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ORIGINAL ARTICLE: NUTRITION

Validation of a Nutritional Screening Tool for Ambulatory

Use in Pediatrics

yz
Gal Rub,
yLuba Marderfeld,
§Irit Poraz, yjjCorina Hartman, ôShlomo Amsel,
#
Israel Rosenbaum, ôShiri Pergamentzev-Karpol, zEfrat Monsonego-Ornan, and yjjRaanan Shamir

ABSTRACT

Objectives: To evaluate the use of Screening Tool for the Assessment of What Is Known
Downloaded from https://journals.lww.com/jpgn by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3i3D0OdRyi7TvSFl4Cf3VC4/OAVpDDa8KKGKV0Ymy+78= on 08/25/2021

Malnutrition in Pediatrics (STAMP) in a primary health care clinic in the

community and to assess the impact of its use on medical staff’s awareness
of nutritional status.
Methods: STAMP scoring system was tested as is and with modifications in
the ambulatory setting. Nutritional risk according to STAMP was compared
with a detailed nutritional assessment performed by a registered dietitian.
Recording of nutrition-related data and anthropometric measurements in
medical files were compared prior and post implementation.
Results: Sixty children were included (31 girls, 52%), ages between 1 and 6
years, mean age 2.8  1.5 (mean  SD). STAMP scores yielded a fair
agreement between STAMP and the dietitian’s nutritional assessment:
k ¼ 0.47 (95% confidence interval [CI] 0.24–0.7), sensitivity of 47.62%
(95% CI 28.34–67.63). Modified STAMP yielded more substantial
agreement: k ¼ 0.57 (95% CI 0.35–0.79), sensitivity of 76.19% (95% CI
54.91–89.37), specificity of 82.05% (95% CI 67.33–91.02). The use of
STAMP resulted in an increase in recording of appetite, dietary intake, and
anthropometric measurements.
Conclusions: Modification of the STAMP improved nutritional risk
evaluation in community setting. The use of STAMP in a primary health
care clinic raised clinician’s awareness to nutritional status. Further work
will identify whether this could be translated into lower malnutrition rates
and better child care.
 Many children in the community experience malnu-
trition that goes unnoticed. Nutritional screening
may assist in identifying children with or at risk
of malnutrition.
 Nutritional screening is not routinely conducted
because there is presently no validated, agreed upon
tool for use in pediatrics.
What Is New
 Our findings suggest that Screening Tool for the
Assessment of Malnutrition in Pediatrics is a reliable
nutrition screening tool for use in primary pediatric
health care clinics.
 Our findings suggest the use of a screening tool raises
clinician’s awareness and increases anthropometric
measurements of children attending primary health
care clinics.

Key Words: anthropometry, community, Malnutrition, nutritional

Received August 13, 2015; accepted November 16, 2015.
From the
Clinical Nutrition and Dietetics Department, Schneider
Children’s Medical Center of Israel, the yInstitute of Gastroenterology,
Nutrition and Liver Diseases, Schneider Children’s Medical Center of
Israel, Clalit Health Services, Petah Tikva, the zFaculty of Agriculture,
Food and Environmental Sciences, The Hebrew University, Rehovot, the
§National Management Office, Clalit Health Services, Tel Aviv, the
jjSackler Faculty of Medicine, Tel-Aviv University, Tel Aviv, the
ôNetka Pediatric Community Center, Tel Aviv, and the #Plotkin
Pediatric Community Center, Tel Aviv, Clalit Health Services, Israel.
Address correspondence and reprint requests to Gal Rub, MSc, Clinical
Nutrition and Dietetics Department, Schneider Children’s Medical
Center, Clalit Health Services, 14 Kaplan St, Petah Tikva, Israel
(e-mail: galarub@gmail.com).
www.clinicaltrials.gov registration number: NCT01718769.
This study was done as an MSc thesis of Gal Rub at the Faculty of
Agriculture, Food and Environmental Sciences of the Hebrew University
of Jerusalem.
This study was partially supported by Abbott Nutrition. Abbott had no
involvement in study design, data collection, analysis, and interpretation
of the study, and was not involved in writing or commenting on the
article.
The authors report no conflicts of interest.
Copyright # 2015 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000001046
assessment, nutritional screening, pediatrics
(JPGN 2016;62: 771–775)
M alnutrition in children is associated with poor growth,
impaired cognitive development, poor social achieve-
ments, and may even affect productivity in adulthood (1–3).
Malnourished children are prone to disease-associated compli-
cations and experience longer hospital stays, thus further increasing
the economic burden on the health care system (4). In hospitalized
children, previous studies reported the prevalence of malnutrition
ranging from 6% to 40% (5). Given the prolonged and continuous
nature of malnutrition and its effects on outcome and clinical
prognosis, identification of malnutrition should not be limited to
the hospital setting. Information on the prevalence of malnutrition
or undernutrition in the community in developed countries is sparse
(6). Identification of children in need for nutritional support (mal-
nourished children or children at risk of malnutrition) is usually
done, presently, by nurses or doctors relying on clinical judgment.
This methodology has been demonstrated as subjective and unreli-
able (7). Children referred to further nutritional intervention need to
undergo full nutritional assessment; a detailed time and resource
consuming process requiring specialist training and knowledge in
nutrition. These shortcomings can be addressed by introducing a
nutritional screening tool (NST) validated for community use. An

