1. Diagnosing Pediatric Malnutrition
By Ashley Bozekowski

2. OBJECTIVES: Define pediatric malnutrition
Challenges and strengths of anthropometric measurements
Review the most up-to-date guidelines for the identification and classification of pediatric malnutrition

3. 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” 5
This dynamic imbalance of nutrients affects children differently than adults and can have profound implications for the developing child

4. THE PROBLEM
Lack of a standardized approach in recognizing and diagnosing malnutrition
Leading to underestimating the prevalence
Makes it difficult to compare results among studies because since definition varies
Routine assessment of nutritional status in high risk children is sporadic and inconsistent
Consensus statement by AAND and ASPEN “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”
Obesity is a form of malnutrition however the consensus statement only addresses undernutrition

5. PREVELANCE
25% of all hospitalized children experience acute protein energy malnutrition
Childhood undernutrition is responsible for approximately 3.1 million child deaths each year.7
Malnutrition is responsible for 11-41% of hospital admissions
20 million children less than 5 years old are severely malnourished which increases their vulnerability to disease and premature death1

6. PREVELANCE Underdeveloped countries
Historically thought only to be an exclusive problem for developing countries
Caused mainly by acute/chronic infections and diarrheal diseases
Usually categorized as Kwashiorkor or Marasmus
Developed countries
Occurs more frequently in injury, congenital anomalies, infections, and acute and chronic illness
Energy imbalance and excess is more common than nutrient deficiency
Environmental or behavioral factors
Can be common in victims of food insecurity
1 in 10 families in the US struggle with food insecurity
Behavioral factors

7. MALNUTRITION’S IMPACT
children with mild clinical conditions and who are already malnourished on admission are at risk for:
further nutritional deterioration
longer hospital stays
higher healthcare costs
poor wound healing
slower returns to baseline functioning and activity

8. ASPEN: 5 Domains of pediatric malnutrition classification scheme
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

9. GROWTH
Growth is the primary outcome measure of nutritional status in children
It is important to have serial measurements, use dynamic changes in weight and length velocity over time rather than a single measured parameter
Expressed and reported in comparison with population data and a reference curve

10. ANTHROPOMETRICS
Record weight, height, BMI, and MUAC and then serially use appropriate growth charts
Head circumference must be obtained in infants younger than 2 years old
If <2 years old length on a length board
>2 years old measured upright
For children who are unable to stand consider using tibia length, knee height, or arm span for height proxy
Weigh infants and children with minimal clothing

11. WHO/CDC CHARTS 2006 WHO charts for children up to 2 years old
Depicts normal human growth under optimal environmental conditions and can be used to assess children everywhere
2000 CDC charts for children 2-20 years old
Were created in an effort to address some of the concerns regarding the extrapolation of NCHS data to heterogeneous populations
Country-specific charts
Medical conditions and syndromes

12. ACUTE VS. CHRONIC MALNUTRITION
Distinguished between based on time
Acute <3 months
Severe Acute
Very low wt/ht: less than -3 SD of the WHO growth standards
Visible severe wasting (MUAC<115mm)
Presence of edema
Wasting defined by as wt/age less than -2 SD (z-score)

13. ACUTE VS. CHRONIC MALNUTRITION
> 3 months
Chronic (stunting)
Height for age <-2 SD
Manifests with growth deficits  height velocity or stunting hallmark of this condition that may be observed earlier than 3 months in the course of malnutrition
May affect long term growth as a result of chronic nutrition deficiency
A high prevalence of chronic malnutrition is found in children with chronic cardiac or renal disease or cancer
Or can be related to environmental or
socioeconomic circumstances

14. ETIOLOGY AND PATHOGENESIS OF MALNUTRITION
Illness-related malnutrition
Caused by nutrient imbalance associated from disease/illness/trauma resulting in decreased intake, increased requirement, increased losses, and altered utilization of nutrients
Non-Illness-related malnutrition
Caused from environmental (starvation/socioeconomic) or behavioral factors resulting from decreased nutrient intake and may be associated with one or more adverse developmental or physiologic outcomes

15. ETIOLOGY AND PATHOGENESIS OF MALNUTRITION
The strongest predictor of malnutrition upon admission was the presence of underlying disease
Patients with multiple diagnoses are most likely to be malnourished 43.8%
Thus it is recommended that the specific disease condition is included in the malnutrition definition if it is responsible for energy and or protein imbalances
I.e. “Burn-related acute malnutrition”
Recognize the role of inflammation on nutrition status
Available lab parameter such as CRP and cytokines
Acute inflammatory responses promotes skeletal muscle breakdown and catabolic effects

16. ETIOLOGY AND PATHOGENESIS OF MALNUTRITION
PREVELANCE OF MALNUTRITION IN:
Neurologic diseases: 40%
Infectious diseases: 34.5%
Cystic fibrosis 33.3%
Cardiovascular disease 28.6%
Oncology patients 27.3%
GI diseases 23.6%

17. FUNCTIONAL STATUS Lean body mass measurements
Muscle dysfunction
Handgrip strength
Lean body mass measurements
MUAC
Increased rates of infections
Behavioral problems:
impaired communication skills
attention deficit hyperactivity disorders
Include developmental assessment and neurocognitive monitoring in determining the impact of malnutrition

