malnutrition in hospitalized childrenaims of the thesis 2 1. study current prevalence of...
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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
Prevalence of undernutrition
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
Prevalence of undernutrition
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
Systematic review screening tools
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
Systematic review screening tools
Study selection
Huysentruyt et al. JPGN 2015
22 Huysentruyt et al. JPGN 2015
Systematic review screening tools
Validation against weight loss
23 Huysentruyt et al. JPGN 2015
Systematic review screening tools
Validation against dietetic referral
26 Huysentruyt et al. JPGN 2015
• 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
Systematic review screening tools
Conclusion
27
Belgian survey
screening for undernutrition
Huysentruyt et al. Acta paediatrica 2015
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
Huysentruyt et al. Acta paediatrica 2015
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)
Huysentruyt et al. Acta paediatrica 2015
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
Huysentruyt et al. Acta paediatrica 2015
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
Huysentruyt et al. Acta paediatrica 2015
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
Huysentruyt et al. Acta paediatrica 2015
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
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