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Rub et al
ideal NST should be swift, specific, easy, and inexpensive, so it can
be used in a variety of facilities and applied by untrained personnel
(8). Several NSTs that address the risk of malnutrition mainly in
hospitalized children have been developed lately (8–13). Some of
these NSTs are demanding in terms of time or expertise required.
We hypothesized that validation of an NST for routine use in the
general ambulatory setting would improve the rate of detection of
children at risk of malnutrition in the community. We chose to
validate the Screening Tool for the Assessment of Malnutrition in
Pediatrics (STAMP) because it is easy to apply, fast, and based on
simple objective criteria. Furthermore, we aimed to evaluate
whether the use of a screening tool in the community will increase
medical staff’s awareness to children’s nutritional status.
METHODS
Validation of STAMP Tool
In order to validate STAMP for use in primary pediatric
health care clinics, STAMP scores were compared with nutritional
risk estimated by a full nutritional assessment.
Subjects
The study was performed at 2 urban primary child-care
clinics. Healthy children ages 1 to 6 years were enrolled during
an occasional visit to the general pediatrician for common
intercurrent disease. Children who were looked after in outpatient
clinics were excluded from this study. The study was approved by
the Meir Medical Center institutional review board (C206/2011).
Collection of Anthropometric Data
Weight and length or height were recorded using standar-
dized techniques (15) using Seca 334 baby scale for children under
2 years and Seca 770 flat electronic scales for children older than
2 years. Children were weighed barefoot either wearing a dry diaper
or light indoor clothing. Both scales were obtained from Medton
LTD, Tel-Aviv, Israel and were calibrated daily. Weight was
recorded to the nearest 10 g and height was recorded to the nearest
0.1 cm. Measurements were plotted on age- and sex-appropriate
WHO 2005 growth charts.
Screening Procedure
After acquiring informed consent, parent and child were
directed to the attending nurse where the child was screened using
the STAMP tool (http://www.stampscreeningtool.org/). STAMP
contains collection of data regarding the child’s diagnosis and its
nutritional implications, nutritional intake, and anthropometry.
Each parameter is given a score that is then summed into an overall
risk score. Children are classified as high risk if they receive a
positive score (that sums up to a score 4 points) in at least 2 of the
3 categories: having a diagnosis that has any nutritional implica-
tions such as behavioral eating problems; having a recently
decreased or poor nutritional intake; and either growing on a
low weight percentile or having a low weight percentile relative
to height percentiles indicating a possible risk for weight faltering
compared with height growth pattern. A care plan is advised
accordingly. Because STAMP is primarily intended for use upon
hospitalization, we hypothesized that a modification of the STAMP
scoring system will be required to better identify cases of milder
malnutrition, which can be easily overridden in the community
