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Consensus Statement of the Academy of Nutrition andDietetics/American Society for Parenteral and EnteralNutrition: Indicators Recommended for theIdentification and Documentation of PediatricMalnutrition (Undernutrition) (http://cdn.clinicalkey.com/rss/issue/22122672.xml) (/ui/service/content/url?eid=1­s2.0­S2212267214013598)

Patricia J. Becker MS, RD, CSP, LDN, CNSC, Liesje Nieman Carney RD, CSP, LDN, Mark Richard Corkins

MD, CNSC, SPR, FAAP, Jessica Monczka RD, LDN, CNSC, Elizabeth Smith RD, LDN, CNSC, Susan

Elizabeth Smith RD, CSP, LD, Bonnie A. Spear PhD, RDN, LD and Jane V. White PhD, RD, LDN, FADA,

FANDConsensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: IndicatorsRecommended for the Identification and Documentation of Pediatric Malnutrition (Undernutrition), 2014­12­01Z, Volume 114,Issue 12, Pages 1988­2000, Copyright © 2014 Academy of Nutrition and Dietetics and the American Society for Parenteral andEnteral Nutrition

Abstract

The Academy of Nutrition and Dietetics and American Society for Parenteral and EnteralNutrition, utilizing an evidence­informed, consensus­derived process, recommend that astandardized set of diagnostic indicators be used to identify and document pediatric malnutrition(undernutrition) in routine clinical practice. The recommended indicators include z scores forweight for height/length, body mass index for age, length/height for age, or mid­upper armcircumference when a single data point is available. When two or more data points are available,indicators may also include weight­gain velocity (younger than 2 years of age), weight loss (2 to 20years of age), deceleration in weight for length/height z score, and inadequate nutrient intake. Thepurpose of this consensus statement is to identify a basic set of indicators that can be used todiagnose and document undernutrition in the pediatric population (ages 1 month to 18 years). Theindicators are intended for use in multiple settings, such as acute, ambulatory care/outpatient,residential care, etc. Several screening tools have been developed for use in hospitalized children.However, identifying criteria for use in screening for nutritional risk is not the purpose of thispaper. Clinicians should use as many data points as available to identify and document thepresence of malnutrition. The universal use of a single set of diagnostic parameters will expeditethe recognition of pediatric undernutrition, lead to the development of more accurate estimates ofits prevalence and incidence, direct interventions, and promote improved outcomes. A

standardized diagnostic approach will also inform the prediction of the human and financialresponsibilities and costs associated with the prevention and treatment of undernutrition in thisvulnerable population, and help to further ensure the provision of high­quality, cost­effective,nutrition care.

Pediatric malnutrition (undernutrition) is estimated to contribute to approximately 45% of allchild deaths globally. Approximately 20 million children younger than 5 years of age worldwideare severely undernourished, leaving them extremely vulnerable to illness and premature death.Many older children in developing countries enter adolescence undernourished, which increasestheir vulnerability to disease and premature death. Poverty, famine, and war are primarycontributors to global malnutrition and limit food distribution and access, even when food isavailable for consumption. Development of acute or chronic infectious and/or diarrheal disease inthose who are already undernourished contributes to the high mortality rates associated withpediatric malnutrition (undernutrition) in developing nations.

Pediatric undernutrition has historically been considered an issue exclusive to developingcountries. Much of the groundbreaking research and initial development of malnutrition(undernutrition) criteria occurred with populations outside of the United States, where acute orchronic infectious and/or diarrheal disease are major contributors to its development and to highrates of mortality. However, the clinical perspective and description of undernutrition has evolvedduring the past 3 decades. Unlike the undernutrition typically observed in developing countries,and usually categorized as marasmus and/or kwashiorkor, undernutrition in developed countriesgenerally occurs in the setting of acute or chronic illness.

A number of US children suffer from energy imbalance and excess rather than nutrient deficiency.It is estimated that approximately 17% of US children and adolescents between 2 and 19 years ofage are obese. Other data sets estimate that 1 in 10 US households with children struggle withfood insecurity. The current prevalence of US children who experience acute or chronicundernutrition is unknown. Children and adolescents who live in homeless shelters, are victims ofabuse or neglect, or live in urban or rural areas where access to high­quality food is difficult, arethought to be at increased risk for undernutrition.

Undernutrition in the United States is most frequently observed in hospitalized acute and/orchronically ill children, and in US children with special health care needs. Children with specialneeds are defined as “those who have or are at increased risk for a chronic physical,developmental, behavioral, or emotional condition and who also require health and relatedservices of a type or amount beyond that of children generally.” This definition encompasseschildren with nutrition­related chronic diseases or conditions, congenital anomalies, severe acuteillness or injury, and those affected by abuse or neglect.

