malnutrition in hospitalized childrenaims of the thesis 2 1. study current prevalence of...

Disease-related undernutrition

in hospitalized children in Belgium

Koen Huysentruyt

Promoters: Prof. Dr. Jean De Schepper

Prof. Dr. Yvan Vandenplas

Public Defense PhD

May 2016

Aims of the thesis

2

1. Study current prevalence of undernutrition in Belgian

hospitalized children General pediatric population

Specific at-risk population

2. Validation of the STRONGkids nutritional screening tool in a

Belgian population

3. Inquire about current knowledge & clinical practice of

nutritional screening in Belgian paediatric departments

4. Propose practical guidelines for early detection of disease-

related undernutrition

Defining under-nutrition

anthropometric criteria

3

Classification Parameter Criteria

GomezWeight for Age

(WFA)

75%-90% WFA

60-74% WFA

<60% WFA

WaterlowWeight for Height

(WFH)

80%-90% WFH

70%-80% WFH

<70% WFH

WHO WFH-2 SD < WFH ≤ -3 SD

WFH < 3 SD

Cole BMI

-1 SD < BMI ≤ -2 SD

-2 SD < BMI ≤ -3 SD

BMI < -3 SD

Sen

Mid-upper Arm

Circumference

(MUAC)

MUAC < -2 SD / MUAC<110 mm

Gomez et al. Adv Pediatr 1955; Waterlow BMJ 1972; WHO 1995; Cole et al. BMJ 2007; Sen et al An Hum Biol 2011

What is the WFH of a boy

with a height of 100 cm and

a body weight of 11 kg ?

1. 100 cm is the

average length of a

3.5 year-old boy

2. 16 kg is the average

weight of a 3.5 y boy

3. 11/16 = 69%

→ Undernutrition

Prevalence of undernutrition

in Belgian hospitals

Total

n (%)

Secondary hospitals

n (%)

Tertiary hospital

n (%)

WFH <-2 SD(p=0.53)

34 (9.0) 26 (10.0) 8 (7.8)

HFA <-2 SD(p=0.40)

29 (7.7) 19 (7.0) 10 (9.5)

Weight loss >2%*(p<0.05)

39 (12.5) 23 (10.2) 17 (20.0)

4 Huysentruyt et al. Acta paediatrica 2013

Prospective study of 379 children (Dec 2010 – Apr 2011) in four Belgian

hospitals:

• Charleroi

• La Louvière

• Hasselt

• UZ Brussel

*n=310

5 Huysentruyt et al. Acta paediatrica 2013


in Belgian hospitals

Total

n (%)

Secondary hospitals

n (%)

Tertiary hospital

n (%)

Nutr. Interv.** 37 (8.9) 18 (6.6) 19 (18.1)

Underl. Dis.** 40 (11.1) 16 (6.3) 24 (23.1)

LoS ≥ 4 days* 125 (36.2) 80 (32.5) 45 (45.5)

Length of hospital stay:

No difference in children with/without acute undernutrition (p=0.27)

1 day longer in children with chronic undernutrition(p<0.01)

>2% weight loss more frequent in children with LoS ≥4 days(8.5% vs 21.8%; p<0.01)

*p<0.05; **p<0.01

Undernutrition & nutritional evolution

in an at-risk population

6 Huysentruyt et al. Plos One 2014

Retrospective study of 56 children (2007-2011) without underlying disease

and pneumonia with parapneumonic effusion in two Belgian hospitals:

• Hasselt

• UZ Brussel

Specific risk factors for nutritional deterioration in this population:

Chronic disease

Long hospital stay

Decreased intake

Exsudative protein loss

Inflammation

Increased metabolism (↗resp. effort & O2 dependency)

Undernutrition & nutritional evolution

in an at-risk population

Parameter Admission

(n=56)

Min. weight

(n=44)

2 weeks FU

(n=35)

1 month FU

(n=26)

