ADA Pediatric Screening Tools

FROM THE ACADEMY
Evidence Analysis Center
Validity and Reliability of Pediatric Nutrition

Screening Tools for Hospital, Outpatient, and
Community Settings: A 2018 Evidence Analysis
Center Systematic Review
Patricia J. Becker, MS, CSP, CNSC, RDN; Sarah Gunnell Bellini, PhD, RDN, CD; Molly Wong Vega, MS, CSP, CSSD, RD; Mark R. Corkins, MD, CNSC;
Bonnie A. Spear, PhD, MS, RDN, FAND; Elizabeth Spoede, MS, RD, CSP, LD; M. Katherine Hoy, EdD, RDN; Tami A. Piemonte, MS, RDN, LD/N;
Mary Rozga, PhD, RDN
ABSTRACT
Background Nutrition screening tools are used to identify risk of malnutrition or change in risk of malnutrition. However, it is unclear
which tools have demonstrated high validity, reliability, and agreement.
Objective Our aim was to conduct a systematic review of valid and reliable pediatric nutrition screening tools for identifying
malnutrition risk (under- or overnutrition), and to determine whether there are differences in validity and reliability according to users
of the tools.
Methods A literature search using Medline, Embase, and CINAHL databases was conducted to identify relevant research published
between 1995 and May 2017 examining validity and reliability of nutrition screening tools in the pediatric population. A multidisci-
plinary workgroup developed eligibility criteria, data were extracted and summarized, risk of bias was assessed, and evidence strength
was graded, according to a standard process.
Results Twenty-nine studies met inclusion criteria. Thirteen pediatric nutrition screening tools designed for various settings were
included in the review (seven inpatient/hospital, three outpatient or specialty setting, and three community). The most frequently
examined tools were the Screening Tool for the Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status
and Growth (13 studies each), and Paediatric Yorkhill Malnutrition Score (nine studies). No tools demonstrated high validity. Reliability
and agreement were reported infrequently.
Conclusions Nutrition screening tools with good/strong or fair evidence and moderate validity included the Screening Tool for the
Assessment of Malnutrition in Pediatrics, Screening Tool for Risk on Nutritional Status and Growth, and Paediatric Yorkhill Malnutrition
Score in the inpatient setting and Nutrition Risk Screening Tool for Children and Adolescents with Cystic Fibrosis in the specialty setting.
No tools in the community setting met these criteria. While differences in validity and reliability measures among tool users were found,
the significance of these findings is unclear. Limitations included few studies examining each tool, heterogeneity between studies
examining a common tool, and lack of tools that included currently recommended indicators to identify pediatric malnutrition.
J Acad Nutr Diet. 2019;-(-):---.
Supplementary materials: Figure 1 type 2 diabetes, breathing problems, with changes in disease processes.
is available at www.jandonline. and gastroesophageal reflux.3 Early Nutrition screening tools should be quick
org identification of malnutrition risk facil- (10 minutes) and easy to use to allow
itates timely nutrition intervention, the process to be carried out by those
I
N THE PEDIATRIC POPULATION,
potentially limiting malnutrition- without formal nutrition training.
optimal nutritional status is crucial
related comorbid complications. Nutrition screening tools that have
to ensure appropriate growth and
Although not part of the Nutrition demonstrated high validity, reliability,
development. Malnutrition related
Care Process, nutrition screening is an and agreement are preferred. Use of
to undernutrition has been associated
important preliminary step that serves tools that have low or undemons-
with functional and intellectual delays,
to notify registered dietitian nutrition- trated validity and reliability may
increased infection rates and immune
ists (RDNs) that a nutrition problem result in missing individuals at risk for
dysfunction, and increased mortality
may exist and initiates entry into the malnutrition. Ineffective nutrition
risk.1 Likewise, malnutrition associated
Nutrition Care Process.4 Nutrition screening may also result in spending
with overnutrition has been associated
screening also supports pragmatic limited RDN resources on nutrition
with adverse health outcomes,
triage for nutrition assessment by assessments for those who are not at
including neurocognitive dysfunction,2
RDNs, especially in the presence of risk. The use of unvalidated tools to
high patient to RDN ratios. identify malnutrition risk (eg, locally
2212-2672/Copyright ª 2019 by the Nutrition screening tools are used to developed tools that have not been
Academy of Nutrition and Dietetics. identify risk of malnutrition or change in tested) or not using any tool at all to
https://doi.org/10.1016/j.jand.2019.06.257
risk of malnutrition, which can occur screen for risk also limits
ª 2019 by the Academy of Nutrition and Dietetics. JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 1
FROM THE ACADEMY
Inclusion criteria Exclusion criteria

Age Infants, children, and adolescents up to 18 19 years of age or older than 24 years
years of age. Young adults up to 24 years (college-aged) of age.
(college-aged) may be considered for inclusion. Results for pediatric population not
Results must be separated by adult and reported separately from adults.
pediatric.
Setting All settings. None excluded.
Health status Any health status. None excluded.
Nutrition- At risk or not at risk for malnutrition or nutrition None excluded.
related problems related to undernutrition or overnutrition.
problem/
condition
Study design Diagnostic, validity, and/or reliability studies. Review article; meta-analysis (pertinent
preferences review articles were hand searched)
Not a research study: poster session,
commentary, letter to editor, “grey”
literature: technical reports from
government agencies or scientific
research groups, working papers from
research groups or committees, white
papers, position papers, abstracts,
conference reports, or preprints.
Nutrition Designed to identify risk for malnutrition or Not designed to identify risk for
screening tool nutrition problems related to under- or malnutrition or nutrition problems,
overnutrition. related to under- or overnutrition.
Quick and easy (<10 minutes to complete). Not quick and easy (longer than
Screening tool contains two or more questions 10 minutes to complete).
or parameters. Screening tools containing laboratory
Administered by a health professional (eg, values, bioelectrical impedance, skinfold
dietetic technician, registered, registered or muscle circumference measurements,
nurse, or others) trained in administering the or diagnostic tests.
screening tool, by a parent or guardian, or Nutrition assessment tool or used as a
self-administered by child. nutrition assessment tool.
Food frequency or diet quality
questionnaires; eating disorders
questionnaires; tools designed to
diagnose disease (eg, avoidant/restrictive
food intake disorder).
Not administered by health care
professional, trained in administering
the screening tool or not
self-administered by patient or
parent/guardian.
Reference Screening tool was compared to an acceptable Reference standard not designed to assess
standard reference standard designed to assess malnutrition alone.
malnutrition. Reference standard was not described or
An acceptable reference standard is defined insufficient to determine whether criteria
as anthropometrics (growth parameters at a were met.
(continued on next page)

a 10 b 1
Figure 2. Inclusion and exclusion criteria. Becker and colleagues. Mehta and colleagues.
2 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -

FROM THE ACADEMY
Inclusion criteria Exclusion criteria

given time or changes in anthropometrics Screening tool was not compared to an
over time).ab Examples of acceptable acceptable reference standard or was
reference standards: compared to another screening tool.
o Pediatric Subjective Global Nutrition Screening tool was not compared to an
Assessment for Children acceptable reference standard (must
o Dietitian assessment include anthropometrics [growth
o Anthropometric data parameters] at a given time or
changes in anthropometrics over time).ab
Outcomes Evaluates validity, agreement, and reliability No evaluation of validity, agreement, or
of the screening tool. reliability of the screening tool.
Reports one or more of the following out- Does not report on at least one of the
comes: outcomes of interest.
o Validity (eg, construct [convergent, divergent] Tools evaluated as predictors of
criterion [concurrent or predictive]) morbidity and mortality outcomes.
o Reliability (eg, inter- or intra-rater; k)
o Sensitivity/specificity
o Positive predictive value/negative
predictive value
o Agreement (k; correlation)
Size of study Sample size must equal 20 for each study group. <20 subjects for each study group.
groups Subject number is unclear or not reported.
Year range 1995 to May 2017 Published before 1995
Authorship If an author is included on more than Studies by same author similar in content.
one review article or primary research article
that is similar in content, the most recent
review or article will be accepted and earlier
versions will be rejected.
If an author is included on more than on review
article or primary research article and the
content is different, then both reviews may
be accepted.
Language Articles in English Articles not in English
Subjects Human Animal studies
Publication Published in peer-reviewed journal Not published in peer-reviewed journal
Figure 2. (continued) Inclusion and exclusion criteria. Becker and colleagues.10 bMehta and colleagues.1
a
standardization of care. These conse- and reliability of pediatric nutrition tools? This related sub-question
quences may ultimately adversely screening tools examined in validity sought to identify any differ-
affect patient outcomes.5 and/or reliability studies. ences in validity and reliability
There is uncertainty regarding The research questions addressed in among various health care users
which tools should be used for iden- this systematic review are: administering the tools.
tification of malnutrition risk in
different practice settings. In addition, 1. What is the validity and reli- METHODS
before 2014, there was no consensus ability of nutrition screening The questions examined in this system-
on the definition of and criteria for tools for identifying risk of atic review are part of the larger Pediatric
diagnosing pediatric undernutrition, malnutrition related to under- Nutrition Screening project in which two
and tools developed before this defi- or overnutrition in the pediatric other research questions examining the
nition were not created with this population? validity and reliability of mid-upper arm
framework in mind.6 Thus, the aim of 2. Is there a difference in (a) val- circumference (MUAC) and the relation-
this systematic review is to provide an idity and (b) reliability among ship between food insecurity and
evidence-based analysis of the validity users of nutrition screening malnutrition risk were examined.
-- 2019 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 3

FROM THE ACADEMY
Identification
Records idenfied through Addional records idenfied

database searching through other sources
(n=1,901) (n=14)
Records aer duplicates removed

(n=1,880)
Screening
Records screened Records excluded

(n=1,880) (n=1,779)
Full-text arcles assessed Full-text arcles excluded

for eligibility (n=72)
Eligibility
(n=101)
Did not answer RQ=28
Measured single
parameter, not tool=13
Studies included in Included adults= 12
qualitave synthesis Review arcle=9
(n=29) Not quick, easy/includes
lab data=7
No reference standard=2
Included
No outcome of interest=1
Figure 3. PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) flow diagram for studies examining
nutrition screening tools. From Moher and colleagues.11
This systematic review followed the PROSPERO (The International Prospec- of five RDNs, all of whom had exten-
Academy of Nutrition and Dietetics tive Register of Systematic Reviews; sive experience in pediatric nutrition
(Academy) Evidence Analysis Library CRD42017064324).9 practice and/or research, and one
protocol, published elsewhere.7 A brief pediatrician. The systematic review
description of methods for the full team supporting the workgroup
project and specific to the research Multidisciplinary Workgroup included a project manager, lead an-
questions for this systematic review In 2016, a six-member expert work- alyst, evidence analysts, systematic
will be discussed. The complete Pedi- group was selected by the Academy’s review methodologists, and a medical
atric Nutrition Screening project can be Evidence Based Practice Committee librarian. The workgroup and other
found on the Evidence Analysis Library to examine the literature regarding team members met two or more
website.8 Details of the protocol for this nutrition screening in the pediatric times per month from September
systematic review were registered on population. The workgroup consisted 2016 through June 2018 in a virtual

