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OPINION Malnutrition screening tools for hospitalized
children
Corina Hartman a, Raanan Shamir a, Christina Hecht b, and Berthold Koletzko b
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.
Keywords
children, nutritional assessment, nutritional screening, screening tools, undernutrition
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Malnutrition screening tools in pediatrics Hartman et al.
status and food intake primarily in hospitalized nutrition screening tools for children. The scope
adults followed by an outcome evaluation 30 days of this review is to describe these tools and
later, which is performed yearly across many the recent ESPEN research project aimed to link
European hospitals. During ‘NutritionDay’ 2006, a anthropometric measurements to outcome (e.g.
history was obtained from 14 665 (90%) partici- length of hospital stay), to establish broadly
pants, and individual information about actual food agreed, evidence-based criteria for malnutrition
intake was obtained from 14 474 (89%) patients. in children and to put forward an evidence-based
Individual food intakes on NutritionDay revealed screening tool for pediatric malnutrition and mal-
that less than half of all patients finished their nutrition risk.
meals. In this single-day audit of food intake, even At least five malnutrition screening tools have
when taking into account other variables, a pro- been developed in the last decade to address the risk
gressive increase of 30-day mortality was associated of malnutrition in hospitalized children (Table 1).
with decreased food intake [37]. These tools have been tested by their authors in
Insufficient nutritional intake in hospital was the original published studies, without having
addressed in 2003 by a resolution from the European been properly validated in larger cohorts or by other
Council; and in 2006 by guidelines from UK’s authors. Furthermore, there is no documentation
National Institute for Health and Clinical Excellence of the impact of screening tools implementation
(NICE): however, it is unknown by now whether with respect to overall benefit and cost, an essential
these initiatives will have impact on nutrition care prerequisite for inclusion of these tools in routine
in European hospitals [38,39]. pediatric care.
Sermet-Gaudelus et al. [43] developed and tested
a screening tool based on prospective nutritional
PEDIATRIC NUTRITION SCREENING TOOLS assessment and a weight loss greater than 2% from
National and international health organizations admission weight as the cut-off for nutrition risk.
have recommended that all adults should have Nutritional risk was assessed prospectively in 296
their nutritional status assessed and screened for children by evaluating various factors within 48 h
nutrition risk at any encounter with health services of admission. Multivariate analysis indicated that
[40,41]. For this purpose, nutrition risk screening food intake less than 50%, pain, and grade 2 and
tools have been designed for the early identification 3 pathologic conditions (P ¼ 0.0001 for all) were
of malnutrition or undernutrition by staff who are associated with weight losses of greater than 2%.
not expert in nutrition [35]. These screening tools The Pediatric Nutritional Risk Score (PNRS) ranged
have been validated in a variety of clinical settings from 0 to 5 and was calculated by adding the values
and with different patient groups. However, none of for the significant risk factors as follows: 1 for food
these adult tools are validated for use in children. intake less than 50%, 1 for pain, 1 for grade 2
The reasons are multiple but mainly the difficulty to pathologic condition and 3 for grade 3 pathologic
assess improper growth, the pediatric equivalent to condition. A score of 1 or 2 is supposed to indicate
adult weight loss based on one weight or height moderate risk and a score of at least 3 to indicate
measurement. In addition, the clinical implications high risk of malnutrition. Although this tool
of diseases are different for children, the underlying appears to be quick and simple to use, the study
cause and pathology differ in some instances, and does not detail on the conditions required for
the impact of disease on growth and subsequent implementation (e.g. staff training and resources)
development is an additional important complicat- or the reliability and the reproducibility of the tool
ing factor. in practice.
In order to improve nutritional care in pediatric Secker and Jeejeebhoy [44] developed and
hospitals, the European Society for Paediatric Gas- tested a Subjective Global Nutritional Assessment
troenterology, Hepatology and Nutrition (www. (SGNA) score for children. The SGNA consisted
ESPGHAN.org) Committee on Nutrition has recom- of a nutrition-oriented physical examination and
mended the establishment of nutrition support information on the child’s recent and current height
teams whose tasks should include among others and weight, parental heights, dietary intake, fre-
‘identification of patients at risk of malnutrition, quency and duration of gastrointestinal symptoms,
provision of adequate nutritional management, current functional capacity and recent changes.
education and training of hospital staff and audit The SGNA was tested on a population of children
of practice’. However, these recommendations have undergoing surgery, and the occurrence of nutri-
not been widely introduced into routine clinical tion-associated complications was documented
practice [42]. During the last few years, impressive at 30 days after surgery. SGNA divided children
efforts have been made to create simple and useful into three groups: well nourished, moderately
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Population/setting
Screening tool Number, age, range Content/items Comments
LOS, length of stay; NPV, negative predictive value; PPV, positive predictive value; PYMS, Pediatric Yorkhill Malnutrition Score; STAMP, Screening Tool for the
Assessment of Malnutrition in Pediatrics; STRONGkids, Screening Tool Risk on Nutritional status and Grow.
malnourished and severely malnourished. The assessment of the assessors. These are critical
children categorized as malnourished had a higher considerations that require clarification.