WFH<-2 SD 2/51 (3.9%) 4/43 (9.3%) 0 (0%) 0 (0%)

↘ WFH 13/32 (40.6%) 5/22 (22.7%)

5% weight loss 17 (38.7%) 4 (11.5%) 5 (19.2%)

10% weight loss 5 (11.4%) 1 (2.9%) 1 (3.8%)

79%

21%

Minimal body weight

Yes

No50%50%

Body weight

discharge

Yes

No

7 Huysentruyt et al. Plos One 2014


our results in perspective

Europe (‘14):• N = 2410

• 7% BMI<-2 SD

• Hospital stay ↗ 1.3d

France (‘13):• N = 923

• 15% BMI <3th centile

Belgium (‘13):• N = 379

• 10% BMI <-2 SD

8 Hecht et al. Clinical nutrition 2014; Sissaoui et al. e-SPEN Journal 2013; Huysentruyt et al. Acta paediatrica 2013

Huysentruyt et al. Acta paediatrica 20139

n = 46 (12%)

Defining undernutrition

Need for a consensus

Defining undernutrition

Need for a consensus

10

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

90,0%

100,0%

Weight &

height

Clinical

appraisal

MUAC

and/or

SFT

Serum

protein

levels

Other

Methods for the evaluation of undernutrition

22.5% based judgement on 1 criterion:• Weight & length (81.3%)

• Clinical appraisal (4.0%)

• MUAC and/or SFT (6.3%)

Huysentruyt et al. Acta Paediatr 2015

Lack of uniform definition could

play a role in under-recognition

Current terminology:

• Mere description of

undernutrition

• No insight in etiology and

interactions associated with

pediatric undernutrition

Key concepts of the new definition

11 Mehta et al. JPEN 2013

Undernutrition

Anthropometry

Growth

EtiologyChronicity

Outcome

Weight loss during hospital stay

Country N

Fr (‘00) 296 25.6% with weight loss >5%

Poor nutritional status on admission no significant predictor of

weight loss

Trk (‘03) 170 Well-nourished: no deterioration

Undernutrition: Significant ↘ %BMI on discharge

B (‘13) 309 12.6% with weight loss >2%

No correlation with WFH on admission

Eur (’14) 938 23% of children lost weight

3.7% with weight loss >5%

6.8% of malnourished children lost weight

12Sermet Gaudelus et al. Am J Clin Nutr 2000; Ozturk et al. J Trop Pediatr2003; Huysentruyt et al. Acta Paediatr 2003; Hecht et al. Clin Nutr

2014

Nutritional

status at

diagnosis

Nutritional

risk

≠

Guidelines nutritional screening

(adults)

Screening for malnutrition:• Result in diagnosis of malnutrition and adverse

outcome

• Result in improved outcome by nutritionaltreatment

ESPEN guidelines nutrition screening tools:• High predictive & content validity

• Reliable

• Practical

• Should be linked to specified protocols for action

• Should lead to nutritional care

13 Kondrup et al. Clinical nutrition 2003

The STRONGkids

nutritional screening

tool

Question Score

Is there an underlying illness with the risk for malnutrition or expected

major surgery ?

No: 0

Yes: 2

Is the patient in a poor nutritional status judged with subjective clinical

assessment ?

No: 0

Yes: 1

Is one of the following items present ?

1. Excessive diarrhea (≥5x/day) and/or vomiting (>3x/day)

2. Reduced food intake during the last few days

3. Pre-existing nutritional intervention

4. Inability to consume adequate nutritional intake because of pain

None: 0

≥1 item: 1

Is there weight loss or no weight loss increase (infants <1 year) during the

last few weeks-months ?

