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Hospital-acquired malnutrition in children with mild clinical conditions

Article  in  Nutrition · March 2009

DOI: 10.1016/j.nut.2008.11.026 · Source: PubMed

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 Nutrition 25 (2009) 540 –547
www.nutritionjrnl.com
Applied nutritional investigation

Hospital-acquired malnutrition in children with mild clinical conditions

Angelo Campanozzi, M.D.a,*, Massimo Russo, Ph.D.b, Alessandra Catucci, M.D.a,
Irene Rutigliano, M.D.a, Gennaro Canestrino, M.D.a, Ida Giardino, M.D.c,
Arturo Romondia, M.D.d, and Massimo Pettoello-Mantovani, M.D., Ph.D.a,e
a
Department of Medical Sciences, Pediatrics, University of Foggia, Foggia, Italy
b
Institute of Statistics, University of Foggia, Foggia, Italy
c
Department of Biomedical Sciences, University of Foggia, Foggia, Italy
d
Pediatric Unit, Public City Hospital, OORR, Foggia, Italy
e
World Health Policy Forum (WHPF), Giessen, Germany

Manuscript received July 6, 2008; accepted November 19, 2008.

Abstract Objective: Little is known about the incidence and risk factors of hospital-acquired malnutrition in
children with mild illness (grade 1 clinical conditions) and its timing of occurrence. The aim of this
study was to recognize any early stage of denutrition and possible risk factors leading to nutritional
deterioration in children hospitalized due to mild clinical conditions.
Methods: Four hundred ninety-six children (age 1–192 mo) with mild clinical conditions were
studied. Weight and height were measured. Weight was assessed daily and body mass index (BMI)
Z-score was calculated for all patients.
Results: Children with a BMI Z-score ⬍⫺2 SD on admission showed a mean BMI decrease at the
end of their hospital stay, which was significantly higher than in children who showed a better
nutritional condition at admission. Risk factors for hospital-acquired malnutrition were an age ⬍24
mo, a duration of hospital stay ⬎5 d, fever, and night-time abdominal pain.
Conclusion: Hospital stay has an impact on the nutritional status of children affected by mild clinical
conditions. Children already malnourished on admission were found to be at risk for further nutritional
deterioration during their hospital stay; and in all groups of children identified by their BMI Z-score at
admission, nutritional status declined progressively. © 2009 Published by Elsevier Inc.

Keywords: Children; Hospital malnutrition; Body mass index

Introduction hospitalized and chronically ill children in economically

Malnutrition is the cellular imbalance between the sup-
ply of nutrients and energy and the body’s demand for these
to ensure growth, maintenance, and specific functions [1]. It
is observed most frequently in economically challenged
countries, where it remains one of the most serious public
health problems in hospitalized and non-hospitalized chil-
dren ⬍5 y old [2]. In Asian, Latin American, Near Eastern,
and African countries, hospital-acquired malnutrition con-
tinues to be an important comorbidity in children, affecting
their clinical outcomes [3]. However, hospital-based mal-
nutrition has been described with increasing frequency in
* Corresponding author. Tel./fax: ⫹39-0881-733718.
E-mail address: a.campanozzi@unifg.it (A. Campanozzi).
advantaged countries such as the United States and Europe
[3,4]. For instance, protein– energy malnutrition [5] is the
most common form of nutritional deficiency in children
who are hospitalized in the United States [6]. Protein–
energy malnutrition is a term used to describe a broad array
of clinical conditions ranging from mild to serious, in which
consumption of protein and energy (measured by calories)
is insufficient to satisfy the body’s nutritional needs [5]. As
many as half of all patients admitted to the hospital in the
United States have malnutrition to some degree [7,8], and in
a recent study in a large children’s hospital, the prevalence
of acute and chronic protein– energy malnutrition was
greater than one half [8]. Furthermore, in a survey focusing
on low-income areas of the United States, 22–35% of chil-
dren 2– 6 y of age were reported to be significantly under-

0899-9007/09/$ – see front matter © 2009 Published by Elsevier Inc.

