Evaluation of malnutrition in hospitalized children by the Screening Tool for the Assessment of Malnutrition in Paediatrics

Overview

Východisko.
K významným úkolům lékařské a ošetřovatelské péče o dítě při hospitalizaci je screening nutričního rizika a identifikace pacientů vyžadujících nutriční podporu. Hlavním cílem studie bylo ověřit využitelnost hodnoticí škály The Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) k posuzování rizika vzniku malnutrice u hospitalizovaných dětí.

Metody.
K porovnání výsledků hodnocení rizika vzniku dětské malnutrice bylo použito skóre Pediatrického nutričního rizika. Soubor tvořilo 130 respondentů (73 chlapců, 57 dívek) ve věku 2 měsíce až 18 let (medián 8 let), kteří byli hospitalizováni na Klinice dětského lékařství ve Fakultní nemocnici Ostrava.

Výsledky.
Byl zjištěn rozdíl v detekci rizika vzniku malnutrice prostřednictvím škály STAMP mezi dětmi s odlišnými medicínskými diagnózami (p=0,000) a v různých věkových kategoriích (p=0,0418), nebyl zaznamenán rozdíl v detekci mezi pohlavími. Byl zaznamenán signifikantní rozdíl v detekování rizika vzniku podvýživy mezi škálami (p=0,000). Celková shoda rizika vzniku malnutrice mezi oběma škálami byla 46, 9 %. Vyšší počet vysokého rizika vzniku malnutrice byl zjištěn škálou STAMP.

Závěr.
Screening malnutrice prostřednictvím škály STAMP může identifikovat dětské pacienty, kteří trpí podvýživou, či jim hrozí její vznik.

Klíčová slova:
malnutrice, screening, dítě, nutriční skóre, škála.

Solution

Malnutrition can be defined as a state of impaired nutrition. In a broader sense it is a violation of nutritional status, whether due the lack of protein, but also due lack of energy reserves of the organism, proteins, vitamins or trace elements. Malnutrition in the strict sense can be understood as protein malnutrition or energy malnutrition. (1)

Given the fact that malnutrition is often underestimated, it is advisable to use screening methods for identification of patients at risk of nutritional disorders. Nutritional screening is quick and simple process performed by the receiving personnel. The result of screening can be a patient who is not at risk of malnutrition, but may need a repeated control in certain intervals, for example once a week in hospitalized patients, a patient who is at risk of malnutrition, it is developed and implemented a nutritional plan as per normal practice of the department, or a patient, who is at risk of malnutrition, but the metabolic or functional problems do not allow the standard procedure, or exist doubts about the patient´s risk. Nutritional screening in the form of a simple questionnaire should be done as soon as possible after the patient is admitted, with regard to the actual priorities of his health status. The screening process should be simple and fast, but at the same time it should be able to detect maximum of patients with malnutrition or its risk. (2)

In studies that were conducted in clinics of the Paediatric section of University Hospital in Prague Motol (FN in Prague Motol) was found, that malnutrition in hospitalized children is not exceptional. The first deeper study was conducted in the framework of investigation in 1998 -1999. From the results of monitoring the nutritional status of children at the time of commencing the hospitalization emerged that practically every seventh child (14,5%) had acute protein-energy malnutrition, every eight child (12,4%) had protein depletion.  Based on the above results in the University Hospital in Prague Motol was gradually formed a nutritional team of the hospital. Among the main priorities of the work of nutritional team was practical implementation of nutritional score of hospitalized patients. Based on some foreign, but also on own experience, the nutritional team of Paediatric section of the hospital has created the Paediatric nutritional score. (3)

Among other possible scales assessing the risk of malnutrition in hospitalized children are the Paediatric Yorkhill Malnutrition Score (PYMS), the Paediatric Subjective Global Nutritional Assessment (SGNA), the Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP). (4)

PYMS was originally developed based on the advice of the European Society for Clinical Nutrition and Metabolism. It is simple and fast scoring system to identify children who are at nutritional risk. PYMS focuses on four basic parameters: Body Mass Index, weight loss in the last 3 months, the recent changes in diet/nutritional support, the influence of clinical status on the nutrition. (5)

SGNA was originally developed for the assessment of nutritional status in adult patients. Based on conducted studies at paediatric clinics was this tool identified as suitable for the assessment of nutritional status in children older 2 years of age. This test tool works compared to other methods with much bigger amount of data, thus it is necessary to allow a longer time period for the result evaluation.  In addition to anthropometric data, nutritional anamnesis, affecting diagnoses, overall clinical status, it also includes laboratory values. (6)

