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Malnutrition in Pediatrics 36
Gal Rub, Luba Marderfeld, and Raanan Shamir
Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 667
Nutritional Screening Tools Currently Available for Use in Pediatrics upon
Hospital Admission . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 668
Comparison Between Different Screening Tools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 671
Nutritional Screening Tools for Specific Medical Conditions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 675
Policies and Protocals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Implementation of Nutritional Screening in Pediatrics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 676
Dictionary of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 678
Summary Points . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 680
G. Rub
Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center of
Israel, Petah Tikva, Israel
e-mail: galarub@gmail.com
L. Marderfeld
Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center of
Israel, Petah Tikva, Israel
Clinical Nutrition and Dietetics Department, Institute of Gastroenterology, Nutrition and Liver
Diseases, Schneider Children’s Medical Center of Israel, Petah Tikva, Israel
e-mail: Lu.marderfeld@yahoo.com
R. Shamir (*)
Institute of Gastroenterology, Nutrition and Liver Diseases, Schneider Children’s Medical Center of
Israel, Petah Tikva, Israel
Sackler Faculty of Medicine, Tel-Aviv University, Tel - Aviv, Israel
e-mail: president@espghan.org; shamirraanan@gmail.com
Abstract
Malnutrition in pediatrics remains a cause for concern due to its considerably high
prevalence and deleterious effects on growth, development, and overall health.
Early identification of malnutrition risk may prevent nutritional deterioration
during hospitalization. There are currently a number of suggested screening
tools for use in pediatrics; however, there is no consensus on a single tool that
is favorable over others. Thus selection of a screening tool for implementation is
perplexing. Presented here is an overview of the screening tools available for use
in pediatrics and further actions needed in order to implement the use of screening
tools in different settings in pediatrics. Seven screening tools that are intended for
use upon admission to the hospital were identified. Two screening tools were
designed for specific medical conditions. One screening tool was designed for
sole use in ambulatory settings. Of the seven tools identified for use upon hospital
admission, some tools were also validated for use in specific medical conditions
and one tool was also validated for use in ambulatory settings. Comparison
between screening tools failed to offer one tool favorable to others. A model
for implementation of nutritional screening in pediatrics in terms of policy change
is suggested. In conclusion, there is currently no single nutritional screening tool
that is superior to others. When selecting a screening tool, one should consider the
setting in which screening will take place, in terms of purposes and applications.
Governments and healthcare providers should promote implementation of nutri-
tional screening in pediatrics in all healthcare facilities.
Keywords
Malnutrition · Malnutrition risk · Nutritional status · Nutritional assessment ·
Nutritional screening · Screening tools · Pediatrics · Children · Hospitalization ·
Undernutrition
List of Abbreviations
ASPEN American Society of Parenteral and Enteral Nutrition
BIA PhA Bioelectrical Impedance Phase Angel
BMI Body Mass Index
CDC Center for Disease Control
ESPEN European Society of Enteral Nutrition
ESPGHAN European Society of Pediatric Gastroenterology Hepatology
and Nutrition
GI Gastro Intestinal
ICD-10 International Classification of Diseases
LOS Length of (hospital) Stay
MUAMC Mid Upper Arm Muscle Circumference
NRI Nutritional Risk Index
NRS Nutrition Risk Score
nutriSTEP Nutritional Screening Tool for Every Preschooler
PeDiSMART The Pediatric Digital Scaled Malnutrition Risk Screening Tool
36 Nutritional Screening Tools for Malnutrition in Pediatrics 667
Introduction
Studies published over the past decade show that malnutrition prevalence upon
admission to pediatric hospitals remains considerably high, ranging from 6% to
14% in developed countries (Joosten and Hulst 2011) with higher prevalence rates in
infants and toddlers (Hecht et al. 2015). In specific medical conditions the described
prevalence is much higher (Joosten and Hulst 2008). Hospital stay has deleterious
impact on the nutritional status leading to weight loss during hospitalization even in
children affected merely by mild clinical conditions (Campanozzi et al. 2009;
Pacheco-Acosta et al. 2014). Early detection of children at malnutrition risk has
been discussed by international organizations such as ASPEN (Corkins et al. 2013),
ESPGHAN (Agostoni et al. 2005), and ESPEN (Kondrup et al. 2003).