setting. STAMP consists of 3 questions, each being answered by a
numeric value. These values are then tallied into a number,
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representing 3 levels of risk: 0 to 1 low risk, 2 to 3 medium risk,
and 4 or more than 4 high risk. Our modification suggested a
different scoring system: 0 for low risk, 1 to 3 for medium risk, 4 or
more than 4 for high risk. This change in scoring category was
decided based on the assumption that, contrary to hospitalized
children, any deviation detected in a healthy child may indicate
nutrition risk. No other modifications other than modifying cut-off
values for risk categories were taken. Both original and modified
STAMP diagnostic values were assessed.
Detailed Nutritional Assessment
The screening procedure was followed by a 30-minute long
interview with a registered dietitian (RD), where a full nutritional
assessment was conducted. In order to avoid bias, nutritional
assessment was conducted by a single RD that was blinded to
the screening performed by the nurse. The nutritional assessment
consisted of the following items:
 Detailed dietary history including eating habits, amount, and
variety of foods consumed.
 Evaluation of the ability to maintain age-appropriate energy and
protein intake, compared with dietary reference intake.
 Anthropometric measurements including weight, height or
length, and use of growth charts.
 A review of medical notes including diagnoses with a nutritional
impact, use of drugs that affect metabolism/ appetite, food
allergies, use of nutritional supplements, and blood work.
The full nutritional assessment subjectively classified
children as ‘‘at risk’’ or ‘‘not at risk’’ of undernutrition. Risk of
undernutrition was considered if a child presented with 1 or more of
the following: a low weight percentile relative to height percentile
and age, suboptimal dietary intake during the recent past that would
be unlikely to improve in the next 3 to 5 days, and a clinical history
that may result in either increased metabolic stress, decreased
dietary intake, or increased nutritional losses (16).
STAMP risk scores were then compared with the nutritional
evaluation conducted by the RD to assess STAMP validity
and reliability.
ASSESSMENT OF THE IMPACT OF STAMP USE
ON MEDICAL STAFF’S AWARENESS TO
NUTRITIONAL STATUS
In order to assess the impact of STAMP on medical staff’s
awareness to nutritional status, upon the end of the validation study
we compared the frequency of nutritional data documentation in
medical files before and after the introduction of STAMP.
Data Collection
Data were obtained randomly from the electronic medical
records kept in the database of the participating clinics, 3 months
prior and post the intervention period.
Statistical Analysis
Age and sex-specific z scores were calculated using WHO
Anthro software for children ages 1 to 5 years (http://
www.who.int/childgrowth/software/en/) and AnthroPlus soft-
ware (http://www.who.int/growthref/tools/en/) for children ages
5 to 6 years. The agreement between STAMP and the dietitian
assessment was calculated using Cohen k statistics and 95%
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JPGN  Volume 62, Number 5, May 2016 A Nutritional Screening Tool for Ambulatory Use in Pediatrics

