritional screening for pediatric inpatients. The near future will provide us with comparative data on the existing tools which may contribute to delineating a standard for useful nutrition screening in pediatrics.

Paediatric growth charts: how do we use them and can we use them better?

AIM

Measurement of growth parameters is a key aspect of paediatric care. The aim of this retrospective study was to ascertain rates of growth assessment in children in an acute paediatric setting and to define the frequency of placement of growth data on appropriate growth charts. The accuracy of plotting of growth data and role of potential factors were also examined.

METHODS

The charts of children attending the Children's Acute Assessment (CAA) unit at Christchurch Public Hospital, New Zealand, were reviewed. The frequency of documentation of height, weight and head circumference in the notes and on the appropriate growth chart was ascertained, along with review of the accuracy of the plotted data.

RESULTS

Weight was documented in the charts of 95% and height in 5% of 103 children. None of the children had measurement of their head circumference. A growth chart was present in the notes of 27% of children, but just 7% of the group had a growth chart with the current measurements plotted.

CONCLUSIONS

This study identifies a missed opportunity for assessment of the nutritional status of children in the hospital setting in New Zealand. The results highlight a need for optimising child growth assessment, particularly at a time of growing awareness of health inequalities and childhood obesity.

Assessment and management of obesity in childhood and adolescence

The increased prevalence of obesity in childhood and adolescence highlights the need for effective treatment approaches. Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination with BMI plotted on a BMI-for-age chart. The degree of investigation is dependent on the patient's age and severity of obesity, the findings on history and physical examination, and associated familial risk factors. There are several broad principles of conventional management: management of comorbidities; family involvement; taking a developmentally appropriate approach; the use of a range of behavior change techniques; long-term dietary change; increased physical activity; and decreased sedentary behaviors. Orlistat can be useful as an adjunct to lifestyle changes in severely obese adolescents and metformin can be used in older children and adolescents with clinical insulin resistance. Bariatric surgery should be considered in those who are severely obese, with recognition of the need for management in centers with multidisciplinary weight management teams and for surgery to be performed in tertiary institutions experienced in bariatric surgery. Finally, given the high prevalence and chronic nature of obesity, coordinated models of care for health-service delivery for the management of pediatric obesity are needed.

Assessment and management of obesity in childhood and adolescence

The increased prevalence of obesity in childhood and adolescence highlights the need for effective treatment approaches. Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination with BMI plotted on a BMI-for-age chart. The degree of investigation is dependent on the patient's age and severity of obesity, the findings on history and physical examination, and associated familial risk factors. There are several broad principles of conventional management: management of comorbidities; family involvement; taking a developmentally appropriate approach; the use of a range of behavior change techniques; long-term dietary change; increased physical activity; and decreased sedentary behaviors. Orlistat can be useful as an adjunct to lifestyle changes in severely obese adolescents and metformin can be used in older children and adolescents with clinical insulin resistance. Bariatric surgery should be considered in those who are severely obese, with recognition of the need for management in centers with multidisciplinary weight management teams and for surgery to be performed in tertiary institutions experienced in bariatric surgery. Finally, given the high prevalence and chronic nature of obesity, coordinated models of care for health-service delivery for the management of pediatric obesity are needed.

Extremes of weight centile are associated with increased risk of mortality in pediatric intensive care

Introduction

Although numerous studies have linked extremes of weight with poor outcome in adult intensive care patients, the effect of weight on intensive care outcome has not previously been reported in the pediatric population. The aim of this study was to investigate the relationship between admission weight centile and risk-adjusted mortality in pediatric intensive care patients.

Methods

Data were collected on 6337 consecutively admitted patients over an 8.5 year period in a 15 bed pediatric intensive care unit (ICU) located in a university-affiliated tertiary referral children's hospital. A weight centile variable was entered into a multivariate logistic regression model that included all other pediatric index of mortality (PIM-2) variables, in order to determine whether weight centile was an independent risk factor for mortality.

