Pediatric Malnutrition: Under the

Curve Beth Scott, RD, CNSC

Objectives

• Discuss the prevalence of pediatric malnutrition and address the

challenges involved in collecting appropriate data.

• Review updated guidelines for the identification and classification

of pediatric malnutrition.

• Discuss the documentation of malnutrition and implications for

reimbursement.

• Case Study presentation

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Prevalence

• 20 million children <5 years of age worldwide

• Contributes to ~45% of all child deaths globally

• Poverty, famine, and war are primary contributors to

global malnutrition

• A clear definition is lacking

– Lead to underestimating the prevalence

– Make it difficult to compare results among the few studies

there are because the definition varies

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• Underdeveloped countries

- Historically thought to be exclusive to developing countries

- Acute/chronic infections and diarrheal diseases are major contributors

to malnutrition and high mortality rates

- Usually categorized as Kwashiorker or Marasmus

• Developed countries

- Occurs more frequently in acute and chronic illness

- Energy imbalance and excess is more common than nutrient deficiency

- There is a portion of the population that are victims of food insecurity

• Homeless, victims of abuse/neglect

• Reside in urban or rural areas where access to high quality food is

limited

• 1 in 10 families in the US struggle with food insecurity

-

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Prevalence

Prevalence

• United States

– Energy imbalance vs. nutrient deficiency

– Prevalence of acute or chronic undernutrition in US children

unknown

– 1 in 10 families struggle with food insecurity

– Most frequently observed in hospitalized acute and/or chronically ill

children and in children with special healthcare needs

• Nutrition Screening for Malnutrition

– Should be done routinely in primary care settings

– Should be a an integral part of routine pediatric care

– Malnutrition can lead to more complicated hospitalizations

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Acute vs. Chronic Undernutrition

• National Centers for Health Statistics (NCHS)

– Distinguish between based on time

• Acute <3 months

• Chronic >3 months

• Chronic condition may contribute to an acute illness

• An acute illness may evolve into a chronic condition if not

addressed

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Acute vs. Chronic Undernutrition

World Health Organization (WHO)/The United Nations

Children’s Fund (UNICEF)

– Distinguish based on diagnostic parameters

• Severe Acute (weight), children 6-60 months

– Very low wt/ht: less than -3 SD of the WHO growth standards

– Visible severe wasting (MUAC<115mm)

– Presence of nutritional edema

– Wasting defined by as wt/age less than -2 SD (z-score)

• Chronic (stunting)

– Ht/age less -2 SD of the median NCHS/WHO international reference

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Acute vs. Chronic Undernutrition

• Stunting

- Well-established indicator of chronic malnutrition

- Height- children >2yrs, taken in standing position

- Length- children <2yrs, taken in recumbent position

- Particularly related to environmental or socioeconomic circumstances

- May also be seen during adolescence as is a period of rapid growth and

development

• Children 0-4 years have the best potential outcomes from

comprehensive assessment for malnutrition because timely

intervention is highly likely to prevent adverse effects

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Definition of Pediatric Malnutrition- Part 1

• Comprehensive definition proposed in 2013

– A uniform and comprehensive definition of malnutrition

based on the available evidence and multidisciplinary

consensus

– Includes both undernutrition and obesity

– Incorporated the chronicity, etiology, and severity of

malnutrition

– Also accounts for the mechanism, impact on growth,

developmental and functional outcomes

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Domains

5 Domains of pediatric malnutrition

A. Anthropometric variables

B. Growth

C. Chronicity of malnutrition- Acute vs. chronic

D. Etiology of malnutrition and pathogenesis of

malnutrition

E. Impact on functional status

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Definition

• “Imbalance between nutrient requirement and intake, resulting in

cumulative deficits of energy, protein, or micronutrients that may

negatively affect growth, development and other relevant

outcomes”

• May be related to illness, adverse environmental or behavioral

factors, injury, congenital anomalies, and so on

• UNICEF states that “malnutrition” is a broad term, commonly used

as an alternative to “undernutrition”, it technically encompasses

overnutrition

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What?