No: 0

Yes: 1

Hulst et al. Clin Nutr 201014

Low risk 0 points

Moderate risk 1-3 points

High risk 4-5 points

STRONGkids

nutritional screening tool

Belgian validation study

Pilot study (n=29)

Inter-rater:

κ= 0.61 (p<0.01)

Intra-rater:

κ= 0.66 (p<0.01)

Ease of use

97% completion rate

<5 minutes

Huysentruyt et al. Nutrition 201315

Prospective study of 368 children (Dec 2010 – Apr 2011) in four Belgian

hospitals:

• Charleroi

• La Louvière

• Hasselt

• UZ Brussel

STRONGkids

nutritional screening tool

Belgian validation study

ρ Sens Spec NPV PPV OR (95% CI)

WFH -0.23** 71.9 49.1 94.8 11.9 2.47 (1.11-5.49)**

HFA -0.06 69.0 48.4 94.8 10.4 2.12 (0.94-4.79)

Huysentruyt et al. Nutrition 201316

Concurrent validity

ρ Sens Spec NPV PPV OR (95% CI)

LoS 0.25** 62.6 53.9 72.0 43.3 1.96 (1.3-3.1)**

Wt loss 0.01 52.6 43.1 29.7 66.5 0.84 (0.53-1.33)

Ntr Intv 0.48** 94.6 52.0 98.9 18.0 18.93 (4.5-80.0)**

Prospective validity

*p<0.05; **p<0.01

*p<0.05; **p<0.01

Children classified as 'low risk' have a 5% probability of being

acutely undernourished, with only a 1% probability of a

nutritional intervention during hospitalization

Overview of paediatric screening tools

17 22-6-2016

NRS PNRS STAMP PYMS STRONGkids

Present weight Present weight Present weight Poor nutrition status

Expected WFH 0 WFA-HFA ≤1 ctles apart 0 BMI below cut-off value ? (subjective assessment)

90-99% of expected WFH 2 WFA-HFA 2-3 ctles apart 1 No 0 No 0

80-89% of expected WFH 4 WFA-HFA ≥3 ctles apart

(or WFA < 2nd

ctle)

3 Yes 2 Yes 1

≤79% of expected WFH 6

Appetite Recent weight loss Poor weight gain (<1y) or

weight loss

Good: eats most of meals 0 Looser clothes/poor w. gain (<2y)

Poor: leaves >½ of meals 2 No 0 No 0

± None: during >4 meals 3 Yes 1 Yes 1

Ability to eat/retain

food

Eating <½ of usual

and/or pain in first

48h

Recent nutritional

intake

↘ Intake past week Ability to eat/retain food

No difficulties

No diarrhoea/vomiting

0 None of the above 0 Good, no change 0 No, usual intake 0 None of the items listed below

present

0

Problems handling food

Vomiting/mild diarrhoea

1 1 of the above 1 Poor or recently ↘ 2 Yes, ↘ of usual intake 1 ≥1 of the items listed below

present

1

Difficulty swallowing

Dental/chewing problems

Vomiting/diarrhoea (1-2/d)

Needs help with feeding

2 Both of the above 2 ± No intake 3 Yes, ± no intake 2 List of items:

- Diarrhoea (≥5x/d) 1-3 days

- Vomiting (>3x/d) 1-3 days

- Pre-existing advised nutr. Interv.

- Adequate intake not possible (pain)Unable to take food orally

Unable to swallow

Vomiting/diarrhoea (>2/d)

Malabsorption

3

Stress factor Stress factor Diagnosis with nutr.

implications

Will condition affect

nutrition next week ?

Expected major surgery

/underlying disease?

None 0 Minor 0 No 0 No 0 No 0

Mild 1 Mild 1 Possible implication 2 ↘ intake or ↗ losses/needs 1 Yes 2

Moderate 2 Severe 3 Definite implication 3 ± no intake 2

Severe 3

LOW RISK: <5/15 LOW RISK: 0/5 LOW RISK: 0-1/9 LOW RISK: 0/7 LOW RISK: 0/5

MODERATE RISK: 5-9/15 MODERATE RISK: 1-2/5 MODERATE RISK: 2-3/9 MODERATE RISK: 1/7 MODERATE RISK: 1-3/5

HIGH RISK: ≥10/15 HIGH RISK: ≥3/5 HIGH RISK: ≥4/9 HIGH RISK: ≥2/7 HIGH RISK: ≥4/5

Which screening tool

should we use ?