Children and youth with special health care needs should be routinely screened for malnutrition inprimary care settings. Registered dietitian nutritionists (RDNs), nurses, and all members of thehealth care team should collaborate to ensure that screening for malnutrition becomes an integralpart of routine pediatric care. Although research is limited, malnutrition in this population canlead to more complicated hospitalizations due to progression of the underlying disease orcondition, poor wound healing, or slow return to previous level of activity, complications that can

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significantly increase the length of stay and cost of hospitalization. Comprehensive assessmentand nutrition intervention in undernourished and malnourished children in primary care settingscan reduce the need for more costly hospitalization by addressing nutritional deficits thatcan predispose the patient to acute illness or exacerbate the underlying disease or condition. Older studies suggest that up to 25% of all hospitalized children experienced acute protein­energymalnutrition, and approximately 27% experience chronic food insecurity.

Inadequate intake, self­starvation, and/or purging behaviors associated with disorderedeating/eating disorders can lead to malnutrition. These behaviors are most common amongteenage girls. It is estimated that 0.5% of adolescents suffer with anorexia nervosa with another1% to 2% meeting a diagnosis of bulimia nervosa. However, it is estimated that up to14% of adolescents suffer from “partial syndromes or eating disorder not otherwise specified” andalready have signs and symptoms of malnutrition. Adolescents often try to hide aberrant eatingbehaviors. Laboratory parameters often remain normal for a period of time after aberrant eatingbehaviors have begun. The adolescent may already be in an undernourished state beforepresenting to a health care provider. In fact, the RDN may be the first provider to recognize thesymptoms or the first provider contacted by the patient or caregivers.

Purpose

The purpose of this consensus statement is to identify a basic set of indicators that can be used todiagnose and document undernutrition in the pediatric population ages 1 month to 18 years. Theindicators are intended for use in multiple settings, such as acute, ambulatory care/outpatient,residential care, etc. Several screening tools have been developed for use in hospitalized children.However, identifying criteria for use in screening for nutritional risk is not the purpose of this

paper. The diagnosis and documentation of undernutrition in neonates, recognition anddocumentation of micronutrient deficits in the pediatric population, and strategies to addressmicronutrient deficits are beyond the scope of this statement. Please refer topublications/resources specific to these topics for additional guidance. The diagnosisand treatment of pediatric obesity (overnutrition) are also not addressed in this statement.

Definition of Pediatric Malnutrition (Undernutrition)

The focus of this consensus statement is pediatric undernutrition. The American Society forParenteral and Enteral Nutrition (A.S.P.E.N.) has defined pediatric malnutrition (undernutrition)as “an imbalance between nutrient requirement and intake, resulting in cumulative deficits ofenergy, protein or micronutrients that may negatively affect growth, development and otherrelevant outcomes.” Pediatric undernutrition may be related to illness, adverse environmentalor behavioral factors, injury, congenital anomalies, etc. The United Nations Children’s Fund(UNICEF) states that although malnutrition is a broad term commonly used as an alternative toundernutrition, it technically also encompasses overnutrition. People are considered tobe malnourished (undernourished) if their diet does not provide adequate energy and protein forgrowth and development, or if they are unable to fully utilize the food/nutrients due to illness.Children are also classified as malnourished (overnourished) if they consume too much energy.Although obesity is a form of malnutrition, a discussion of overnutrition is not the purpose thisarticle.

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Acute vs Chronic Undernutrition

Undernutrition is often characterized as acute or chronic. One way to distinguish between acuteand chronic is time. Acute diseases or conditions are typically severe and sudden in onset.A chronic disease or condition tends to develop and become more severe over an extended periodof time. The National Center for Health Statistics defines “chronic” as a disease or condition thathas lasted for 3 months or longer. A chronic condition may contribute to an acute illness, just asan acute illness may evolve into a chronic condition, if unaddressed.

The World Health Organization (WHO) and UNICEF have also provided guidance to distinguishbetween acute and chronic undernutrition by offering diagnostic parameters that help clinicianscharacterize the acuity level of undernutrition experienced by pediatric populations. Weight isprimarily affected during periods of acute undernutrition, and chronic undernutrition typicallymanifests as stunting. Severe acute undernutrition, experienced by children ages 6 to 60 monthsof age, is defined as a very low weight for height (less than −3 standard deviations [SD]; z scores)of the median WHO growth standards), by visible severe wasting (a mid­upper arm circumference[MUAC] ≤115 mm), or by the presence of nutritional edema. Wasting is defined as a weight for ageless than −2 SD ( z score). Chronic undernutrition or stunting is defined by WHO as having aheight (or length) for age that is less than −2 SD ( z score) of the median of the NCHS/WHOinternational reference. An in­depth discussion of the z score is presented later in this paper.

