Clinical Hey-Academy of Nutrition and Paedritic

(http://www.ugm.ac.
id)
FULLTEXTARTICLE
ConsensusStatementoftheAcademyofNutritionand
Dietetics/AmericanSocietyforParenteralandEnteral
Nutrition:IndicatorsRecommendedforthe
IdentificationandDocumentationofPediatric
Malnutrition(Undernutrition)
(http://cdn.clinicalkey.com/rss/issue/22122672.xml) (/ui/service/content/url?eid=1s2.0
S2212267214013598)
PatriciaJ.BeckerMS,RD,CSP,LDN,CNSC,LiesjeNiemanCarneyRD,CSP,LDN,MarkRichardCorkins
MD,CNSC,SPR,FAAP,JessicaMonczkaRD,LDN,CNSC,ElizabethSmithRD,LDN,CNSC,Susan
ElizabethSmithRD,CSP,LD,BonnieA.SpearPhD,RDN,LDandJaneV.WhitePhD,RD,LDN,FADA,
FAND
ConsensusStatementoftheAcademyofNutritionandDietetics/AmericanSocietyforParenteralandEnteralNutrition:Indicators
RecommendedfortheIdentificationandDocumentationofPediatricMalnutrition(Undernutrition),20141201Z,Volume114,
Issue12,Pages19882000,Copyright2014AcademyofNutritionandDieteticsandtheAmericanSocietyforParenteraland
EnteralNutrition
Abstract
TheAcademyofNutritionandDieteticsandAmericanSocietyforParenteralandEnteral
Nutrition,utilizinganevidenceinformed,consensusderivedprocess,recommendthata
standardizedsetofdiagnosticindicatorsbeusedtoidentifyanddocumentpediatricmalnutrition
(undernutrition)inroutineclinicalpractice.Therecommendedindicatorsincludezscoresfor
weightforheight/length,bodymassindexforage,length/heightforage,ormidupperarm
circumferencewhenasingledatapointisavailable.Whentwoormoredatapointsareavailable,
indicatorsmayalsoincludeweightgainvelocity(youngerthan2yearsofage),weightloss(2to20
yearsofage),decelerationinweightforlength/heightzscore,andinadequatenutrientintake.The
purposeofthisconsensusstatementistoidentifyabasicsetofindicatorsthatcanbeusedto
diagnoseanddocumentundernutritioninthepediatricpopulation(ages1monthto18years).The
indicatorsareintendedforuseinmultiplesettings,suchasacute,ambulatorycare/outpatient,
residentialcare,etc.Severalscreeningtoolshavebeendevelopedforuseinhospitalizedchildren.
However,identifyingcriteriaforuseinscreeningfornutritionalriskisnotthepurposeofthis
paper.Cliniciansshoulduseasmanydatapointsasavailabletoidentifyanddocumentthe
presenceofmalnutrition.Theuniversaluseofasinglesetofdiagnosticparameterswillexpedite
therecognitionofpediatricundernutrition,leadtothedevelopmentofmoreaccurateestimatesof
itsprevalenceandincidence,directinterventions,andpromoteimprovedoutcomes.A
standardizeddiagnosticapproachwillalsoinformthepredictionofthehumanandfinancial
responsibilitiesandcostsassociatedwiththepreventionandtreatmentofundernutritioninthis
vulnerablepopulation,andhelptofurtherensuretheprovisionofhighquality,costeffective,
nutritioncare.
Pediatricmalnutrition(undernutrition)isestimatedtocontributetoapproximately45%ofall
childdeathsglobally.1Approximately20millionchildrenyoungerthan5yearsofageworldwide
areseverelyundernourished,leavingthemextremelyvulnerabletoillnessandprematuredeath.
Manyolderchildrenindevelopingcountriesenteradolescenceundernourished,whichincreases
theirvulnerabilitytodiseaseandprematuredeath.2Poverty,famine,andwarareprimary
contributorstoglobalmalnutritionandlimitfooddistributionandaccess,evenwhenfoodis
availableforconsumption.Developmentofacuteorchronicinfectiousand/ordiarrhealdiseasein
thosewhoarealreadyundernourishedcontributestothehighmortalityratesassociatedwith
pediatricmalnutrition(undernutrition)indevelopingnations.3
Pediatricundernutritionhashistoricallybeenconsideredanissueexclusivetodeveloping
countries.Muchofthegroundbreakingresearchandinitialdevelopmentofmalnutrition
(undernutrition)criteriaoccurredwithpopulationsoutsideoftheUnitedStates,4whereacuteor
chronicinfectiousand/ordiarrhealdiseasearemajorcontributorstoitsdevelopmentandtohigh
ratesofmortality.However,theclinicalperspectiveanddescriptionofundernutritionhasevolved
duringthepast3decades.Unliketheundernutritiontypicallyobservedindevelopingcountries,
andusuallycategorizedasmarasmusand/orkwashiorkor,undernutritionindevelopedcountries
generallyoccursinthesettingofacuteorchronicillness.3
AnumberofUSchildrensufferfromenergyimbalanceandexcessratherthannutrientdeficiency.
Itisestimatedthatapproximately17%ofUSchildrenandadolescentsbetween2and19yearsof
ageareobese.5Otherdatasetsestimatethat1in10UShouseholdswithchildrenstrugglewith
foodinsecurity.6ThecurrentprevalenceofUSchildrenwhoexperienceacuteorchronic
undernutritionisunknown.Childrenandadolescentswholiveinhomelessshelters,arevictimsof
abuseorneglect,orliveinurbanorruralareaswhereaccesstohighqualityfoodisdifficult,are
thoughttobeatincreasedriskforundernutrition.
UndernutritionintheUnitedStatesismostfrequentlyobservedinhospitalizedacuteand/or
chronicallyillchildren,andinUSchildrenwithspecialhealthcareneeds.37Childrenwithspecial
needsaredefinedasthosewhohaveorareatincreasedriskforachronicphysical,
developmental,behavioral,oremotionalconditionandwhoalsorequirehealthandrelated
servicesofatypeoramountbeyondthatofchildrengenerally.7Thisdefinitionencompasses
childrenwithnutritionrelatedchronicdiseasesorconditions,congenitalanomalies,severeacute
illnessorinjury,andthoseaffectedbyabuseorneglect.