doi:10.1016/j.nut.2008.11.026
 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547
weight; and recent studies in European countries also have
suggested that children hospitalized due to clinical mild or
moderate stress factors are at risk for fat or protein depletion
and development of malnutrition [4,8 –10].
The nutritional status of children often declined after
admission to the hospital, resulting in early and serious
consequences, such as slowing of growth and increased
susceptibility to various infections [4,11,12]. Although
hospital-acquired malnutrition is frequently associated
with a risk of adverse clinical events and a longer hos-
pital stay leading to higher health care costs [12], it is a
problem that remains largely underestimated and often
unrecognized by health care workers [4,13].
Malnutrition in adult hospitalized subjects is well docu-
mented [14], yet relatively few studies have investigated the
nutritional status of children admitted to hospitals. Such studies
have shown that malnutrition is also a common finding in
pediatric inpatients [15]. However, they have focused particu-
larly on severe and chronically ill children, documenting a
significant increased risk for malnutrition in these subjects [4].
The impact of hospitalization on the nutritional status of chil-
dren with mild illness is still not completely clarified [4,9].
Although no classification system for pathologic condition
in children is currently accepted worldwide, the criteria pro-
posed by the American Academy of Pediatrics (AAP) and the
American Dietetic Association (ADA) [4,16,17] are generally
adopted to assess nutritional risk factors in hospitalized chil-
dren [4]. According to such classification, patients are ranked
in three grades. Grade 1 conditions involve mild stress factors,
e.g., admission for diagnostic procedures, minor infection,
other episodic illnesses, or minor surgery. Grade 2 conditions
involve moderate stress factors, e.g., severe but not life-threat-
ening infection, routine surgery, fracture, chronic illness with-
out acute deterioration, or inflammatory bowel disease. Grade
3 conditions involve severe stress factors, e.g., acquired im-
munodeficiency syndrome, malignancy, severe sepsis, major
surgery, multiple injuries, acute deterioration of chronic dis-
ease, or major depression.
Few studies are available in the literature and very little is
known about the onset of malnutrition in children with grade 1
conditions, its timing of occurrence, and its relation to length of
hospital stay or other possible clinical variables. The present
study was undertaken to evaluate the incidence of malnutrition
in children admitted for grade 1 conditions to a general medical
pediatric ward and during their hospital stay. The study aimed
at identifying any early stage of undernutrition and possible
risk factors leading to nutritional deterioration in children hos-
pitalized for mild stress factors.
Materials and methods
The Pediatric Unit of the Public City Hospital of Foggia,
Italy, was selected for the study. At the time of our survey,
it was the only pediatric unit serving the city and surround-
ing area (approximately 200 000 people). The absence of
541
options in the choice for the hospital by the children’s
parents or guardians made this pediatric unit a relatively
closed system. It was sufficiently descriptive of the health
problems affecting the local pediatric population and useful
to study the nutritional status of children hospitalized for
grade 1 clinical conditions identified according to AAP and
ADA criteria [4].
During a period of 6 mo all children within an age range of
1 mo to 16 y, consecutively admitted to the medical pediatric
ward for grade 1 conditions, were enrolled in the study. Grade
1 conditions, characterized by mild stress factors, were those
involving admission for diagnostic procedures, minor infec-
tions, or other episodic illness as described elsewhere [4].
The research was conducted as follows: 1) classification of
patients in homogeneous subgroups in terms of nutritional
deterioration after 72 h of hospital stay and on discharge; 2)
identification of an early segmentation model by using the
entire number of pediatric patients observed as a learning
sample. The outcome variable was nutritional status on dis-
charge, and the information collected on admission was as-
sumed as predictive variables. 3) Identification of a further
segmentation model that uses the same outcome variable as
before and considers those observations collected after the
72-h hospital stay as additional predictive variables.
The exclusion criteria were a hospital stay ⬍72 h, an age
⬍1 mo, chronic disease, a need for hydroelectrolytic par-
enteral support or dehydration identified by a prolonged
capillary refill time, skin turgor, and an abnormal respira-
tory pattern.
Weight and height were measured as a part of the routine
admission procedure. Standard measurement techniques were
applied, such as measuring supine length up to 24 mo of age
and standing height from 24 mo onward. Standing height was
measured to the nearest 0.5 cm on a standardized wall-
mounted height board. Weight was measured daily under the
same conditions (nude, after voiding, in the morning before
breakfast) and was determined to the nearest 0.1 kg by a
physician scale; a baby scale was used for infants weighing
⬍15 kg. The weight at admission was considered the reference
weight.
Body mass index (BMI), based on age and sex, was
evaluated for each patient using well-established reference
curves by Rolland-Cachera et al. [16]. BMI was calculated
from body weight (in kilograms) divided by height (meters)
squared. It was registered on admittance, after 72 h, and on
discharge. A BMI Z-score system was used according to
methods and values previously reported [16] to evaluate the
nutritional status of children, because it is widely recog-
nized as being a most reliable system for analysis of an-
thropometric data [16]. It expresses anthropometric values
as several standard deviations (SDs) below or above the
reference mean or median value. Because the Z-score scale
is linear, summary statistics such as means, SDs, and stan-
dard errors can be computed from Z-score values. Further-
more, Z-score summary statistics are helpful for grouping
growth data by age and sex and the summary statistics can
542 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547