Results

Weight centile was associated with mortality in both univariate and multivariate analysis, with the lowest mortality being associated with weights on the 75^th centile and increasing symmetrically around this nadir. A transformed weight centile variable (absolute value of weight centile-75) was independently associated with mortality (odds ratio 1.02, P = 0.000) when entered into a multivariate logistic regression model that included the PIM-2 variables.

Conclusions

In this single-center cohort, weight centile was an independent risk factor for mortality in the ICU, with mortality increasing for patients at either end of the weight spectrum. These observations suggest that the accuracy of mortality prediction algorithms may be improved by inclusion of weight centile in the models. A prospective multicenter study should be undertaken to confirm our findings.

Nutritional status of children with coeliac disease

AIMS

The main aim of this study was to assess the nutritional status of children with newly diagnosed Coeliac disease (CD)with comparison to matched controls. A further aim was to assess relationships between presentation patterns and nutrition in childhood CD.

METHODS

The nutritional status of newly diagnosed CD was assessed by anthropometry, Bioelectrical Impedance and serum leptin levels, and contrasted to age and gender matched controls.

RESULTS

Twenty-five children with CD (mean age of 8.2 +/- 4.5 years) and 25 control children (mean age 8.1 +/- 4.4.) were enrolled. Thirteen (52%) children with CD had gastrointestinal symptoms with 14 having a family history of CD. At presentation 8.7% were wasted, 4.2% were stunted and 20.8% overweight, although none were obese. Mean height and weight for age, other nutritional parameters and serum leptin did not differ between the groups. Serum leptin correlated with BMI in both groups.

CONCLUSIONS

Children with CD more commonly present with atypical symptoms than with classical features. Variations in nutrition (under to overnutrition) may be seen at diagnosis, without relationship to the presence of symptoms. Leptin levels were not altered specifically in the setting of CD. Nutritional assessment remains important in the assessment and management of CD in children.

Obesity identified by discharge ICD-9 codes underestimates the true prevalence of obesity in hospitalized children

OBJECTIVES

To define inpatient care of obese children with or without an obesity diagnosis.

STUDY DESIGN

A total of 29,352 inpatient discharges (18,459 unique inpatients) from a tertiary children's hospital were analyzed. Body mass index (BMI) was calculated from measured height and weight. "Obesity" was defined as BMI >or=95th percentile by using Centers for Disease Control and Prevention 2000 growth charts. "Diagnosed obesity" was defined by primary, secondary or tertiary International Classification of Diseases, Ninth Revision codes for "obesity" or "overweight." Analyses controlled for multiple inpatient records per individual.

RESULTS

A total of 5989 discharges from the hospital (20.4%) were associated with obesity, but only 512 discharges (1.7%) indicated obesity as a diagnosis. An obesity diagnosis identified only 5.5% of inpatient days for obese inpatients. Obese patients with an obesity diagnosis (Ob/Dx) had fewer hospital discharges per person and shorter lengths of stay than obese patients without an obesity diagnosis (Ob/No Dx). Patients with Ob/Dx had higher odds of mental health, endocrine, and musculoskeletal disorders than non-obese inpatients, but Ob/No Dx patients generally did not.

CONCLUSIONS

Inpatient obesity diagnoses underestimate inpatient utilization and misidentify patterns of care for obese children. Extreme caution is warranted when using obesity diagnoses to study healthcare utilization by obese children.

Secondary malnutrition and overweight in a pediatric referral hospital: associated factors

OBJECTIVES

To establish the prevalence and identify the clinical and sociodemographic factors associated with malnutrition and overweight in a pediatric referral hospital.

PATIENTS AND METHODS

We studied a cross-sectional, random sample from a pediatric hospital. Malnutrition was defined as acute when the z score of weight/height was less than -2.0 and as chronic if in addition the height/age z score was less than -2.0. Overweight risk was defined as a body mass index percentile between 85 and 94, and overweight as a body mass index percentile of 95 or higher.