Stunting is a well­established indicator of chronic malnutrition, particularly undernutritionrelated to environmental or socioeconomic circumstances. The height­for­age measurementrepresents the linear growth or stature actually achieved by the child at the age at which the childis measured. Height (ie, stature) is measured in the standing position. Length­for­age refers tomeasurements taken in the recumbent position and is recommended for children ≤2 years of age.Children in the age range of 0 to 4 years have the best potential outcomes from comprehensive

assessment for malnutrition because timely intervention is highly likely to prevent adverse effects.Stunting may be observed during adolescence, which is also a period of rapid growth and

development.

The Figure (tbl4) lists examples of software programs that are available for individual z scorecalculation. Also, many growth charts (Fenton, WHO, Centers for Disease Control andPrevention [CDC]) are available on mobile technology applications and have made plotting veryeasy.

Figure

Resources for determining z scores for anthropometrics.

CDC Growth Charts a (hl0000054) WHO Growth Charts b (hl0000057)

STAT GrowthCharts (compatible withiPod Touch, iPhone, iPad [Apple Inc])

STAT GrowthCharts WHO (compatible with iPodTouch, iPhone, iPad [Apple Inc])

Epi Info NutStat: (available fordownload)

WHO z score charts:

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CDC website: z score data filesavailable as tables:

WHO Multicentre Growth Study website: All fourmacros (SAS, S­plus, SSPS, and STATA) calculate theindicators of the attained growth standards

PediTools Home: Clinical tools forpediatric providers; growth charts,calculators, etc; mobile compatible

PediTools Home: Clinical tools for pediatric providers;growth charts, calculators, etc; mobile compatible

a CDC=Centers for Disease Control and Prevention.

b WHO=World Health Organization.

Indicators of Pediatric Undernutrition

A standardized approach to the recognition and diagnosis of pediatric undernutrition, particularlyin the pediatric population older than 60 months, is lacking. Controversy surrounding the bestand most useful approach(es) abound. Therefore, routine assessment of nutritional status in high­risk children in the United States is sporadic and inconsistent among facilities. A true measure ofthe impact of pediatric undernutrition on overall health is difficult to obtain. The US Survey ofChildren with Special Health Care Needs does not currently include assessment offood/nutrition services provided; this data deficit must be addressed and the survey instrumentrevised to accommodate the collection of such data.

Attributes of Indicators Selected for Inclusion

A multitude of parameters have been developed for obtaining measurements in children in aneffort to determine nutritional status. However, the increasing economic constraints of theUS health care system mandate identification of the most reliable, reproducible, safe/low risk, andcost­effective indicators to support nutrition evaluation. Attributes of the indicators that werecommend are as follows:

• are evidence­informed/consensus derived;

• are universally available and validated;

• can be applied inexpensively in multiple settings;

• can be properly used with minimal training;

• can reproducibly identify undernutrition;

• can quantify severity of undernutrition; and

• can be used to monitor changes in nutritional status.

Indicators recommended to identify pediatric malnutrition are typically continuous rather thandiscrete variables. As such, clinical expertise and sound clinical judgment must be exercised whenobtaining a history, completing the physical examination, developing differential diagnostic

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options, making a diagnosis, and implementing and monitoring a plan of care. Remember that therecommended list of indicators to be assessed may change over time, as evidence to support orto discontinue their use accrues, or as advances in assessment technology supplant their use.

Consensus Recommendations

We recommend that the following list of indicators be used when assessing and diagnosingpediatric malnutrition:

Food/Nutrient Intake

Food and nutrient intake are the primary determinants of nutritional status. Therefore, accurateassessment of intake and estimation of adequacy is critical. The primary concern is whether or notthe child’s current intake is adequate to meet their nutrient needs in the context of their currentclinical situation, growth pattern, and developmental level. Other diagnostic indicators arebasically outcome measures of dietary adequacy.

Estimates of the adequacy of protein/energy intake should be routinely determined for all childrenand especially in those identified as at increased risk for malnutrition. Accuracy in the estimationof adequacy of nutrient needs and assessment of the adequacy of food and nutrient intake arecrucial to determining the magnitude of the deficit, as well as the extent and acuity of the deficit.Food/nutrient intake details can be obtained by history and/or by direct observation of foodand/or nutrients consumed. Prescribed nutrition therapy intake should be monitored to ensurethat the intended amounts are actually ingested by the child.