Systematic review screening tools

Search strategy

PICO search question:

• P: hospitalized children in developed countries

• I+C: Paediatric nutritional screening tools

• O: “Nutritional risk”

No language or time restrictions

Hand searching of references from included articles and narrative reviews

Contact with panel of international experts for identification of additional articles

“Developed country”: International Statistical Institute (ISI)

• Based on country’s Gross National Income

18 Huysentruyt et al. JPGN 2015

19

15.967 records identified via

MEDLINE, EMBASE and

Cochrane Central Database

(until 17-01-2014)

14.521 records screened

54 full-text articles assessed for

eligibility

18 papers included in detailed

assessment

11 studies included in

qualitative synthesis

Huysentruyt et al. JPGN 2015


Study selection

20

Validation methods of ‘nutritional risk’:

Weight loss

Full dietetic assessment

Clinical decision for nutritional intervention

Clinical decision for dietetic referral

WFA/BMI/HFA z-scores

Description of nutritional risk without validation

Length of hospital stay


Study selection

Huysentruyt et al. JPGN 2015



Validation against weight loss



Validation against dietetic referral


• Four validated nutritional screening tools

• STAMP

• PYMS

• PNRS

• STRONGkids

• Choice of cut-off values greatly influences sens & spec of

screening tools

• Choice of screening tool will depend on other factors such

as local validation, ease of use and reliability


Conclusion

27

Belgian survey

screening for undernutrition


Nationwide survey (Sept ‘13 – Febr ‘14)

• Department heads of all Belgian, non-university hospitals with paediatric

department

• Postal or electronic questionnaire

• Dutch and French version of the questionnaire

• 1 reminder was sent to non-responders

• Respondents blinded for investigators

Overall response:

• 71/97 (73.2%)66.7%

78.2%

p=0.205

Belgian survey

Respondent characteristics

28

Total

N (%)

Flemish

N (%)

Walloon

N (%)

Significance

(p-value)

Number of beds on ward 0.385

<20 beds 31 (43.7) 17 (39.5) 14 (50.0)

≥20 beds 40 (56.3) 26 (60.5) 14 (50.0)

Median (range) 20 (10 - 72) 20 (15 - 48) 19 (10 - 72) 0.445

Admission undernourished children 0.804

Never 1 (1.4) 1 (2.3) 0 (0.0)

<1x/month 56 (78.9) 35 (81.4) 21 (75.0)

1x/week – 1x/month 12 (16.9) 6 (14.0) 6 (21.4)

≥1x/week 2 (2.8) 1 (2.3) 1 (3.6)

Total

N (%)

Small centre

N (%)

Large centre

N (%)

Significance

(p-value)

Paediatric NST/dietician present 0.102

No 38 (53.5) 20 (64.5) 18 (45.0)

Yes 33 (46.5) 11 (35.5) 22 (55.0)

Number of dieticians 0.068

No dieticians 39 (58.2) 22 (71.0) 17 (47.2)

>0 - ≤1 full time dieticians 25 (37.3) 9 (29.0) 16 (44.4)

>1 full time dieticians 3 (4.5) 0 (0.0) 3 (8.3)

Missing 4 0 4


Belgian survey

Opinions regarding screening

29

Total

N (%)

Small centres

N (%)

Large centres

N (%)

Significance

(p-value)

Aware of nutritional screening tools 0.893

Yes 35 (49.3) 15 (48.4) 20 (50.0)

No 36 (50.7) 16 (51.6) 20 (50.0)

