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TOPIC OF THE MONTH

Identification and Management of Acute Malnutrition in


Hospitalized Children: Developed Country Perspective
Juliana F. Vaughan and George J. Fuchs

(JPGN 2015;61: 610612) A discharge diagnosis of malnutrition in the United States increased
from 1.4% to 3.2% from 1993 to 2010, among all age groups (6). A
European multicenter study in 12 countries reported 7% of the

D uring the past 3 decades, there has been an increased


awareness of malnutrition (undernutrition) in developed
countries. In contrast to developing countries where most of the
hospitalized children were malnourished upon admission (7). In this
and other surveys, rates of malnutrition are higher in association
with specific disease conditions including psychiatric disorders,
childhood malnutrition is related to food insecurity and poverty, a gastrointestinal disease, congenital heart disease, among others
majority of malnourished children in developed countries are (3,7). Notably, many and sometimes most hospitalized malnour-
secondarily malnourished because of a specific, usually chronic ished children do not receive nutrition support (5).
disorder. Severe acute malnutrition constitutes a small proportion of
all malnutrition in this setting, yet accounts for a disproportionately
high risk of morbidity and mortality and, once identified, is DEFINITION
considered a medical emergency. This review focuses on the The most widely accepted and validated definition of mal-
identification and management of acute malnutrition in hospitalized nutrition is based on the World Health Organization (WHO) criteria
children in developed countries. using anthropometric z scores. In the clinical context, indices of
weight-for-length/weight-for-height or, in children older than 2
years of age, body mass index (wasting) and height-for-age (stunt-
METHODS ing) generally reflect acute and past or chronic malnutrition,
A search was conducted of PubMed and Cochrane databases respectively (Table 2) (8). A weight-for-length/weight-for-height
for studies and reviews on the topic of acute malnutrition in or BMI <2.0 SD or edematous malnutrition indicates the need for
hospitalized children in developed countries. The search was lim- short-term or immediate therapeutic intervention.
ited to articles in English published in the past 5 years. Articles that The American Society for Parenteral and Enteral Nutrition
were published more than 5 years ago were included if relevant. The proposed a more expansive definition of pediatric malnutrition
authors focused their search and included all the studies that (undernutrition) as an imbalance between nutrient requirement
contained the following key words: prevalence of malnutrition in and intake, resulting in cumulative deficits of energy, protein, or
developed countries, definition of malnutrition, outcomes, micronutrients that may negatively affect growth, development, and
and management. other relevant outcomes and categorized it further by etiology,
severity, mechanism, and chronicity (9). The authors conceptual
PREVALENCE framework attempts to integrate elements of established nutrition
Several malnutrition-screening tools have been developed pathophysiology and disease context, nutritional screening (risk),
for hospitalized children; however, validation is usually proble- and nutritional status, the latter using the WHO anthropometric
matic (1,2). This is in contrast to nutritional status for which definitions as the quantified correlates of risk of morbidity and
anthropometric indices of deficiency have an established progress- mortality. The practical application and a closer association with
ive (mild to moderate to severe malnutrition) association with outcome of combining these elements in this manner remain to
increasing risk of abnormal physiologic states (eg, impaired immu- be validated.
nity, metabolic disturbances) and risk of mortality (3,4). Regardless
of the parameter used, surveys of hospitalized children reveal a Effect on Hospitalization or Outcome
substantial prevalence of malnutrition (Table 1). Huysentruyt et al
in 2013, their review of the literature for the 15 years prior, reported Acute malnutrition is associated with longer hospital stays
rates of moderate-to-severe undernutrition to be 3% to 20% and (5,7). In a 12-country multicenter study, moderate malnutrition
2.5% to 18% for acute and chronic undernutrition, respectively (5). (BMI <2 to 3 SDs) and severe malnutrition (BMI <3 SDs)
were associated with a 1.3 (95% confidence interval [CI] 1.01
1.55) and 1.6 (95% CI 1.272.10) days longer hospitalizations,
From the Pediatric Gastroenterology, Hepatology, and Nutrition, Uni- respectively. Reduced BMI <2 SDs was also associated with
versity of Arkansas for Medical Sciences and Arkansas Childrens lower quality of life and more frequent occurrence of diarrhea (22%
Hospital, Little Rock, AR. vs 12%, P < 0.001) and vomiting (26% vs 14%, P < 0.001) (7).
Address correspondence and reprint requests to George Fuchs, MD, Offering oral nutritional supplements reduced length of hospital
University of Arkansas for Medical Sciences, Little Rock, AR (e-mail:
fuchsgeorgej@uams.edu).
stay by 1.1 days and lowered the cost by 9.7% (10). In view of the
The authors report no conflicts of interest. significant prevalence of malnutrition in hospitalized children and its
Copyright # 2015 by European Society for Pediatric Gastroenterology, impact on outcomes, a nutrition screen upon admission has become
Hepatology, and Nutrition and North American Society for Pediatric standard practice. Use of a computerized malnutrition screening
Gastroenterology, Hepatology, and Nutrition system in a cluster randomized trial enabled early nutrition support
DOI: 10.1097/MPG.0000000000000987 team intervention and facilitated improved clinical practices (11).