FROM THE ACADEMY
searched for articles that met eligi-

Table 1. Cut points for interpreting data of pediatric malnutrition screening tools bility criteria.
Title and abstract screening was
Criteria for individual study results Overall classification for each tool completed by the lead analyst and
project manager. Full-text articles were
Validity results Validity results
reviewed for eligibility criteria by at
Se,a Sp,b PPV,c NPVde Overall degree of Se, Sp, PPV, NPV least two workgroup members with
90% to 100%, Excellent High content experience, and any discrep-
ancies were discussed until consensus
80% to 90%, Good Moderate
was reached. Articles not meeting in-
70% to 80%, Fair Low clusion criteria were excluded from
60% to 70%, Insufficient Low analysis.
A total of 1,901 articles were
50% to 60%, Poor Low
retrieved from the search of databases.
Reliability and agreement results Reliability and agreement results Workgroup members reviewed the full
k Statisticf Overall level of agreement and reliability text of 101 articles, and 29 studies were
selected for inclusion in qualitative
>.90, Almost perfect High
analysis for research question 1
.80 to .90, Strong High (Figure 3). A list of articles that were
.60 to .79, Moderate Moderate excluded during full-text review can be
found on the Evidence Analysis Library
.40 to .59, Weak Low
website.8 A subsequent review of the
.21 to .39, Minimal Low 29 articles was conducted by the
0 to .20, None Low workgroup to determine inclusion of
studies for research question 2. Studies
Cronbach’s ag Overall level of internal consistency
that did not compare at least two
a.9, Excellent High different users of the tool or did not
.9>a.8, Good High specify the users of the tool when
reporting validity and reliability mea-
.8>a.7, Acceptable Moderate
sures were excluded for research
.7>a.6, Questionable Low question 2. Twenty-two studies did not
.6>a.5, Poor Low meet these criteria, leaving 7 studies
for inclusion in qualitative analysis for
.5>a, Unacceptable Low
research question 2.
Intraclass correlation coefficienth Overall level of testeretest reliability
>0.90, Excellent High
Data Extraction, Evidence
0.75 to 0.9, Good High Synthesis, and Quality
0.5 to 0.75, Moderate Moderate Assessment
<0.5, Poor Low For the included articles, data were
extracted by trained evidence analysts
a
Se¼sensitivity. using the Academy’s Data Extraction
b
Sp¼specificity. Tool.12 Fields extracted from each study
c
PPV¼positive predictive value.
d
NPV¼negative predictive value
included bibliographic information,
e
Criteria were set based on Neelemaat and colleagues.14 eligibility criteria, participant charac-
f
Criteria were set based on McHugh.15 teristics, screening tool evaluated,
g
Criteria were set based on Tavakol and colleagues.17 reference standard used, and quanti-
h
Criteria were set based on Koo and colleagues.16 tative results. All data extraction was
reviewed by the lead analyst. Articles
were reviewed for risk of bias by two
workspace to develop research ques- librarian using Medline, Embase, and blinded reviewers using the Academy’s
tions and eligibility criteria, screen CINAHL databases to identify diag- Quality Criteria Checklist.12 A third re-
articles for inclusion, approve evi- nostic, validity, or reliability studies view was completed to resolve any
dence summaries, develop conclu- evaluating nutrition screening tools discrepancies. Evidence summary ta-
sion statements, and grade the in the pediatric population. Search bles and narrative syntheses were
strength of the evidence. inclusion dates were 1995 through created by the lead analyst and
May 1, 2017. A list of search terms can reviewed by staff and workgroup
be found in Figure 1 (available at members. Conclusion statements were
Eligibility Criteria, Literature www.jandonline.org). Inclusion and written to summarize evidence for
Search, and Study Selection exclusion criteria were developed a each research question. Secondary
A comprehensive literature search priori and can found in Figure 2. analysis was conducted for individual
was conducted by the medical Relevant review articles were hand studies to calculate outcome measures

FROM THE ACADEMY
Figure 4. Algorithm to determine high, moderate, or low validity for each malnutrition screening tool.
of interest, but there was no meta- when evaluating screening tools Seven tools were designed for use in
analysis conducted for this systematic because the tool attempts to identify the inpatient or hospital setting:
review. Analysts had no contact with risk and the need for nutrition Screening Tool for Assessment of
study authors. Conclusion statements assessment as opposed to diagnosis.5 Malnutrition in Pediatrics (STAMP),18-30
were graded by the workgroup and Similar procedures were followed to Screening Tool for Risk on Nutritional
represent evidence strength or weak- determine the overall reliability and Status and Growth (STRONG-
ness and, therefore, the level of confi- agreement for each tool. The k statis- kids),18,19,21,23,24,28,30-36 Paediatric
dence, in the findings described.7 tic was the preferred method of Yorkhill Malnutrition Score
Evidence grading included consider- measurement because it is a more (PYMS),18,20,23,24,26,28-30,37 Paediatric
ation of the number and quality of robust and conservative estimate Malnutrition Screening Tool (PMST),26
studies, consistency in findings, sample compared to other measures of Pediatric Nutrition Screening Tool
sizes, risk of bias across studies, preci- agreement. However, if k values were (PNST),38 Pediatric Nutrition Risk Score
sion of findings, and generalizability to not reported, Cronbach’s a or intra- (PNRS),28,39 and Integrated Management
the population of interest. class correlation was accepted of Childhood Illness (IMCI) algorithm
(Table 1). (Table 2).40 While these tools were
largely tested in inpatient facilities, one
Validity and Reliability Criteria study evaluated STAMP in an outpatient
In concordance with the methods of RESULTS clinic25 and another study evaluated
the Academy’s Adult Nutrition STAMP, STRONGkids, PYMS, and PNRS in
Screening Project,13 the level of val- Research Question 1: Validity and both inpatient and outpatient facilities,
idity, reliability, and agreement was Reliability of Nutrition Screening but data were not separated by setting.28
assessed for the individual studies, Tools The Pediatric Digital Scaled Malnutrition
then findings were aggregated for the Fourteen pediatric nutrition screening Risk Screening Tool (PeDiSMART) was
studies examining each tool, and an tools for identifying under- and over- designed for the inpatient setting, but
overall classification for each of these nutrition were identified in the litera- was excluded from analysis because the
measures was assigned (Table 1).14-17 ture. The most common parameters study examining the tool did not meet
When determining overall validity included in the tools to identify inclusion criteria.41
for a tool, sensitivity and negative malnutrition risk were appetite or di- Three tools were designed for use in
predictive value were given more etary intake in 11 tools; clinical infor- the outpatient or specialty setting:
weight than specificity and positive mation, such as medical condition or Screening Tool for the Assessment of
predictive value (Figure 4). This treatment in 9 tools; and one or more Malnutrition in Pediatrics-Modified
approach reduces the chance of false anthropometric measures or concerns (Modified-STAMP),25 Nutrition Risk
negatives, that is, identifying an in- about weight or growth in 7 tools. Screening Tool for Children and Ado-
dividual as not being at risk for Figure 5 identifies the components lescents with Cystic Fibrosis (NRST-
malnutrition when malnutrition is utilized for each of the 13 screening CF),42 and Nutrition Screening Tool for
actually present. This is appropriate tools reviewed. Childhood Cancer43 (SCAN) (Table 3).

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Screening tool Tool description Tool Components

2019 Volume
Body Weight/ Weight Appetite/ Clinical

mass age change/ dietary informationa/
index weight/ loss intake otherb
length
-
Number
height
velocity
-
Inpatient/hospital setting
IMCI (Integrated Management of Designed by World Health Organization to be used by Xb
Childhood health workers in developing countries
Illness) algorithm
PMST (Paediatric Malnutrition Modified version of STAMP for hospitalized children X X X
Screening aged <2 to 17 years; screens for both under- and
Tool) overnutrition
PNRS (Pediatric Nutrition Risk Score) Developed for hospitalized children >1 month of age X Xa
at risk of acute malnutrition
PNST (Pediatric Nutrition Screening Developed to improve simplicity of nutrition screening X X X Xa
Tool) in hospitalized children
PYMS (Paediatric Yorkhill Malnutrition Developed for hospitalized children >1 year of age X X X Xa
JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS
Score)
STAMP (Screening Tool for the Developed for hospitalized children aged 2 to 17 years; X X X Xa
Assessment of Malnutrition) allows for repeated screening
STRONGkids (Screening Tool for Risk Developed for hospitalized children to decrease X X Xab
on Nutritional status and Growth) complexity of previously available tools
Outpatient or specialty clinic setting
FROM THE ACADEMY

NRST-CF (Nutrition Risk Screening Tool Developed for children with cystic fibrosis in the X X X Xa
for Children and Adolescents with inpatient or outpatient setting
Cystic Fibrosis)
SCAN (Nutrition Screening Tool for Developed for children with a cancer diagnosis X X Xa
Childhood Cancer)

a
Figure 5. Pediatric nutrition screening tool components. Clinical information may include one or more of the following: visible severe wasting; bipedal edema; medical
condition or diagnosis; severity of disease or intensive treatment; gastrointestinal symptoms, pain, or other symptoms causing inability to eat; and visibly under- or
overweight. bOther information may include one or more of the following: dietary behavior, physical activity/sedentary behavior, pre-existing nutrition intervention, food
security, screen time, dietary habits, cooking techniques, and meal patterns. cIncludes parent/caregiver reported concerns about weight/growth.
7
FROM THE ACADEMY
Three tools were designed for use
overweight. bOther information may include one or more of the following: dietary behavior, physical activity/sedentary behavior, pre-existing nutrition intervention, food
Figure 5. (continued) Pediatric nutrition screening tool components. aClinical information may include one or more of the following: visible severe wasting; bipedal edema;
medical condition or diagnosis; severity of disease or intensive treatment; gastrointestinal symptoms, pain, or other symptoms causing inability to eat; and visibly under- or
informationa/ in the community setting: Electronic
Kids Index (E-KINDEX),44 Nutrition
Screening Tool for Every Preschooler
Clinical
otherb
(NutriSTEP),45,46 and Toddler-

NutriSTEP47 (Table 4).
Xb
Xb
Xa
Xa
The overall validity, reliability, and
agreement for each pediatric nutrition
Appetite/
screening tool can be found in

dietary
intake
X
Figure 6, and the conclusion state-
security, screen time, dietary habits, cooking techniques, and meal patterns. cIncludes parent/caregiver reported concerns about weight/growth.
Tool Components
ments for each tool and evidence

grade can be found in Figure 7. Only
three tools had more than two studies
change/
Weight
that met inclusion criteria for analysis:

STAMP (13 studies), STRONGkids (13
loss
studies), and PYMS (9 studies). Two

tools had two studies that met inclu-
sion criteria for analysis: PNRS and
Weight/
velocity
weight/
NutriSTEP. All other tools had only one

length
height
study that met inclusion criteria. The

age
Xc
Xc
majority of studies used the World
Health Organization anthropometric
definitions as the reference standard
index
Body
mass
to determine classification of malnu-

X
trition. Some studies used anthropo-

metric definitions from Centers for
Electronic tool designed for children in the community;
Disease Control and Prevention

focus is on self-reported nutrition behaviors related
growth reference data or similar data

Modified version of NutriSTEP; a community-based,
parent-administered tool for toddlers aged 18 to
A community-based, parent-administered tool for
from the population’s country of

Modified version of STAMP for children in the
origin. Other studies used the pediat-

ric Subjective Global Nutrition
Assessment, International Classifica-
tion of Diseases, 10th Revision criteria,
or nutrition assessment by a dietitian
as reference standards (Tables 2, 3,
and 4).
For tools used in the hospital
setting, only one conclusion state-
ment (STAMP) was supported by
preschool children
to risk for obesity.
outpatient setting
Grade I (good/strong) evidence.