Table 1 groups of patients, the most homogeneous possible, with

Characteristics of 496 children hospitalized for mild clinical conditions regard to the outcome variable (nutritional deterioration),
at study entry
for estimating the potential risk of malnutrition within each
Variable No. of patients (%) group. The exhaustive chi-square automatic interaction de-
Age (mo) tector method [18,19] was used due to the qualitative nature
1–12 174 (35) of the outcome variable (presence or absence of nutritional
13–24 72 (14.5) deterioration), the simultaneous presence of qualitative and
25–36 48 (9.7)
quantitative independent variables, and the advantages from
37–72 84 (16.9)
⬎72 118 (23.8) non-binary partition. Data elaboration was realized by using
Nutritional status on admission SPSS 11.0 (Answer Tree 3.0; SPSS Inc., Chicago, IL,
BMI Z-score ⬍⫺2 51 (10.2) USA). The parameters included in the analysis were age,
BMI Z-score ⫺2/⫹2 387 (78.1) sex, BMI, type of disease (gastrointestinal, respiratory, oth-
BMI Z-score ⬎⫹2 58 (11.7)
ers), malnutrition at 72 h (as measured by BMI changes),
Diagnosis on admission
Respiratory infections 187 (37.7) food intake, vomiting, diarrhea, bloody diarrhea, dysphagia,
Gastrointestinal infections 131 (26.4) night-time abdominal pain, daytime abdominal pain, fever,
Other minor infections 178 (35.9) and duration of hospital stay. Student’s t test was used to
Food intake ⬎50% 246 (49.6) verify the difference between quantitative parameters of two
Food intake ⬍50% 250 (50.4)
populations. A Z test was performed to evaluate differences
BMI, body mass index between percentage values. Statistical significance was pre-
determined as P ⬍ 0.05.

be compared with the reference, which has an expected

mean Z-score of 0 and an SD of 1.0 for all normalized
Results
growth indices [16].
The 95% distribution of BMI values, from ⫺2 to ⫹2
A total of 496 children, 276 boys (55.6%) and 220 girls
Z-score (cutoff points), was considered the normal range for
(44.4%), were enrolled in the study. Median age was 25 mo
nutritional screening of the patients enrolled in the study
(range 1–192 mo). Children admitted to the study showed
and a BMI decrease ⱖ0.25 Z-score was arbitrarily taken as
the following grade 1 clinical conditions: 26.4% had acute
the endpoint criterion to reveal evidence of nutritional de-
gastrointestinal disorders, 37.7% had upper or lower acute
terioration during their hospital stay.
respiratory infections, and 35.9% had other minor infections
Parents and, when possible, patients were interviewed by
(urinary infections, arthritis, viral rashes) or were hospital-
the same pediatric dietitian on admission and after 3 d of
ized because of an elective diagnostic procedure (biopsies,
hospital stay to evaluate food intake (⬍50% or ⬎50% of the
upper or lower gastrointestinal endoscopies, magnetic res-
dietary allowance offered by the hospital catering service, in
onance imaging). Their baseline characteristics are listed in
accordance with the recommended dietary allowance), dif-
Table 1.
ficulty retaining food (at least three episodes per day of
loose stools or at least three episodes per day of vomiting),
and pain. Symptoms and clinical signs that interfered with
food intake were properly reported, in particular daytime or 140
night-time abdominal pain and fever. Length of hospital
stay was registered. 120

The study was performed according to the World Med-

Number of Patients

100
ical Association Declaration of Helsinki for ethical princi-
ples in medical research involving human subjects and ap- 80
proved by the internal ethical committee of the Medical
School of the University of Foggia for studies performed in 60
subjects of minor age (ⱕ16 y). Written informed consent to
40
the study was obtained by the parents or guardians for the
participation of their child in the study. 20