Childrenandyouthwithspecialhealthcareneedsshouldberoutinelyscreenedformalnutritionin
primarycaresettings.Registereddietitiannutritionists(RDNs),nurses,andallmembersofthe
healthcareteamshouldcollaboratetoensurethatscreeningformalnutritionbecomesanintegral
partofroutinepediatriccare.Althoughresearchislimited,malnutritioninthispopulationcan
leadtomorecomplicatedhospitalizationsduetoprogressionoftheunderlyingdiseaseor
condition,poorwoundhealing,orslowreturntopreviouslevelofactivity,complicationsthatcan
significantlyincreasethelengthofstayandcostofhospitalization.89Comprehensiveassessment
andnutritioninterventioninundernourishedandmalnourishedchildreninprimarycaresettings
canreducetheneedformorecostlyhospitalizationbyaddressingnutritionaldeficitsthat
canpredisposethepatienttoacuteillnessorexacerbatetheunderlyingdiseaseorcondition.10
Olderstudiessuggestthatupto25%ofallhospitalizedchildrenexperiencedacuteproteinenergy
malnutrition,andapproximately27%experiencechronicfoodinsecurity.611
Inadequateintake,selfstarvation,and/orpurgingbehaviorsassociatedwithdisordered
eating/eatingdisorderscanleadtomalnutrition.12Thesebehaviorsaremostcommonamong
teenagegirls.Itisestimatedthat0.5%ofadolescentssufferwithanorexianervosawithanother
1%to2%meetingadiagnosisofbulimianervosa.However,itisestimatedthatupto
14%ofadolescentssufferfrompartialsyndromesoreatingdisordernototherwisespecifiedand
alreadyhavesignsandsymptomsofmalnutrition.13Adolescentsoftentrytohideaberranteating
behaviors.Laboratoryparametersoftenremainnormalforaperiodoftimeafteraberranteating
behaviorshavebegun.Theadolescentmayalreadybeinanundernourishedstatebefore
presentingtoahealthcareprovider.14Infact,theRDNmaybethefirstprovidertorecognizethe
symptomsorthefirstprovidercontactedbythepatientorcaregivers.15
Purpose
Thepurposeofthisconsensusstatementistoidentifyabasicsetofindicatorsthatcanbeusedto
diagnoseanddocumentundernutritioninthepediatricpopulationages1monthto18years.The
indicatorsareintendedforuseinmultiplesettings,suchasacute,ambulatorycare/outpatient,
residentialcare,etc.Severalscreeningtoolshavebeendevelopedforuseinhospitalizedchildren.
16However,identifyingcriteriaforuseinscreeningfornutritionalriskisnotthepurposeofthis
paper.Thediagnosisanddocumentationofundernutritioninneonates,recognitionand
documentationofmicronutrientdeficitsinthepediatricpopulation,andstrategiestoaddress
micronutrientdeficitsarebeyondthescopeofthisstatement.Pleasereferto
publications/resourcesspecifictothesetopicsforadditionalguidance.17181920Thediagnosis
andtreatmentofpediatricobesity(overnutrition)arealsonotaddressedinthisstatement.
DefinitionofPediatricMalnutrition(Undernutrition)
Thefocusofthisconsensusstatementispediatricundernutrition.TheAmericanSocietyfor
ParenteralandEnteralNutrition(A.S.P.E.N.)hasdefinedpediatricmalnutrition(undernutrition)
asanimbalancebetweennutrientrequirementandintake,resultingincumulativedeficitsof
energy,proteinormicronutrientsthatmaynegativelyaffectgrowth,developmentandother
relevantoutcomes.21Pediatricundernutritionmayberelatedtoillness,adverseenvironmental
orbehavioralfactors,injury,congenitalanomalies,etc.TheUnitedNationsChildrensFund
(UNICEF)statesthatalthoughmalnutritionisabroadtermcommonlyusedasanalternativeto
undernutrition,ittechnicallyalsoencompassesovernutrition.22Peopleareconsideredto
bemalnourished(undernourished)iftheirdietdoesnotprovideadequateenergyandproteinfor
growthanddevelopment,oriftheyareunabletofullyutilizethefood/nutrientsduetoillness.
Childrenarealsoclassifiedasmalnourished(overnourished)iftheyconsumetoomuchenergy.
Althoughobesityisaformofmalnutrition,adiscussionofovernutritionisnotthepurposethis
article.
AcutevsChronicUndernutrition
Undernutritionisoftencharacterizedasacuteorchronic.Onewaytodistinguishbetweenacute
andchronicistime.Acutediseasesorconditionsaretypicallysevereandsuddeninonset.
Achronicdiseaseorconditiontendstodevelopandbecomemoresevereoveranextendedperiod
oftime.TheNationalCenterforHealthStatisticsdefineschronicasadiseaseorconditionthat
haslastedfor3monthsorlonger.23Achronicconditionmaycontributetoanacuteillness,justas
anacuteillnessmayevolveintoachroniccondition,ifunaddressed.
TheWorldHealthOrganization(WHO)andUNICEFhavealsoprovidedguidancetodistinguish
betweenacuteandchronicundernutritionbyofferingdiagnosticparametersthathelpclinicians
characterizetheacuitylevelofundernutritionexperiencedbypediatricpopulations.Weightis
primarilyaffectedduringperiodsofacuteundernutrition,andchronicundernutritiontypically
manifestsasstunting.Severeacuteundernutrition,experiencedbychildrenages6to60months
ofage,isdefinedasaverylowweightforheight(lessthan3standarddeviations[SD]zscores)
ofthemedianWHOgrowthstandards),byvisibleseverewasting(amidupperarmcircumference
[MUAC]115mm),orbythepresenceofnutritionaledema.Wastingisdefinedasaweightforage
lessthan2SD(zscore).2425ChronicundernutritionorstuntingisdefinedbyWHOashavinga
height(orlength)foragethatislessthan2SD(zscore)ofthemedianoftheNCHS/WHO
internationalreference.2425Anindepthdiscussionofthezscoreispresentedlaterinthispaper.
Stuntingisawellestablishedindicatorofchronicmalnutrition,particularlyundernutrition
relatedtoenvironmentalorsocioeconomiccircumstances.2425Theheightforagemeasurement
representsthelineargrowthorstatureactuallyachievedbythechildattheageatwhichthechild
ismeasured.Height(ie,stature)ismeasuredinthestandingposition.Lengthforagerefersto
measurementstakenintherecumbentpositionandisrecommendedforchildren2yearsofage.
26Childrenintheagerangeof0to4yearshavethebestpotentialoutcomesfromcomprehensive
assessmentformalnutritionbecausetimelyinterventionishighlylikelytopreventadverseeffects.
26Stuntingmaybeobservedduringadolescence,whichisalsoaperiodofrapidgrowthand
development.
TheFigure(tbl4)listsexamplesofsoftwareprogramsthatareavailableforindividualzscore
calculation.27Also,manygrowthcharts(Fenton,WHO,CentersforDiseaseControland
Prevention[CDC])areavailableonmobiletechnologyapplicationsandhavemadeplottingvery
easy.
Figure
Resourcesfordeterminingzscoresforanthropometrics.