• Lack of standardized approach to the recognition and diagnosis

• No agreement as to the best and most useful approach

• Routine assessment of nutritional status in high risk children in the US is

sporadic and inconsistent

• A consensus statement was produced by AAND and ASPEN to “identify a

basic set of indicators that can be used to diagnose and document

undernutrition in the pediatric population ages 1 month to 18 years” to be

used in routine clinical practice

• Intended for use in multiple settings

• Obesity is a form of malnutrition however the intention of the consensus

statement was to address only undernutrition

Why?

• The universal use of a single set of diagnostic parameters will:

– expedite the recognition of pediatric undernutrition, lead to the

development of more accurate estimates of its prevalence and

incidence, direct interventions, and promote improves outcomes.

– Allow a prediction of the human and financial responsibilities and

costs associated with the prevention and treatment of undernutrition

and help to further ensure the provision of high-quality, cost-effective

nutritional care.

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Indicators of Pediatric

Undernutrition

• Attributes of Indicators

– Evidenced based, consensus derived

– Universally available and validated

– Applied inexpensively and in multiple settings

– Require minimal training

– Reproducibly identify undernutrition

– Quantify severity of undernutrition

– Can be used to monitor changes in nutritional status

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Indicators of Pediatric Undernutrition

1) Food and Nutrient Intake

2) Assessment of energy and protein needs

3) Growth parameters

4) Weight gain velocity

5) Mid-upper arm circumference (MUAC)

6) Handgrip strength

7) Proxy measures as substitutes for traditional

anthropometric measures

8) Documentation of Tanner Staging

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1) Food and Nutrient Intake

• The primary determinant of nutritional status.

• Estimates of adequacy of protein/energy should be determined for

all children, especially those at high risk for malnutrition.

• Is the child’s intake adequate to meet their nutritional needs in

the context of their current clinical situation, growth pattern and

developmental level?

• Prescribed therapy should be monitored to ensure the child is

actually ingesting the intended amounts

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2) Assessment of Energy and Protein Needs

• Energy needs measured by indirect calorimetry or estimated

through the use of standard equations

– FAO/WHO and Schofield are the most widely used

– RDA, RDI can also be used

– Based on the energy needs of healthy children

• Protein needs

• See Reference #1 for Summary of Estimating Nutrition Needs

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3) Growth Parameters

• Growth is the primary outcome measure of nutritional status in

children

• Measured at every healthcare encounter- for preventive, acute, or

chronic care

• Trends should be monitored over time and problems identified

addressed in a timely manner

• Monitor Z-scores, or compare units of standard deviations from

norms for reference groups, to track and assess nutritional status

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Growth Parameters

• A Z-score is a statistical measure that tells how a single data point

compares with normal data and, if above or below “average”, how

atypical the measurement is.

• Growth measurements that cross Z-score lines indicate possible

risk

• Normal growth/development will be on or between -1 and 1 z-

scores of a given indicator

• Interpretation of the significance of the Z-score data is based on

the point at which, in the child’s pattern of growth, the change

began and the childs’ health status relative to the point and

progression of the change.

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Z-scores

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4) Weight Gain Velocity

• Growth is defined as “an increase in size and the development to

maturity”

• Growth velocity is defined as “the rate of change in weight or

length/height over time”

– Early sign of healthy/unhealthy response to the nutritional

environment

– On initial presentation, length/height reflects the child’s nutritional

status over a prolonged period of time

– Negative z-score can be used to determine pediatric malnutrition

when only 1 set of measurements is available

– Over time, decreases in z-scores for linear growth can also be used as

a characteristic of malnutrition

• With adequate nutrient intake, average daily/monthly rates of

weight gain allow a child to remain on a stable growth curve.

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Weight Gain Velocity

• Very low weight velocity has been noted to be

“independently and more closely related to mortality

than other indicators of malnutrition such as BMI for

age”

• In short term undernutrition/cessation of growth (as in

illness or trauma) there is an adaptive response that

allows the child to achieve “catch-up” growth

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5) Mid-Upper Arm Circumference

• MUAC can be used as an independent anthropometric assessment

tool in standards developed by WHO.