RESULTS

The study included 641 patients, with mean age 7.1 +/- 4.9 years (56% male). The overall prevalence of acute malnutrition was 8% and chronic malnutrition 17.0%. Overweight risk was present in 15.4% and overweight in 12.2%. Acute malnutrition was predicted by conditions on admission (hospitalization: odds ratio [OR] 2.3, confidence interval [CI] 1.3-4.3; nonsurgical subspecialty: OR 2.1, CI 1.0-4.3) and number of siblings (1 child, single mother: OR 2.6, CI 1.3-5.0). Chronic malnutrition was predicted by age (infants vs preschoolers: OR 2.0, CI 1.1-3.6; infants vs school children: OR 3.1, CI 1.8-5.5) and illness duration (>30 days: OR 2, CI 1.1-3.7). Overweight risk was associated with age (>36 months: OR 2.0, CI 1.6-3.4) and the father's educational level (college and university: OR 2.3, CI 1.3-4.3). Overweight was predicted by sex (boys: OR 2.0, CI 1.0-3.6) and age (>36 months: OR 1.7, CI 1.0-2.8).

CONCLUSIONS

Overweight was as prevalent as malnutrition. Malnutrition was associated with clinical condition, age, family size, and illness duration, whereas overweight was related to age, sex, and father's education. Overweight appears as a novel finding in the nutritional profile of pediatric referral hospitals in Mexico.

Overweight in medical paediatric inpatients: detection and parent expectations

AIMS

(i) To determine prevalence and rates of detection of overweight/obesity among general paediatric inpatients. (ii) To explore parental expectations regarding detection and management of overweight/obesity during admission.

METHODS

This is a cross-sectional survey conducted in the Royal Children's Hospital, Melbourne, Australia. A total of 102 children aged 2-12 years admitted to a general paediatric unit at the Royal Children's Hospital and their parents participated in the survey. The main outcome measures are body mass index (BMI); documentation of weight, height and BMI in patient notes; parent description of child's weight, parent concern about child's weight, and parent opinion about detection and management of overweight.

RESULTS

Twelve of 102 children (11.7%, 95% confidence intervals 6.2%, 19.7%) were overweight or obese. All children had a documented weight, two children (2.0%) had a documented height and none had BMI documented. Seven of 12 parents of overweight children described their child's weight as healthy; five of 12 parents of overweight children were not concerned about their child's weight. Eight of 12 parents of overweight children believed all admitted children should have their BMI calculated. All parents thought the hospital should take action if a child was found to be overweight.

CONCLUSIONS

Although prevalence of overweight was lower than expected, documentation of overweight did not occur for any patient in the study. Parents of overweight children with acute illnesses believed that the hospital should screen for overweight and discuss it with parents. Further studies are required to determine expectations among other patient populations.

Outcomes of a nutrition audit in a tertiary paediatric hospital: implications for service improvement

OBJECTIVE

To examine the process of anthropometric assessment of nutritional status in a tertiary paediatric hospital, to identify the barriers and to make recommendations for service improvement.

METHODS

The accuracy of height and weight scales in wards was checked. Dietitians measured height and weight of a representative sample of 245 inpatients and checked whether these measurements had been recorded on bed charts. Patients were classified as overweight, obese or under-nourished. Diagnoses and procedures were obtained for each patient. Funding implications were modelled for inappropriate coding of nutritional status.

RESULTS

The barriers to nutritional assessment and management of nutritional comorbidities were: (i) inaccurate height scales in seven out of 12 wards; (ii) under-recording of height and weight on patient bed charts (73% height missing, 12% both height and weight missing); (iii) under-reporting of obesity and under-nutrition in medical notes (one of eight obese patients, and none of 28 undernourished patients, reported); and (iv) low referral rate of obese or under-nourished children to dietetic services (two of 42 overweight/obese patients referred, five of 28 undernourished patients referred). Funding simulation showed that if under-nourished patients were correctly diagnosed then the potential facility reimbursement would have increased by $A52 326.

CONCLUSIONS

Barriers to nutritional assessment can lead to failure to diagnose and treat both over- and under-nutrition, thereby affecting quality of patient care, and may have financial implications for hospitals. Suggestions for service improvement include provision of accurate equipment, adequate training of staff undertaking nutritional assessments and clear definitions of staff responsibilities in all aspects of the process.