CDCGrowthChartsa(hl0000054)
WHOGrowthChartsb(hl0000057)
STATGrowthCharts(compatiblewith
STATGrowthChartsWHO(compatiblewithiPod
iPodTouch,iPhone,iPad[AppleInc]) Touch,iPhone,iPad[AppleInc])
EpiInfoNutStat:(availablefor
download)
WHOzscorecharts:
CDCwebsite:zscoredatafiles
WHOMulticentreGrowthStudywebsite:Allfour
availableastables:
macros(SAS,Splus,SSPS,andSTATA)calculatethe
indicatorsoftheattainedgrowthstandards
PediToolsHome:Clinicaltoolsfor
pediatricprovidersgrowthcharts,
PediToolsHome:Clinicaltoolsforpediatricproviders
growthcharts,calculators,etcmobilecompatible
calculators,etcmobilecompatible
aCDC=CentersforDiseaseControlandPrevention.
bWHO=WorldHealthOrganization.
IndicatorsofPediatricUndernutrition
Astandardizedapproachtotherecognitionanddiagnosisofpediatricundernutrition,particularly
inthepediatricpopulationolderthan60months,islacking.Controversysurroundingthebest
andmostusefulapproach(es)abound.Therefore,routineassessmentofnutritionalstatusinhigh
riskchildrenintheUnitedStatesissporadicandinconsistentamongfacilities.Atruemeasureof
theimpactofpediatricundernutritiononoverallhealthisdifficulttoobtain.TheUSSurveyof
ChildrenwithSpecialHealthCareNeeds7doesnotcurrentlyincludeassessmentof
food/nutritionservicesprovidedthisdatadeficitmustbeaddressedandthesurveyinstrument
revisedtoaccommodatethecollectionofsuchdata.
AttributesofIndicatorsSelectedforInclusion
Amultitudeofparametershavebeendevelopedforobtainingmeasurementsinchildreninan
efforttodeterminenutritionalstatus.However,theincreasingeconomicconstraintsofthe
UShealthcaresystemmandateidentificationofthemostreliable,reproducible,safe/lowrisk,and
costeffectiveindicatorstosupportnutritionevaluation.Attributesoftheindicatorsthatwe
recommendareasfollows:
areevidenceinformed/consensusderived
areuniversallyavailableandvalidated
canbeappliedinexpensivelyinmultiplesettings
canbeproperlyusedwithminimaltraining
canreproduciblyidentifyundernutrition
canquantifyseverityofundernutritionand
canbeusedtomonitorchangesinnutritionalstatus.
Indicatorsrecommendedtoidentifypediatricmalnutritionaretypicallycontinuousratherthan
discretevariables.Assuch,clinicalexpertiseandsoundclinicaljudgmentmustbeexercisedwhen
obtainingahistory,completingthephysicalexamination,developingdifferentialdiagnostic
options,makingadiagnosis,andimplementingandmonitoringaplanofcare.Rememberthatthe
recommendedlistofindicatorstobeassessedmaychangeovertime,asevidencetosupportor
todiscontinuetheiruseaccrues,orasadvancesinassessmenttechnologysupplanttheiruse.
ConsensusRecommendations
Werecommendthatthefollowinglistofindicatorsbeusedwhenassessinganddiagnosing
pediatricmalnutrition:
Food/NutrientIntake
Foodandnutrientintakearetheprimarydeterminantsofnutritionalstatus.Therefore,accurate
assessmentofintakeandestimationofadequacyiscritical.Theprimaryconcerniswhetherornot
thechildscurrentintakeisadequatetomeettheirnutrientneedsinthecontextoftheircurrent
clinicalsituation,growthpattern,anddevelopmentallevel.21Otherdiagnosticindicatorsare
basicallyoutcomemeasuresofdietaryadequacy.
Estimatesoftheadequacyofprotein/energyintakeshouldberoutinelydeterminedforallchildren
andespeciallyinthoseidentifiedasatincreasedriskformalnutrition.Accuracyintheestimation
ofadequacyofnutrientneedsandassessmentoftheadequacyoffoodandnutrientintakeare
crucialtodeterminingthemagnitudeofthedeficit,aswellastheextentandacuityofthedeficit.
Food/nutrientintakedetailscanbeobtainedbyhistoryand/orbydirectobservationoffood
and/ornutrientsconsumed.Prescribednutritiontherapyintakeshouldbemonitoredtoensure
thattheintendedamountsareactuallyingestedbythechild.
AssessmentofEnergyandProteinNeeds
Energyneedscanbemeasuredbyindirectcalorimetry2829orestimatedthroughtheuseof
standardequations.30Eachofthemethodstoestimateenergyneedsarejustthat,anestimation.
Ideally,cliniciansshouldperformindirectcalorimetrytomeasureachild'sactualenergy
requirements.Indirectcalorimetryisthemostprecisemethodforthedeterminationofenergy
expenditurebecausepredictiveequationsdonotaccuratelydetermineenergyexpenditureor
accountforthevariabilityofachildsmetabolicstateduringthecourseofanillness.2829The
FoodandAgricultureOrganization/WHO31andSchofield32equations,althoughimpreciseand
developedtoestimatetheenergyutilizationofhealthychildren,arethemostwidelyusedformulas
toestimateenergyneeds.Theseequationsarefrequentlyusedwhenequipmentforindirect
calorimetryassessmentisunavailable.Estimationofenergyrequirementcanalsobedetermined
usingthe1989RecommendedDietaryAllowance33orthe2005DietaryReferenceIntake
estimatedenergyrequirements.19However,bothofthesemethodsalsorepresentestimationsof
theenergyneedsofthehealthychild.30Predictiveequationsfordeterminingenergy
requirementscanbeusedinitiallyandaresummarizedinTable1(tbl1).
Table1
Estimatingnutrientneeds:A.S.P.E.N.2010PediatricNutritionSupportCoreCurriculum[objectObject]
Nameofequation
orformulaand
Descriptionand
applicationto
Calculationsfortheequationorformula
source
patient
population
Energy
1989
Basedonthe
Infants:0to0.5y:108weight(kg)0.5to1y:
Recommended
DailyAllowance
medianenergy
intakesofchildren
98weightChildren:1to3y:102weight4to6y:
(RDA)Committee
inDietary
Allowances,Food
andNutrition
90weight7to10y:70weightMales:11to14y:
followedin
55weight15to18y:45weightFemales:11to14y:
longitudinalgrowth
47weight15to18y:40weight
studiesItcan
overestimate
Board,National
needsinnonactive
ResearchCouncil. populations(eg,
Recommended
Dietary
bedridden)and
doesnotprovidea
Allowances.10th
ed.Washington,
rangeofenergy
DC:National
Academies
outdated
reference,still
Press1989.