Statistical analysis 0
<-2 - 2/- 1 - 1/ 0 0/+1 +1/+2 >+2

Classification trees analysis [17] was used to study the BMI Z-score
relation between malnutrition and a list of predictive vari- Fig. 1. Nutritional conditions in 496 children 1–16 y of age hospitalized for
ables recorded in the course of hospitalization. Classifica- mild stress factors (grade 1). Distribution of BMI Z-scores on admission.
tion tree is a multivariate analysis that classifies different BMI, body mass index.
 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547 543

Table 3
80 Mean BMI variation during hospital stay of children hospitalized for
mild clinical conditions, according to their BMI Z-score on admission
70
BMI Z-score on admission After 72 h Discharge
Number of Patients

60
⬍⫺2 ⫺0.07 ⫾ 0.8 ⫺0.27 ⫾ 2.7
50 ⫺2/0 ⫺0.01 ⫾ 0.4 ⫺0.01 ⫾ 0.4*
0/⫹2 ⫺0.02 ⫾ 0.23 ⫺0.02 ⫾ 0.32†
40 ⬎⫹2 ⫺0.04 ⫾ 0.17 ⫺0.04 ⫾ 0.18‡

30 BMI, body mass index

* P ⬍ 0.05 versus a BMI Z-score ⬍⫺2.
20 †
P ⬍ 0.05 versus a BMI Z-score ⬍⫺2.
‡
P ⫽ NS versus a BMI Z-score ⬍⫺2.
10

0
<-2 - 2/- 1 -1/ 0 0/+1 +1/+2
BMI Z-score
Fig. 2. Nutritional conditions in 246 children ⬍2 y of age hospitalized for
mild stress factors (grade 1). Distribution of BMI Z-scores on admission.
BMI, body mass index.
On admission, 51 of 496 children (10.2%) were below
the normal range distribution of BMI Z-scores (⬍⫺2), 387
(78.1%) were within the normal range (⫺2/⫹2), and 58
(11.7%) were above the upper limit (⬎⫹2; Fig. 1). Similar
results were seen if the analysis of data was limited to the
group of 246 children (49.5%) 1–24 mo of age (Fig. 2). By
applying Waterlow’s criteria [21] to monitor the nutritional
status of children during their hospital stay, only a non-
significant increasing trend of mild acute malnutrition was
observed between the first and last days of hospitalization
(Table 2). However, children with a BMI Z-score ⬍⫺2 SD
on admission showed a mean BMI decrease at the end of
their hospital stay that was significantly higher (P ⬍ 0.05)
than the children with a better nutritional condition at ad-
mission (BMI ⫺2 to ⫹2; Table 3 and Fig. 3). Vomiting was
observed in 106 patients (21.3%), but their BMI Z-score
decrease was not significantly different from children
without vomiting (– 0.09 ⫾ 0.3 and – 0.02 ⫾ 0.3, respec-
tively). Diarrhea was present in 87 children (17.5%) and
>+2
(group A) and those with a BMI decrease not reaching the
endpoint criterion (group B). Group A consisted of 97
children (19.56% of total population) with a BMI decrease
ⱖ0.25 SD and group B included 399 children (80.44% of
total population) with a BMI decrease not reaching the
endpoint criterion (Table 4). Early nutritional deterioration
was present after 72 h in 86.3% of patients in group A
versus 8.0% of patients in group B (P ⬍ 0.001).
In children already malnourished on admission found to
be at risk of further nutritional deterioration in the course of
their hospital stay and in all groups of children identified by
their BMI Z-score at admission, nutritional status declined
progressively. Figure 4 shows a significant BMI Z-score
decrease (ⱖ0.25 SD) at discharge in patients whose Z-score
at admission was ⬍⫺2 to ⫹2.
Daily food intake is a variable recognized to affect the
nutritional status of hospitalized subjects. A BMI Z-score
decrease ⱖ0.25 SD was present in 11.8% (29 of 246) of
children usually eating ⱖ50% of their dietary allowance
and in 27.2% (68 of 250) of those accepting ⬍50% (P ⬍
0.001).
Based on the chi-square automatic interaction detector
tree (Fig. 5), four main risk factors for nutritional deterio-
p <0.05
Mean BMI Z-score loss during Hospital Stay

the BMI Z-score change (⫺0.07 ⫾ 0.32) in these subjects p <0.05

-0,3
was not significantly different from patients without di-
arrhea (0.03 ⫾ 0.26). -0,25
Based on their nutritional conditions at discharge, pa- -0,2
tients were divided in two groups: children who at discharge
reached the endpoint criterion of a BMI decrease ⱖ0.25 SD -0,15 After 72 h
Discharge
-0,1