– MUAC-for-age reference data in standard deviations is only available

for 6-59 months

– MUAC (“arm circumference”) data given in percentiles for ages 1-75

yrs

– When serial Z-scores are unavailable serial measurements are still

beneficial in monitoring changes in body composition by using the

child as her own control

• MUAC measures should be part of the anthropometric assessment

of all pts, but it is particularly helpful in those with fluid shifts

(edema, ascites, etc).

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6) Handgrip Strength

• A dynamometer is a simple, noninvasive and low-cost instrument to

measure functional status.

• Measures baseline functional status, tracks progress

• Predicts post-op complications, length of hospitalization, readmission,

likelihood of returning to previous home setting, and mortality.

• BMI Z-scores correlate with the admission handgrip strength

measurement.

• Age-appropriate, gender-specific reference ranges must be used.

• Normal reference ranges in large populations not yet established

• Can identify the presence but not severity of malnutrition

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7&8) Additional Indicators

• Proxy measures substitutes when unable to take direct

measurements

• Tanner Staging

– Can’t be used as a marker for nutritional status however may

be useful as an indicator in preteens and adolescents who have

entered puberty, when Tanner progression or stagnation may be

influenced by nutritional status

– Area for future research

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Classification of Pediatric Malnutrition

• Past recommendations:

– Percent of ideal body weight

– Gomez Classification, Waterlow Criteria

– Other definitions used included decreases in percentiles, weight below

the 5th %tile, and deceleration of weight over time

• Current recommendations:

– Use of Z-scores, declines, and negative scores to identify and

document

• Children with wt/ht z-scores of less than -3 SD were at a 9-fold

greater risk of dying than children with a z-score of -1 SD

– MUAC measures (in children 6-60 months)

• Severe malnutrition <11.5cm

• Moderate malnutrition 11.5-12.4cm

• At risk of malnutrition 12.4-13.5cm

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Classification of Pediatric Malnutrition

• Mild Malnutrition

– Usually the result of an acute event, either due to economic

circumstances or acute illness

– Presents with unintentional weight loss or weight gain velocity less

than expected

• Moderate Malnutrition

– Occurs due to undernutrition of a significant duration that results in

weight for length/height values or BMI for age values below the

normal range

• Severe Malnutriton

– Occurs as a result of prolonged undernutrition and is most frequently

quantified by declines in rates of linear growth that result in stunting

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Classification of Pediatric Malnutrition

• Single data point

– Weight/height or length z score

– BMI/age z score

– length or height/age z score

– MUAC

• Two or more data points

– Weight gain velocity (<2 yrs of age)

– Weight loss (2-20 yrs)

– Deceleration in weight/length or height z-score

– Inadequate nutrient intake

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Single Data Point

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Mild Moderate Severe

Weight/Height z-

score -1 to -1.9 -2 to -2.9 -3 or greater

BMI/age z-score -1 to -1.9 -2 to -2.9 -3 or greater

Length or

Height/age z-score No data No data -3

MUAC

Greater than or

equal to

-1 to -1.9

Greater than or

equal to

-2 to -2.9

Greater than or

equal to

-3

Multiple Data Points

Mild Moderate Severe

Weight gain velocity (<2y

of age)

<75% of the norm for

expected weight gain

<50% of the norm for

expected weight gain

<25% of the norm for

expected weight gain

Weight loss (2-20y) 5% of UBW 7.5% of UBW 10% of UBW

Deceleration in wt/length

or ht z score Decline of 1 z score Decline of 2 z score Decline of 3 z score

Inadequate nutrient

intake

51-75% estimated

energy/protein need

26-51% estimated

energy/protein need

<25% estimated

energy/protein need

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Why is this important?

• Earlier identification

– Less severe malnutrition

– Identified earlier cost less to treat- shorter inpt stays, possible outpt

treatment, less disease-related complications

• Highlighting the problem may lead to:

– Increased allocation of resources

– Required universal screening

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Importance

The universal use of a single set of diagnostic parameters

will :

– Expedite the recognition of pediatric malnutrition

– Lead to more accurate estimates of prevalence and incidence

– Promote improved outcomes

– Allow a prediction of the human/financial responsibilities and

costs associated with the prevention and treatment

– Help ensure the provision of high-quality, cost effective

nutritional care

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References

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Case Study

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