18. HANDGRIP STRENGTH Decreased grip strength correlates with the loss of
total body protein and BMI z scores
has been shown to be a good marker of immediate postoperative complications and predictive of major complications and loss of functional status
Not a good measurement in infants and younger children
Muscle strength plays a key role in pediatric physical rehabilitation
Is a non-invasive feasible and reliable measurement however requires adequate staff training and procedure standardization
Does not quantify mild, moderate, or severe; it only establishes the presence of malnutrition

19. MUAC
MUAC can be used as an independent anthropometric assessment tool in children 6-59 months old in standards developed by WHO
MUAC better indicator for those with fluid shifts (edema, ascites, etc)
Data suggest that MUAC is a nutritional indicator that is most responsive to nutritional stress
MUAC has been indicated as a more sensitive prognostic indicator for mortality than weight for height parameters in malnourished pediatric patients
MUAC changes very little during the early years and is simple and accurate and predicts malnutrition related mortality with reasonable specificity and sensitivity

21. MUAC Fat and muscle represent 30% of body weight in children
Under stress and infection muscle is directly affected
MUAC measures directly muscle and fat mass
MUAC<115mm= severe acute malnutrition/wasting
MUAC <110mm predicts the risk of death from malnutrition within 6 months

23. LET’S PRACTICE MEASURING MUAC!

24. Z-SCORES

25. Z score
Describes how far a child’s weight is from the mean weight of a child at the same height in the reference data
WHO recommends the use of z scores
It better depicts the anthropometric status than percentile curves
CDC has computer programs that allow for easy calculation of z scores without needing extensive manual plotting and calculations

26. Z-SCORES Also known as standard deviation (SD) scores
Z-scores or SD scores are used to describe how far a measurement is from the median
Comparable across ages, sexes, and anthropometric measures
Can be analyzed as a continuous variable in studies
Can quantify extreme growth status at both ends of the distribution

29. LENGTH/HEIGHT-FOR-AGE
This indicator helps identify children who are stunted (short) due to prolonged undernutrition or repeated illness
Length or height are charted in centimeters
Age is plotted in completed weeks from birth until age 3 months; in completed months from 3 to 12 months; and then in completed years and months

31. WEIGHT-FOR-AGE
Weight-for-age reflects body weight relative to the child’s age on a given day
This indicator is used to assess whether a child is underweight or severely underweight, but it is not used to classify a child as overweight or obese
Because weight is relatively easily measured, this indicator is commonly used, but it cannot be relied upon in situations where the child’s age cannot be accurately determined, such as refugee situations.
It is important to note also that a child may be underweight either because of short length/height (stunting) or thinness or both.
Note: If a child has edema of both feet, fluid retention increases the child’s weight, masking what may actually be very low weight.

33. WEIGHT-FOR-LENGTH
This indicator is especially useful in situations where children’s ages are unknown (e.g. refugee situations)
Weight-for-length/height charts help identify children with low weight-for- height who may be wasted or severely wasted
Wasting is usually caused by a recent illness or food shortage that causes acute and severe weight loss, although chronic undernutrition or illness can also cause this condition
These charts also help identify children who may be at risk of becoming overweight or obese
In these charts, the x-axis shows length or height in centimeters, and the y-axis shows weight in kilograms.

35. INTERPRETATIONS OF Z-SCORES
Z scores are used to identify trends in a child’s growth and are indicators plotted at a series of visits.
Trends may helps identify if a child has a growth problem, or if they are “at risk” of a problem and should be reassessed soon
Most children will grow in a “track” = on or between z-score lines and roughly parallel to the median, the track may be below or above the median
Problem that may suggest risk:
A child’s growth line crosses a z-score line
There is a sharp incline or decline in the child’s growth line
The child’s growth line remains flat (stagnant); no gain in weight or length/height
A problem or risk depends on where the change in the growth trend began and where it is headed
For example, if a child has been ill and lost weight, a rapid gain (shown by a sharp incline on the graph) can be good and indicate “catch-up growth.”
It is very important to consider the child’s whole situation when interpreting trends on growth charts.

36. DETERMINANTS OF PEDIATRIC MALNUTRITION
Food and Nutrient Intake
Assessment of energy and protein needs
Growth parameters
Weight gain velocity
Mid-upper arm circumference (MUAC)
Handgrip strength

37. PRIMARY INDICATORS WHEN 2 OR MORE DATA POINTS ARE AVAILABLE

38. PRIMARY INDICATORS WHEN ONLY SINGLE DATA POINTS ARE AVAILABLE

39. OUTCOMES
Anthropometric parameters (height, weight, head circumference)
Achievement of age-appropriate developmental milestones
Lean body mass measurements
Muscle strength
Immune function
Frequency or severity of acquired infections
Wound healing
Length of hospital stay

40. CASE STUDY CELIAC DISEASE 6 months old to 1 year
Cecile’s height for age dropped from -1 to -2 in a 9 month period
Her growth in length seems to have slowed during a period where rapid growth is expected

41. CASE STUDY Chronic diarrhea Anorexia Abdominal distension and pain
Poor weight gain
Vomiting
Behavioral changes
irritability
Introverted attitude.

43. CASE STUDY -2 Z SCORES Meeting 26-50% ESTIMATED ENERGY NEEDS
PES STATEMENT:
Nutrition Intervention: Pediasure
Monitoring: weight and po intake

44. REFERENCES