Assessment of Energy and Protein Needs

Energy needs can be measured by indirect calorimetry or estimated through the use ofstandard equations. Each of the methods to estimate energy needs are just that, an estimation.Ideally, clinicians should perform indirect calorimetry to measure a child's actual energyrequirements. Indirect calorimetry is the most precise method for the determination of energyexpenditure because predictive equations do not accurately determine energy expenditure oraccount for the variability of a child’s metabolic state during the course of an illness. TheFood and Agriculture Organization/WHO and Schofield equations, although imprecise anddeveloped to estimate the energy utilization of healthy children, are the most widely used formulasto estimate energy needs. These equations are frequently used when equipment for indirectcalorimetry assessment is unavailable. Estimation of energy requirement can also be determinedusing the 1989 Recommended Dietary Allowance or the 2005 Dietary Reference Intakeestimated energy requirements. However, both of these methods also represent estimations ofthe energy needs of the “healthy” child. Predictive equations for determining energyrequirements can be used initially and are summarized in Table 1 (tbl1) .

Table 1

Estimating nutrient needs: A.S.P.E.N. 2010 Pediatric Nutrition Support Core Curriculum [object Object]

Name of equationor formula and

Description andapplication to

Calculations for the equation or formula

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source patientpopulation

Energy

1989RecommendedDaily Allowance(RDA) Committeein DietaryAllowances, Foodand NutritionBoard, NationalResearch Council. RecommendedDietaryAllowances. 10thed. Washington,DC: NationalAcademiesPress; 1989.

Based on themedian energyintakes of childrenfollowed inlongitudinal growthstudies It canoverestimateneeds in nonactivepopulations (eg,bedridden) anddoes not provide arange of energyneeds Although anoutdatedreference, stillwidely used Mostoften used forhealthy infantsand children

Infants: 0 to 0.5 y: 108×weight (kg) 0.5 to 1 y:98×weight Children: 1 to 3 y: 102×weight 4 to 6 y:90×weight 7 to 10 y: 70×weight Males: 11 to 14 y:55×weight 15 to 18 y: 45×weight Females: 11 to 14 y:47×weight 15 to 18 y: 40×weight

Estimated energyrequirements(EER) (newDRI/IOM b

(hl0000323)

equation) andphysical activity(PA) coefficients National Academyof Sciences,Institute ofMedicine, Foodand NutritionBoard. DietaryReference Intakesfor Energy,Carbohydrate,Fiber, Fat, FattyAcids, Cholesterol,Protein, and AminoAcids

Replaces the 1989RDA Energyneeds weredetermined fromchildren withnormal growth,body composition,and activity, andwho are alsometabolicallynormal Childrenwith normalgrowth, bodycomposition, andactivity, and whoare alsometabolicallynormal Fourcategories ofphysical activity

EER = total energy expenditure (TEE)+energydeposition Ages 0 to 36 mo: 0 to 3 mo: (89×weight[kg]−100)+175 4 to 6 mo: (89×weight [kg]−100)+56 7to 12 mo: (89×weight [kg]−100)+22 13 to 36 mo:(89×weight [kg]−100)+20 Ages 3 to 8 y boys: EER=88.5−(61.9×age [y])+PA×(26.7×weight[kg]+903×height [m])+20 kcal PA=1 if PAL isestimated to be >1 <1.4 (sedentary) PA=1.13 if PAL isestimated to be >1.4 <1.6 (low active) PA=1.26 if PALis estimated to be >1.6 <1.9 (active) PA=1.42 if PAL isestimated to be >1.9 <2.5 (very active) Ages 3 to 8 y,girls: EER=135.3−(30.8×age [y])+PA×(10×weight[kg]+934×height [m])+20 kcal PA=1 if PAL isestimated to be >1 <1.4 (sedentary) PA=1.16 if PAL isestimated to be >1.4 <1.6 (low active) PA=1.31 if PALis estimated to be >1.6 <1.9 (active) PA=1.56 if PAL isestimated to be >1.9 <2.5 (very active) Ages 9 to 18 y— Boys: EER=88.5−(61.9×age [y])+PA×(26.7×weight[kg]+903×height [m])+25 kcal PA=1 if PAL is

Acids(Macronutrients)(2005).

level (PAL) estimated to be >1 <1.4 (sedentary) PA=1.13 if PAL isestimated to be >1.4 <1.6 (low active) PA=1.26 if PALis estimated to be >1.6 <1.9 (active) PA=1.42 if PAL isestimated to be >1.9 <2.5 (very active) Ages 9 to 18 y— Girls: EER=135.3−(30.8×age [y])+PA×(10×weight[kg]+934×height [m])+25 kcal PA=1 if PAL isestimated to be >1 <1.4 (sedentary) PA=1.16 if PAL isestimated to be >1.4 <1.6 (low active) PA=1.31 if PALis estimated to be >1.6 <1.9 (active) PA=1.56 if PAL isestimated to be >1.9 <2.5 (very active)

EER (new DRI/IOMequation) andobesitycoefficients/factors National Academyof Sciences,Institute ofMedicine, Foodand NutritionBoard. DietaryReference Intakesfor Energy,Carbohydrate,Fiber, Fat, FattyAcids, Cholesterol,Protein, and AminoAcids(Macronutrients)(2005).