STAMP is the first nationally approved screening tool to identify malnutrition in children in Great Britain. (7)

Methodology

The aim of the study was to verify the applicability of the scale STAMP for assessing the risk of formation of malnutrition in hospitalized children. The sample consisted of 130 children aged two months to 18 years (median 8 years) who were hospitalized at the Clinic of Paediatrics University Hospital Ostrava in the period from January to August 2011.  Children were divided into six age categories, according to Vagnerova. (8) Out of the total number of 130 children were 23 (18%) infants, 21 (16%) toddlers, 13 (10%) preschool children, 24 (19%) children of younger school age, 21 (16%) school children and 28 (21%) adolescents. The group included 73 (56%) boys and 57 (44%) girls. Out of 130 children had 73 (56%) intake diagnoses of internal character (acute 56 and chronic character 17) and 57 (44%) of children were diagnosed with surgical character (39 acute and 18 chronic character).

For the assessment of risk of formation of malnutrition were used two evaluation methods. The first was the score of Paediatric nutritional risk, which is commonly used at the Clinic of Paediatrics University Hospital in Ostrava. Paediatric nutritional risk includes the evaluation of disease severity (low, medium, great). This parameter is evaluated from 0 to 3 points, where low severity determines, in situations, when the paediatric patient is admitted to control examination, small surgical intervention, or has a mild infection (0 points). Medium severity of illness is determined as chronic decompensated disease, moderately severe surgical intervention, fracture and inflammatory bowel disease (1 point). Great severity of disease occurs in an acute decompensated chronic disease, bigger surgical intervention, cardio-surgical intervention, polytrauma, extensive burns, severe infection, malignant disease and severe depression (3 points). Another assessed item of Paediatric nutritional risk is stress factor. The reviewer is offered three possible answers that are: none stress factor (0 points), medium stress factor or intensive pain (1 point) and none or less than half the intake of food  prior to hospitalization (1 point). Individual recorded stress factors can be added up. The sum of points of Paediatric nutritional risk reflects the nutritional risk from a small risk (0 points), through a moderate risk (1-2 points) to a high risk (3-5 points).

The second scale The Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP) is a valid nutritional scale, which was formed in Manchester in Great Britain and is freely available for clinical use. (7) This assessment method includes a combination of three assessed items – diagnoses with nutritional consequences, momentary nutritional intake and evaluation of nutritional status (body height and body weight). The first step of assessment is scoring according to the diagnoses. Scoring is based on criteria that are part of the STAMP form and divide diseases into three groups, according to the influence on nutritional status of the child(without nutritional consequence – 0 points, potential nutritional consequences – 2 points, some nutritional consequences – 3 points). The disease, which according to STAMP, has certain  nutritional consequences include intestinal disorders, diarrhea, burns, polytrauma, Crohn´s disease, cystic fibrosis, dysphagia, liver disease, major surgical intervention, food allergies (intolerance), active cancer treatment, kidney disease, hereditary metabolic disorders. The disease with potential nutritional consequences includes eating problems, heart disease, cerebral palsy, cleft lip and palate, celiac disease, diabetes, gastroesophageal reflux, minor surgery, neuromuscular disability, psychiatric disorders, respiratory syncytial virus, a simple food allergy (intolerance). Diagnoses that have no nutritional consequences are those that require only one-day surgery or outpatient treatment. (7) This list is not exhaustive, in case of doubt, the authors of the STAMP scale recommend contacting the nutritional therapist.

The second step of the evaluation is the assessment of nutritional intake of child during hospitalization. Nutritional intake can be assessed as without any change in eating habits (0 points), reduced nutritional intake (2 points) or the child does not accept food (3 points).

In the last step is recorded into the attached table the measured value of body height and body weight of the child and it is compared with reference values by age and sex of the child. To the identified percentiles is assigned score 0-3. The attached table allows also rapid comparison of values of height and weight between each other. If the value of height and weight are far more than three and more than three columns from each other, is the point value of this monitored parameter 3 points. Two columns from each other are assessed by 1 point and one or no column value of height and weight from each other is assessed  by 0 points.

The combination of these items determines score that corresponds with the risk of child malnutrition. Achieved final score of scale STAMP 0-1 point indicates low risk of malnutrition, 2-3 points indicates moderate risk of malnutrition and more than 4 points indicates a high risk of malnutrition. This scale is commonly used by nurses of Paediatric Clinic in Oxford, UK. (9) In addition to screening form and diagnostics includes the methodological guidance as well guidelines for weighing, measuring, percentile tables and plan of care based on the overall nutritional risk. The evaluation tool was translated into Czech language, linguistically controlled and the translation was consulted with a professional academic worker.