widelyusedMost
oftenusedfor
needsAlthoughan
healthyinfants
andchildren
Estimatedenergy
requirements
Replacesthe1989 EER=totalenergyexpenditure(TEE)+energy
RDAEnergy
depositionAges0to36mo:0to3mo:(89weight
(EER)(new
needswere
determinedfrom
[kg]100)+1754to6mo:(89weight[kg]100)+567
(89weight[kg]100)+20Ages3to8yboys:
equation)and
childrenwith
normalgrowth,
physicalactivity
(PA)coefficients
bodycomposition,
andactivity,and
[kg]+903height[m])+20kcalPA=1ifPALis
NationalAcademy
ofSciences,
whoarealso
metabolically
Instituteof
Medicine,Food
normalChildren
withnormal
andNutrition
growth,body
composition,and
girls:EER=135.3(30.8age[y])+PA(10weight
activity,andwho
arealso
estimatedtobe>1<1.4(sedentary)PA=1.16ifPALis
metabolically
isestimatedtobe>1.6<1.9(active)PA=1.56ifPALis
normalFour
estimatedtobe>1.9<2.5(veryactive)Ages9to18y
DRI/IOMb
(hl0000323)
Board.Dietary
ReferenceIntakes
forEnergy,
Carbohydrate,
Fiber,Fat,Fatty
Acids,Cholesterol, categoriesof
Protein,andAmino physicalactivity
Acids
to12mo:(89weight[kg]100)+2213to36mo:
EER=88.5(61.9age[y])+PA(26.7weight
estimatedtobe>1.4<1.6(lowactive)PA=1.26ifPAL
estimatedtobe>1.9<2.5(veryactive)Ages3to8y,
Boys:EER=88.5(61.9age[y])+PA(26.7weight
Acids
(Macronutrients)
level(PAL)
(2005).
estimatedtobe>1.9<2.5(veryactive)Ages9to18y
Girls:EER=135.3(30.8age[y])+PA(10weight
estimatedtobe>1.9<2.5(veryactive)
EER(newDRI/IOM Overweight
WeightmaintenanceTEEinoverweightboysAges3
equation)and
obesity
to18y:TEE=114(50.9age[y])+PA(19.5weight
childrenwhoare
metabolically
[kg]+1,161.4height[m])PA=1ifPALisestimatedto
coefficients/factors normal
NationalAcademy
be>1<1.4(sedentary)PA=1.12ifPALisestimatedto
ofSciences,
Instituteof
tobe>1.6<1.9(active)PA=1.45ifPALisestimated
Medicine,Food
andNutrition
TEEinoverweightgirlsages3to18y:
be>1.4<1.6(lowactive)PA=1.24ifPALisestimated
tobe>1.9<2.5(veryactive)Weightmaintenance
TEE=389(41.2age[y])+PA(15weight
Board.Dietary
ReferenceIntakes
[kg]+701.6height[m])PA=1ifPALisestimatedtobe
>1<1.4(sedentary)PA=1.18ifPALisestimatedtobe
forEnergy,
Carbohydrate,
>1.4<1.6(lowactive)PA=1.35ifPALisestimatedto
be>1.6<1.9(active)PA=1.6ifPALisestimatedtobe
Fiber,Fat,Fatty
Acids,Cholesterol,
>1.9<2.5(veryactive)
Protein,andAmino
Acids
(Macronutrients)
(2005).
SchofieldWN.
Predictingbasal
Apredictive
equationfor
metabolismrate,
calculatingbasal
newstandardsand metabolicrate
reviewofprevious
work.HumNutr
(BMR)inhealthy
childrenthatwas
developedby
ClinNutr.
198539(suppl1):5 analysisofFritz
Talbottables
41.
Healthychildren,
acutelyillpatients
inthehospital
setting
Males:0to3y:(0.167weight[kg])+(15.174height
[cm])617.63to10y:(19.59weight[kg])+
(1.303height[cm])+414.910to18y:(16.25weight
[kg])+(1.372height[cm])+515.5>18y:
(15.057weight[kg])+(1.0004height[cm])+705.8
Females:0to3y:(16.252weight[kg])+
(10.232height[cm])413.53to10y:(16.969weight
[kg])+(1.618height[cm])+371.210to18y:
(8.365weight[kg])+(4.65height[cm])+200>18y:
(13.623weight[kg])+(23.8height[cm])+98.2)
FAO/WHOc
TheWHO
Males:0to3y:(60.9weight[kg])543to10y:
(hl0000326)World
equationwas
developedforuse
(22.7weight[kg])+49510to18y:(17.5weight
Health
[kg])+651Females:0to3y:(61weight[kg])513to
Protein
Requirements.
inhealthychildren,
10y:(22.5weight[kg])+49910to18y:(12.2weight
however,itis
[kg])+746
commonlyusedto
predictresting
ReportofaJoint
FAO/WHO/UNU
energy
expenditure(REE)
Expert
Consultation.
ofacutelyill
TechnicalReport
Series724.
hospitalsetting
Organization.
Energyand
patientsinthe
Geneva:World
Health
Organization1985.
Estimatingcalorie
Childrenwith
Cerebralpalsy(age5to11yd(hl0000329)):Mildto
needsfor
developmental
developmental
disabilities(DD)
moderateactivity:13.9kcal/cmheightSevere
disabilities
RokusekC,
HeindiclesE.
Nutritionand
Feedingofthe
Developmentally
Disabled.
Brookings,SD:
physicalrestrictions:11.1kcal/cmheightSevere
mayhaveaslower restrictedactivity:10kcal/cmheightAthetoidcerebral
basalenergyneed
palsy:Upto6,000kcal/day(adolescence)Down
duetodecreased
syndrome(5to12yd(hl0000329)):Boys16.1kcal/cm
muscletone,
heightGirls14.3kcal/cmheightPraderWilli
growthrate,and
syndrome(forallchildrenandadolescents):10to11
motoractivityThe
kcal/cmheightformaintenance8.5kcal/cmheightfor
recommendation
weightlossMyelomeningocele(spinabifida)(older
tocalculate
than8yofageandminimallyactive):9to11kcal/cm
energyneedsin
SouthDakota
heightformaintenance7kcal/cmheightforweight
UniversityAffiliated childrenwithDD
percmofheightis lossApproximately50%RDAforageafterinfancy
Program,
basedonthefact
Interdisciplinary
Centerfor
Disabilities1985.
thattheytendto
haveashorter
heightwhen
comparedto
childrenwith
normalgrowth
ChildrenwithDDs
Peterson'sFailure
toThrivePeterson
KE,etal.Team
managementof
Thiscalculates
[RDAforweightage(kcal/kg)idealbodyweightfor
nutrientsinexcess height]actualweight
ofthe
requirementsof
managementof
requirementsof
failuretothrive.
theRDAConcerns
withusingthis
JADA.
198484(7):810
815.
equationinclude
refeeding
syndromeInfants
andchildrenwho
present
underweightand
needtoachieve
catchupgrowth
FAO/WHO/UNUe
(hl0000332)(aka
Overweight/obese
adolescentsinan
Boys10to18yBMR=16.6weight(kg)+77height
Dietzequation)
outpatientsetting
height(m)+217
(m)+572Girls10to18yBMR=7.4weight(kg)+482
DietzWH,Bandini
LG,SchoellerDA.