Overweightchildren who aremetabolicallynormal

Weight maintenance TEE in overweight boys Ages 3to 18 y: TEE=114−(50.9×age [y])+PA×(19.5×weight[kg]+1,161.4 × height [m]) PA=1 if PAL is estimated tobe >1 <1.4 (sedentary) PA=1.12 if PAL is estimated tobe >1.4 <1.6 (low active) PA=1.24 if PAL is estimatedto be >1.6 <1.9 (active) PA=1.45 if PAL is estimatedto be >1.9 <2.5 (very active) Weight maintenanceTEE in overweight girls ages 3 to 18 y: TEE=389−(41.2×age [y])+PA×(15×weight[kg]+701.6×height [m]) PA=1 if PAL is estimated to be>1 <1.4 (sedentary) PA=1.18 if PAL is estimated to be>1.4 <1.6 (low active) PA=1.35 if PAL is estimated tobe >1.6 <1.9 (active) PA=1.6 if PAL is estimated to be>1.9 <2.5 (very active)

Schofield WN.Predicting basalmetabolism rate,new standards andreview of previouswork. Hum NutrClin Nutr .1985;39(suppl 1):5­41.

A predictiveequation forcalculating basalmetabolic rate(BMR) in healthychildren that wasdeveloped byanalysis of FritzTalbot tables Healthy children,acutely ill patientsin the hospitalsetting

Males: 0 to 3 y: (0.167×weight [kg])+(15.174×height[cm])−617.6 3 to 10 y: (19.59×weight [kg])+(1.303×height [cm])+414.9 10 to 18 y: (16.25×weight[kg])+(1.372×height [cm])+515.5 >18 y:(15.057×weight [kg])+(1.0004×height [cm])+705.8 Females: 0 to 3 y: (16.252×weight [kg])+(10.232×height [cm])−413.5 3 to 10 y: (16.969×weight[kg])+(1.618×height [cm])+371.2 10 to 18 y:(8.365×weight [kg])+(4.65×height [cm])+200 >18 y:(13.623×weight [kg])+(23.8×height [cm])+98.2)

FAO/WHO c

(hl0000326) WorldHealthOrganization. Energy andProteinRequirements.Report of a JointFAO/WHO/UNUExpertConsultation. Technical ReportSeries 724.Geneva: WorldHealthOrganization; 1985.

The “WHOequation” wasdeveloped for usein healthy children,however, it iscommonly used topredict restingenergyexpenditure (REE)of acutely illpatients in thehospital setting

Males: 0 to 3 y: (60.9×weight [kg])−54 3 to 10 y:(22.7×weight [kg])+495 10 to 18 y: (17.5×weight[kg])+651 Females: 0 to 3 y: (61×weight [kg])−51 3 to10 y: (22.5×weight [kg])+499 10 to 18 y: (12.2×weight[kg])+746

Estimating calorieneeds fordevelopmentaldisabilities Rokusek C,Heindicles E. Nutrition andFeeding of theDevelopmentallyDisabled. Brookings, SD:South DakotaUniversity AffiliatedProgram,InterdisciplinaryCenter forDisabilities; 1985.

Children withdevelopmentaldisabilities (DD)may have a slowerbasal energy needdue to decreasedmuscle tone,growth rate, andmotor activity Therecommendationto calculateenergy needs inchildren with DDper cm of height isbased on the factthat they tend tohave a shorterheight whencompared tochildren withnormal growth Children with DDs

Cerebral palsy (age 5 to 11 y d (hl0000329) ): Mild tomoderate activity: 13.9 kcal/cm height Severephysical restrictions: 11.1 kcal/cm height Severerestricted activity: 10 kcal/cm height Athetoid cerebralpalsy: Up to 6,000 kcal/day (adolescence) Downsyndrome (5 to 12 y d (hl0000329) ): Boys 16.1 kcal/cmheight Girls 14.3 kcal/cm height Prader­Willisyndrome (for all children and adolescents): 10 to 11kcal/cm height for maintenance 8.5 kcal/cm height forweight loss Myelomeningocele (spina bifida) (olderthan 8 y of age and minimally active): 9 to 11 kcal/cmheight for maintenance 7 kcal/cm height for weightloss Approximately 50% RDA for age after infancy

Peterson's Failureto Thrive PetersonKE, et al. Teammanagement of

This calculatesnutrients in excessof therequirements of

[RDA for weight age (kcal/kg)×ideal body weight forheight]÷actual weight

management offailure­to­thrive. JADA .1984;84(7):810­815.

requirements of

the RDA Concernswith using thisequation includerefeedingsyndrome Infantsand children whopresentunderweight andneed to achievecatch­up growth

FAO/WHO/UNU e

(hl0000332) (aka“Dietz equation”) Dietz WH, BandiniLG, Schoeller DA.Estimates ofmetabolic rate inobese and non­obese adolescents. J Pediatr .1991;118:146­149.