For the data description, obtained by research investigation, was used descriptive statistics. For comparison of the risks of the formation of malnutrition assessed by two scoring systems was used Spearman´s correlation coefficient for ordinal data. The relationship of risk of malnutrition between medical diagnoses and gender was evaluated by Chi-test and Fisher´s test (n<5) for categorical data. The relation to age was evaluated by non-parametric Kruskal-Wallis test for multiple selections. Statistical tests were evaluated at the level of significance of 5%. Statistical analysis was done by programme Stata v10.

Results

In both assessed scales of risk of formation of malnutrition was proved significant difference in assessing the risk of formation of malnutrition in children with different medical diagnoses (p<0,001). Children with income surgical diagnoses were more likely at high risk of malnutrition, compared to children with internal intake diagnoses. Through the score of Paediatrics nutritional risk was low risk of malnutrition observed in two children with internal and in two children with surgical diagnosis, moderate risk in 55 (75,3%) children with internal diagnosis and in 22 (38,6%) children with surgical diagnosis. High risk of malnutrition was found in 16 (22%) children with internal intake diagnosis and in 33 (58%) children with surgical diagnosis.  Using the score STAMP was identified a low nutritional risk in 26 (36%) children with internal diagnosis and in 4 (7%) children with surgical diagnosis, moderate risk in 10 (14%) children with internal diagnosis and in 11 (19%) children with surgical diagnosis. High nutritional risk was detected by the scale STAMP in 37 (51%) children with internal diagnosis and in 42 (74%) children with surgical diagnosis.

The results showed that at the scale of Paediatric nutritional risk the overall nutritional score was not influenced by age category, to which the child was enrolled (p = 0.7474). According to this scale was recorded mostly moderate risk of malnutrition in all age categories except for the toddler period. Out of 21 toddlers was found most often high level of risk of malnutrition in ten of them. In contrast at the STAMP scale the age category, to which the child was enrolled, had affected the overall nutritional score (p = 0.0418). High nutritional risk was observed mainly in the youngest age categories, especially in 19 out of 23 infants and in 13 of 21 toddlers. In the adolescent age was most often reported low risk of malnutrition (12 adolescents from 28). The influence of gender on the risk of formation of malnutrition was not found in none of the scales (p = 0.396, p = 0.290). Through the scale Paediatric  nutritional risk was identified  low risk of malnutrition in one boy and in two girls, moderate level of risk in 47 (62%) boys and 30 (56%) girls and high level of risk in 28 boys (37%) and 21 girls (40%). The STAMP scale showed low risk of malnutrition in 14 (18%) boys and 16 (30%) girls, moderate risk in 14 (18%) boys and 7 (13%) girls and high risk in 48 (63%) boys and 31 (57%) girls.

After an overall review of the individual scales was found statistically significant difference in detecting the risk of formation of malnutrition among the scales (p = 0.000). The scale of Paediatric nutritional risk has detected from the total number of 130 respondents, 4 children with low risk of formation of malnutrition, 77 (59%) children with moderate risk of malnutrition and 49 (38%) children with high risk. According to the STAMP score was 30 (23%) children ranked into the zone of low risk, 21 (16%) children into the zone of moderate risk. In high risk of malnutrition were 79 (61%) children (Figure 1).

In a zone of low nutritional risk was reached 2.3% consensus between both scales. In moderate zone of risk of malnutrition have coincided 11.5% of respondents and the biggest consensus was in the area of high risk, ie 33.0% of respondents (Table 1). Overall consensus of risk of formation of malnutrition between both scales is 46, 9%. This consensus is by using the Kappa index defined as mild.

The results show that with age grows the consensus between both scales (the value of Spearman's coefficient increases with age). The closer to 1.0, the greater the consensus between both scales (Table 2).

Discussion The main task in the diagnosis of malnutrition is carrying out screening of nutritional risk and identification of patients requiring nutritional support. European Society for Paediatric Gastroenterology, Hepatology and Nutrition published recommendations regarding the above-mentioned problem. One of the key points is the screening of nutritional status on admission for hospitalization, which should be simple and feasible in all paediatric wards. The statement of disorder of nutritional status is the reason for nutritional intervention and follow-up of nutritional status of children admitted at paediatric wards. (10)

Nutritional screening is not implemented in all hospitals or takes place only when admitting a child for hospitalization. In the future, it is necessary, that the screening is not only introduced, but that it will be truly functional, because according to International accreditation standards for hospitals, is one of the indicators of quality of care. (11) An appropriate, time-saving screening method could help the introduction of screening into everyday nursing practice. In our investigation the STAMP scale proved as a simple tool, however requiring further testing in the conditions of Czech practice, because it does not correlate with the scale used for screening the risk of malnutrition yet. The reason may be particularly an item evaluating anthropometric parameters.