Estimatesof
metabolicratein
obeseandnon
obeseadolescents.
JPediatr.
1991118:146149.
Whiteequation
WhiteMS,
ShepherdRW,
McEnieryJA.
Developedforuse EE(kJ/day)=(17age[mo])+(48weight[kg])+
inthepediatric
(292bodytemperature[C])9,677
criticalcare
populationby
Energyexpenditure including
temperatureasa
in100ventilated,
criticallyillchildren: gaugeofthe
bodys
improvingthe
accuracyof
predictive
inflammatory
equations.Crit
commonlyusedin
clinicalpractice,
CareMed.
200028(7):2307
2312.
responseItisnot
andrecentstudies
haveshown
decreased
accuracy
especiallyin
smaller,younger
patientsThis
equationshould
notbeusedin
patientsyounger
than2moofage
Pediatriccritical
carepopulation
Stressfactorsforenergy
Stressfactors
Theuseofstress
Starvation0.70to0.85Surgery1.05to1.5Sepsis1.2
LeonbergB.ADA
PocketGuideto
factorsalongwith
predictiveenergy
to1.6Closedheadinjury1.3Trauma1.1to1.8
PediatricNutrition
equationsshould
Assessment.
beconsideredfor
Chicago,IL:
AmericanDietetic
useinhospitalized
childrenwhose
Association2007.
energy
Table8.10.
requirementsmay
Growthfailure1.5to2Burn1.5to2.5
bealtereddueto
metabolicstress
Pediatric
hospitalized
population
Protein
A.S.P.E.N.Clinical
Metabolicstress
Guidelines:
increases
NutritionSupportof catabolismand
theCriticallyIll
breakdownoflean
ChildMehtaNM,
bodymassTo
CompherC,
ASPENBoardof
meetthe
increased
Directors.
demandsof
A.S.P.E.N.Clinical
metabolicstress
Guidelines:
andsparetheuse
NutritionSupportof ofendogenous
theCriticallyIll
proteinstores,a
Child.JPENJ
greateramountof
ParenterEnteral
Nutr.
proteinisneeded
inthispopulation
200933(3):260
untilthe
276.
underlyingstress
hasbeen
overcome
Recommendations
0to2y:2to3g/kg/day2to13y:1.5to2g/kg/day13
to18y:1.5g/kg/day
arebasedon
limiteddata
Pediatriccritical
carepopulation
Fortheinjured
Metabolicstress
0to2y:2to3g/kg/day2to13y:1.5to2g/kg/day
childJaksicT.
increases
Adolescents:1.5g/kg/day
Effectiveand
efficientnutritional
catabolismand
supportforthe
bodymassTo
injuredchild.Surg
meetthe
ClinNorthAm.
200282(2):379
increased
demandsof
391,vii.
metabolicstress
breakdownoflean
andsparetheuse
ofendogenous
proteinstores,a
greateramountof
proteinisneeded
inthispopulation
untilthe
underlyingstress
hasbeen
overcome
Pediatric
critical/surgical
carepopulation
DietaryReference
Replacesthe1989 0to6mo:1.52g/kg/day(ThisisanAdequateIntake
Intake(DRI)
RDAProtein
recommendation,notenoughresearchhasbeen
NationalAcademy
ofSciences,
needswere
determinedfrom
conductedtoestablishanRDAforthisagegroup.)6
Instituteof
childrenwith
13y:0.95g/kg/day14to18y:0.85g/kg/day>18y:
Medicine,Food
normalgrowth,
andNutrition
Board.Dietary
bodycomposition,
andactivity,and
ReferenceIntakes
whoarealso
forEnergy,
metabolically
Carbohydrate,
Fiber,Fat,Fatty
normalChildren
withnormal
Acids,Cholesterol,
growth,body
Protein,andAmino composition,and
Acids
(Macronutrients)
activity,andwho
arealso
metabolically
to12mo:1.2g/kg/day12to36mo:1.05g/kg/day4to
0.8g/kg/day
metabolically
(2005).
normal
1989
Basedonthe
0to6mo:2.2g/kg/day6to12mo:1.6g/kg/day1to3
Recommended
mediannutrient
y:1.2g/kg/day4to6y:1.1g/kg/day7to14y:1
Dietary
Allowance(RDA)
intakesofchildren
followedin
g/kg/day15to18y(males):0.9g/kg/day15to18y
Committeein
longitudinalgrowth
Dietary
studiesItcan
Allowances,Food
andNutrition
overestimate
needsinnonactive
Board,National
populations(eg,
(females):0.8g/kg/day
ResearchCouncil. bedridden)and
Recommended
Dietary
doesnotprovidea
rangeofenergy
Allowances.10th
needsAlthoughan
ed.Washington,
outdated
DC:National
Academies
reference,still
Press1989.
Childrenwith
widelyused
normalgrowth,
bodycomposition,
andactivity,and
whoarealso
metabolically
normal
Peterson'sFailure
Thiscalculates
toThrivePeterson
KE,etal.Team
nutrientsinexcess weightforage(kg)]actualweight(kg)
ofthe
managementof
requirementsof
failuretothrive.
theRDAConcerns
JADA.
198484(7):810
withusingthis
equationinclude
815.
refeeding
syndromeItcan
becalculated
usingamethod
similartotheone
forcaloriesabove
Infantsand
childrenwho
present
underweightand
needtoachieve
[Proteinrequiredforweightage(g/kg/day)ideal
needtoachieve
catchupgrowth
aAdaptedfromCarneyLN.Assessmentofnutritionstatusbyageanddeterminingnutrientneeds.
In:CorkinsMR,BalintJ,BoboE,PlogstedS,YaworskiJA,eds.TheA.S.P.E.N.PediatricNutrition
SupportCoreCurriculum.SilverSpring,MD:AmericanSocietyforParenteralandEnteral
Nutrition2010:418419,withpermissionfromtheAmericanSocietyforParenteralandEnteral
Nutrition(A.S.P.E.N.).A.S.P.E.N.doesnotendorsetheuseofthismaterialinanyformotherthan
itsentirety.
bDRI/IOM=DietaryReferenceIntake/InstituteofMedicine.
cFAO/WHO=FoodandAgriculturalOrganizationoftheUnitedNations/WorldHealth
Organization.
dThisreferenceappliestothespecificageslisted.Pleaserefertoanotherequationforages
outsideofthereferencedages,andapplyanappropriateactivity/stressfactor.
eUNU=UnitedNationsUniversity.