Nutritional screening is a process aimed to identify an individual who is malnour-
ished or who is at risk for malnutrition, to determine if a detailed nutritional assessment
is indicated (Teitelbaum et al. 2005). An ideal screening tool should demonstrate good
ranking at concurrent validity (the extent to which screening tools agree with each
other), predicative validity (the extent to which screening tools predict certain out-
comes), reproducibility (agreement between users of a given tool), and applicability in
terms of ease and speed of administration (Elia and Stratton 2011).
However widely used in adults, nutritional screening is not routinely conducted in
children because of the lack of a simple, properly validated screening tool (Hartman
et al. 2012). Also, since there is no one universally accepted definition of malnutri-
tion, there is also lack of consensus on a single definition for nutritional risk
(Huysentruyt et al. 2015). As a result, different screening tools were developed for
different purposes using different methodological methods (Elia and Stratton 2011),
making it nearly impossible to compare between tools in order to favor one tool over
the others. Thus, adding to the difficulties to choose an appropriate screening tool
there is lack of agreement between tools (Chourdakis et al. 2016) and evidence for an
impact of the screening on long-term outcome is lacking. In this chapter we will
review the literature on pediatric screening tools and discuss the complexity of
choosing a single tool. We will also discuss the policy needed to ensure implemen-
tation of nutritional screening in pediatrics.
668 G. Rub et al.
The main components of the following screening tools are described in Table 1.
1. Nutrition Risk Score (NRS) – Developed by Reilly et al. (1995), the NRS is a
screening tool validated for use by the nursing staff to assess the risk of nutritional
depletion in hospitalized patients, both adults and pediatrics. The NRS collects
data on weight loss (amount and duration), BMI for adults or percentile charts for
children, food intake (appetite and the ability to eat and retain food), and stress
factors (effect of medical condition on nutritional requirements). Each parameter
is given a score affected by the severity of the condition described. The scores are
summed and patients are allocated into nutritional risk groups. A course of action
is then advised accordingly. The tool was validated on a sample of 20 patients
ranging from 6 weeks of age to 79 years. The NRS scores were assessed in
comparison to Nutritional Risk Index (NRI) (r = 0.68, p < 0.001) and a dietitian’s
clinical impression of the patient (r = 0.83, p < 0.001). Inter-rater reliability was
also assessed by comparing NRS scores conducted by two dietitians (r = 0.91,
p < 0.001). It should be noted that this tool was validated by comparison to the
NRI (Wolinsky 1990) which was originally designed for use in geriatrics. More-
over, this tool is not specifically intended for use in pediatrics and the study’s
sample size was exceptionally small with a large age range. No data on sample
size calculations was mentioned in the text.
2. Pediatric Nutritional Risk Score (PNRS) – Originally developed by Sermet-
Gaudelus et al. (2000), this tool is designed to identify children at risk of losing
2% or more of their admission weight, during hospitalization. Nutritional risk was
Table 1 Main components of screening tools. Different screening tools take into consideration
different nutritional related data when assessing nutritional risk. The table describes the different
screening tools with regards to their components
Current
Effect of nutritional Anthropometry Weight Other
Tools disease intake measurements loss components
NRS ٧ ٧ ٧ ٧ GI symptoms,
ability to eat
PNRS ٧ ٧ Pain
STRONGkids ٧ ٧ ٧
PYMS ٧ ٧ ٧ ٧
STAMP ٧ ٧ ٧
PNST ٧ ٧
PeDiSMART ٧ ٧ ٧ GI symptoms
Key: NRS nutrition risk score, PNRS pediatric nutrition risk score, STRONGkids screening tool for
risk on nutritional status and growth, PYMS paediatric yorkhill malnutrition score, STAMP screen-
ing tool for the assessment of malnutrition in pediatrics, SGNA subjective global nutritional
assessment, PeDiSMART the pediatric digital scaled malnutrition risk screening tool, GI gastro
intestinal
36 Nutritional Screening Tools for Malnutrition in Pediatrics 669
nurse-rated PYMS identified 59% of those rated at high risk by full nutritional
assessment. Of those rated at high risk by nurse-rated PYMS, 47% were con-
firmed at high risk by the full nutritional assessment. These results could be
interpreted that approximately 40% of children considered at high risk were not
identified by nurse-rated PYMS. Moreover, 53% of children were falsely identi-
fied at high risk by nurse-rated PYMS and inadequately referred to dietitians
(Hartman et al. 2012). PYMS demonstrated a moderate agreement with full
dietitians’ assessment (k = 0.46) and inter-rater reliability (k = 0.53) when
nurse-rated PYMS was compared with dietitian-rated PYMS.