confidence intervals were calculated and interpreted according to Anthropometric Measurements

the tables published by Landis and Koch (17). Sample size was
calculated based on the assumption that k value will exceed 0.4,
a value considered appropriate based on the previous data in the
field (17). To avoid the possibility of low statistical power, we
chose a doubled sample size using Cohen k statistics. McNemar
test was used to determine whether there was a significant
difference between risk categories according to STAMP and
the RDs assessment. Because patients at both medium and high
risk require additional attendance, we combined medium and
high-risk categories on contingency tables to calculate the
STAMP diagnostic value (agreement, sensitivity, specificity,
and positive and negative predictive values). We examined
whether STAMP diagnostic scores could be explained by anthro-
pometry indexes alone. For that, Spearman correlations were
calculated for nonparametric variables to check the statistical
dependence between STAMP scores and various anthropometric
z scores including body mass index (BMI) z scores. Comparison
of continuous data between groups was carried out using Mann-
Whitney test. In order to assess how the use of STAMP influ-
enced the frequency of nutritional-related data collection, we
compared the change in documented variables before and after
the intervention period using Pearson x2 test for categorical data.
We considered P (2-sided) < 0.05 to be significant. Taking into
consideration the rate of 10.1% of anthropometry measurements
performed in the community and assuming an increase of
measurements performance to at least 20% (18), beta was set
at 0.2, whereas alpha was set at 0.05, thus yielding a power of
80%. Accordingly, a minimal sample size of 90 patient files was
required at each period of time. Data management and statistical
analyses were carried out with SPSS statistics version 22 (IBM
SPSS Statistics, Armonk, NY).
RESULTS
Of the 63 families approached, the final analysis included
60 children with a signed informed consent and that had undergone
both the STAMP screening procedure and a full nutritional assess-
ment. Mean age was 2.8  1.5 (mean  SD) years, 35 of 60 (58%)
ages 1 to 3 years, 29 boys and 31 girls. Thirty-three percent of
children (n ¼ 19) were taking nutritional supplements: 10 (17%)
consumed multivitamin, 5 (8%) probiotics, 4 (7%) iron, 2 (3%)
omega 3, and 2% (n ¼ 1 for each category) consumed dietary fibers,
vitamin C or vitamin D. No child was given formula supplements.
Weight and height measurements were available for all of the
participants. The prevalence of acute undernutrition (defined as
BMI  2 SDS or 2.3nd percentile) was 13.3% (n ¼ 8) and
chronic undernutrition (defined as height or length for age  2
SDS or 2.3nd percentile) was 3% (n ¼ 2). Overall undernutrition
prevalence (acute and chronic malnutrition combined) was
observed in 16.6% (n ¼ 10) of children. Prevalence of overweight
and obesity (defined as BMI  85th percentile) was 16.6% (n ¼ 10).
(http://www.who.int/nutgrowthdb/about/introduction/en/index5.
html)
Validation of STAMP Nutritional Risk Screening
Tool in the Ambulatory Setting
According to RD’s assessment, 39 children were at low risk,
17 at medium risk, and 4 at high risk. Table 1 presents the
comparison of distribution within each of risk categories for the
original and the modified STAMP. The original STAMP identified
more children to be at low nutritional risk and less children at
medium risk when compared with modified STAMP and the
dietitian’s assessment.
The agreement between the original STAMP and full
nutritional assessment was fair to moderate (k ¼ 0.47 [95% CI
0.24–0.7]). The modified STAMP tool yielded a better agreement
(k ¼ 0.57 [95% CI 0.35–0.79]) with higher sensitivity rates.
Sensitivity, specificity, positive and negative predictive values of
original and modified STAMP compared with the full dietitian
assessment are displayed in Table 1. McNemar test (P ¼ 0.77) result
showed no significant difference between the modified STAMP
low, medium, or high-risk categorization, compared with the
nutritional assessment evaluation.
Assessing nutritional status using STAMP yielded different
results from those observed using anthropometry alone. Although
we observed a significant difference between mean BMI values in
each STAMP risk category (P ¼ 0.02), there was only a low
agreement between STAMP risk categories and BMI values
(k ¼ 0.26), and a weak correlation between BMI z-score values
and STAMP risk within each category (r ¼ 0.24, P ¼ 0.06).
Comparison of z-score means of the different anthropometric
measures throughout STAMP or RD risk categorization showed
no statistical difference (data not shown).

TABLE 1. Cross classification of malnutrition risk on original STAMP and modified STAMP tools compared with full RD assessment, agreement
(Cohen k statistics), sensitivity, specificity, PPV, and NPV

STAMP N ¼ 60 Modified STAMP N ¼ 60

Assessment tool
Risk category Low Medium High At risk Low Medium High At risk

Low risk 37 10 0 32 4 0
Medium risk 2 6 0 7 12 0
High risk 0 1 4 0 1 4
At risk (medium and high) 10 16
Agreement (k) 0.47 (95% CI 0.35–0.79) 0.57 (95% CI 0.35–0.79)
Sensitivity, % 47.6 (95% CI 28.3–67.6) 76.2 (95% CI 54.9–89.4)
Specificity, % 94.9 (95% CI 0.81–0.99) 82.1 (95% CI 67.3–91.0)
PPV, % 83.3 69.6
NPV, % 77.1 86.5

CI ¼ confidence interval; NPV ¼ negative predictive value; PPV ¼ positive predictive value; RD ¼ ??; STAMP ¼ Screening Tool for the Assessment of
Malnutrition in Pediatrics.