TheDietaryReferenceIntakeforprotein19istypicallyusedtoestimateproteinneedsforboththe
healthychildandthehospitalizedchild.However,thechildsclinicalstatusshouldbeconsidered
whenestimatingproteinrequirements.Somesituationsmayrequireproteinintakesgreaterthan
theDietaryReferenceIntaketoachieveapositivenitrogenbalance.Examplesincludemajor
surgery,woundhealing,infection,andcatchupgrowth.Conversely,somesituations(eg,critically
illpatientwithacuterenalfailure)maywarrantmoderateproteinrestriction.Acomprehensive
discussionofthisissueisbeyondthescopeofthisarticle,butmaybefoundelsewhereinthe
literature.303435363738
GrowthParameters
Growthistheprimaryoutcomemeasureofnutritionalstatusinchildren.213039Growthshould
bemonitoredatregularintervalsthroughoutchildhoodandadolescenceandshouldalsobe
measuredeverytimeachildpresents,inanyhealthsetting,forpreventive,acute,orchroniccare.
Inchildrenyoungerthan36monthsofage,measuresofgrowthincludelengthforage,weight
forage,headcircumferenceforage,andweightforlength.Inchildrenages2to20years
standingheightforage,weightforage,andbodymassindex(BMI)foragearetypically
collected.4041424344
Anthropometricmeasuresofgrowtharetypicallyexpressedandreportedincomparisonto
populationdata.Traditionally,thesemeasuresareexpressedaspercentilesandexpresstherank
orpositionofachildsmeasurementsonastandardreferencecurve.Percentilesindicatethe
portionofthereferencepopulationthatliesaboveorbelowthatofthechildbeingmeasured.Itis
usedtohelpparentsunderstandwheretheirchildfitsinapopulationofchildrenofsimilarages,
heights,and/orweights.Thechartsaredesignedsothatgrowthtrendsintheindividualchildcan
beobservedovertime,andgrowthproblems,whendetected,areaddressedinatimelymanner.40
However,apercentiledoesnotrevealtheactualdegreeofdeviationfrompopulationnorms.The
percentilewillalwaysbepositivebecausethebellshapedcurve,statistically,hasaninfinitetailon
bothsides.
Morerecently,growthchartsthatfacilitatecomparisonofunitsofSDfromnormsforreference
agegroups,zscore(SD)comparisons,arerecommendedfortrackingandassessingnutritional
statusinchildren.214445Azscoreisastatisticalmeasurethattellshowasingledatapoint
comparestonormaldataand,ifaboveorbelowaverage,howatypicalthemeasurementis.
Growthmeasurementsthatcrosszscorelinesindicatepossiblerisk.Childrenwhoaregrowing
anddevelopingnormallywillbeonorbetween1and1zscoreofagivenindicator.Interpretation
ofthesignificanceofzscoredataisbasedonthepointatwhich,inthechildspatternofgrowth,
thechangebeganandthechildshealthstatusrelativetothepointandprogressionofchange.21
4647
TheCDCrecommendthattheWHOcomparativedatachartsbeusedasnormativestandardsfor
USchildrenfrombirthto2yearsofageandthattheCDCcomparativedatachartsbeusedas
normativestandardsforUSchildrenages2to20years.44AccordingtotheCDC,growthcharts
arenotintendedforuseasasolediagnosticinstrument,butcontributetotheformationofan
overallclinicalimpressionofthechildbeingassessed.
WeightGainVelocity
Mehtaandcolleagues21suggestthatabetterdefinitionofmalnutritionshouldincludegoalsof
earlyidentificationofchildrenatriskformalnutritionandthedevelopmentofthresholdsfor
intervention.Onecriterionfortheearlyidentificationofundernutritionistheassessmentof
growthvelocityanditscomparisontoastandard.TheA.S.P.E.N.workgroupincludedgrowth
withinitsfivedomains,aspartoftheconstructofthedefinitionofpediatricmalnutrition.21
Growthisdefinedasanincreaseinsizeandthedevelopmenttomaturity,andgrowthvelocityas
therateofchangeinweightorlength/heightovertime.Thisrateofchangecanbeinterpretedas
anearlysignofhealthyorunhealthyresponsetothenutritionalenvironment.48Uponinitial
presentation,lengthforchildrenunder24monthsofageandheightforchildrenolderthan24
monthsofagereflectsthechildsnutritionalstatusoveraprolongedperiodoftime.Anegativez
scorecanbeusedtodeterminepediatricmalnutritionwhenonlyasingledatapointisavailable.
Overtime,declinesinzscoresforlength/heightcanalsobeusedasacharacteristictodetermine
undernutrition.
Averagedaily/monthlyratesofweightgainthatallowachildtoremainstableonagrowthcurve
occurwhenadequatenutrientintaketakesplace.Theseratesaredeterminedbythetrajectoryof
thegrowthcurveandvarybyageandperiodofdevelopment.Duringperiodsofgrowth,an
averagedailyormonthlyweightgainisrequiredforthechildtoremainstableonthegrowth
curve.Verylowweightvelocityasoccurswithlackofweightgainandweightlossinachild,has
beennotedtobeindependentlyandmorecloselyrelatedtomortalitythanotherindicatorsof
malnutrition,suchasBMIforage.49
Thereisatremendousamountofplasticityingrowthintheshortterm.Thisadaptiveresponseis
seenwhenaneventsuchasillnessortraumaoccursthatresultsincessationofgrowth.With
ongoingadequatenutrientintake,thechildrecoversandcatchupgrowthwithgreaterthan
normalratesofweightgainvelocityresults.50
MUAC
MUACshouldbemeasuredwhenassessingthenutritionalstatusofpediatricpatients.20MUAC
canbeusedasanindependentanthropometricassessmenttoolindeterminingmalnutritionin
children6to59monthsofagewhencomparedwiththestandardsdevelopedbyWHO.51
AlthoughreferencerangeswithSDsarenotavailableforolderchildrenandadolescents,
Frisancho52providespercentileguidelinesforages1to79years.MUAChasbeencorrelatedto
BMIinchildren5354andadults55andhasshowntobemoresensitivetochangesinmuscleand
fatmassthanBMIinadults.55
MUACmeasurementsshouldbepartofthefullanthropometricassessmentinallpatients,andare
particularlyimportantinthosewhoseweightmaybeaffectedbylowerextremityedema,ascites,
orsteroids,asweighttrendsaloneareunreliablerelatedtofluidstatus.Whenserialzscoresare
unavailable,serialMUACmeasurementscanbeusedtomonitorchangesinbodycomposition
usingthechildashisorherowncontrol.MUAChasbeenindicatedasamoresensitiveprognostic
indicatorformortalitythanweightforheightparametersinmalnourishedpediatricpatients.56
57Itisadvisabletohavetrainedindividualsconsistentlyperformthesemeasurementsforbest
longtermcomparisonofdata.
HandgripStrength
Handgripstrengthisasimple,noninvasivemeasurementcommonlyusedtomeasurebaseline
functionalstatusandtrackprogressthroughoutthecourseoftherapy.Usingahandheld
dynamometer,subjectsperformaseriesofstandardizedmovementsthatmeasurethemaximum
isometricstrengthofthehandandforearmmuscles.Thedynamometerisasimple,noninvasive,
andlowcostinstrumenttomeasurefunctionalstatus.