Tool description
STAMP demonstrated moderate val-

idity, high reliability, and low agree-
35 months
ment. The conclusion statements for

four tools (Pediatric Nutrition
Screening Tool, PMST, PYMS, and
STRONGkids) were supported by
Grade II (fair) evidence. The PNST
demonstrated moderate or low val-
NutriSTEP (Nutrition Screening Tool for
Tool for Every PreschoolereToddler)

STAMP-Modified (Screening Tool for
idity, depending on the anthropometric

the Assessment of Malnutrition in
E-KINDEX (Electronic Kids Dietary
parameter used for assessment; reli-

ability and agreement were not re-
NutriSTEP-Toddler (Nutrition
ported. The PMST demonstrated

moderate validity and low agreement;
reliability was not reported. Both PYMS
PediatricseModified)
and STRONGkids demonstrated moder-

Community setting
Every Preschooler)
ate validity, moderate reliability, and low

Screening tool
agreement. The evidence supporting the

conclusion statements for two tools
Screening
(IMCI algorithm and PNRS) was Grade III

Index)
(limited/weak). The IMCI algorithm

demonstrated moderate or low val-
idity, depending on various visual

--
Table 2. Studies examining validity and reliability of pediatric nutrition screening tools in hospital settingsab
2019 Volume
Author(s),
year, Positive Negative
location, Setting, Sample size, Reference Administered predictive predictive Reliability,
-
quality population age standard by Sensitivity, % Specificity, % value, % value, % agreement

Number
STAMP
Chourdakis and Patients at n¼1,253 Anthropometricsc Trained 79.04 (73.19- 42.68 23.57 (23.57- 90.10 Reliability: NR
-
colleagues, hospital Age: 2-16 y (height/length, assessorsd 84.12)e (39.62 e 25.13)e (87.52-2.2)e Agreement: NR
201618 admission weight, BMI) 45.77)e
Europe (across 12
Rating: Positive countries)
Galera- Patients aged 1 n¼223 Anthropometricsg Expertsh 46.97 (34.56- 31.85 (24.65- 22.46 (18.0- 58.82 (50.86- Inter-rater:
Martinez mo at Mean age¼5.59 y (BMI) 59.66)e 39.75)e 27.67)e 66.35)e k¼.74 (.67-
and admission to 5 (95% CI 4.94e6.22) .81), P<0.001
colleagues, hospitals (3 Agreement: NR
201719f tertiary, 2 Non-expertsh 37.88 (6.22- 35.67 (28.19- 19.84 (15.1- 57.74 (50.74-
Spain secondary 50.66)e 43.7)e 25.62)e 64.43)e
Rating: Positive centers)
Gerasimidis Patients aged 1- n¼247 Dietitian Dietitians HR vs LRþMR: HR vs LRþ HR vs HR vs Reliability: NR
and 16 y on 5 wards Mean assessment 81 MR: 78 LRþMR: 31 LRþMR: 97 Agreement:
colleagues, at a tertiary ageSD¼8.14y k¼.34 (.2-.5)

201020 pediatric
United hospital
Kingdom
Rating: Positive
Ling and Patients at n¼43 Anthropometricsc Dietitians Acute: 100 Acute: 30.77 Acute: 12.9 Acute: 100e Reliability: NR
FROM THE ACADEMY

colleagues, hospital Mean age¼6 y, 4 mo (height/length, (39.76-100)e (17.02- (10.73- Chronic: 1.67 Agreement: NR
201121 admission (range¼6 wk to 16 weight) Chronic: 87.5 47.57)e 15.44)e (62.25-
d
United y) (47.35- Chronic: 1.43 Chronic: 98.66)e
Kingdom 99.68)e (16.85- 22.58
Rating: Neutral 49.29)e (17.12-
29.17)e
9
FROM THE ACADEMY
10
Table 2. Studies examining validity and reliability of pediatric nutrition screening tools in hospital settingsab (continued)
Author(s),
McCarthy and Patients aged 2- n¼238 E.phase: mean RD assessment (at Nurse At risk vs no At risk vs no At risk vs no At risk vs no Reliability: NR
colleagues, 17 y at hospital ageSD¼8.44.6y risk vs no risk)i risk: 70 (51- risk: 91 (86- risk: 54.8 risk: 94.9 Agreement:
2012 22f
admission 84) 94) (38.8-69.8) (90.5-97.4) k¼.541 (.461-
United .621)
Kingdom 20% sub-sample NR NR NR NR Inter-rater:
Rating: Positive D.phase: n¼24 D.phase:
E.phase: n¼48 k¼.882 (.646-
1.0)
E.phase: k¼.921
(.763-1.0)
Agreement: NR
Moeeni and Patients at n¼119 Anthropometricsc NR 90 (73.47- 37.08 (27.07- 32.53 (28.32- 91.67 (78.43- Reliability: NR
colleagues, hospital Median age¼3.6 y (height/length, 97.89)e 47.97)e 37.04)e 97.08)e Agreement: NR
201223 admission (range¼1-17.2 y) weight, MUAC
Iran for <5y, BMI)
Rating: Neutral
Moeeni and Patients at n¼162 Anthropometricsc 1st Assessor 93.75 (69.77- 23.97 (17.3- 11.9 (10.36- 97.22 (83.7- Reliability: NR
colleagues, hospital Median age¼5.1 y (height/length, 99.84)e 31.73)e 13.64)e 99.58)e Agreement: NR
New Zealand for <5 y, BMI)
Rating: Positive
n¼15 (9.2% of 2nd Assessor NR NR NR NR Inter-rater: 0.89-
patients) 0.93j
Agreement: NR
Rub and Patients aged 1-6 n¼60 Full RD assessment Nurse At risk vs no At risk vs no At risk vs no At risk vs no Reliability: NR
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colleagues, y seen at Mean ageSD¼ (At risk vs no risk: 47.6 risk: risk: 83.3 risk: Agreement:
201625 primary care 2.81.5 y risk)h (28.3-67.6) 94.9 (0.81- 77.1 Dietitian: k¼.47
2019 Volume
Israel clinic for inter- 0.99) (.24-.7)

Rating: Positive current disease BMI: k¼.26
-
Number
-
--
2019 Volume
Author(s),
-

Number
Thomas and Patients at n¼159 Anthropometricsc NR 63.2 36.3 35.6 63.8 Reliability: NR
colleagues, hospital Median age¼38 mo (height/length, Agreement: k¼
-
201626 admission to (range¼0-17.64 y) weight, BMI) e.005

United acute care unit
Kingdom
Rating: Positive
Wang and Patients with SCI n¼45 Anthropometricsc NR 100 73.3 65.2 100 Reliability: NR
colleagues, admitted to Age: 0-12 y (height/length, Agreement:
201727 rehabilitation weight, BMI) k¼.603
China hospital
Rating: Positive
Wiskin and Patients with IBD n¼46 Anthropometricsk NR 100 (29.24- 0 (0-8.22)e 6.52 (6.52- NR Reliability: NR
colleagues, seen by GE at Median age¼14.6 y (height/length, 100)e 6.52)e Agreement: k¼
201228 outpatient clinic (range¼3-17 y) weight, BMI) e.014
United or hospital
Kingdom
Rating: Neutral
Wong and Patients at n¼51 Dietitian Dietitians and 83.3 66.7 78.1 73.6 Inter-rater:
colleagues, admission to Median age¼11.3 y assessment nurses dietitians vs
201329f SCI center (range¼1-17.9 y) nurses:
United k¼.752 (.568-
FROM THE ACADEMY

Kingdom .935)
Rating: Positive Intra-rater:
dietitian vs
dietitian:
k¼.635 (.392-
.878)
Agreement:
k¼.507
11
FROM THE ACADEMY
12
Author(s),
Wonoputri and Patients at n¼116 Pediatric SGNA NR HR/SR vs HR/SR vs HR/SR vs HR/SR vs Reliability: NR
colleagues, hospital Age: 1-15 y LRþMR: 100 LRþMR: LRþMR: LRþMR: Agreement: NR
201430 admission (0.94-1) 11.54 (0.05- 58.2 (0.48- 100 (0.61-
Indonesia 0.23) 0.67) 1)
Rating: Neutral Anthropometricsc NR NR NR NR NR Reliability: NR
(height/length, Agreement:
weight) Acute: k¼.018
(0-.140)
Chronic: k¼0 (0-
.140)
STRONGkids
Chourdakis and Patients at n¼1,253 Anthropometricsc Trained 75.11 (68.99- 50.59 (47.48- 25.37 (23.58 90.09 (87.8- Reliability: NR
colleagues, hospital Age: 2-16 y (height/length, assessorsd 80.57)e 53.69)e e 27.25)e 91.98)e Agreement: NR
201618 admission weight, BMI)
Europe (across 12
Durakbasa and Patients at n¼494 Anthropometricsc Physicians Acute: 48.0 Acute: 65.77 Acute: 13.64 Acute: 91.87 Reliability: NR
colleagues, admission to Mean age (height/length, (33.66- (61.15- (10.32- (89.51- Agreement: NR
201431 tertiary hospital SD¼70.156.1 weight, BMI) 62.58)e 70.17)e 17.8)e 93.66)e
Turkey for surgery mo (range¼1-220 Chronic: 52.17 Chronic: 65.6 Chronic: 6.94 Chronic: 6.54
Rating: Neutral mo) (30.59- (61.0-69.9)e (4.71- (94.77-
e
73.18) 10.10)e 97.73)e
Galera- Patients aged 1 n¼223 Anthropometricsg Expertsh 27.27 (17.03- 16.56 (11.11- 12.08 (8.43- 35.14 (27.01- Inter-rater:
Martinez and mo at Mean age¼5.59 y (height/length, 39.64)e 23.32)e 17.01)e 44.22)e k¼.72 (.63 e
colleagues, admission to 5 (95% CI 4.94-6.22 y) weight, BMI) .80), P<0.001
--
201719f hospitals Agreement: NR

Spain (tertiary, Non-expertsh 22.73 (13.31- 26.75 (20.01- 11.54 (7.64- 45.16 (38.13-
2019 Volume
Rating: Positive secondary 34.7)e 34.39)e 17.05)e 52.4)e

centers)
-
Number
-
--
2019 Volume
Author(s),
-

Number
Hulst and Patients at n¼424 Anthropometricsl Physicians; 75.64 (64.6- 41.59 (36.29- 22.96 (20.34- 88.12 (83.11- Reliability: NR
colleagues, admission to Median age¼3.5 y (height/length, nursing 84.65) 47.04) 25.81) 91.8) Agreement: NR
-
201032 pediatric ward (range¼31 d to 17.7 weight) staff

Netherlands y)
Rating: Positive
Huysentruyt Patients at Reproducibility study: N/A Nurses NR NR NR NR For risk score:
and admission to n¼29 Inter-rater:
colleagues, secondary and Median age¼1.5 y k¼.61, P<0.01
201333 tertiary (range¼0.4-15.5 y) Intra-rater:
Belgium hospitals k¼.66, P<0.01
Rating: Neutral Agreement: NR
Validity study: n¼343 Anthropometricsm Nurses Acute: WHZ: Acute: Acute: Acute: Reliability: NR
Age: 0-1 y: 31%; 1-2 y: (height/length, 71.9 WHZ: 49.1 WHZ: 11.9 WHZ: 94.8 Agreement: NR
17.2%; 2-10 y: weight) Chronic: HAZ: Chronic: Chronic: Chronic:
34.2%; 69 HAZ: 48.4 HAZ: 10.4 HAZ: 94.8
>10 y: 17.5%
Patients at Prospective validity During NR Acute: Acute: Acute: WL: Acute: Reliability: NR
discharge study: n¼NR hospitalization: WL: 52.6 WL: 43.1 66.5 WL: 29.7 Agreement: NR
WL >2%; start of Chronic: Chronic: Chronic: Chronic:
NI NI: 94.6 NI: 52.0 NI: 18.0 NI: 98.9
Ling and Patients at n¼43 Anthropometricsc Dietitian Acute: 100 Acute: 25.64 Acute: 12.12 Acute: 100e Reliability: NR
FROM THE ACADEMY

e
colleagues, hospital Mean age¼6 y and 4 (height/length, (39.76-100) (13.04- (10.29- Chronic: 90 Agreement: NR
201121 admission mo (range¼6 wk to weight, BMI) Chronic: 87.5 42.13)e 14.23)e (56.94-
United 16 y) (47.35- Chronic: 25.71 Chronic: 98.39)e
e
Kingdom 99.68) (12.49- 21.21
Rating: Neutral 43.26)e (16.26-
27.18)e
13
FROM THE ACADEMY
14
Author(s),
Marginean and Patients at n¼271 Anthropometricsc NR 97 (91.49- 50.29 (42.56- 53.3 (49.44- 96.63 (90.3- Reliability: NR
colleagues, hospital Median age¼5.2 y (height/length, 99.38)e 58.02)e 57.12)e 98.8)e Agreement:
201434 admission (range¼1-17 y) weight) k¼.61,
Romania P¼0.001
Rating: Neutral
Moeeni and Patients at n¼119 Anthropometricsc NR 83.33 (65.28- 49.44 (38.67- 35.71d 89.8 (79.37- Reliability: NR
colleagues, hospital Median age¼3.6 y (height/length, 94.36)e 60.25)e (29.98- 95.27)e Agreement: NR
201223 admission (range¼1-17.2 y) weight, MUAC 41.89)e
Iran for <5 y, BMI)
Rating: Neutral
Moeeni and Patients at n¼162 Anthropometricsc 1st Assessor 100 (79.41- 41.1 (33.03- 15.69 (13.98- 100e Agreement: NR
colleagues, hospital Median age¼5.1 y (height/length, 100)e 49.53)e 17.56)e
New Zealand n¼15 (9.2% of for <5 y, BMI) 2nd Assessor NR NR NR NR Inter-rater:
Rating: Positive patients) k¼.89-93j
Agreement: NR
Moeeni and Patients at n¼162 Anthropometricsc Pediatrician 89.47 (66.86- 27.97 (20.79- 14.17 (12.86- 95.24 (84.01- Agreement: NR
colleagues, hospital Age: 1 mo to 16.4 y (height/length, 98.7) 36.9) 16.57) 98.7)
201435f admission weight, BMI) Pediatric 84.21 (60.42- 30.3 (22.61- 14.81 (12.2- 93.02 (82.06- Inter-rater:
New Zealand nursing 96.62) 38.9) 17.88) 97.49) k¼.65
Rating: Positive staff
Spagnuolo and Patients at n¼144 Anthropometricsn Nurse 71 (48-89) 53 (43-63) 21 (17-25) 85 (85-90) Reliability: NR
colleagues, hospital Mean ageSD¼ (height/length, Agreement: NR
201336 admission to 6.54.5 y (range¼ weight)
Italy 12 hospitals 5.7-7.2 y)
--
Rating: Neutral
2019 Volume
-
Number
-
--
2019 Volume
Author(s),
-