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TABLE 2. Comparison of nutritional-related data documentation before and after STAMP implementation study

Nutritional-related documentation

Nutrition-related documentation (N) Before STAMP validation N ¼ 150 After STAMP validation N ¼ 150 Significance


Anthropometry, measurements 32 57 0.002
Use of growth charts 3 0 0.082


Evaluation of intake 3 10 0.047


Nutrition-related diagnosis 0 6 0.013
Referral to dietitian 7 10 0.454

The data were compared using x2 method. STAMP ¼ Screening Tool for the Assessment of Malnutrition in Pediatrics.


P < 0.05 was considered statistically significant.

Medical Staff Awareness to Nutritional Status
Following the Use of STAMP
Data from 300 patient files were collected; 150 patients
that attended the clinic before the implementation period and
150 patients post implementation. The implementation period led
to an increase in staff awareness to nutritional status, expressed
as increase in the amount of data related to nutritional status
documented in patient files. The use of STAMP resulted in an
increase in the recording of anthropometric measurements and the
documentation of appetite and dietary intake of children attending
the clinic (Table 2). There was no change in growth charts use or
physicians referrals to dietitian’ evaluation or counseling.
DISCUSSION
This study showed that the modified STAMP offers a valid
screening tool for the detection of malnutrition and malnutrition risk
in pediatric primary health care setting. Furthermore, the use of
STAMP in a primary health care clinic raised clinician’s awareness
to nutritional status as indicated by an increase in anthropometric
measurements and in documentation of nutritional status following
study implementation. Improved awareness to nutritional status
was, however, not followed by further action (referral to dietitian
assessment or counseling) because this was not part of the study
protocol.
The present study aimed at validation of a nutritional risk-
screening tool originally developed for hospital use (10) in the
ambulatory setting. This validation enables continuity of nutritional
risk assessment between hospital and community care. The only
validated tool for community use, NutriStep (9), relies on the
parent’s subjective assessment and was not meant for hospital
use as well. Although some tools, such as the Subjective Global
Nutritional Assessment tool (SGNA) (14,19) or STRONGkids (11),
rely on subjective clinical judgment, STAMP requires no previous
training or expert knowledge. In addition, STAMP provides an
immediate risk assessment unlike the Paediatric Nutrition Risk
Score tool (PNRS) (12) that requires nutritional intake to be
documented before risk assessment (thus suggesting a greater
similarity to a nutritional assessment tool rather than nutritional
screening). In the study of Gerasimidis et al, STAMP was preferred
over the Paediatric Yorkhill Malnutrition Score (PYMS) (13),
because it showed better validity (k ¼ 0.54 compared with
k ¼ 0.46, and sensitivity rate of 70% compared with 59% (10,13)).
As we anticipated, a modification to the STAMP scoring
system was essential to maintain the tool validity in community
settings. Before modification, STAMP yielded a fair to moderate
agreement (k ¼ 0.47, sensitivity ¼ 47.6%), but fell short of
the agreement described for use in hospitals (k ¼ 0.54,
sensitivity ¼ 70%) (10). Such low sensitivity rates suggest under-
recognition of children at risk of malnutrition, therefore failing to
address the challenge it is set to resolve. Modification to the tools
scoring system improved agreement and sensitivity rates (k ¼ 0.57,
sensitivity ¼ 76.2%) making it more suitable for community use.
One may assume that anthropometric indexes alone would be
sufficient for assessing malnutrition. The lack of a statistical
significance between mean z scores of various anthropometric
components, however, suggests that the division between high-,
medium-, and low-risk STAMP categorizations is determined by
variables not captured by the anthropometric indexes alone.
Although anthropometry identifies malnourished individuals, nutri-
tional screening not only identifies these individuals but also allows
for early identification of individuals at risk of malnutrition.
Furthermore, when different anthropometric indexes were applied
as part of the full nutritional assessment, we witnessed great
variability between measuring methods, a difficulty well acknowl-
edged in the literature (20). Nevertheless, identification of risk of
malnutrition before deterioration of nutritional status is captured
by anthropometric measurements, should be followed by timely
intervention including dietitian counseling to prevent progression
to malnutrition.
In this study, we observed high malnutrition prevalence
in apparently healthy children, without underlying illness,
suggesting that nutritional screening and monitoring may be
considered in all child-care settings. The prevalence of over-
nutrition observed in this study was 16.6%. An Israeli survey of
electronic medical records of children ages 60 to 83 months
reported prevalence of overweight risk in 12.9% of children
and overweight in 25.6% (18). Furthermore, the 2013 Organis-
ation for Economic Co-operation and Development report (21)
described similar rates of overweight and obesity of approxi-
mately 20% for girls and 24% for boys in Israel. The lower
prevalence observed in this study could be explained by differ-
ences in mean age. In our study, mean age of children was
lower than the one described in the Organisation for Economic
Co-operation and Development report.
In an audit conducted by Grek et al (22), the authors showed
that even when STAMP implementation was required as part of
routine care at hospital admission, simple anthropometry was often
omitted and nutritional screening was poorly implemented. In this
study, we showed that the use of a screening tool not only helped
identifying children in need of nutritional intervention but also
increased the medical staff’s awareness of nutritional status. Indeed,
following their participation in our study, primary physicians were
found to collect more nutritional data during their routine care than
before participation in the study. This was evidenced by an increase
in documentation of nutritional intake or appetite. The use of
STAMP in the intervention period has also led to increase in

