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European Journal of Clinical Nutrition (2010) 64, S22S24

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REVIEW
Nutritional screening and guidelines for managing
the child with faltering growth
K Joosten1 and R Meyer2

1
Department of Paediatric Intensive Care, Sophia Childrens Hospital, Erasmus MC, The Netherlands and 2Imperial College, London, UK

European Journal of Clinical Nutrition (2010) 64, S22S24; doi:10.1038/ejcn.2010.44

Introduction be identified at the time of hospital admission to enable


appropriate nutritional interventions at an early stage.
Malnutrition is common in the hospitalized paediatric Currently, there is no consensus on the ideal method for
population (Joosten and Hulst, 2008). Across Europe the the screening and assessment of nutritional risk in children
documented prevalence varies according to the cut-offs used admitted to hospital. Furthermore, there is a lot of confusion
to define malnutrition. It is, however, thought that disease- between the risk of becoming malnourished and current
associated malnutrition affects about 1530% of hospitalized nutritional status; therefore, these are commonly combined.
children (Joosten and Hulst, 2008; Pawellek et al., 2008). Four groups have made an attempt (Hulst et al., 2009) to
Nutrient requirements per kg body weight are significantly develop a risk-screening tool. Sermet-Gaudelus et al. (2000)
higher in growing children than in adults, whereas body and Secker and Jeejeebhoy (2007) developed simple
stores are lower (Agostoni et al., 2005). This makes the young tools, the pediatric nutritional risk score and the subjective
child more vulnerable to the effects of malnutrition, hence global nutritional assessment, respectively. These identify
the requirement for early recognition and appropriate children at risk of malnutrition during hospitalization.
treatment (Agostoni et al., 2005). Over the last few years, a However, these tools are often considered rather complicated
significant body of evidence has emerged looking at the and time-consuming. Recently, McCarthy et al. (2008)
efficacy of nutritional screening in the paediatric popula- developed the STAMP tool, which is a combination of
tion. Similarly, advances have also been made in the measurements of weight and height, with two additional
management of faltering growth and the development of questions on disease risk and intake. In 2006 the group of
guidelines to aid healthcare professionals in this regard. Joosten developed a risk-screening tool called STRONGkids
(Tables 13). This tool is a simple method of assessing the
nutritional risk. It consists of four key items: risk of disease,
intake, weight loss and subjective global assessment, each
Nutritional screening
allocated a score of 12 points, with a maximum total score
of 5 points. The four questions in this tool can be completed
In adult clinical practice, there are several widely used
on admission and by just one assessor, making it extremely
nutritional risk-screening tools, such as the Malnutrition
practical and simple. With this tool, the risk is immediately
Universal Screening Tool and Simplified Nutritional Appetite
calculated. The tool was tested in 2007 during 3 consecutive
Questionnaire) (Kruizenga et al., 2005). Interestingly, in chil-
days in 424 children admitted to 44 hospitals in the
dren, who may be considered even more vulnerable, no
Netherlands. In 98% of the children the tool was successfully
nutritional risk tool has yet been developed and accepted across
applied. Using this tool, a significant relationship was
Europe. This is currently being reviewed by the European Society
found between having a high risk score, a negative standard
of Paediatric Gastroenterology, Hepatology and Nutrition.
deviation score in weight-for-height and a prolonged
Ideally, for hospital-acquired malnutrition with its
hospital stay.
complications, the risk of nutritional depletion needs to
In conclusion, screening of malnutrition is important for
early identification of children at risk of poor nutritional
Correspondence: Dr K Joosten, Department of Paediatric Intensive Care,
status. In paediatrics, unlike adults, a nutritional risk-
Sophia Childrens Hospital, Dr Molewaterplein 60, 3015 GJ Rotterdam,
Erasmus MC, The Netherlands. screening tool has not yet been universally accepted. The
E-mail: k.joosten@erasmusmc.nl reasons for this are multifactorial, but may be related to the
Nutritional screening and guidelines
K Joosten and R Meyer
S23
Table 1 STRONGkids (screening tool for risk of nutritional status clinician to consider important issues including clinical
and growth) appearance, high-risk diseases, nutritional losses, inadequate
(1) Subjective clinical assessment (1 point) intake and weight evolution, and to ensure that early
Is the patient in a poor nutritional status judged by subjective clinical interventions are considered.
assessment (diminished subcutaneous fat and/or muscle mass and/or
hollow face)?

(2) High-risk disease (2 points) Guidelines for the nutritional management of


Is there an underlying illness with a risk of malnutrition or expected faltering growth
major surgery?