Number
Wiskin and Patients with IBD n¼46 Anthropometricsk NR 100 (29.24- 0 (0-8.22)e 6.52 (6.52- Unable to Reliability: NR
colleagues, seen by GE at Median age¼14.6 y (height/length, 100)e 6.52)e estimate Agreement: k¼
-
201228 outpatient clinic (range¼3-17 y) weight, BMI) e.013

United or hospital
Kingdom
Rating: Neutral
colleagues, hospital Age: 1-15 y LRþMR: 100 LRþMR: 7.7 LRþMR: LRþMR:
201430 admission (0.94-1) (0.03-0.18) 57.14 100 (0.51-
Indonesia (0.479- 1)
Rating: Neutral 0.659)
Anthropometricsc NR NR NR NR NR Agreement:
(height/length, Acute: k¼.028
weight) (0-.149)
Chronic: k¼0 (0-
.144)
PYMS
Chourdakis and Patients at n¼1,253 Anthropometricsc Trained 69.4 (63.02- 67 (64.12- 32.06 (29.45- 90.75 (88.93- Reliability: NR
colleagues, hospital Age: 2-16 y (height/length, assessorsd 5.33)e 9.96)e 34.78)e 92.30)e Agreement: NR
201618 admission weight, BMI)
Europe (across 12
FROM THE ACADEMY

n¼247 Dietitian Dietitians HR vs MRþLR: HR vs MRþLR: HR vs HR vs Agreement:
Gerasimidis Patients aged 1- Mean ageSD¼ assessment 85 87 MRþLR: 44 MRþLR: 98 k¼.51 (.4-.7)
and 16 y on 5 wards 8.14 y Nurses HR vs MRþLR: HR vs MRþLR: HR vs HR vs Inter-rater:
colleagues, at a tertiary 59 92 MRþLR: 47 MRþLR: 95 k¼.53 (.38-.67)
201020f pediatric
United hospital
Kingdom
Rating: Positive
15
FROM THE ACADEMY
16
Author(s),
Gerasimidis Patients on 5 n¼1,571 Global clinical Nurse NR HR vs MRþLR: HR vs HR vs Reliability: NR

and wards at a Median age¼4.7-7.6 y judgment by 95 MRþLR: MRþLR: 92 Agreement: NR
colleagues, tertiary dietitian 86-89o
201137 pediatric
United hospital
Kingdom
Rating: Neutral
Moeeni and Patients at n¼119 Anthropometricsc NR 90e 31.5e 30.7e 90.3e Reliability: NR
colleagues, hospital Median age¼3.6 y (height/length, Agreement: NR
Iran for <5 y, BMI)
Rating: Neutral
Moeeni and Patients aged 1- n¼162 Anthropometricsc 1st Assessor 81.3e 67.8e 97.1e 98e Reliability: NR
colleagues, 17 y at hospital Median age¼5.1 y (height/length, Agreement: NR
New Zealand for <5 y, BMI)
Rating: Positive n¼15 (9.2% of 2nd Assessor NR NR NR NR Inter-rater: 0.89-
patients) 0.93j
Agreement: NR
Thomas and Patients admitted n¼116 Anthropometricsc NR 26.1 67.1 34.3 58.0 Reliability: NR
colleagues, to hospital Median age¼38 mo (height/ Agreement: k¼
201626 acute care unit (range¼0-17.6 y) length;weight) e.71
United
Kingdom
Rating: Positive
--
Wiskin and Patients with IBD n¼46 Anthropometricsj NR 100e 53.5e 13.04e 100e Reliability: NR
colleagues, seen by GE at Median age¼14.6 y (height/length, Agreement:
2019 Volume
201228 outpatient clinic (range¼3-17 y) weight) k¼.079

United or hospital
Kingdom
-
Rating: Neutral
Number

-
--
2019 Volume
Author(s),
-

Number
Wong and Patients at n¼51 Dietitian Nurse 82.6e 50e 57.6e 77.8e Reliability: NR
colleagues, admission to Median age¼13 y assessment Agreement: NR
-
201329 SCI center (range¼1-18 y)

United
Kingdom
Rating: Positive
colleagues, hospital Age: 1-15 y LRþMR: LRþMR: LRþMR: LRþMR: Agreement: NR
201430 admission 95.31 (0.87- 76.92 (0.63- 83.56 93.02
Indonesia 0.98) 0.86) (0.73-0.90) (0.81-0.97)
Rating: Neutral Anthropometricsc NR NR NR NR NR Reliability: NR
(height/length, Agreement:
weight) Acute k¼.348
(.191-.506)
Chronic k¼.125
(.0-.299)
PMST
Thomas and Patients at n¼266 Anthropometricsc Single 94.4 29.0 40.5 91.1 Reliability: NR
colleagues, hospital Median age¼38 mo (height/length, observer Agreement:
201626 admission (range¼0-17.6 y) weight, BMI) k¼.177
United
FROM THE ACADEMY

Kingdom
Rating: Positive
17
FROM THE ACADEMY
18
Author(s),
PNST
White and Patients aged 0- n¼295 0-2 y: WHO growth NR WAZ: WAZ: WAZ: WAZ: Reliability: NR
colleagues, 16 y admitted Infants <12 mo: reference e2: 89.5 e2: 65.0 e2: 15.3 e2: 98.9 Agreement: NR
201638 to 2 pediatric n¼155 standard e3: 100 e3: 62.9 e3: 5.4 e3: 100
Australia tertiary Median age¼4.5 mo >2 y: CDC HAZ: HAZ: HAZ: HAZ:
Rating: Positive hospitals and (IQR¼2.15-7.68 mo) reference data e2: 55.6 e2: 62.4 e2: 4.5 e2: 97.8
one regional Children 12 mo: e3: 75.0 e3: 62.3 e3: 2.7 e3: 99.4
hospital n¼140 BAZ: BAZ: BAZ: BAZ:
Median age¼73 mo e2: 89.3 e2: 66.2 e2: 22.5 98.4
(IQR¼38.0-116.0 e3: 100 e3: 62.8 e3: 5.4 e3: 100
mo) BMI 85th BMI 85th BMI 85th BMI 85th
percentile: percentile: percentile: percentile:
45.5 64.1 32.4 75.8
Pediatric SGNA 77.8 82.1 69.3 87.6 NR
PNRS
Sermet- Patients admitted n¼296 WL<2% or 2% NR 99.25 (95.91- 26.54 (19.92- 52.78 (50.44- 97.73 (85.71- Reliability: NR
Gaudelus to medical or Median age¼15 mo body weight 99.98)e 34.04)e 55.11)e 99.68)e Agreement: NR
and surgical ward (range¼1-72þ mo) during hospital
colleagues, stay
200039
France
Rating: Positive
Wiskin and Patients with IBD n¼46 Anthropometricsj NR 100r 0e 6.52e 0e Reliability: NR
colleagues, seen by GE at Median age¼14.6 y (height/length, Agreement:
201228 outpatient clinic (range¼3-17 y) weight) k¼.013
--
United or hospital
2019 Volume
Kingdom
Rating: Neutral
-
Number
-
--
2019 Volume
Author(s),
-

Number
IMCI algorithm
Hamer and Children aged 2- n¼352 Assessment by Nurses Severe Severe Severe Severe Reliability: NR
-
colleagues, 60 mo from Median age¼16 mo trained wasting: wasting: wasting: wasting: Agreement: NR
200440 pediatric (range¼9.8-27 mo) observerp 55.9 (39.2- 95.3 (93- 55.9 (39.2- 95.24e
Gambia outpatient clinic Anthropometricsq 72.6) 97.6) 72.6) BPE: 95.91e
Rating: Neutral admitted to (height/length, BPE: 22.2 (3.0- BPE: 99.1 BPE: 57.1 Severe
hospital weight) 41.4) (98.1-100.1) (20.4-93.8) wasting
Severe wasting Severe Severe and/or
and/or BPE: wasting wasting BPE: 92.04e
50.0 (36.1- and/or BPE: and/or Stunted
63.9) 95.7 (93.4- BPE: 65.8 growth:
Stunted 98.0) (50.7-80.9) 97.09e
growth: 71.4 Stunted Stunted VLWA: 94e
(38.0-104.9) growth: growth:
VLWA: 62.0 60.0 (35.2- 10.71e
(48.5-75.5) 84.8) VLWA: 88.6

VLWA: 98.7 (78.1-99.1)
(97.4-100)
a
BAZ¼ BMI-for-age z-score; BMI¼body mass index; BPE¼bipedal edema; CDC¼Centers for Disease Control and Prevention; D.phase¼development phase; E.phase¼evaluation phase; GE¼gastroenterology; HAZ¼length/height-for-age z-score;
HR¼high risk for malnutrition; IMCI¼Integrated Management of Childhood Illness; IQR¼interquartile range; LR¼low risk for malnutrition; MR¼moderate risk for malnutrition; MUAC¼mid-upper arm circumference; N/A=not applicable; NI¼nutrition
intervention; NR¼not reported or unclear; PMST¼Paediatric Malnutrition Screening Tool; PNRS¼Pediatric Nutrition Risk Score; PNST¼Pediatric Nutrition Screening Tool; PYMS¼Paediatric Yorkhill Malnutrition Score; RD¼Registered Dietitian;
SCI¼spinal cord injury; SD¼standard deviation; SGNA¼Subjective Global Nutrition Assessment; SR¼severe risk for malnutrition; STAMP¼Screening Tool for the Assessment of Malnutrition in Pediatrics; STRONGkids¼Screening Tool for Risk on
FROM THE ACADEMY