rate of infectious complications and a longer post- STAMP – Screening Tool for the Assessment of
operative length of stay than the well nourished Malnutrition in Pediatrics – is a 5-step tool that was
children. Although this is so far the only pediatric tested in comparison to a full nutritional assessment
tool that correlated nutritional status categories in a group of 89 children aged 2–17 years admitted
with outcome, one of the limitations of SGNA use for surgery [45]. STAMP consists of three elements:
in clinical practice may be the time required to clinical diagnosis (classified by the possible nutri-
complete it. Although referred to as a screening tool, tional implications), nutritional intake and anthro-
the name acknowledges that the SGNA is more a pometric measurements (weight). Each element is
structured nutritional assessment. The authors did scored and nutritional risk is translated into the
not report the time taken to complete the SGNA need for a referral for full assessment. No outcomes
or the level of training and expertise in nutrition were evaluated with the STAMP tool.
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Malnutrition screening tools in pediatrics Hartman et al.
The Paediatric Yorkhill Malnutrition Score STRONGkids has two weak points: the subjective
(PYMS) assesses four steps considered as predictors clinical assessment item ‘was carried out by skilled
or symptoms of malnutrition: BMI, history of recent pediatricians’, whereas one would ideally wish for a
weight loss, changes in nutritional intake and the screening tool that can be applied by all healthcare
predicted effect of the current medical condition on workers; the 4th item ‘weight loss or poor weight
the nutritional status of the patient [46]. Each step gain’ or anthropometric indices calculation require
bears a score of up to 2, and the total score reflects either previous knowledge of the child weight/
the degree of the nutrition risk of the patient. Of length (rarely available beside infancy) or time-
the 247 children studied, the nurse-rated PYMS consuming assessment and interpretation of these
identified 59% of those rated at high risk by full indexes.
dietetic assessment. Of those rated at high risk by
the nursing PYMS, 47% were confirmed as high risk
on full assessment. These results can be interpreted FUTURE CONSIDERATIONS
that at least half of children were inadequately None of the tools described above were validated
referred to dietitians for evaluation, and almost in larger study populations beyond the first
40% were missed by the nurse-administered PYMS, publication setting. Most of these screening tools
but most of these children would not have been have not been correlated with clinical outcome or
identified at all without PYMS. As has been shown have weaknesses that may be a barrier for using
by earlier studies, health staff are poor at recognizing them as universal screening tools. Assessment of
undernutrition [26,27]. The fact that use of PYMS the consequences of implementing any of these
by a dietitian identified more true cases also suggests tools in pediatric clinical routine practice, including
that the diagnostic accuracy of the PYMS might potential benefit and burdens for the patients
possibly be improved by further training and and their families as well as health and economic
continuous use. The authors also performed a com- consequences, is not available.
parison of screening tools with research dietitians’ A research project to address some of the open
assessment. SGNA had the highest specificity and questions is currently being performed with support
positive predictive value, but very low sensitivity, by a Network Grant of ESPEN and in collaboration
which might not be surprising considering that the with the Working Group on Malnutrition of the
SGNA is rather an assessment method than a screen- ESPGHAN. This mutlticenter study coordinated by
ing tool. The PYMS identified all the children who Professor Berthold Koletzko, Munich, Germany, is
screened at high risk by the SGNA, but only 52% of performed in 14 pediatric departments in 12
those screened at high risk by the STAMP. Likewise, European countries. Demographic and medical data
the STAMP and the PYMS completed by the research were collected in over 2400 pediatric inpatients.
dietitians both achieved high specificity and sensi- Anthropometric measurements and interviews were
tivity, but the positive predictive value was higher performed during the first 24 h after admission, and
for the PYMS which also showed higher agreement outcome data were collected after discharge. The
with the research dietetic assessment. initial interview included the questions of three pre-
STRONGkids – Screening Tool Risk on Nutri- viously proposed screening tools: STAMP, PYMS and
tional status and Growth – has been developed and STRONGkids. The results of this project will help to
tested in a multicenter study that included 424 establish the criteria to link anthropometric measure-
children aged 3.5 years (range 31 days to 17.7 years) ments with outcomes such as length of hospital stay.
admitted to seven academic and 37 general hospi- Hopefully, it will lead to agreed, evidence-based
tals in the Netherlands [47]. The STRONGkids criteria for malnutrition in children and provide
screening tool consists of four elements: subjective further information on possible selection of an
clinical assessment, high-risk disease, nutritional appropriate screening tool for children.
intake and weight loss or poor weight gain. Measure-
ments of weight and length were also performed. SD
scores of 2 or less for weight-for-height and height- CONCLUSION
for-age were considered to indicate acute and Proper assessment of nutritional status should be
chronic malnutrition, respectively. The study data a standard requirement of child care aimed to
show a significant relationship between high-risk identify those patients who can benefit from and
score in STRONGkids and weight for height z-score. need targeted intervention. Nutritional assessment
In addition, the length of hospital stay was signifi- should provide reliable information on the child’s
cantly different between the lowest and highest nutritional status, a risk assessment of future develop-
risk groups. The authors claim great simplicity ment of underweight or overweight, and the basis for
with the use of their screening tool; however, the decisions on further diagnostic steps, monitoring
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Paediatrics
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