Overweight/obeseadolescents in anoutpatient setting

Boys 10 to 18 y BMR=16.6 weight (kg)+77 height(m)+572 Girls 10 to 18 y BMR=7.4 weight (kg)+482height (m)+217

White equation White MS,Shepherd RW,McEniery JA.Energy expenditurein 100 ventilated,critically ill children:improving theaccuracy ofpredictiveequations. CritCare Med .2000;28(7):2307–2312.

Developed for usein the pediatriccritical carepopulation byincludingtemperature as agauge of thebody’sinflammatoryresponse It is notcommonly used inclinical practice,and recent studieshave showndecreasedaccuracyespecially insmaller, youngerpatients Thisequation shouldnot be used in

EE (kJ/day)=(17×age [mo])+(48×weight [kg])+(292×body temperature [°C])−9,677

patients youngerthan 2 mo of age Pediatric criticalcare population

Stress factors for energy

Stress factors Leonberg B. ADAPocket Guide toPediatric NutritionAssessment .Chicago, IL:American DieteticAssociation; 2007.Table 8.10.

The use of stressfactors along withpredictive energyequations shouldbe considered foruse in hospitalizedchildren whoseenergyrequirements maybe altered due tometabolic stress Pediatrichospitalizedpopulation

Starvation 0.70 to 0.85 Surgery 1.05 to 1.5 Sepsis 1.2to 1.6 Closed head injury 1.3 Trauma 1.1 to 1.8 Growth failure 1.5 to 2 Burn 1.5 to 2.5

Protein

A.S.P.E.N. ClinicalGuidelines:Nutrition Support ofthe Critically IllChild Mehta NM,Compher C,ASPEN Board ofDirectors.A.S.P.E.N. ClinicalGuidelines:Nutrition Support ofthe Critically IllChild. JPEN JParenter EnteralNutr. 2009;33(3):260­276.

Metabolic stressincreasescatabolism andbreakdown of leanbody mass Tomeet theincreaseddemands ofmetabolic stressand spare the useof endogenousprotein stores, agreater amount ofprotein is neededin this populationuntil theunderlying stresshas beenovercome Recommendations

0 to 2 y: 2 to 3 g/kg/day 2 to 13 y: 1.5 to 2 g/kg/day 13to 18 y: 1.5 g/kg/day

are based onlimited data Pediatric criticalcare population

For the injuredchild Jaksic T.Effective andefficient nutritionalsupport for theinjured child. SurgClin North Am. 2002;82(2):379­391, vii.

Metabolic stressincreasescatabolism andbreakdown of leanbody mass Tomeet theincreaseddemands ofmetabolic stressand spare the useof endogenousprotein stores, agreater amount ofprotein is neededin this populationuntil theunderlying stresshas beenovercome Pediatriccritical/surgicalcare population

0 to 2 y: 2 to 3 g/kg/day 2 to 13 y: 1.5 to 2 g/kg/day Adolescents: 1.5 g/kg/day

Dietary ReferenceIntake (DRI) National Academyof Sciences,Institute ofMedicine, Foodand NutritionBoard. DietaryReference Intakesfor Energy,Carbohydrate,Fiber, Fat, FattyAcids, Cholesterol,Protein, and AminoAcids(Macronutrients)

Replaces the 1989RDA Proteinneeds weredetermined fromchildren withnormal growth,body composition,and activity, andwho are alsometabolicallynormal Childrenwith normalgrowth, bodycomposition, andactivity, and whoare alsometabolically

0 to 6 mo: 1.52 g/kg/day ( This is an Adequate Intakerecommendation, not enough research has beenconducted to establish an RDA for this age group. ) 6to 12 mo: 1.2 g/kg/day 12 to 36 mo: 1.05 g/kg/day 4 to13 y: 0.95 g/kg/day 14 to 18 y: 0.85 g/kg/day >18 y:0.8 g/kg/day

(2005) .

metabolically

normal

1989RecommendedDietaryAllowance (RDA) Committee inDietaryAllowances, Foodand NutritionBoard, NationalResearch Council. RecommendedDietaryAllowances. 10thed. Washington,DC: NationalAcademiesPress; 1989.