Nutritional Status and Growth; VLWA¼very low weight-for-age; WAZ¼weight-for-age z score; WHO¼World Health Organization; WHZ¼weight-for-length/height z score; WL¼weight loss.
b
Results presented are for moderate/high risk vs no/low risk unless otherwise noted. Values are rounded to the nearest hundredth. Values in parentheses are 95% CIs, if reported, unless otherwise noted.
c
WHO growth reference data were used to determine malnutrition risk classification.
d
Trained assessors included nurses, dietitians, nutritionists, and medical students.
e
Calculated from study data.
f
Study was also included in the research question “Is there a difference in validity and reliability among users of nutrition screening tools?”
g
Spanish growth reference data used to determine malnutrition risk classification.
h
Experts included dietitians or experienced physicians; Non-experts included inexperienced nurses and physicians.
i
“At risk” was determined using three criteria; one or more had to be present: low weight percentile relative to height percentile and age (WHO growth charts), suboptimal dietary intake unlikely to improve in next 3 to 5 days, and clinical history/
treatment plan that might result in either increased metabolic stress, decreased dietary intake, or increased nutritional losses.
j
Inter-rater reliability was for all 3 tools (PYMS, STAMP, and STRONGkids).
k
International Classification of Diseases, 10th Revision criteria were used to determine degree of malnutrition.
l
Dutch growth reference data used to determine malnutrition risk classification.
m
Belgian growth reference data used to determine malnutrition risk classification.
n
Italian growth reference data used to determine malnutrition risk classification.
o
Positive predictive value was based on two sites.
19
p
Nurses’ assessments were compared with number of children with severe wasting defined as WHZ score < e3, VLWA defined as WAZ score < e3, severe stunting was defined as HAZ score < e3, and BPE as identified by a trained observer.
q
Risk classification determined using CDC reference data.
FROM THE ACADEMY
20
Table 3. Studies examining validity and reliability of pediatric nutrition screening tools in outpatient or specialty settingsab
Author(s),
location, Setting, Sample Reference Administered Sensitivity, Specificity, predictive Predictive Reliability
quality population size, age standard by % % value, % value, % agreement
Modified-STAMP
Rub and colleagues, Patients aged n¼60 Full RD Nurse At risk vs no At risk vs no At risk vs no At risk vs no Reliability: NR
201625 1-6 y seen at Mean assessment risk: 76.2 risk: 82.1 risk: 69.6 risk: 86.5 Agreement:
Israel primary care ageSD¼ (at risk vs no (54.9-89.4) (67.3-91.0) k¼.57
Rating: Positive clinic for inter- 2.81.5 y risk)c
current disease
NRST for CF
McDonald, 200842d Children and n¼85 CFF 2002 RD 84 75 75e 83.67e Reliability: NR
Utah, US adolescents CF outpatient Consensus Agreement:
Rating: Neutral case studies records Report on NR
Age: 2-20 y Nutrition
Screening
n¼18 case In-depth RD RD 86 78 85.71e 77.78e Inter-rater:
studies assessment; k¼.85
Age: 2-20 y 2002 Agreement:
NR
SCAN
Murphy and Patients Study 1: n¼32 Pediatric SGNA Dietitian or 100 (76-100) 39 (17-64) 56 (35-76) 100 (59-100) Reliability: NR
colleagues, 201643 admitted to Mean by dietitian nutritionist in Agreement:
Australia cancer hospital ageSD¼ consultation NR
Rating: Neutral for treatment 6.24.1 y with parents
or caregivers
Study 2: n¼58 Anthropometricsf 100 (63.06- 60 (45.18- 28.57 (22.17- 100c
Mean (height/length, 100)e 73.59)e 35.97)e
ageSD¼ weight, BMI)
--
11.03.3 y
2019 Volume
a
BMI¼body mass index; CF¼cystic fibrosis; CFF¼Cystic Fibrosis Foundation; NRST for CF¼Nutrition Risk Screening Tool for Cystic Fibrosis; NR¼not reported or not clear; Modified STAMP¼Screening Tool for the Assessment of Malnutrition in
Pediatrics-modified; RD¼Registered Dietitian; SCAN¼Nutrition Screening Tool for Childhood Cancer; SD¼standard deviation; SGNA¼Subjective Global Nutrition Assessment.
b
Results presented are for moderate/high risk vs no/low risk unless otherwise noted. Values are rounded to the nearest hundredth. Values in parentheses are 95% CIs, if reported, unless otherwise noted.
c
“At risk” was determined using three criteria; one or more had to be present: low weight percentile relative to height percentile and age (World Health Organization growth charts), suboptimal dietary intake unlikely to improve in next 3 to 5 days,
-
and clinical history/treatment plan that might result in either increased metabolic stress, decreased dietary intake, or increased nutritional losses.
Number
d
Study was also included in the research question “Is there a difference in validity and reliability among users of nutrition screening tools?”
e
f
Risk classification determined using Centers for Disease Control and Prevention reference data.
-
--
Table 4. Studies examining validity and reliability of pediatric nutrition screening tools in community settingsab
2019 Volume
Author,
location, Setting, Reference Administered Sensitivity, Specificity, predictive predictive Reliability
-
quality population Sample size, age standard by % % value, % value, % agreement

Number
E-KINDEX
Lazarou and 4th-6th graders n¼622 Anthropometrics Dietitian OW/OBc vs OW/OB vs OW/OB vs OW/OB vs Internal
-
colleagues, in 24 primary Mean (height, weight, NW: 73.91 NW: 46.22 NW: NW: 80.5d reliability:
201144 schools in ageSD¼10.70.9 y BMI, waist (68.97- (40.62- 37.38d OB vs NW/ a¼.601
Greece urban and (range¼9-13 y) circumference) 78.85) 51.82) OB vs NW/ OW: 96.01d Agreement: NR
Rating: Positive rural areas of OB vs NW/ OB vs NW/ OW:
Cyprus OW: OW: 79 19.23d
60.87 (55.38- (74.42-
66.36) 83.58)
NutriSTEP
Carducci and Children in Internet study: Paper vs Internet P/G NR NR NR NR Testeretest:
colleagues, preschool n¼63 version ICC¼0.91
201545 community Age: 3-5 y (0.90-0.96)
Canada programs Agreement:
Rating: Positive and school k¼.58,
sites P¼0.000e
Onscreen study: Paper vs onscreen P/G NR NR NR NR Testeretest:
n¼64 version ICC¼0.91
Age: 3-5 y (0.85-0.95)
Agreement:
k¼.50,
FROM THE ACADEMY

P¼0.000e
Randall Simpson Children in Study 1: n¼269 RD assessment P/G >20f: 53 >20: 79 >20: 55.64d >20: 77.17d Reliability: NR
and colleagues, preschool Age: 3-5 y >25g: 84 >25: 46 >25: 20.94d >25: 74.19d Agreement: NR
200846 community
Canada programs
Rating: Positive
Study 2: n¼140 RD assessment P/G NR NR NR NR Testeretest:
Age: 3-5 y ICC¼0.89
(0.85-0.92),
P<0.001
Agreement: NR
21
FROM THE ACADEMY
observations of malnutrition; reli-
BMI¼body mass index; E-KINDEX¼Electronic Kids Dietary Index; ICC¼intraclass correlation coefficient; NR¼not reported or not clear; NutriSTEP¼Nutrition Screening Tool for Every Preschooler; NW¼normal weight; OB¼obese; OW¼overweight; P/
Agreement: NR
Agreement: NR
ability and agreement were reported.
Reliability: NR
ICC¼0.951,
Testeretest:
The PNRS demonstrated moderate
agreement
P<0.001
Reliability validity and low agreement; reli-
ability was not reported.
In the outpatient or specialty setting,
the conclusion statements for
Modified-STAMP and NRST-CF were
21: 56.43d 21: 88.12d
26: 34.48d 26: 96.46d
predictive
supported by Grade II (fair) evidence,

Negative
value, %
while the evidence supporting the

conclusion statement for SCAN was
NR
Results presented are for moderate/high risk vs no/low risk unless otherwise noted. Values are rounded to the nearest hundredth. Values in parentheses are 95% CI, if reported, unless otherwise noted.
Grade III (limited/weak) (Figure 7).
NRST-CF demonstrated moderate val-
predictive
idity and high reliability; agreement

value, %
Positive
was not reported. Modified-STAMP

demonstrated low validity and low
NR
agreement; reliability was not re-

Table 4. Studies examining validity and reliability of pediatric nutrition screening tools in community settingsab (continued)
ported. SCAN demonstrated moderate

Specificity,
validity; reliability and agreement

21: 61
26: 43
were not reported.

The conclusion statements for all
NR
%
three tools for the community setting

were supported by Grade III (limited/
Administered Sensitivity,
weak) evidence (Figure 7). The Toddler-

26g: 95
21f: 86
NutriSTEP demonstrated moderate

G¼parent/guardian; RD¼registered dietitian; SD¼standard deviation; Toddler NutriSTEP¼Nutrition Screening Tool for Every Preschooler for Toddlers.
validity and high testeretest reliability.

NR
%
In contrast, the original NutriSTEP

demonstrated low validity and low
testeretest reliability. The E-KINDEX
demonstrated low validity and low in-
ternal reliability. None of the three
P/G
tools reported inter-rater reliability or

by
agreement.
Validity study: n¼200 RD assessment
Overweight and obesity determined using International Obesity Task Force criteria based on age and sex.
Research Question 2: Differences

Reference
in Validity and Reliability among

standard
Users of Nutrition Screening

Agreement for individual questions dichotomized as risk/no risk among three risk categories.
Tools
Of the 29 studies included in Research
Cut point for determining moderate risk for malnutrition according to the tool score.
Question 1, seven studies examined

Cut point for determining high risk for malnutrition according to the tool score.
differences in validity or reliability be-

Sample size, age
Reliability study:
tween specified users of at least one of

Age: 18-35 mo
Age: 18-35 mo
four nutrition screening tools (NRST-CF,

PYMS, STAMP, and STRONGkids). Users
n¼133
of the tools included dietitians, nurses,

pediatricians, and “experts” (dietitians
or experienced physicians) and “non-
experts” (inexperienced nurses and
centers and
physicians). All seven studies (five

child care
programs
population
Children in
positive quality19,20,22,29,35 and two

nutrition
neutral quality32,42) reported inter-

Setting,
reliability and four of these (three

positive quality19,20,35 and one neutral
quality42) also reported validity mea-
Toddler-NutriSTEP
and colleagues,
sures of two different users of the tool

Randall Simpson
Rating: Positive
(Tables 2 and 3).

Validity of the tools examined
201547
location,
was different among dietitians

Author,
Canada
quality
administering NRST-CF and among

year,
dietitians and nurses administering

b
g
e
a
PYMS. Validity was the same when

FROM THE ACADEMY
Validitya Grade,
Tool Reliabilityc Agreementc evidence
Sensitivity Specificity PPV NPV Overall
validityb strengthd
E-KINDEX Lowe NR III, limited

Obesity/ Low Low Low Moderate Low — — —
overweight vs
normal
weight
Obesity vs Low Low Low High Low — — —
normal
weight/
overweight
IMCI NR NR III, limited
algorithm
Severe Low High Low High Low — — —
wasting
Very low Low High Moderate High Moderate — — —
weight for
age
Bipedal Low High Low High Low — — —
edema
Severe Low High Low High Low — — —
wasting and/
or
bipedal
edema
Stunted Low Low Low High Low — — —
growth
NRST for CF Moderate Low Moderate Moderate Moderate High NR II, fair
f
NutriSTEP High HIGH III, limited
Moderate Low Low Low Low Low — — —
risk cut point
High risk cut Moderate Low Low Low Low — — —
point
NutriSTEP- Highf NR III, limited
Toddler

Figure 6. The evidence for validity, reliability, and agreement of pediatric nutrition screening tools for identifying risk of malnutrition.
BMI¼body mass index; E-KINDEX¼Electronic Kids Dietary Index; IMCI¼Integrated Management of Childhood Illness Nutrition;
NPV¼negative predictive value; NR¼not reported; NRST for CF¼Nutrition Risk Screening Tool for Cystic Fibrosis; NutriSTEP¼Nutrition
Screening Tool for Every Preschooler; NutriSTEP-Toddler¼Nutrition Screening Tool for Every Preschooler for Toddlers; PMST¼Paediatric
Malnutrition Screening Tool; PNRS¼Pediatric Nutrition Risk Screening; PNST¼Pediatric Nutrition Screening Tool; PPV¼positive predictive
value; PYMS¼Paediatric Yorkhill Malnutrition Score; SCAN¼Nutrition Screening Tool for Childhood Cancer; STAMP¼Screening Tool for the
Assessment of Malnutrition in Pediatrics; Modified-STAMP¼Modified Screening Tool for the Assessment of Malnutrition in Pediatrics;
STRONGkids¼Screening Tool for Risk on Nutritional Status and Growth. aSee Table 1 for sensitivity, specificity, PPV, and NPV cutoff values.
b
Based on the algorithm to determine the overall validity found in the NSP: Validity and Reliability Criteria section (www.andeal.org/nsp).
c
See Table 1 for k cutoff values. Inter-rater reliability is reported, unless otherwise specified. dElements considered in the conclusion
statement grade include: quality of the evidence, consistency of results across studies, quantity of studies and number of subjects,
clinical impact of outcomes, and generalizability to population of interest. eSee Table 1 for Cronbach’s a (internal reliability) cutoff values.
f
See Table 1 for intraclass correlation coefficient (testeretest reliability) cutoff values.
FROM THE ACADEMY
Validitya Grade,
Tool Sensitivity Specificity PPV NPV Overall Reliabilityc Agreementc evidence
validityb strengthd
Moderate Moderate Low Low Moderate Moderate — — —