Inthehospitalizedsetting,handgripstrengthhasbeenshowntopredictpostoperative
complications,lengthofhospitaladmission,readmission,likelihoodofreturningtoprevious
homesetting,andmortality.58Becausemusclefunctionreactsearliertochangesinnutritional
statusthanmusclemass,handgripstrengthmaybeamoreacutemeasurementofresponseto
nutritioninterventionsthantraditionalbiochemicaloranthropometricmeasurementsinchildren
ages6yearsandolder.Inhospitalizedpediatricpatients,handgripstrengthhasbeenusedasa
simplenoninvasivetestoffunctionalcapacityatadmissionforsurgery.BMIzscorescorrelated
withtheadmissionhandgripstrengthmeasurement,regardlessofsex,age,diseaseseverity,or
anthropometriccharacteristics.59
Accuratehandgripmeasurementsrequireprocedurestandardization.Equipmentcalibration,
adequatestafftraining(patientpositioning/dynamometersetting),anduseoftheappropriate
referencerange(devicedependent)areimportantcomponentsinensuringaccurateresults.5859
60Appropriateageandsexspecificreferencerangesmustbeused.Inpediatricpopulations,
handhelddynamometryhasbeenprovenfeasibleandreliableacrossawideagerange(6years
andolder)andmultiplediagnoseshowever,normalreferencerangesinlargepopulationshave
notbeenestablished.Mild,moderate,andseveredeficitrangesasmeasuredbyhandgripstrength
havenotbeenestablished,therefore,handgripstrengthcanhelptoidentifythepresenceof
malnutritionbutnottoquantifythedegreeofthedeficit.
ProxyMeasuresasSubstitutesforTraditionalAnthropometricMeasures
Inselecteddiseasesorconditions,physicalanomaliesorpatientfrailtymaylimittheclinicians
abilitytoobtainthetypicalanthropometricmeasurementsusedtoassessgrowth.Anumberof
alternativemeasurementshavebeenusedinsuchinstancestoestimateweightandlength.2030
PleaserefertoTable1(tbl1)forexamplesofsuchproxymeasuresandreviewrelevantliteratureto
determinewhichmeasuresofferthegreatestaccuracyintheclinicalcontextinwhichthepatient
presents.
DocumentationofTannerStage
Thereisawellrecognizedassociationbetweennormalpubertaldevelopmentandnutritional
statushowever,determinantsoftheageofonsetofpubertyaremultifactorial.AlthoughTanner
stagecannotbeusedasamarkerofnutritionalstatusinprepubescentchildren,itmightbeuseful
asanindirectindicatorinpreteensandadolescentswhohaveenteredpuberty,whenTanner
progressionorstagnationmaybeinfluencedbynutritionalstatus.
Theonsetofpubertyvariesfromindividualtoindividual,witharangeofabout5years.61Basic
inheritedgeneticdeterminantsinteractwithenvironmentalinfluencestotriggertheonsetof
puberty.61Pubertaldevelopmentisclassicallystagedbyasetofphysicalparametersdescribedby
MarshallandTanner.6263Reportsfromdevelopingcountriesindicatethatgirlswithlower
weightandheightareatlowerTannerstagesthantheirpeersofthesameage.6465USdatafrom
thelastNationalHealthandNutritionExaminationSurveyIII(19881994)foundasignificant
discordanceforTannerstagingbetweenthephysicalparametersforboysandgirlsiftheweight
andBMIwereaboveorbelowthemeanofchildrenintheirsameagegroup.66
TheuseofTannerstagingasanutritionmarkerislimitedbythesignificantdegreeofvariabilityin
geneticdeterminantsfortheonsetofpubertyfromonechildtoanother.Thereisalsothecurrently
unknowncorrelationofhowpubertaldevelopmentcouldbealteredtoagreaterorlesserextent
dependingonthedegreeofmalnutrition.Thisiscertainlyafertileareaforadditionalresearch.
ClassifyingPediatricMalnutrition
Historically,pediatricmalnutritionrelatedtoundernutritionhasbeenclassifiedasapercentageof
idealbodyweight.Thistypeofdistributionofpercentagesofidealbodyweightwasfirstdescribed
byGomezandcolleagues,41whodemonstratedacorrelationbetweentheseverityof
undernutritionanddeath.TheGomezClassification41andtheWaterlowCriteria67usethis
standardanddefinemild,moderate,andseveremalnutritionas76%to90%,61%to75%,<60%,
41and80%to89%,70%to79%,and<70%,67respectively.
Inthepast,thedefinitionsofundernutritionandfailuretothriveincludeddecreasesintwocentile
channelsorfalteringgrowthasweightgainbelowthefifthpercentile.676869Adecelerationof
weightintimehasalsobeenusedtodefinemalnutrition.70Theuseofzscore,declineinzscore,
andnegativezscoretoidentifyanddocumentpediatricmalnutrition/undernutritionisnow
recommended.
ClassificationofundernutritionusingMUACmeasureswassuggestedinchildrenbetweenthe
agesof6and60months.Childrenwhoareseverelymalnourishedaredefinedasthosewith
measurements<11.5cm,moderatelymalnourishedisthosewithmeasurementsbetween11.5and
12.4cm,andthoseatriskofmalnutritionarethosewithmeasurementsbetween12.5and13.4cm.
71
AnanalysisbytheWHOandUNICEFshowedthatchildrenwithaweightforheightwithzscores
lessthan3SDwereataninefoldgreaterriskofdeaththenwerechildrenwithazscoreof1SD.
21SimilarstudiesusingMUACasadiagnosticcriteriashowedthatriskofdyingincreasedwith
measuresof11.5cm.7273747576
Mildmalnutritionrelatedtoundernutritionisusuallytheresultofanacuteevent,eitherdueto
economiccircumstancesoracuteillnessandpresentswithunintentionalweightlossorweight
gainvelocitylessthanexpected.
Moderatemalnutritionrelatedtoundernutritionoccursduetoundernutritionofsignificant
durationthatresultsinweightforlength/heightvaluesorBMIforagevaluesthatarebelowthe
normalrange.
Severemalnutritionrelatedtoundernutritionoccursasaresultofprolongedundernutritionand
ismostfrequentlyquantifiedbydeclinesinratesoflineargrowththatresultinstunting.
Oninitialpresentation,achildmayhaveonlyasingledatapointforuseasacriterionforthe
identificationanddiagnosisofmalnutritionrelatedtoundernutrition.Whenthisisthecase,the
useofzscoresforweightforheight/length,BMIforage,length/heightforageorMUACcriteriaas
statedinTable2(tbl2)isindicated.