Necessity of nutritional screening 0.168

All hospitalized children 26 (36.6) 9 (29.0) 17 (42.5)

Only in case of suspicion 43 (60.6) 20 (64.5) 23 (57.5)

Unnecessary, clinical judgement sufficient 2 (2.8) 2 (6.5) 0 (0.0)

Dangerous, may lead to decreased skills of staff 0 (0.0) 0 (0.0) 0 (0.0)

Total

N (%)

Flemish

N (%)

Walloon

N (%)

Significance

(p-value)

Aware of nutritional screening tools 0.120

Yes 35 (49.3) 18 (41.9) 17 (60.7)

No 36 (50.7) 25 (58.1) 11 (39.3)

Necessity of nutritional screening 0.009

All hospitalized children 26 (36.6) 10 (23.3) 16 (57.1)

Only in case of suspicion 43 (60.6) 31 (72.1) 12 (42.9)

Unnecessary, clinical judgement sufficient 2 (2.8) 2 (4.7) 0 (0.0)

Dangerous, may lead to decreased skills of staff 0 (0.0) 0 (0.0) 0 (0.0)


Belgian survey

Options to raise priority

30

0% 20% 40% 60% 80% 100%

Obliged by governement

Obliged by department head

More training about screening

More attention for nutrition

management in general

Other

Walloon

Flemish

p=0.005

p=0.011

Missing: n=2


Belgian survey

Barriers preventing screening

31

0,0%

10,0%

20,0%

30,0%

40,0%

50,0%

60,0%

70,0%

80,0%

Small centres

Large centresp= 0.070

p= 0.003

Missing: n=7


Belgian survey

Current clinical practice

28%

18%

43%

11%

Current screening in

Wallonia

61%16%

16%

7%

Current screening in

Flanders

32

p=0.009

Currently used screening method Total

N (%)

Growth charts/WFH/BMI 7 (25.0)

STRONGkids 6 (21.4)

Own tool 5 (17.9)

No systematic method 4 (14.3)

More elaborate assessment 3 (10.7)

Other 3 (10.7)

Missing 9


33 Huysentruyt et al. JPGN 2016 (accepted for publication)

Early detection of undernutrition

Proposal for practical algorithm

Limitations of this work

34

1. No association length of hospital stay and acute undernutrition

In contrast with other, larger studies

Underpowered? Interaction with other factors?

2. Static anthropometric definitions used

What about constitutional thin children...

What about children with weight loss but still above cut-off values...

3. Short duration of hospital stay

Difficult to correlate with nutritional outcome

Interventions need to be carried on after discharge

4. Study on children with parapneumonic effusion

Retrospective, small sample size, high number of drop-outs

5. Lack of golden standard for defining nutritional risk

Each measure has its own strengths and weaknesses

Complication of finding the ideal screening tool

6. Lack of evidence-based practice for validation of algorithm

Overall conclusion

35

Undernutrition in hospitalized children also exists in Belgian hospitals

Lack of recognition of undernutrition

Increased nutritional risk for children with more severe conditions and

those hospitalized for longer time periods

STRONGkids is a validated screening tool and easy to use in everyday

practice

Nutritional screening is not yet common practice

Major barriers for nutritional screening were a lack of awereness and a

lack of training

We proposed a nutritional algorithm for use in everyday practice

What next ?

36

Validation of the algorithm in a broader, multicentric population

Search for anthropometric criteria that are linked with disease-specific

outcome parameters

Role of body composition ?

Further raising awereness on nutritional screening and a good

nutritional policy

The use of screening as a quality indicator ?

Screening in other settings ?

Special thanks to...

37

Prof. Vandenplas Prof. De Schepper

Dr. Devreker Prof. Cools

Dr. Alliet

Dr. Bontems

Dr. Muyshondt

Mrs. Vandecandelaere

Mr. Descheemaeker

malnutrition in hospitalized childrenaims of the thesis 2 1. study current prevalence of...

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