Table 2 -0,05
Waterlow’s criteria for categorizing acute malnutrition in 496 children
with mild clinical conditions during their hospital stay 0
<-2 -2/0 0/+2 >+2
Type of acute No. of patients at No. of patients at BMI Z-score on admission
malnutrition hospital admission (%) hospital discharge (%)

Mild 73 (14.7) 80 (16.1) Fig. 3. Mean of BMI decrease measured after 72 h and at discharge in 496
Moderate 15 (3.1) 15 (3.1) children hospitalized for mild stress factors (grade 1). Subjects were
Severe 4 (0.8) 2 (0.4) grouped based on their BMI Z-score on admission: 51 children (10.2%)
Total 92 (18.5%) 97 (19.6) showed a BMI Z-score ⬍⫺2, 387 (78.1%) were within the normal range
(⫺2/⫹2), and 58 (11.7%) had a score ⬎⫹2. BMI, body mass index.
544 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547

Table 4
Comparison between children hospitalized for mild clinical conditions who at discharge showed a BMI decrease ⱖ0.25 SD (group A) and those with a
BMI decrease ⬍0.25 SD (group B)
Group No. of patients (%) BMI Z-score P

At admission At discharge Admission versus discharge

A 97 (19.56) ⫺0.22 ⫾ 2.12 ⫺0.88 ⫾ 2.65 ⫺0.49 ⫾ 0.27 ⬍0.05

B 399 (80.44) ⫹0.23 ⫾ 1.93 ⫹0.34 ⫾ 1.88 ⫹0.08 ⫾ 0.20 NS

BMI, body mass index

ration were identified in the 496 children enrolled in the hospital stay, in 35 of 119 children (29.4%) hospitalized for
study: 1) an age ⬍24 mo, 2) a hospital stay ⬎5 d, 3) fever, 6 – 8 d, and in 20 of 49 children (40.8%) with ⬎8 d of
and 4) night-time abdominal pain. hospitalization (Fig. 7).

Age younger than 24 mo Fever

A BMI Z-score decrease ⱖ0.25 SD was present in 60 of The nutritional endpoint criterion was reached by 29 of
246 children (24.4%) 1–24 mo of age and in 37 of 250 73 patients with fever (39.7%) and by 68 of 423 children
children (14.8%) ⬎24 mo (P ⬍ 0.001; Table 5). A mean (16.0%) without fever (P ⬍ 0.001; Table 5).
Z-score variation of – 0.006 ⫾ 0.48 was documented in
children ⬍2 y, and a variation of – 0.02 ⫾ 0.38 (P ⫽ NS) Night-time abdominal pain
was observed in children ⬎2 y.
In children with night-time abdominal pain, a BMI Z-
Hospital stay longer than 5 d score decrease ⱖ0.25 SD was present in 38% (29 of 76) of
cases and in 16% (68 of 420) of those without nocturnal
The mean length of hospitalization was 5.1 ⫾ 2.2 d abdominal pain (P ⬍ 0.001; Table 5).
(range 3–14 d) for the total population; hospital stays were These results, obtained by multivariate analysis, per-
6.6 ⫾ 3.3 d in children who at discharge reached the sisted after excluding the group of children with acute
established endpoint criterion of a BMI decrease ⱖ0.25 SD digestive disease.
(group A) and 5.2 ⫾ 2.3 d in children with a BMI decrease
not reaching the endpoint criterion (group B). The differ-
ence between groups A and B was significant (P ⬍ 0.05). A
Discussion
significant difference of BMI (P ⬍ 0.001) was also ob-
served between children with ⱕ5 d of hospital stay (Z-score
Nutritional status in children is an indicator of health and
0.05 ⫾ 0.4) and children with ⬎5 d of hospital stay (Z-score
well-being at the individual and population levels [9]. Mal-
⫺0.11 ⫾ 0.4; Fig. 6). A BMI Z-score decrease ⱖ0.25 SD
nutrition has been associated with an increased prevalence
was significantly higher in children hospitalized for ⬎5 d
of complications in hospitalized children and several studies
(Table 5). In particular, BMI Z-score decreases ⱖ0.25 SD
have suggested that providing appropriate nutritional sup-
were present in 42 of 328 children (12.8%) with ⱕ5 d of
port during hospital stay decreases the risk of slowing of
growth and an increased susceptibility to various infections
35%
[12].
*° The majority of the available studies have assessed the
30% * ° p< 0.05
Percentage of patients