risk cut point
High risk cut High Low Low High Moderate — — —
point
PMST High Low Low High Moderate NR Low II, fair
PNRS High Low Low Moderate Moderate NR Low III, limited
PNST — — — — — NR NR II, fair
Weight-for- Moderate Low Low High Moderate — — —
age z score
(e2)
Weight-for- High Low Low High Moderate — — —
age z score
(e3)
Height-for- Low Low Low High Low — — —
age z score
(e2)
Height-for- Low Low Low High Low — — —
age z score
(e3)
BMI z score Moderate Low Low High Moderate — — —
(e2)
BMI z score High Low Low High Moderate — — —
(e3)
BMI 85th Low Low Low Low Low — — —
percentile
Dietitian Low Moderate Low Moderate Low — — —
assessment
PYMS Moderate Low Low High Moderate Moderate Low II, fair
SCAN High Low Low High Moderate NR NR III, limited
STAMP Moderate Low Low High Moderate High Low I, good
Modified- Low Moderate Low Moderate Low NR Low II, fair
STAMP
STRONGkids Moderate Low Low High Moderate Moderate Low II, fair
Figure 6. (continued) The evidence for validity, reliability, and agreement of pediatric nutrition screening tools for identifying risk of
malnutrition. BMI¼body mass index; E-KINDEX¼Electronic Kids Dietary Index; IMCI¼Integrated Management of Childhood Illness Nutrition;
NPV¼negative predictive value; NR¼not reported; NRST for CF¼Nutrition Risk Screening Tool for Cystic Fibrosis; NutriSTEP¼Nutrition
Screening Tool for Every Preschooler; NutriSTEP-Toddler¼Nutrition Screening Tool for Every Preschooler for Toddlers; PMST¼Paediatric
Malnutrition Screening Tool; PNRS¼Pediatric Nutrition Risk Screening; PNST¼Pediatric Nutrition Screening Tool; PPV¼positive predictive
value; PYMS¼Paediatric Yorkhill Malnutrition Score; SCAN¼Nutrition Screening Tool for Childhood Cancer; STAMP¼Screening Tool for the
Assessment of Malnutrition in Pediatrics; Modified-STAMP¼Modified Screening Tool for the Assessment of Malnutrition in Pediatrics;
STRONGkids¼Screening Tool for Risk on Nutritional Status and Growth. aSee Table 1 for sensitivity, specificity, PPV, and NPV cutoff values.
b
Based on the algorithm to determine the overall validity found in the NSP: Validity and Reliability Criteria section (www.andeal.org/nsp).
c
See Table 1 for k cutoff values. Inter-rater reliability is reported, unless otherwise specified. dElements considered in the conclusion
statement grade include: quality of the evidence, consistency of results across studies, quantity of studies and number of subjects, clinical
impact of outcomes, and generalizability to population of interest. eSee Table 1 for Cronbach’s a (internal reliability) cutoff values. fSee
Table 1 for intraclass correlation coefficient (testeretest reliability) cutoff values.
FROM THE ACADEMY
Tool Conclusion statementa Evidence grade Number of studies

(strength) (quality rating)
RQ1: What is the validity and reliability of the [tool below] for identifying risk of malnutrition related to under- or
overnutrition in the pediatric population in the inpatient/hospital setting?
Integrated ICMI algorithm demonstrated a low degree of III (limited/weak) 1 study (neutral)
Management of validity in identifying risk of malnutrition, based
Childhood Illness (ICMI) on visual observations of either severe wasting,
algorithm bipedal edema, severe wasting or bipedal
edema, or stunted growth, and a moderate
degree of validity in identifying risk of
malnutrition, based on very low weight for age,
in children admitted to the hospital. Agreement
and reliability of the tool were not reported.
Pediatric Digital Scaled No evidence meeting inclusion criteria was found V (not assignable) 0 studies
Malnutrition Risk to evaluate the validity and reliability of the
Screening Tool PeDiSMART for identifying risk of malnutrition
(PeDiSMART) related to under- or over-nutrition in the
pediatric population.
Paediatric Malnutrition PMST demonstrated a moderate degree of validity II (fair) 1 study (positive)
Screening Tool (PMST) in identifying risk of malnutrition in children
admitted to the hospital. Agreement of the tool
was low. Reliability was not reported.
Pediatric Nutrition Risk PNRS demonstrated a moderate degree of validity III (limited/week) 2 studies (1 positive;
Score (PNRS) in identifying risk of malnutrition in children. 1 neutral)
Agreement of the tool was low. Reliability was
not reported.
Pediatric Nutrition PNST demonstrated a moderate degree of validity II (fair) 1 study (positive)
Screening Tool (PNST) in identifying risk of malnutrition in hospitalized
children based on either weight-for-age z score
or BMI) z score, and a low degree of validity in
identifying risk of malnutrition in hospitalized
children based on either height-for-age z score,
BMI in at least 85th percentile or dietitian
assessment. Agreement and reliability of the tool
were not reported.
Paediatric Yorkhill PYMS demonstrated a moderate degree of validity, II (fair) 9 studies (5 positive;
Malnutrition Score low agreement, and a moderate degree of inter- 4 neutral)
(PYMS) rater reliability in identifying risk of malnutrition
in hospitalized children.
Screening Tool for the STAMP demonstrated a moderate degree of I (good/strong) 13 studies (9
Assessment of validity in identifying risk for malnutrition in positive; 4 neutral)
Malnutrition in hospitalized children. Tool agreement was low,
Pediatrics (STAMP) but inter-rater reliability was high.

Figure 7. Pediatric nutrition screening tool systematic review conclusion statements and grades. BMI¼body mass index;
RDN¼registered dietitian nutritionist; RQ¼research question. aSee Table 1. Cut points for interpreting data of pediatric malnutrition
screening tools for overall degree (high, moderate, or low) validity, reliability, and agreement.

FROM THE ACADEMY

Screening Tool for Risk STRONGkids demonstrated a moderate degree of II (fair) 13 studies (5
on Nutritional Status validity in identifying risk for malnutrition in positive; 8 neutral)
and Growth hospitalized children. Agreement of the tool was
(STRONGkids) low. Inter- and intra-rater reliability were
moderate.
overnutrition in the pediatric population in the outpatient/specialty setting?
Nutrition Risk Screening NRST for CF demonstrated a moderate degree of II (fair) 1 study (neutral)
Tool for Children and validity in identifying risk of malnutrition in
Adolescents with Cystic children and adolescents with CF. Inter-rater
Fibrosis (NRST for CF) reliability was high. Agreement of the tool was
not reported.
Nutrition Screening SCAN demonstrated a moderate degree of validity III (limited/weak) 1 study (neutral)
Tool for Childhood in identifying risk of malnutrition in inpatient
Cancer (SCAN) children being treated for cancer. Agreement
and reliability of the tool were not reported.
Screening Tool for the Modified STAMP demonstrated a low degree of II (fair) 1 study (positive)
Assessment of validity in identifying risk of malnutrition in
Malnutrition in children seen for intercurrent disease in
Pediatrics (STAMP)- outpatient clinics. Agreement of the tool was
Modified low. Reliability was not reported.
overnutrition in the pediatric population in the community setting?
Electronic Kids Dietary E-KINDEX demonstrated a low degree of validity in III (limited/weak) 1 study (positive)
Index (E-KINDEX) identifying malnutrition risk related to obesity
and overweight and a low degree of validity in
identifying malnutrition risk related to obesity
alone in pre-adolescent children. Internal
reliability of the tool was low. Agreement and
inter-rater reliability were not reported.
Nutrition Screening NutriSTEP demonstrated a low degree of validity in III (limited/weak) 2 studies (2 positive)
Tool for Every identifying risk for malnutrition according to
Preschooler (NutriSTEP) moderate risk and high-risk cut points and a
high testeretest reliability in preschool children.
Agreement of the tool was high. Inter-rater
reliability was not reported.
Toddler Nutrition Toddler NutriSTEP demonstrated a III (limited/weak) 1 study (positive)
Screening Tool for moderate degree of validity in identifying risk of
Every Preschooler malnutrition according to moderate-risk and
high-risk cut points and a high testeretest
reliability in toddlers. Agreement and inter-rater
reliability of the tool were not reported.

Figure 7. (continued) Pediatric nutrition screening tool systematic review conclusion statements and grades. BMI¼body mass index;

FROM THE ACADEMY

RQ2a. Is there a difference in validity among users of nutrition screening tools?
Differences in individual validity measures for II (fair) 4 studies (3 positive;
sensitivity, specificity, and positive and negative 1 neutral)
predictive values among different users of the
tools were found. The overall validity of the tools
was different between RDNs administering
NRST-CF and between dietitians and nurses
administering PYMS. However, the overall
validity of tools was the same when experts
(RDNs or experienced physicians) and non-
experts (inexperienced nurses and physicians)
administered STAMP and when pediatricians
and nurses administered STRONGkids. The
relevance of these findings on the impact to the
overall validity of each screening tool is unclear.
RQ2b. Is there a difference in reliability among users of nutrition screening tools?
Inter-rater reliability varied according to nutrition II (fair) 7 studies (5 positive;
screening tool examined and types of users that 2 neutral)
were compared. Inter-rater reliability was
moderate to high between RDNs administering
STAMP and NRST-CF and between nurses
administering STRONGkids and STAMP, and
moderate between pediatricians and nurses
administering STRONGkids and experts and non-
experts administering STAMP and STRONGkids.
Inter-rater reliability was low between dietitians
and nurses administering PYMS.
Figure 7. (continued) Pediatric nutrition screening tool systematic review conclusion statements and grades. BMI¼body mass index;
experts and non-experts administered DISCUSSION AND PRACTICE reported, reliability, and agreement
STAMP and when pediatricians and IMPLICATIONS varied among the tools.
nurses administered STRONGkids.
Reliability varied, depending on the Summary of Findings
tool and user. Inter-rater reliability Through a systematic search of the Definitions of Malnutrition in the
was moderate to high among di- literature, 13 nutrition screening tools Pediatric Population: Then and
etitians administering STAMP and to identify malnutrition risk in the pe- Now
NRST-CF and among nurses adminis- diatric population were reviewed. Of While the aim of nutrition screening
tering STRONGkids and STAMP, and these, only one conclusion statement tools is to identify malnutrition risk, at
moderate among pediatricians and was supported by Grade I (good/ the time many of these tools were
nurses administering STRONGkids and strong) evidence. The conclusion developed, there was no standard
experts and non-experts adminis- statements for six tools were sup- definition of malnutrition related to
tering STAMP and STRONGkids. Inter- ported by Grade II (fair) evidence and undernutrition for the pediatric popu-
rater reliability was low among di- six were supported by Grade III lation. This systematic review exam-
etitians and nurses administering (limited) evidence. No tools examined ined validity and reliability of nutrition
PYMS. While differences in validity in this review demonstrated both high screening tools for identifying malnu-
and reliability measures were found, validity and reliability supported by trition risk, primarily for undernutri-
the significance of these findings is Grade I evidence. Slightly more than tion, compared to accepted reference
unclear. Conclusion statements were half of the tools demonstrated moder- standards. However, the validity of the
supported by Grade II (fair) evidence ate validity and the validity of the tools must also be examined through
and can be found in Figure 7. remaining tools was low. When the currently accepted definition of