610 JPGN  Volume 61, Number 6, December 2015


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JPGN  Volume 61, Number 6, December 2015 Identification and Management of Acute Malnutrition in Children

TABLE 1. Rates of malnutrition reported in developed countries 19952015



References Patients with acute malnutrition, % Weight-for-height or BMI Comments

Huysentruyt et al (5) 9 <2 SD Children in Belgian hospitals


Marteletti et al (17) 11 <2 SD Children in French hospitals
Pawellek et al (18) 6.1 <80% median Children in German hospitals
Hecht et al (7) 7 <2 SD Children in European hospitals
Hendricks et al (19) 7.1 <80% median Children in US hospitals
Corkins et al (6) 3.2 <1 SD Children and adults in US hospitals
Baxter et al (20) 6.9 <2 SD Children in a Canadian hospital
Groleau et al (21) 11 <3%ile Children in a Canadian hospital

BMI body mass index; SD standard deviation; US United States.



All values are moderate to severe malnutrition except for reference (6).

Management children in this phase does not exceed 100 kcal  kg1  day1
because this is the phase in which children are at the greatest risk of
Once an acutely malnourished child is identified, nutritional refeeding syndrome. The rehabilitation phase is clinically identified
rehabilitation (preferably oral or enteral) is implemented without by return of appetite, progressive weight gain, reduction of apathy,
delay. The composition of therapeutic feeds and the mode of and increasing social interaction. Emphasis in this stage is on
nutrient delivery often need to be modified in context of specific intensive refeeding with 150 to 220 kcal  kg1  day1 to attain
underlying conditions. For example, children with renal failure catch-up growth.
require less potassium, and certain children with short bowel A major reason for the success of the guidelines is that, by
syndrome or Crohn disease may require enteral tube feeding or being prescriptive in nature, they prevent the exercise of discretion
total parenteral nutrition. by physicians and health workers that is unnecessary and often
In general, children with mild and moderate acute malnu- dangerous (16). For example, although severely malnourished
trition require approximately twice the protein and 1.5 times the children often do not have obvious signs of infections such as
energy requirements as well as specific micronutrients to enable a fever and tachypnea because of impaired immunity, the prevalence
minimum of 5 g  kg1  day1 catch-up weight gain that results in of infections is high and with a high associated mortality; the WHO
complete catch-up growth by 1 month or less (12). protocol, therefore, promotes the use of immediate anticipatory
Children with severe acute malnutrition present unique antibiotic treatment in all severely malnourished children for pre-
challenges. Refeeding syndrome is a set of metabolic abnorm- sumed infection. Severely malnourished children are typically
alities that occur upon the initiation of nutritional therapy and is not depleted in several essential micronutrients including phosphorus,
only the result of isolated metabolic abnormalities, especially magnesium, potassium, zinc, among others even with normal blood
phosphate depletion, but also the combined effect of various concentrations of these elements (Table 3); supplemental, not
disturbances including deficiencies of phosphate, potassium, mag- maintenance, amounts are provided rather than being withheld
nesium, fluid, vitamins, and/or micronutrients that lead to life- until there is an abnormal laboratory value. Somewhat analogous
threatening pathophysiologic states (13). In addition to slowly to the premature newborn, severely malnourished children have
increasing caloric intake, standard treatment in developed countries unique stereotypical pathophysiologic abnormalities that require
and prevention of refeeding syndrome have emphasized close and both anticipatory and special management. Although the prescrip-
frequent monitoring of laboratory data with subsequent correction tive nature of the guidelines is an essential characteristic that
of abnormal values. accounts for its success, it may also be a point of conflict on the
The WHO developed guidelines for the protocolized man- part of some health care providers who are either uninformed about
agement of complicated severe acute malnutrition of hospitalized the guidelines or unconvinced of the superiority of decision making
children older than 6 months of age in developing countries that has by an algorithm instead of clinical judgment and discretionary
resulted in a marked reduction in case fatality rates. Principles of management. Furthermore, it advocates only a few select laboratory
these guidelines are based on 10 essential steps divided into 3 tests and instead largely addresses refeeding syndrome in a pre-
phases of management: stabilization, rehabilitation, and eventual ventive rather than reactive way. If severe acute malnutrition in a
follow-up (14,15). The initial phase focuses on the stabilization of child is identified, the conceptual approach of the WHO guidelines
metabolic imbalances, stabilization of electrolyte imbalances, and is relevant and applicable to the developed country setting, unless
treatment of infection as well as any associated complications such controlled trials, which are lacking, indicate otherwise. Not all
as shock, anemia, and associated illnesses. Energy intake in younger components of the WHO guidelines can, however, be easily or

TABLE 2. Classification of malnutrition using z scores



Nutritional status Weight-for-height Height-for-age Weight-for-age

Adequate >1.0 >1.0 >1.0


Mild 1.0 to >2.0 1.0 to >2.0 1.0 to >2.0
Moderate 2.0 to >3.0 2.0 to >3.0 2.0 to >3.0
Severe 3.0y 3.0 3.0y

Or BMI in children >2 years of age.
y
Or edema, regardless of weight.

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Vaughan and Fuchs JPGN  Volume 61, Number 6, December 2015

TABLE 3. Selected biochemical changes in severe malnutrition 5. Huysentruyt K, Alliet P, Muyshont L, et al. Hospital-related under-
nutrition in children: still an often unrecognized and undertreated
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diagnoses in hospitalized patients: United States, 2010. JPEN J Parenter
Body composition Enteral Nutr 2014;38:18695.
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Total body potassium Low Lower 539.
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Total body sodium High High
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Serum or plasma Parenter Enteral Nutr 2013;37:46081.
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