nutritional status of children hospitalized for a wide range of

25% pathologic conditions after their admission to the hospital,
*
20% ° whereas in our study we investigated the impact of hospital
After 72 h
15% Discharge
stay on the nutritional status of children affected by grade 1
clinical conditions [4] (mild stress factors) from the time of
10%
admission to discharge.
5%
Our study confirms that malnutrition, either overnutrition
0% or undernutrition, is a frequent finding in children at the
<-2 -2/0 0/+2 >+2
time of their hospital admission (Table 1) and it shows that
Z-scores on admission a risk for hospital-acquired nutritional deterioration is
Fig. 4. Percentage of BMI decrease ⱖ0.25 SD during hospitalization in 496
present in children with mild illness-related stress factors. In
children with mild clinical conditions. Subjects were grouped by their fact, the growth charts of Rolland-Cachera et al. [16], used
Z-score at admission in the hospital. BMI, body mass index. as references/standards, indicated that 19.56% of children
 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547
Fig. 5. Risk factors for nutritional deterioration identified by multivariate analysis in the 496 children enrolled in the study (chi-square automatic interaction
detector tree of decision). abd., abdominal.
enrolled in our study had a BMI decrease in the course of
hospitalization. Such risk was present mostly in children
already malnourished at their hospital admission.
There is no universally accepted nutritional screening
tool for children [9]. However, it is standard practice in
pediatrics to use height and weight charts to calculate
growth velocity, which is highly sensitive to nutritional sta-
tus [20]. The anthropometric indicator most often used is
weight-for-age, but it is less efficient than weight-for-height
and height-for-age, because a low weight-for-age does not
distinguish between wasting and stunting [4,22]. BMI-for-age
provides more information because it correlates weight-for-
height to age and the Z-score is a BMI-for-age SD score [21].
This measurement is recommended by the World Health Or-
ganization for studies in large populations and it is more
accurate than describing anthropometric status by using the
centile scale [22].
Our study showed that children with a BMI Z-score
⬍⫺2 SD on admission had a weight decrease in the course
of their hospital stay, which was significantly more impor-
tant than in normally nourished patients. Furthermore, in
most of the children who were malnourished at discharge, a
BMI decrease was already detected after 72 h. This finding
suggests the possibility of early detection of children who
are candidates for hospital-acquired malnutrition and estab-
lish an appropriate nutritional management tool to prevent
545
the development of such adverse conditions during their
hospital stay.
The risk of nutritional depletion in hospitalized children
should be recognized as soon as possible to begin a timely
and appropriate nutritional intervention [23], particularly in
children with grade 1 clinical conditions, because the risk
for malnutrition in these subjects might be underestimated
[4]. Our study identified four main risk factors for hospital-
acquired malnutrition in children hospitalized for mild
stress factors: an age ⬍24 mo, length of hospital stay, fever,
and night-time abdominal pain.
Infants need a daily caloric intake per kilogram of body
weight much higher than children and adolescents, and any
mild reduction of food intake may lead to a severe reduction
of BMI. In fact, several studies have shown that children
⬍24 mo of age are more at risk of hospital malnutrition
[24]. Our results confirm these data, because a significantly
larger percentage of patients ⬍2 y old reached the cutoff
point of ⫺0.25 BMI Z-score.
Length of hospital stay negatively affected the nutritional
status of children enrolled in the study (Figs. 6 and 7),
inducing a significant reduction of their BMI, which was
related to reduced food intake compared to the recom-
mended dietary allowance (Table 5). In particular, the nu-
tritional cutoff point of ⫺0.25 BMI Z-score was reached by
12.8% of children hospitalized for 3–5 d, by 29.4% of those
546 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547

Table 5
0,06
Risk factors for hospital-acquired malnutrition in children hospitalized
for mild clinical conditions 0,04 326 pts