FROM THE ACADEMY
pediatric malnutrition that was deter- Many existing nutrition screening Compatibility with Electronic
mined after many of these tools were tools evaluated in this systematic re- Health Records
developed. view were created before the publica- Many of the pediatric nutrition
In July of 2013, the American Society tion of the Pediatric Malnutrition screening tools examined in this sys-
of Parenteral and Enteral Nutrition Consensus Statement6 and used other tematic review were created before the
(ASPEN) Pediatric Malnutrition Work- definitions of malnutrition. Most of the widespread implementation of the
group published a thorough review of nutrition screening tools examined in electronic health record (EHR).
the existing literature from 1955 to this systematic review used growth Screening tool components, such as the
2011 in order to propose a common charts for percentiles, not z scores and, STAMP Child Weight and Height Cen-
definition of pediatric malnutrition. thus, are not aligned with currently tile Tables39 and the PYMS BMI Scoring
This definition was based on five do- recommended indicators for identi- Guide,20 may be challenging to incor-
mains that included anthropometric fying pediatric malnutrition. The nutri- porate into an EHR.
parameters, growth, chronicity, etiol- tion screening tools examined in this Work is underway to create nutrition
ogy or cause, and developmental and systematic review also utilized nutri- screening tools that are compatible
functional outcomes. The resulting tion parameters that were not indicated with today’s EHRs. A recent study
definition was an imbalance between in the consensus statement for diag- examined the practical application for
nutrient requirements and intake that nosing malnutrition, including weight- using the anthropometric data con-
results in cumulative deficits of energy, for-age, height velocity, and appetite tained within the EHR to screen chil-
protein, or micronutrients that may (Figure 5). In both the 2014 Consensus dren for malnutrition risk. Authors
negatively affect growth, development, Report and in the current systematic demonstrated the usability and feasi-
and other relevant outcomes.1 The goal review, workgroup discussion bility of converting common screening
of establishing a uniform definition included concerns about the accuracy criteria and corresponding clinical
was to standardize research on the of anthropometric measurements. characteristics of the pediatric malnu-
impact of pediatric malnutrition on This concern prompted the workgroup trition indicators from the Consensus
outcomes and provide the basis for to include a research question exam- Statement6 into an automated malnu-
evidence-based practice. ining the validity and reliability of trition screening tool.50 EHRs that
Following standardization of the MUAC to identify malnutrition risk contain electronic growth charts allow
definition of pediatric malnutrition, in related to undernutrition.8 Unfortu- users of screening tools to easily obtain
December 2014, the Academy and nately, in pediatric populations from data such as BMI-for-age z scores or
ASPEN published a consensus state- economically developed countries, weight-for-length z scores. Such
ment of indicators recommended for only limited evidence was found accessibility makes the addition of
the identification and documentation examining MUAC as a single- these anthropometric data to a screen a
of pediatric malnutrition (undernutri- parameter nutrition screening tool. viable option as an alternative to
tion). The purpose of this statement cumbersome paper tables or guides.
was to establish a standardized set of Populations Examined in
indicators to diagnose and document Research vs Real-World Settings
pediatric malnutrition related to un- In the United States, there were Strengths and Limitations
dernutrition in routine clinical prac- approximately 2.1 million hospitaliza- Strengths of this systematic review
tice.6 The recommended indicators for tions annually for children aged 1 month include rigorous methodology and
diagnosing pediatric malnutrition upon to 17 years between 2002 and 2011. Each collaboration of a multidisciplinary
initial presentation include: body mass year, more than 54,600 of these hospi- workgroup. The Pediatric Nutrition
index (BMI)-for-age z score, weight- talizations had a coded diagnosis of Screening workgroup, in cooperation
for-length z score, and MUAC z score, malnutrition. The highest unadjusted with another Academy workgroup
as they are single data point indicators. rates of coded diagnosis of malnutrition examining adult nutrition screening
When two or more data points are were observed among children younger tools, created and utilized a defined
available, indicators that may be used than 1 year old (4.1%), whereas the framework to reach transparent con-
in assessment for malnutrition include lowest rates were among children aged 5 clusions with respect to the validity
weight-gain velocity (younger than 2 years and older (1.6%). Hospital admis- and reliability of nutrition screening
years of age), weight loss (2 to 20 years sion rates are highest in children under tools. In addition, to our knowledge,
of age), deceleration in weight for the age of 4 years, with the highest this was the first systematic review to
length/height z score, and inadequate subset being infants under the age of 1 examine the validity and reliability of
nutrient intake.6 These parameters year.49 However, validation of the pediatric nutrition screening tools in
used to diagnose malnutrition related screening tools in this systematic re- outpatient or specialty settings and
to undernutrition may also be consid- view was conducted primarily in chil- community settings.
ered in nutrition screening because the dren older than 2 years of age. The Limitations of this systematic review
goal of screening is to identify risk of majority of pediatric admissions and include heterogeneity in the methods,
malnutrition. Parameters used to therefore the majority of children who outcomes measures, and results reported
screen for malnutrition related to require screening for risk of malnutri- among the studies. For example, authors
overnutrition may be based on current tion are 2 years of age or younger. examined pediatric patients of different
standards to diagnose malnutrition Consequently, the generalizability of ages, used different risk classifications
defined by Centers for Disease Control these tools for this vulnerable popu- and reference standards, and sometimes
and Prevention.48 lation is unclear. used multiple cut points to measure and

FROM THE ACADEMY
report tool validity. This heterogeneity advantageous to update these validated findings is unclear. User training,
made comparisons and synthesis of data tools in order to incorporate them more especially when more than one indi-
challenging. Several studies did not easily into the EHR. MUAC is known to vidual administers the tool, is indis-
report all validity outcomes (sensitivity, identify malnutrition in the pediatric pensable to maximize the accuracy of
specificity, positive predictive value, and population; however, more studies are any nutrition screening tool.
negative predictive value). However, the needed to evaluate the use of MUAC to Health care facilities may use their
lead analyst was able to conduct some screen for malnutrition risk as opposed own nutrition screening tool, and
secondary analyses for these outcome to nutrition assessment. More studies these tools should be validated
measures if the authors provided specific are needed to validate screening tools in against gold standard nutrition
data, including the number of partici- larger populations and in all age groups, assessment tools and current param-
pants defined as having malnutrition risk infants to adolescents, particularly in eters used to diagnose pediatric
using a screening tool and the reference those younger than 2 years of age. malnutrition. Practitioners should
standard. Currently, only three tools (PYMS, weigh the applicability and appropri-
In tools with more than one included STAMP, and STRONGkids) are examined ateness of valid and reliable nutrition
study, there were often wide ranges of in more than two validation studies; screening tools for the populations
validity, reliability, or agreement re- validated tools and those with updated they serve.
sults. While the reason for this wide anthropometric elements that still need
variability is unknown, some variances validation should be examined in mul-
may be due to use of different refer- tiple studies in order to improve confi- References
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276-282. 45. Carducci B, Reesor M, Haresign H, et al.
31. Durakbasa CU, Fettahoglu S, Bayar A, NutriSTEP is reliable for internet and
16. Koo TK, Li MY. A guideline of selecting Mutus M, Okur H. The prevalence
and reporting intraclass correlation co- onscreen use. Can J Diet Pract Res.
of malnutrition and effectiveness of 2015;76(1):9-14.
efficients for reliability research. J Chiropr STRONGkids tool in the identification of
Med. 2016;15(2):155-163. malnutrition risks among pediatric sur- 46. Randall Simpson JA, Keller HH,
17. Tavakol M, Dennick R. Making sense of gical patients. Balkan Med J. 2014;31(4): Rysdale LA, Beyers JE. Nutrition
Cronbach’s alpha. Int J Med Educ. 2011;2: 313-321. Screening Tool for Every Preschooler
53-55. (NutriSTEP): Validation and test-retest
32. Hulst JM, Zwart H, Hop WC, Joosten KF. reliability of a parent-administered
18. Chourdakis M, Hecht C, Gerasimidis K, Dutch national survey to test the questionnaire assessing nutrition risk
et al. Malnutrition risk in hospitalized STRONGkids nutritional risk screening of preschoolers. Eur J Clin Nutr.
children: Use of 3 screening tools in a tool in hospitalized children. Clin Nutr. 2008;62(6):770-780.
large European population. Am J Clin Nutr. 2010;29(1):106-111.
2016;103(5):1301-1310. 33. Huysentruyt K, Alliet P, Muyshont L, et al. 47. Randall Simpson J, Gumbley J, Whyte K,
The STRONG(kids) nutritional screening et al. Development, reliability, and val-
19. Galera-Martinez R, Morais-Lopez A, idity testing of Toddler NutriSTEP: A
Rivero de la Rosa MD, et al. Reproduc- tool in hospitalized children: A validation
study. Nutrition. 2013;29(11-12):1356- nutrition risk screening questionnaire
ibility and inter-rater reliability of 2 for children 18-35 months of age. Appl
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Physiol Nutr Metab. 2015;40(9):877-886.
J Pediatr Gastroenterol Nutr. 2017;64(3): 34. Marginean O, Pitea AM, Voidazan S,
e65-e70. Marginean C. Prevalence and assessment 48. Centers for Disease Control and Preven-
20. Gerasimidis K, Keane O, Macleod I, of malnutrition risk among hospitalized tion. Childhood Overweight and Obesity.
Flynn DM, Wright CM. A four-stage eval- children in Romania. J Health Popul Nutr. https://www.cdc.gov/obesity/childhood/
uation of the Paediatric Yorkhill Malnu- 2014;32(1):97-102. index.html. Published 2018. Accessed
trition Score in a tertiary paediatric 35. Moeeni V, Walls T, Day AS. The STRONG- February 20, 2019.
hospital and a district general hospital. Br kids nutritional risk screening tool can be 49. Cecil E, Bottle A, Ma R, et al. Impact of
J Nutr. 2010;104(5):751-756. used by paediatric nurses to identify preventive primary care on children’s
21. Ling RE, Hedges V, Sullivan PB. Nutritional hospitalised children at risk. Acta Paediatr. unplanned hospital admissions: A
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and evaluation of the Screening Tool for the setting. Ital J Pediatr. 2013;39:81. ric malnutrition screen using anthropo-
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FROM THE ACADEMY
AUTHOR INFORMATION
P. J. Becker is a pediatric nutrition specialist, Dayton Children’s Hospital Medical Center Dayton, OH, and owner, KidsRD.com and
PediatricMalnutrition.com. S. Gunnell Bellini is didactic program in dietetics director and assistant professor, Brigham Young University, Provo, UT.
M. Wong Vega is a pediatric clinical dietitian and E. Spoede is a pediatric dietitian and clinical nutrition specialist, Texas Children’s Hospital,
Houston, TX. M. R. Corkins is a professor of pediatrics, University of Tennessee Health Science Center, Memphis. B. A. Spear is a professor pe-
diatrics emerita, University of Alabama at Birmingham. M. K. Hoy is a nutritionist, US Department of Agriculture, Beltsville, MD. T. A. Piemonte is a
project manager and consultant and M. Rozga is a nutrition researcher, Evidence Analysis Center, Academy of Nutrition and Dietetics, Chicago, IL.
Address correspondence to: Mary Rozga, PhD, RDN, Evidence Analysis Center, Academy of Nutrition and Dietetics, Chicago, IL 60606-6995.
E-mail: mrozga@eatright.org
STATEMENT OF POTENTIAL CONFLICT OF INTEREST
No potential conflict of interest was reported by the authors.
FUNDING/SUPPORT
This systematic review was funded by the Commission on Dietetic Registration and the Academy of Nutrition and Dietetics.
ACKNOWLEDGEMENTS
We would like to thank our evidence analysts, who extracted data and assessed article quality for this project, and Margaret Foster, MS, MPH,
AHIP (librarian), for contributions to this project.
AUTHOR CONTRIBUTIONS
All authors contributed to research question development, article screening, development of evidence summaries, and conclusion statements
and grading of evidence. P. J. Becker, S. Gunnell Bellini, M. Wong Vega, and M. Rozga wrote the first draft of the manuscript and all co-authors
provided significant feedback and editing.