The evaluation of these parameters according to the table STAMP is not based on measurements of Czech paediatric population. Before its further testing it would be first necessary to review these reference parameters. The STAMP scale had predicted high risk of malnutrition in children more often than the score of Paediatric nutritional risk. Similar conclusions had also authors of the study from 2011, which was published by the Paediatric Hospital in Oxford and focused on the evaluation of the validity and ease of use of two new tools to assess nutritional risk in children. The study compared the scale STAMP and the scale STRONGKIDS. The results of the study showed that the STAMP scale identifies high and moderate risks of malnutrition in children in higher numbers than the scale STRONGKIDS. The study also indicates that the results of nutritional screening in the STAMP scale did not correlate with the measured BMI value. This finding may be the cause of excessive identification of risk in the framework of high zone. (9) The positive of the STAMP scale is more detailed definition of diagnosis joined in individual categories assessing the nutritional effects of diagnoses. Proposed intervention measures that are part of the instruction manual of the STAMP scale, are another positive. Paediatric nutritional risk only determines the risk of malnutrition in children without follow-up measure. The evaluation through the STAMP scale takes about 10 minutes longer thanks to the measurement, but due to the necessary measurements of the child during the admission for hospitalization, there is no extra activity. With a longer time for evaluation is necessary to count at repeated assessment of the child during his hospitalization. Repeated evaluation of body height and body weight of the child however objectifies the current nutritional status of the child during hospitalization. When monitoring the risk of malnutrition through the STAMP scale in our survey was found a higher detection of risk in children who were admitted for surgical interventions. The cause may by more serious conditions of children, such as burns, polytrauma, fracture of long bones, ileus conditions. Higher detection of high risk of malnutrition was found in the younger age categories. The connection can be seen in more frequent finding of low levels of body weight of younger children that did not correspond to their body height, anthropometric parameters were significant factor that influence the final nutritional score. Tlaskal (3) in his study also indicated that children with malnutrition were significantly younger. A possible reason for this is, in his opinion, probable connection with a greater intensity of growth and development and lower energy reserves of children at an early period of their lives. Also, a prospective study in Brazil showed that the risk of malnutrition was associated with low birth weight and younger age of the child. (12)

The STAMP scale showed to be more complex method of assessing the risk of malnutrition in hospitalized children in comparison to the Paediatric nutritional risk score, which is complemented also by the measurement of selected anthropometric parameters, however the results of measurements are not counted in the score. Given the low number of children represented in each age categories it is necessary to evaluate conclusions as tentative.

Conclusion

Child malnutrition is often in public associated with a presence especially in developing countries, especially Africa. Unfortunately, in general, malnutrition belongs among the most serious and the main reasons for deaths of children even in developed countries. What's more - it turns out that it is worsening during hospitalization. (13)

A quality assessment of nutritional status on admission to hospital or outpatient treatment and early intervention by diet or artificial feeding demonstrably improves the course of disease. Nutritional teams of physicians - nutritionists, nutritional therapists and specialist nurses are optimal to ensure nutritional monitoring of patients and optimal interventions. Physicians and nutritional therapists visit, in the form of nutritional Consilium, patients of different departments and often only by providing individual diet can significantly improve the nutritional status of the patient and thereby influence the course of the disease. (14) For the early detection of risk of malnutrition in children serves the STAMP scale, which was in the presented study compared with most often used scale in the Czech Republic, the scale of Paediatric nutritional risk. The results revealed higher detection of moderate and higher risk of malnutrition through the STAMP scale. Due to the small number of children represented in the study it is possible to consider results as only tentative. Timely solution of the risk of inadequate nutrition can prevent more expensive treatment (for example, to prevent the formation of decubitus, reduce the risk of break-up of surgical wounds, reduce the number of early re-hospitalisation), but also reduce the cost spent on usage of parenteral nutrition and many other costs.

List of used abbreviation

• BMI – Body Mass Index
• FN in Prague Motol – University Hospital in Prague Motol
• PYMS - Paediatric Yorkhill Malnutrition Score
• SGNA - Paediatric Subjective Global Nutritional Assessment
• STAMP - Screening Tool for the Assessment of Malnutrition in Paediatrics