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anthropometric measurements during routine care. This finding is
of unique importance because most children attending their local
health care centers are not routinely measured. Nevertheless, the
increase in nutritional monitoring during routine care was not
accompanied by an increase of referrals to dietitians for follow-
up. Therefore, in addition to implementing the use of a malnutrition
screening tool, further changes needs to be undertaken to establish a
policy that empowers a dietitian’s position as part of the primary
health care team.
There are limitations to our study. First, an inherent
problem to all of the studies comparing screening tools to formal
nutritional assessment is the subjective evaluation of data arising
from the considered ‘‘criterion standard’’; formal nutritional
assessment. We used conventional risk categories recommended
for nutritional assessment but the risk scores were determined
as the result of clinical judgment of the investigating dietitian.
Moreover, since there is no generally accepted anthropometric
definition of malnutrition (nonetheless of malnutrition risk)
and no criterion standard for determining nutritional status,
studying diagnostic accuracy of a nutritional tool is extremely
difficult.
Other limitations to our study include small sample size and
the lack of follow-up on nutritional outcome following nutritional
risk screening. The interventions recommended by the original
STAMP are intended for hospitalized children; therefore, the
appropriateness and practicability of these recommendations for
the community should be further investigated. Further work will
identify whether this could be translated into lower malnutrition
rates and better child care.
The strengths of this study rely on its novelties. This is the
first study that addressed malnutrition prevalence in ambulatory
setting in Israel, and the first study validating a nutritional screening
tool for ambulatory use. This is also one of very few studies
assessing the impact of a nutritional risk screening tool on medical
staff’s knowledge and behavior toward nutritional status, although
future studies should assess long-term outcome on nutritional status
of these children.
In conclusion, this work is the first to assess pediatric
malnutrition risk in the community setting, and also one of the
first to assess the impact on medical staff awareness toward
nutritional evaluation. We believe that using the modified STAMP
in the ambulatory setting can help raise clinician’s awareness of
children’s nutritional status. We also believe that this will help
identifying children that could benefit from a nutritional interven-
tion. The high prevalence of malnutrition risk described in this
study in apparently healthy children in primary care indicates
the need for further research to identify the magnitude of this
problem as well as establish a thorough primary prevention strategy,
incorporating routine nutritional screening in primary health
care settings.
Acknowledgments: The authors thank Dr Maharan Farhadian,
Dr Avital Bilker-Reich, Dr Bobby Gross, and Dr Suzanna
Weinberg-Zeltzer for participating in sample recruitment.
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