Table2
Primaryindicatorswhenonlyasingledatapointisavailableforuseasacriterionforidentificationand
diagnosisofmalnutritionrelatedtoundernutrition:AcademyofNutritionandDietetics/AmericanSocietyof
ParenteralandEnteralNutrition2014PediatricMalnutritionConsensusStatement[objectObject],[object
Object],[objectObject],[objectObject],[objectObject]
Primary
Mildmalnutrition
Moderatemalnutrition
indicators
Severe
malnutrition
Weightforheightz 1to1.9zscore
2to2.9zscore
3orgreaterzscore
1to1.9zscore
2to2.9zscore
3orgreaterzscore
Nodata
Nodata
3zscore
score
BMIa(hl0000388)
foragezscore
Length/heightz
score
Midupperarm
Greaterthanorequal
Greaterthanorequal
Greaterthanor
circumference
to1to1.9zscore
to2to2.9zscore
equalto3zscore
aBMI=bodymassindex.
Whenachildpresentswithhistoricalmedicalinformationandtwoormoredatapointsare
availableforuseascriteriafortheidentificationanddiagnosisofmalnutritionrelatedto
undernutrition,thecriteriainTable3(tbl3)mightalsobeusedtosupportmalnutritions
(undernutrition)identificationanddiagnosis.The1982Fomandataarestillbeingusedasgrowth
velocitystandards,butwerecommendusingtheWHOdataforpatients<2yearsofage.77
Table3
Primaryindicatorswhentwoormoredatapointsareavailableforuseascriteriaforidentificationand
diagnosisofmalnutritionrelatedtoundernutrition:AcademyofNutritionandDietetics/AmericanSocietyof
ParenteralandEnteralNutrition2014PediatricMalnutritionConsensusStatement[objectObject],[object
Object],[objectObject],[objectObject],[objectObject]
Primary
Mildmalnutrition
Moderatemalnutrition
Severemalnutrition
Weightgain
<75%a(hl0000445)of
<50%a(hl0000445)of
<25%a(hl0000445)of
velocity(<2yof
thenormb(hl0000450)
thenormb(hl0000450)
thenormb(hl0000450)
age)
forexpectedweightgain forexpectedweightgain forexpectedweightgain
Weightloss(2
5%usualbodyweight
7.5%usualbodyweight 10%usualbodyweight
Declineof1zscore
Declineof2zscore
Declineof3zscore
Inadequate
51%to75%estimated
26%to50%estimated
25%estimated
nutrientintake
energy/proteinneed
energy/proteinneed
energy/proteinneed
indicators
to20yofage)
Decelerationin
weightfor
length/heightz
score
aFromGuoetal.
bWorldHealthOrganizationdataforpatientsyoungerthan2yold.
NutritionSurveillanceandContinuityofCare
Oncethediagnosisofpediatricundernutritionismade,itiscrucialtodeterminehowoften
nutritionalstatusshouldbemonitoredandwhatprocesseswillbeestablishedtoensurecontinuity
ofcarebetweensettings.Thesequestionsrequireanswersthatensureimprovedoutcomesforthe
childwiththisdiagnosis.
OneofthemandatesoftheAffordableCareActandmeaningfuluseistofacilitatecaretransition
acrossthehealthcaresystem.78TheCentersforMedicareandMedicaidServiceswillrequire
monitoringandreevaluationofpatientshealthconditionsandthatcontinuationofcareis
planned,executed,anddocumented(seewww.HealthIT.gov(http://www.healthit.gov)).Aspecific
timeframefortheserequirementshasyettobedelineated.Providingnutritionsurveillancewill
undoubtedlyimproveoutcomesandreducehospitalreadmissionrates.Thenutritioncareprocess
79providesguidelinesformonitoringandevaluationofnutritiontherapyprovided.Theideal
frequencyfornutritionsurveillance,however,remainselusive.
Itwillbedifficulttostandardizefollowupsurveillanceintervalsbecauseofthegreatvariationin
severityofgrowthfailure,nutritionalhabits,andincoexistingmorbidities,chronicdisease(s),
socialsituations,etc.80818283Optimally,followupintervalsforpediatricmalnutrition
(undernutrition),likeanyothermedicalcondition,shouldbeindividualized.
CalltoAction:NextSteps
Thisconsensusstatementrepresentsastartingpointintheefforttostandardizeadiagnostic
approachtotheidentificationanddocumentationofpediatricundernutrition.Itisimportantthat
allclinicianscaringforpediatricpatientsusetherecommendeddiagnosticindicatorstoidentify
anddocumentnutritionalstatusinchildrenandadolescents.Itisalsoimperativethatclinicians
makeeveryefforttoobtainandenternumericaldataintosearchablefieldsintheelectronic
medicalrecord,inordertomaketrackingwithinandamonginstitutionsfeasible.
Membersofthehealthcareteamshouldcometogethertodeterminestrategiesfor
implementationcompatiblewiththeirowninstitutionspoliciesandpractices.Standardized
formatsforthecollectionofdataassociatedwitheachindicatorsuseareneededinorderto
validateanddeterminewhichcharacteristicsarethemostorleastreliableintheidentificationof
pediatricundernutritionanditstreatment.Uniformdatacollectionacrossfacilitiesatlocal,
regional,andnationallevelswouldfacilitatefeasibilitytestingonabroadscale.Theindicators
recommendedinthisconsensusstatementshouldbereviewedandrevisedatregularintervalsto
reflectvalidationdatathatoffersevidenceofefficacy.
Wealsoneedtobegintodevelopsystemsthattrackthediseasesorconditions,andenvironmental
orsocioeconomiccircumstancesthatcontributeto,orthatareroutinelyassociatedwith,the
developmentofpediatricundernutrition.Thehumanandfinancialimpactoftheroutineuseof
therecommendedindicatorsinsuchareasasresourceutilization,revenuegeneration,and
personnelneededtoadequatelyaddresstheneedsofundernourishedchildrenandadolescentsin
acute,ambulatory,home,andresidentialcaresettingsshouldalsobetracked.
Theeducationandtrainingneedsofnutrition,medical,andalliedhealthprofessionalsshouldbe
determined,withappropriateoutreachinitiatedtoremediateidentifieddeficits.Additional
traininginthenutritionassessmentprotocolisrecommendedandinthedevelopmentand
utilizationofelectronicsystemsthatfacilitatedatacollectioninthishighlyvulnerableandcostly
segmentofourpopulationshouldbeofferedinmultiplevenuesasspecificidentifiedneedsarise.
Summary
Therecommendedindicatorstodiagnosepediatricundernutritiondelineatedinthisconsensus
statementareaworkinprogress.Cliniciansshouldexpecttoseeanevolutionofthese
recommendationsasdataregardingtheirusearesystematicallycollected,analyzed,and
disseminatedtoresearchandclinicalcommunities.Periodicreviewandrevisionofour
recommendationswillensurethatthehealthofthepublicisoptimizedandthatutilizationof
healthcareresourcesproceedswithmaximumefficiency.
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