FROM THE ACADEMY
SYSTEMATIC REVIEW SEARCH PLAN

PubMed May 12, 2017: Updated Search
((("nutritional risk"[Title/Abstract] OR "malnutrition risk"[Title/Abstract] OR "nutrient poor"[Title/Abstract] OR "dietary risk"[Title/
Abstract])) OR ((("Child Nutrition Disorders/etiology"[MeSH Terms]) OR ((("Feeding and Eating Disorders of Childhood/
diagnosis"[MeSH Terms])) OR ("Feeding and Eating Disorders of Childhood/etiology"[MeSH Terms]))) OR (((“Malnutrition/
diagnosis”[MeSH] OR “Nutrition Assessment”[MeSH] OR “Child Nutrition Disorders/diagnosis”[MeSH] OR “nutrition
assessment”[Title/Abstract] OR “nutrition diagnostic”[Title/Abstract] OR “nutrition diagnosis”[Title/Abstract] OR “nutrition
screening”[Title/Abstract] OR “malnutrition assessment”[Title/Abstract] OR “malnutrition-inflammation score”[Title/Abstract] OR
“malnutrition diagnosis”[Title/Abstract] OR “malnutrition diagnostic”[Title/Abstract] OR “malnutrition screening”[Title/Abstract]
OR “nutritional assessment”[Title/Abstract] OR “nutritional diagnosis”[Title/Abstract] OR “nutritional screening”[Title/Abstract])))))
AND (((((“Child”[MeSH] OR “Adolescent”[MeSH] OR "Pediatrics"[MeSH] OR child[Title/Abstract] OR children[Title/Abstract] OR
adolescent[Title/Abstract] OR adolescents[Title/Abstract] OR pediatric[Title/Abstract] OR paediatric[Title/Abstract] OR paediatrics
[Title/Abstract] OR pediatrics[Title/Abstract] OR infant[Title/Abstract] OR infant[Title/Abstract])) AND (((((((((reliability[Title/
Abstract] OR sensitive[Title/Abstract] OR sensitivity[Title/Abstract] OR specific[Title/Abstract] OR specificity[Title/Abstract] OR
validated[Title/Abstract] OR validation[Title/Abstract] OR validity[Title/Abstract] OR ("Sensitivity and Specificity"[Mesh]) OR
("Reproducibility of Results"[Mesh]) OR "Reference Values"[Mesh)))))) OR (("overall agreement"[Title/Abstract] OR
"detected"[Title/Abstract] OR "correlated"[Title/Abstract])))) NOT (((animals[MeSH terms] NOT humans[MeSH terms])) AND (
"1995/01/01"[PDat] : "2017/12/31"[PDat] ) AND English[lang]).
PubMed: 1,154 Results, Added to Rayyan
((“Malnutrition/diagnosis”[MeSH] OR “Nutrition Assessment”[MeSH] OR “Child Nutrition Disorders/diagnosis”[MeSH] OR
“nutrition assessment”[Title/Abstract] OR “nutrition diagnostic”[Title/Abstract] OR “nutrition diagnosis”[Title/Abstract] OR
“nutrition screening”[Title/Abstract] OR “malnutrition assessment”[Title/Abstract] OR “malnutrition-inflammation score”[Title/
Abstract] OR “malnutrition diagnosis”[Title/Abstract] OR “malnutrition diagnostic”[Title/Abstract] OR “malnutrition
screening”[Title/Abstract] OR “nutritional assessment”[Title/Abstract] OR “nutritional diagnosis”[Title/Abstract] OR “nutritional
screening”[Title/Abstract]) AND (“Child”[MeSH] OR “Adolescent”[MeSH] OR "Pediatrics"[MeSH] OR child[Title/Abstract] OR
children[Title/Abstract] OR adolescent[Title/Abstract] OR adolescents[Title/Abstract] OR pediatric[Title/Abstract] OR paediatric
[Title/Abstract] OR paediatrics[Title/Abstract] OR pediatrics[Title/Abstract] OR infant[Title/Abstract] OR infant[Title/Abstract])
NOT (animals [mh] NOT humans [mh])) AND (reliability[Title/Abstract] OR sensitive[Title/Abstract] OR sensitivity[Title/Abstract]
OR specific[Title/Abstract] OR specificity[Title/Abstract] OR validated[Title/Abstract] OR validation[Title/Abstract] OR validity
[Title/Abstract] OR ("Sensitivity and Specificity"[Mesh]) OR ("Reproducibility of Results"[Mesh]) OR "Reference Values"[Mesh) AND
( "1995/01/01"[PDat] : "2017/12/31"[PDat] ) AND English[lang])).
Updated Search: 197 New Results Added To Rayyan (Two Duplicates, 195 Newly Added)
Added a few additional terms on malnutrition:
((("nutritional risk"[Title/Abstract] OR "malnutrition risk"[Title/Abstract] OR "nutrient poor"[Title/Abstract] OR "dietary risk"[Title/
Abstract])) OR ((("Child Nutrition Disorders/etiology"[MeSH Terms]) OR ((("Feeding and Eating Disorders of Childhood/
diagnosis"[MeSH Terms])) OR ("Feeding and Eating Disorders of Childhood/etiology"[MeSH Terms]))) OR (((“Malnutrition/
diagnosis”[MeSH] OR “Nutrition Assessment”[MeSH] OR “Child Nutrition Disorders/diagnosis”[MeSH] OR “nutrition
assessment”[Title/Abstract] OR “nutrition diagnostic”[Title/Abstract] OR “nutrition diagnosis”[Title/Abstract] OR “nutrition
screening”[Title/Abstract] OR “malnutrition assessment”[Title/Abstract] OR “malnutrition-inflammation score”[Title/Abstract] OR
“malnutrition diagnosis”[Title/Abstract] OR “malnutrition diagnostic”[Title/Abstract] OR “malnutrition screening”[Title/Abstract]
OR “nutritional assessment”[Title/Abstract] OR “nutritional diagnosis”[Title/Abstract] OR “nutritional screening”[Title/Abstract])))))
AND (((((“Child”[MeSH] OR “Adolescent”[MeSH] OR "Pediatrics"[MeSH] OR child[Title/Abstract] OR children[Title/Abstract] OR
adolescent[Title/Abstract] OR adolescents[Title/Abstract] OR pediatric[Title/Abstract] OR paediatric[Title/Abstract] OR paediatrics
[Title/Abstract] OR pediatrics[Title/Abstract] OR infant[Title/Abstract] OR infant[Title/Abstract])) AND (((reliability[Title/Abstract]
OR sensitive[Title/Abstract] OR sensitivity[Title/Abstract] OR specific[Title/Abstract] OR specificity[Title/Abstract] OR validated
[Title/Abstract] OR validation[Title/Abstract] OR validity[Title/Abstract] OR ("Sensitivity and Specificity"[Mesh]) OR
("Reproducibility of Results"[Mesh]) OR "Reference Values"[Mesh))) NOT (((animals[MeSH terms] NOT humans[MeSH terms]))
AND ( "1995/01/01"[PDat] : "2017/12/31"[PDat] ) AND English[lang]).
((“Malnutrition/diagnosis”[MeSH] OR “Nutrition Assessment”[MeSH] OR “Child Nutrition Disorders/diagnosis”[MeSH] OR
“nutrition assessment”[Title/Abstract] OR “nutrition diagnostic”[Title/Abstract] OR “nutrition diagnosis”[Title/Abstract] OR
“nutrition screening”[Title/Abstract] OR “malnutrition assessment”[Title/Abstract] OR “malnutrition diagnosis”[Title/Abstract] OR
Figure 1. Systematic review search plan.
31.e1 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -
FROM THE ACADEMY
“malnutrition diagnostic”[Title/Abstract] OR “malnutrition screening”[Title/Abstract] OR “nutritional assessment”[Title/Abstract]

OR “nutritional diagnosis”[Title/Abstract] OR “nutritional screening”[Title/Abstract]) AND (“Child”[MeSH] OR “Adolescent”[MeSH]
OR "Pediatrics"[MeSH] OR child[Title/Abstract] OR children[Title/Abstract] OR adolescent[Title/Abstract] OR adolescents[Title/
Abstract] OR pediatric[Title/Abstract] OR paediatric[Title/Abstract] OR paediatrics[Title/Abstract] OR pediatrics[Title/Abstract] OR
infant[Title/Abstract] OR infant[Title/Abstract]) NOT (animals [mh] NOT humans [mh])) Filters: Publication date from 2000/01/01
to 2017/12/31; English
Retrieved: 3, 812.
CINAHL, January 1, 1995 to May 1, 2017: 1,156 Retrieved, Excluding Medline, 241 Unique Added to Rayyan
(MH "Child Nutrition Disordersþ") OR (MH "Infant Nutrition Disorders/DI/ET") OR (MH "Feeding and Eating Disorders of
Childhood/DI/ET") OR (MH "Malnutrition/DI/ET") OR (MH "Nutritional Assessment") OR TI ( ((nutrition* or malnutrition or dietary)
n1 (risk* or diagnos* or screen* or assessment*)) or (Nutrient* n1 poor) or “malnutrition-inflammation score” ) OR AB (
((nutrition* or malnutrition or dietary) n1 (risk* or diagnos* or screen* or assessment*)) or (Nutrient* n1 poor) or “malnutrition-
inflammation score” )
AND
( (MH "Childþ") OR (MH "Infantþ") ) OR TI ( Child* OR adolescen* OR pediatric* OR paediatric* OR infant* ) OR AB ( Child* OR
adolescen* OR pediatric* OR paediatric* OR infant* )
AND
( (MH "Reference Values") OR (MH "Reproducibility of Results") OR (MH "External Validity") OR (MH "Reliabilityþ") OR (MH
"Reliability and Validityþ") ) OR TI ( reliability OR sensitive OR sensitivity OR specific OR specificity OR validated OR validation OR
validity) ) OR AB ( reliability OR sensitive OR sensitivity OR specific OR specificity OR validated OR validation OR validity) ).
EMBASE, January 1, 1995 to May 1 2017: Retrieved 570, Limited to Embase Unique Records, 39 Uploaded to Rayyan
1 exp child/ or exp adolescent/ or exp infant/ or ((Child* or adolescen* or pediatric* or paediatric* or infant*).ti, ab.)
2 exp "sensitivity and specificity"/ or exp reproducibility/ or reference value/ or exp validity/ or exp reliability/ or (reliability
OR sensitive OR sensitivity OR specific OR specificity OR validated OR validation OR validity).ti, ab.
3 ((nutrition* or malnutrition or dietary) adj1 (risk* or diagnos* or screen* or assessment*)) or (Nutrient* adj1 poor) or
“malnutrition-inflammation score”).ti, ab. Or exp nutritional assessment/ or exp nutritional status/Limited to English.
Figure 1. (continued) Systematic review search plan.
-- 2019 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 31.e2

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FROM THE ACADEMY

Evidence Analysis Center

Validity and Reliability of Pediatric Nutrition

Inclusion criteria Exclusion criteria

(continued on next page)

2 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -

Inclusion criteria Exclusion criteria

-- 2019 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 3

Records idenﬁed through Addional records idenﬁed

Records aer duplicates removed

Records screened Records excluded

Full-text arcles assessed Full-text arcles excluded

4 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -

searched for articles that met eligi-

-- 2019 Volume - Number - JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS 5

6 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -

Screening tool Tool description Tool Components

Body Weight/ Weight Appetite/ Clinical

FROM THE ACADEMY

(continued on next page)

Three tools were designed for use

(NutriSTEP),45,46 and Toddler-

screening tool can be found in

ments for each tool and evidence

that met inclusion criteria for analysis:

studies), and PYMS (9 studies). Two

NutriSTEP. All other tools had only one

study that met inclusion criteria. The

to determine classiﬁcation of malnu-

trition. Some studies used anthropo-

Disease Control and Prevention

growth reference data or similar data

from the population’s country of

origin. Other studies used the pediat-

Grade I (good/strong) evidence.

STAMP demonstrated moderate val-

ment. The conclusion statements for

Tool for Every PreschoolereToddler)

idity, depending on the anthropometric

E-KINDEX (Electronic Kids Dietary

parameter used for assessment; reli-

ported. The PMST demonstrated

and STRONGkids demonstrated moder-

ate validity, moderate reliability, and low

agreement. The evidence supporting the

(IMCI algorithm and PNRS) was Grade III

(limited/weak). The IMCI algorithm

8 JOURNAL OF THE ACADEMY OF NUTRITION AND DIETETICS -- 2019 Volume - Number -

quality population age standard by Sensitivity, % Speciﬁcity, % value, % value, % agreement

colleagues, at a tertiary ageSD¼8.14y k¼.34 (.2-.5)

FROM THE ACADEMY

Israel clinic for inter- 0.99) (.24-.7)

quality population age standard by Sensitivity, % Speciﬁcity, % value, % value, % agreement

201626 admission to (range¼0-17.64 y) weight, BMI) e.005

FROM THE ACADEMY

201719f hospitals Agreement: NR

Rating: Positive secondary 34.7)e 34.39)e 17.05)e 52.4)e

quality population age standard by Sensitivity, % Speciﬁcity, % value, % value, % agreement

201032 pediatric ward (range¼31 d to 17.7 weight) staff

FROM THE ACADEMY

quality population age standard by Sensitivity, % Speciﬁcity, % value, % value, % agreement

201228 outpatient clinic (range¼3-17 y) weight, BMI) e.013

FROM THE ACADEMY

colleagues, at a tertiary ageSD¼8.14y k¼.34 (.2-.5)