(3) Nutritional intake and losses (1 point) For both children who are at risk of developing malnutrition
Are there any of the following items present? and for those identified as being malnourished or having
Excessive diarrhoea (X5 per day) and/or vomiting (43 times/day)
the last few days?
faltering growth, nutritional treatment should commence in
Reduced food intake during the last few days before admission order to achieve better outcomes. This includes short-term
(not including fasting for an elective procedure or surgery)? outcomes such as shorter hospital stay and less infectious
Pre-existing dietetically advised nutritional intervention? complications, as well as long-term benefits such as better
Inability to consume adequate intake because of pain?
growth and development (Secker and Jeejeebhoy, 2007;
(4) Weight loss or poor weight gain? (1 point) Joosten and Hulst, 2008; Hulst et al., 2009). The nutritional
Is there weight loss or no weight gain (infants o1 year) during the management of faltering growth depends on the severity
last few weeks/months?
(that is, wasted only or wasted and stunted) and the cause of
malnutrition (that is, organic or non-organic; Shaw and
Lawson, 2007). Several guidelines have been published to
assist the clinician in making the correct decision, from oral
Table 2 Nutritional risk score and recommended nutritional
nutritional support to tube feeding and lastly to parenteral
intervention
nutrition (ASPEN Board of Directors and The Clinical
Score Risk Intervention Guidelines Task Force, 2002; Koletzko et al., 2005). The
decision with regard to the optimal route of feeding is related
45 High Consult doctor and dietitian for full diagnosis and
to the childs ability to achieve the energy requirement and
individual nutritional advice and follow-up
Start prescribing sip feeds until further diagnosis demonstrate weight gain. If a child does not achieve
13 Medium Consult doctor for full diagnosis; consider nutritional nutritional requirements orally (via oral supplements),
intervention with dietitian. Check weight twice a week then enteral feeding must be considered and in cases
and evaluate the nutritional risk after 1 week
where enteral feeding does not meet the requirements due
0 Low No intervention necessary. Check weight regularly,
conform to hospital policy and evaluate the nutritional to increased requirements, increased losses and/or poor-
risk after 1 week tolerance parenteral nutrition may be indicated. This process
should be managed by a nutritional care team (Kruizenga
et al., 2005).
Table 3 Classification of high-risk disease using the screening tool There seems to be paucity in guidelines on dietary
management for children with faltering growth requiring
Anorexia nervosa Liver disease, chronic
Burns Kidney disease, chronic
oral support. Although disease-specific guidelines exist on
Bronchopulmonary dysplasia Pancreatitis nutrient requirements, no universally accepted guidelines
(max age 2 years) exist for children with non-organic faltering growth, which
Coeliac disease Short-bowel syndrome is more commonly seen. The most common consensus
Cystic fibrosis Muscle disease
Dysmaturity/prematurity Metabolic disease
guidelines used in the United Kingdom have been produced
(corrected age 6 months) by the Great Ormond Street Hospital (Great Ormond Street
Cardiac disease, chronic Trauma Hospital for Children NHS Trust, 2009). These provide
Infectious disease (AIDS) Mental handicap/retardation guidance on energy and protein requirements in both health
Inflammatory bowel disease Expected major surgery
Cancer Not specified (classified by physician)
and disease, highlighting the importance of an optimal
protein:energy ratio. Following the recent WHO guidelines
for catch-up growth (Table 4), the focus of dietary manage-
ment during faltering growth has changed from supplement-
simplicity of the method. Many experts have attempted to ing only with energy to optimizing catch-up by providing
develop such a tool, but some tools have failed due to their adequate energy and protein (WHO/FAO/UNU expert con-
complexity or inability to detect those at risk. The STRONG- sultation, 2007). These guidelines suggest that 8.911.5% of
kids tool was developed as a simple nutritional risk-screening energy should be supplied as protein, to provide optimal
method and has been shown to work in practice (Hulst et al., catch-up growth of lean and fat mass (from 10 g/kg/day
2009). It helps to raise the clinicians awareness of the 8.9 PE% to 20 g/kg/day 11.5 PE%; 73:27 lean:fat mass).
importance of nutritional status in children. It directs the The importance of a correct protein:energy ratio has also