Based on themedian nutrientintakes of childrenfollowed inlongitudinal growthstudies It canoverestimateneeds in nonactivepopulations (eg,bedridden) anddoes not provide arange of energyneeds Although anoutdatedreference, stillwidely used Children withnormal growth,body composition,and activity, andwho are alsometabolicallynormal

0 to 6 mo: 2.2 g/kg/day 6 to 12 mo: 1.6 g/kg/day 1 to 3y: 1.2 g/kg/day 4 to 6 y: 1.1 g/kg/day 7 to 14 y: 1g/kg/day 15 to 18 y (males): 0.9 g/kg/day 15 to 18 y(females): 0.8 g/kg/day

Peterson's Failureto Thrive PetersonKE, et al. Teammanagement offailure­to­thrive. JADA .1984;84(7):810­815.

This calculatesnutrients in excessof therequirements ofthe RDA Concernswith using thisequation includerefeedingsyndrome It canbe calculatedusing a methodsimilar to the onefor calories above Infants andchildren whopresentunderweight andneed to achieve

[Protein required for weight age (g/kg/day)×idealweight for age (kg)]÷actual weight (kg)

need to achieve

catch up growth

a Adapted from Carney LN. Assessment of nutrition status by age and determining nutrient needs.In: Corkins MR, Balint J, Bobo E, Plogsted S, Yaworski JA, eds. The A.S.P.E.N. Pediatric NutritionSupport Core Curriculum. Silver Spring, MD: American Society for Parenteral and EnteralNutrition; 2010:418­419, with permission from the American Society for Parenteral and EnteralNutrition (A.S.P.E.N.). A.S.P.E.N. does not endorse the use of this material in any form other thanits entirety.

b DRI/IOM=Dietary Reference Intake/Institute of Medicine.

c FAO/WHO=Food and Agricultural Organization of the United Nations/World HealthOrganization.

d This reference applies to the specific ages listed. Please refer to another equation for agesoutside of the referenced ages, and apply an appropriate activity/stress factor.

e UNU=United Nations University.

The Dietary Reference Intake for protein is typically used to estimate protein needs for both thehealthy child and the hospitalized child. However, the child’s clinical status should be consideredwhen estimating protein requirements. Some situations may require protein intakes greater thanthe Dietary Reference Intake to achieve a positive nitrogen balance. Examples include majorsurgery, wound healing, infection, and catch­up growth. Conversely, some situations (eg, criticallyill patient with acute renal failure) may warrant moderate protein restriction. A comprehensivediscussion of this issue is beyond the scope of this article, but may be found elsewhere in theliterature.

Growth Parameters

Growth is the primary outcome measure of nutritional status in children. Growth shouldbe monitored at regular intervals throughout childhood and adolescence and should also bemeasured every time a child presents, in any health setting, for preventive, acute, or chronic care.In children younger than 36 months of age, measures of growth include length­for­age, weight­for­age, head circumference­for­age, and weight­for­length. In children ages 2 to 20 yearsstanding height­for­age, weight­for­age, and body mass index (BMI)­for­age are typicallycollected.

Anthropometric measures of growth are typically expressed and reported in comparison topopulation data. Traditionally, these measures are expressed as percentiles and express the rankor position of a child’s measurements on a standard reference curve. Percentiles indicate theportion of the reference population that lies above or below that of the child being measured. It isused to help parents understand where their child “fits” in a population of children of similar ages,heights, and/or weights. The charts are designed so that growth trends in the individual child canbe observed over time, and growth problems, when detected, are addressed in a timely manner.

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However, a percentile does not reveal the actual degree of deviation from population norms. Thepercentile will always be positive because the bell­shaped curve, statistically, has an infinite tail onboth sides.

More recently, growth charts that facilitate comparison of units of SD from norms for referenceage groups, z score (SD) comparisons, are recommended for tracking and assessing nutritionalstatus in children. A z score is a statistical measure that tells how a single data pointcompares to normal data and, if above or below “average,” how atypical the measurement is.Growth measurements that cross z score lines indicate possible risk. Children who are growingand developing normally will be on or between −1 and 1 z score of a given indicator. Interpretationof the significance of z score data is based on the point at which, in the child’s pattern of growth,the change began and the child’s health status relative to the point and progression of change.

The CDC recommend that the WHO comparative data charts be used as normative standards forUS children from birth to 2 years of age and that the CDC comparative data charts be used asnormative standards for US children ages 2 to 20 years. According to the CDC, growth chartsare not intended for use as a sole diagnostic instrument, but contribute to the formation of anoverall clinical impression of the child being assessed.