5. Screening Tool for the Assessment of Malnutrition in Pediatrics (STAMP) –
Developed by McCarthy et al. (2012), STAMP consists of three steps and gathers
information aimed to detect low percentile weight for age, reported weight loss,
discrepancy between weight and height percentile, recently changed appetite, and
the expected nutrition risk of clinical diagnoses. All were identified as predictors
of nutrition risk, in the development phase of the tool. Nutritional risk is trans-
lated into the need for a referral to a full nutritional assessment. No outcomes
were evaluated in the validation study (Hartman et al. 2012). The tool was
validated in a cohort of 238 children upon admission to hospitalization. STAMPs’
allocation to nutritional risk groups was compared with a classification deter-
mined by a registered dietitian. The tool demonstrated fair to moderate reliability
(k = 0.54), and sensitivity and specificity were estimated at 70% and 91%,
respectively. It should be noted that this tool assesses growth parameters using
specific charts that were developed for this purpose (based on either UK90 or
CDC charts). Therefore one might claim implementation of such tool requires
resources, such as time and money, in order to train healthcare staff accordingly.
However, McCarthy et al. (2012) claim STAMP utilizes information that should
be routinely collected by nursing staff upon admission, thus introduction of the
tool required minimal training. Moreover, in the validation study, STAMP was
completed by different members of the nursing staff, including student nurses and
nursing supporting staff, suggesting implementation of the tool requires no
specific training.
6. Pediatric Nutrition Screening Tool (PNST) – Developed by White et al. (2016),
PNST consists of four dichotomous (yes/no) nutritional screening questions and
requires no data collection on medical condition or anthropometric measure-
ments. The PNST was validated on 295 hospitalized children from birth to
16 years in Australia. The pediatric SGNA and anthropometry were chosen as
the gold standards in defining nutritional risk. The sensitivity and specificity for
the PNST compared with the pediatric SGNA were moderate and high, scoring
77.8% and 82.1%, respectively. However, it should be noted that screening
procedure was performed by the same investigator using both PNST and
SGNA. No clinical outcome was investigated.
7. The Pediatric Digital Scaled Malnutrition Risk Screening Tool (PeDiSMART) -
Developed and validated by Karagiozoglou-Lampoudi et al. (2015), the
PeDiSMART is a software that consists of four elements: weight for age z-scores,
nutrition level intake, overall disease impact, and symptoms affecting intake.
36 Nutritional Screening Tools for Malnutrition in Pediatrics 671
Other than anthropometric data, all other parameters are described as categorical
variables rated 0–4. In order to validate the tool, PeDiSMART was compared to
bioelectrical impedance phase angle (BIA PhA) on 161 hospitalized children
aged 1 month to 17 years in Greece. Data showed inverse correlation between the
tool and PhA values (R = 0.582, p < 0.001). PeDiSMART was then compared
to STAMP, PYMS, and STRONGkids screening tools in 500 hospitalized chil-
dren. Patient allocation to nutritional risk groups on admission was associated
with clinical outcomes such as weight loss or nutritional support and LOS. ROC
curves showed sensitivity of 87% and specificity of 75%, ranking better than
STRONGkids and STAMP. In regards to outcome measurements, PeDiSMART
accuracy in predicting weight loss/nutritional intervention was higher than PYMS
and comparable to STAMP and STRONGkids. PeDiSMART accuracy in pre-
dicting LOS > 7 days was higher than STAMP and STRONGkids and compa-
rable to PYMS. Inter-rater reliability was evaluated in 57 patients by two
dietitians and showed moderate agreement of k = 0.474. Authors claim
PeDiSMART is rapid, easy to use, and suitable for use by all clinical staff
members. Since the software incorporates information documented on electronic
medical files automatically, the authors suggest the use of this technology may
facilitate and possibly improve the prediction of nutritional risk.
It should be noted that although some may refer to the Subjective Global
Nutritional Assessment (SGNA) tool published by Secker and Jeejeebhoy (2007)
as a nutritional screening tool, we chose not to describe this tool as it resembles a
nutritional assessment tool rather than a nutritional screening tool. In fact, it was
sometimes used as a gold standard for validation of a new tool, as was performed in
the validation of the PNST (White et al. 2016).