European Journal of Clinical Nutrition


Nutritional screening and guidelines
K Joosten and R Meyer
S24
Table 4 WHO guidelines for energy and protein intake for optimal References
catch-up growth
Agostoni C, Axelson I, Colomb V, Goulet O, Koletzko B, Michaelsen
Rate of gain Protein Energy Protein KF et al. (2005). The need for nutrition support teams in pediatric
(g/kg/day) (g/kg/day) (kcal/kg/day) energy ratio units: a commentary by the ESPGHAN committee on nutrition.
(PE %) J Pediatr Gastroenterol Nutr 41, 811.
A.S.P.E.N. Board of Directors and The Clinical Guidelines Task
10 2.82 126 8.9 Force (2002). Guidelines for the use of parenteral and enteral
20 4.82 167 11.5 nutrition in adult and pediatric patients. J Parenter Enteral Nutr 26,
1SA134SA.
Clarke SE, Evans S, MacDonald A, Davies P, Booth IW (2007).
been highlighted by several recent studies investigating Randomized comparison of a nutrient-dense formula with an
optimal oral/enteral feeds for catch-up growth (Clarke energy-supplemented formula for infants with faltering growth.
J Hum Nutr Diet 20, 329339.
et al., 2007).
Great Ormond Street Hospital for Children NHS Trust (2009).
It is important to note that the WHO guidelines on Nutritional Requirements for Children in Health and Disease, 4th
catch-up growth do not replace the disease-specific energy edn. Great Ormond Street Hospital: London.
and protein requirements that have been published (that is, Hulst JM, Zwart H, Hop WC, Joosten KF (2009). Dutch national
survey to test the STRONG(kids) nutritional risk screening tool in
cardiac conditions, cystic fibrosis and renal failure; Mitchell hospitalized children. Clin Nutr 29, 106111.
et al., 1994; Shaw and Lawson, 2007; Trabulsi et al., 2007). Joosten KF, Hulst JM (2008). Prevalence of malnutrition in pediatric
It is, however, a useful guide for considering optimal hospital patients. Curr Opin Pediatr 20, 590596.
protein:energy ratios in malnourished children and for those Koletzko B, Goulet O, Hunt J, Krohn K, Shamir R (2005). Guidelines
on Paediatric Parenteral Nutrition of the European Society of
conditions where, until now, little was known about the Paediatric Gastroenterology, Hepatology and Nutrition (ESP-
actual requirements, especially protein. GHAN) and the European Society for Clinical Nutrition
Once energy and protein requirements have been estab- and Metabolism (ESPEN), Supported by the European Society of
lished, it is often the presumption that requirements are Paediatric Research (ESPR). J Pediatr Gastroenterol Nutr 41 (Suppl 2),
S1S87.
automatically and easily met, with nutritional support.
Kruizenga HM, Seidell JC, de Vet HC, Wierdsma NJ, van Bokhorst-de
However, this is rarely the case. Problems with delivery van der Schueren MA (2005). Development and validation of a
of nutrients, the childs taste preferences and intolerance to hospital screening tool for malnutrition: the short nutritional
oral/tube feeds are often described. It is therefore important assessment questionnaire (SNAQ). Clin Nutr 24, 7582.
McCarthy H, McNulty H, Dixon M, Eaton-Evans MJ (2008). Screen-
to ensure that the requirements set are practically achievable
ing for nutrition risk in children: the validation of a new tool.
for the parent/child, that the supplement is accepted by the J Hum Nutr Diet 21, 395396.
child and, most importantly, that parents are empowered to Mitchell IM, Davies PS, Day JM, Pollock JC, Jamieson MP (1994).
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In conclusion, nutritional management of organic and
374380.
non-organic faltering growth is essential to reduce the Pawellek I, Dokoupil K, Koletzko B (2008). Prevalence of malnutri-
short- and long-term impact of malnutrition. Guidelines tion in paediatric hospital patients. Clin Nutr 27, 7276.
have been published to assist in this regard and optimize the Secker DJ, Jeejeebhoy KN (2007). Subjective global nutritional
assessment for children. Am J Clin Nutr 85, 10831089.
catch-up weight gain. It is, however, important to ensure Sermet-Gaudelus I, Poisson-Salomon AS, Colomb V, Brusset MC,
that the nutritional management plan is achievable and is Mosser F, Berrier F et al. (2000). Simple pediatric nutritional risk
regularly monitored to adjust for the childs specific nutri- score to identify children at risk of malnutrition. Am J Clin Nutr 72,
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Shaw V, Lawson M (2007). Clinical Paediatric Dietetics, 3rd edn.
Blackwell Publishing: Oxford, UK.
Trabulsi J, Ittenbach RF, Schall JI, Olsen IE, Yudkoff M, Daikhin Y
Conflict of interest et al. (2007). Evaluation of formulas for calculating total energy
requirements of preadolescent children with cystic fibrosis.
Am J Clin Nutr 85, 144151.
K Joosten and R Meyer have received consulting fees from WHO/FAO/UNU expert consultation (2007). Protein and Amino Acid
Danone. Requirements in Human Nutrition, vol. 935. WHO: Geneva. pp 1265.

European Journal of Clinical Nutrition