BMI Z-score change

0,02
Risk factors No. of patients (%)
0
Age (mo)
-0,02 123 pts
1–24 60/246 (24.4)* 47 pts
Food intake ⬍50% 38/60 (63.3)† -0,04
⬎24 37/250 (14.8)* -0,06
Food intake ⬍50% 29/37 (75.6)† -0,08
Hospital stay (d)
ⱕ5 42/328 (12.8)* -0,1
Food intake ⬍50% 30/42 (71.4)† -0,12
⬎5 55/168 (32.7)* 3-5 6-8 >8
Food intake ⬍50% 39/55 (70.9)† Days of Hospital stay
Fever
Present 29/73 (39.7)* Fig. 6. BMI decrease was related to length of hospital stay in children as
Food intake ⬍50% 23/29 (79.3)† demonstrated by the BMI Z-score change in 496 patients hospitalized for
Absent 68/423 (16.0)* mild clinical conditions. BMI, body mass index; pts, patients.
Food intake ⬍50% 46/68 (67.6)†
Night-time abdominal pain
Present 29/76 (38.0)*
Food intake ⬍50% 22/29 (75.8)† conditions (mild stress factors) also are at risk for malnu-
Absent 68/420 (16.0)* trition.
Food intake ⬍50% 48/68 (70.5)† Nutritional problems causing potential clinical deteriora-
BMI, body mass index tion and a risk for increased morbidity should be promptly
* P ⬍ 0.001, BMI Z-score decrease ⱖ0.25. recognized in hospitalized children [29]. We suggest that
†
P ⫽ NS. screening pediatric patients for nutritional conditions at hos-
pital admission and during the first 72 h should be consid-
ered standard practice in pediatric care units. BMI measure-
staying 6 – 8 d, and by 40.8% of children with a hospital stay ment is rapid and cost effective to recognize a nutritional
⬎8 d. In that regard, studies from the literature have sug- risk in hospitalized children and it should be performed
gested a negative relation between the duration of hospital routinely by a nutritional team.
stay and satisfaction with the food provided, with the pa- There is good evidence to suggest that improvements in
tients staying longest being the most dissatisfied with the catering services and a better organization of the daily
food [25]. schedule in pediatric care units will increase a patient’s
Insufficient energy intake is known to be responsible for nutritional intake and status, with a positive impact on
energy imbalance and malnutrition, and fever is always length of stay and morbidity of hospitalized children [9].
linked to increased energy expenditure [26]. Furthermore, in For instance, many adolescents enrolled in our study la-
case of fever, anorexia is often the result of general malaise,
a sense of abandonment, or an alteration of taste and smell
resulting from drug–nutrient interactions [27]. In our study,
Patients (%) with BMI loss ≥ 0.25 SD

79% of malnourished children with fever (BMI decrease 45

ⱖ0.25 Z-score) showed a reduction of food intake.
We also found that night-time abdominal pain is a further 40
risk factor for hospital-acquired malnutrition. Thirty-eight 35
percent of patients with night-time abdominal pain reached 30
the nutritional endpoint criterion at the end of their hospital 25
stay versus 16% of children with no night-time abdominal
pain. This variable has been distinguished from daytime 20
abdominal pain because it is a painful condition that wakes 15
the patient and it is generally not associated with a func- 10
tional condition. 5
In conclusion, hospital-acquired malnutrition continues
to be a common finding in hospitalized children, as recently 0
3-5 6-8 >8
emphasized in a study by Pawellek et al. [28] that deter-
mined the prevalence of malnutrition in a series of uns- Days of Hospital stay
elected patients consecutively admitted as inpatients to a Fig. 7. Number of children (percentage) with a BMI decrease ⱖ0.25 SD
large tertiary care children’s hospital in Germany. Our study was related to length of hospitalization in 496 children with mild clinical
has shown that children hospitalized for grade 1 clinical conditions. BMI, body mass index.
 A. Campanozzi et al. / Nutrition 25 (2009) 540 –547
mented the impossibility of receiving solid food from 19:00
to 08:00 h, with only milk being available in the kitchen of
the ward. The provision of meals should be flexible and
individualized, and all patients should have the possibility
of ordering food and extra food at any time [27] and be
informed of this possibility. Menus for children should also
include foods with a high energy density [30]. Furthermore,
overnight fasting and bowel-cleansing protocols with di-
etary restrictions should not be used routinely, because they
are nutritionally dangerous and often without any therapeu-
tic effect [31].
Knowledge of performing an appropriate nutritional as-
sessment and implementing a rational nutritional therapy in
children should be part of any hospital plan of care. Famil-
iarity with nutritional assessment scoring systems and nu-
tritional assessment tools should be part of the staff exper-
tise in any pediatric care unit.
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