While a number of screening tools had emerged in the field of nutritional
screening upon hospitalization in the last decade, very few focused on nutritional
screening in community settings. Randall Simpson et al. (2008) developed the
nutriSTEP, a parent-administered questionnaire intended for nutritional risk screen-
ing in preschoolers. However, we choose not to focus on this tool since it is intended
to be solely used in community settings and was validated for that purpose only.
Despite Rub et al. (2016) validated STAMP for ambulatory use in pediatrics, further
research in the field is necessary before a definitive recommendation can be made.
Table 2 Aims of the nutritional screening tools. Different screening tools were developed for
different aims, thus providing different uses. Table 3 describes the different screening tools with
regards to their aims
Determine
nutritional Identify need for Predict clinical outcome without
Tools status nutritional intervention nutritional intervention
NRS ٧
PNRS ٧ ٧
STRONGkids ٧ ٧
PYMS ٧ ٧ ٧
STAMP ٧ ٧
PNST ٧ ٧
PeDiSMART ٧ ٧
Key: NRS nutrition risk score, PNRS pediatric nutrition risk score, STRONGkids screening tool for
risk on nutritional status and growth, PYMS paediatric yorkhill malnutrition score, STAMP screen-
ing tool for the assessment of malnutrition in pediatrics, SGNA subjective global nutritional
assessment, PeDiSMART the pediatric digital scaled malnutrition risk screening tool
used. As was previously proposed by (Elia and Stratton 2011), different screening
tools were designed for diverse purposes, for use by people with different back-
grounds and for application by one or more settings, one or more age groups, and
one or more disease groups.
With regards to the aims of the tools, while NRS, STAMP, PYMS, and
STRONGkids are designed to be completed upon admission, PNRS requires the
assessment of nutritional intake over the first 48 h of hospitalization. Ergo, using the
PNRS requires time and resources spent on nutritional intake documentation and
analysis, suggesting this tool has greater resemblance to a nutritional assessment tool
rather than a nutritional screening tool. The aims of the aforementioned screening
tools are displayed in Table 2.
Within the aforementioned tools STAMP, SGNA, and PYMS include anthropo-
metric measurements thus identifying nutritional status upon admission, while the
other tools merely provide the perceived risk of deterioration. PNRS, PYMS, and
STRONGkids were also designed to prognostically predict clinical outcomes (with-
out nutritional intervention) such as weight loss of >2% or LOS. However, it should
be noted that LOS may not function as a direct assessment of nutritional risk because
it may be influenced by many other factors and a causative relation has not been
shown (Huysentruyt et al. 2015).
Another complexity arising from comparison is the validation methods used for
each tool. There is currently no agreed upon “gold standard” for the assessment of
malnutrition and malnutrition risk (since there is no universally accepted definition
of malnutrition). In the absence of a nutrition screening tool that can act as a “gold”
standard, information on the agreement between tools (concurrent validity) is used,
especially when the comparison involves tools developed for the same purpose and
when no judgment is made about the superiority of one tool over another (Elia and
Stratton 2012). For example, the NRS was compared to NRI for validation, the
36
Table 3 Studies comparing different screening tools with regards to clinical outcomes. The table presents studies recently published comparing different
screening tools in regards to their ability to predict clinical outcome, in the hopes of identifying one nutritional screening tool superior to other. Different studies
compared different tools with regards to different outcomes
NRS PNRS STRONGkids PYMS STAMP PNST PeDiSMART Clinical outcome
Chourdakis et al. ٧ ٧ ٧ Anthropometry, LOS, infection rates
2016
Huysentruyt et al. ٧ ٧ ٧ ٧ >2% weight loss, referral to dietitian,
2015 dietitians’ assessment, nutritional intervention
Karagiozoglou- ٧ ٧ ٧ ٧ Weight loss, nutritional support, LOS
Lampoudi et al.
2015
Galera-Martinez et ٧ ٧ Anthropometry, LOS
al. 2017
Nutritional Screening Tools for Malnutrition in Pediatrics
use with substantial intra- and inter-rater reliability rates. Furthermore, in another
very recently published study by Galera-Martinez et al. (2017), STAMP and
STRONGkids were assessed for reproducibility and inter-rater reliability between
expert staff specialized in pediatric nutrition (physicians and dietitians) and clinical
staff nonexpert in nutrition. Agreement between expert and nonexpert staff was
good: 94.78% for STRONGkids (k = 0.72 [p < 0.001]) and 92.55% for STAMP
(k = 0.74 [p < 0.001]). These findings suggest whether STRONGkids was
originally developed for administration by qualified personnel, it can be used for
practice by clinical staff, as it is already widely used in current clinical practice by
nurses (Joosten and Hulst 2014). The PeDiSMART was claimed to be appropriate
for use with all clinical staff members. Nonetheless, it was validated for use by
certified dietitians (Karagiozoglou-Lampoudi et al. 2015). Further research is
needed to assess PeDiSMARTs’ inter-rater reliability between a dietitian’s assess-
ment and other members of the clinical staff.
Not all nutritional screening tools describe the course of action that is advised
according to screening results, and the ones who do, describe different follow-up
care plans. The care plans advised by the different nutritional screening tools are
displayed in Table 4.
Different screening tools are designed for different purposes, to be used on one or more
underlying disease (Elia and Stratton 2011). Some tools were originally designed to be
used upon specific conditions such as SCAN, nutritional screening tool for childhood
cancer (Murphy et al. 2016), or the nutrition risk screening tool in cystic fibrosis
(McDonald 2008), while other tools were later on validated for specific purposes. For
example, PeDiSMART was validated in 30 children with chronic kidney disease
(Apostolou et al. 2014). Moderate inverse correlation was found between PeDiSMART
score and PhA ( p = 0.001), MUAMC ( p = 0.008) as well as protein intake
( p = 0.016). STAMP was also validated in 51 pediatric spinal cord injury (SCI) patients
admitted to a tertiary SCI center (Wong et al. 2013). STAMP had moderate agreement
with dietitians’ assessment (k = 0.507). STAMP, PYMS, and PMST (modified
STAMP) were tested in acute pediatric setting in 300 children (Thomas et al. 2016).
The tools were compared to WHO growth reference cutoffs for malnutrition.
Those who scored medium or high risk by the tools were compared with those who
could be considered malnourished or at risk of malnutrition using the WHO’s
definitions. The results showed poor sensitivity and specificity rates; however, it
should be noted that WHOs’ definitions for malnutrition assess current state rather
than the risk for malnutrition. Thus it may not be the most suitable reference to test
validity. Moreover, the majority of children at PICU are at nutritional risk of some
degree, thus it may be more effective to directly perform nutritional assessment in
the form of growth and intake assessment rather than nutritional screening.
PNRS, PYMS, STAMP, and STRONGkids were also tested in children with IBD
(Wiskin et al. 2012). The tools were tested on 46 children and risk score was
676 G. Rub et al.
Table 4 The care plans advised by the different nutritional screening tools according to screening
result. Each screening tool offers a specific care plan according to the allocated risk group. The table
presents the course of action advised by each tool according to the different risk groups allocated
Tools Low risk Moderate risk High risk
NRS N/A N/A N/A
PNRS None Weight surveillance, report Nutritional assessment, monitor
intake, consider dietetic intake, consider nutritional
consult intervention
STRONGkids Repeat Check weight twice a week, Refer the child to a dietitian
screening consider referring the child
weekly to a dietitian
PYMS Repeat Repeat screening after Refer the child to a dietitian
screening 3 days
weekly
STAMP Repeat Monitor the child’s Refer the child to a dietitian/
screening nutritional intake for nutritional support team/
weekly 3 days, repeat screening consultant
after 3 days
PNST None Not relevant (moderate risk Refer the child for further
category does not appear in nutritional assessment, check if
the PNST) child was previously cared for by
a dietitian, measure weight and
height, commence food and fluid
intake record
PeDiSMART Check Check weight status twice a Refer to a dietitian
weight week, repeat the screening
status after a week
weekly
Key: N/A no care plan available, NRS nutrition risk score, PNRS pediatric nutrition risk score,
STRONGkids screening tool for risk on nutritional status and growth, PYMS paediatric yorkhill
malnutrition score, LOS length of (hospital) stay, STAMP screening tool for the assessment of
malnutrition in pediatrics, SGNA subjective global nutritional assessment, PeDiSMART the pediat-
ric digital scaled malnutrition risk screening tool
In this chapter we have described recently published research in the field of nutri-
tional screening in pediatrics, and the complexity of comparing the different tools in
the hopes of identifying one screening tool that can be considered superior to others.
36 Nutritional Screening Tools for Malnutrition in Pediatrics 677
Below we describe the detailed policies that should be adopted in order to make
implementation of nutritional screening in pediatrics feasible in various settings.
Policy should acknowledge a number of main areas:
Dictionary of Terms
Summary Points
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