Weight Gain Velocity

Mehta and colleagues suggest that a better definition of malnutrition should include goals ofearly identification of children at risk for malnutrition and the development of thresholds forintervention. One criterion for the early identification of undernutrition is the assessment ofgrowth velocity and its comparison to a standard. The A.S.P.E.N. workgroup included growthwithin its five domains, as part of the construct of the definition of pediatric malnutrition.

Growth is defined as an increase in size and the development to maturity, and growth velocity asthe rate of change in weight or length/height over time. This rate of change can be interpreted asan early sign of healthy or unhealthy response to the nutritional environment. Upon initialpresentation, length for children under 24 months of age and height for children older than 24months of age reflects the child’s nutritional status over a prolonged period of time. A negative zscore can be used to determine pediatric malnutrition when only a single data point is available.Over time, declines in z scores for length/height can also be used as a characteristic to determineundernutrition.

Average daily/monthly rates of weight gain that allow a child to remain stable on a growth curveoccur when adequate nutrient intake takes place. These rates are determined by the trajectory ofthe growth curve and vary by age and period of development. During periods of growth, anaverage daily or monthly weight gain is required for the child to remain stable on the growthcurve. Very low weight velocity as occurs with lack of weight gain and weight loss in a child, hasbeen noted to be “independently and more closely related to mortality than other indicators ofmalnutrition, such as BMI for age.”

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There is a tremendous amount of plasticity in growth in the short term. This adaptive response isseen when an event such as illness or trauma occurs that results in cessation of growth. Withongoing adequate nutrient intake, the child recovers and “catch up growth” with greater thannormal rates of weight gain velocity results.

MUAC

MUAC should be measured when assessing the nutritional status of pediatric patients. MUACcan be used as an independent anthropometric assessment tool in determining malnutrition inchildren 6 to 59 months of age when compared with the standards developed by WHO. Although reference ranges with SDs are not available for older children and adolescents,Frisancho provides percentile guidelines for ages 1 to 79 years. MUAC has been correlated toBMI in children and adults and has shown to be more sensitive to changes in muscle andfat mass than BMI in adults.

MUAC measurements should be part of the full anthropometric assessment in all patients, and areparticularly important in those whose weight may be affected by lower­extremity edema, ascites,or steroids, as weight trends alone are unreliable related to fluid status. When serial z scores areunavailable, serial MUAC measurements can be used to monitor changes in body compositionusing the child as his or her own control. MUAC has been indicated as a more sensitive prognosticindicator for mortality than weight­for­height parameters in malnourished pediatric patients. It is advisable to have trained individuals consistently perform these measurements for best

long­term comparison of data.

Handgrip Strength

Handgrip strength is a simple, noninvasive measurement commonly used to measure baselinefunctional status and track progress throughout the course of therapy. Using a handhelddynamometer, subjects perform a series of standardized movements that measure the maximumisometric strength of the hand and forearm muscles. The dynamometer is a simple, noninvasive,and low­cost instrument to measure functional status.

In the hospitalized setting, handgrip strength has been shown to predict postoperativecomplications, length of hospital admission, readmission, likelihood of returning to previoushome setting, and mortality. Because muscle function reacts earlier to changes in nutritionalstatus than muscle mass, handgrip strength may be a more acute measurement of response tonutrition interventions than traditional biochemical or anthropometric measurements in childrenages 6 years and older. In hospitalized pediatric patients, handgrip strength has been used as asimple noninvasive test of functional capacity at admission for surgery. BMI z scores correlatedwith the admission handgrip strength measurement, regardless of sex, age, disease severity, oranthropometric characteristics.

Accurate handgrip measurements require procedure standardization. Equipment calibration,adequate staff training (patient positioning/dynamometer setting), and use of the appropriatereference range (device dependent) are important components in ensuring accurate results. Appropriate age­ and sex­specific reference ranges must be used. In pediatric populations,

hand­held dynamometry has been proven feasible and reliable across a wide age range (6 years

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59

58 5960

and older) and multiple diagnoses; however, normal reference ranges in large populations havenot been established. Mild, moderate, and severe deficit ranges as measured by handgrip strengthhave not been established, therefore, handgrip strength can help to identify the presence ofmalnutrition but not to quantify the degree of the deficit.

Proxy Measures as Substitutes for Traditional Anthropometric Measures

In selected diseases or conditions, physical anomalies or patient frailty may limit the clinician’sability to obtain the typical anthropometric measurements used to assess growth. A number ofalternative measurements have been used in such instances to estimate weight and length. Please refer to Table 1 (tbl1) for examples of such proxy measures and review relevant literature todetermine which measures offer the greatest accuracy in the clinical context in which the patientpresents.

Documentation of Tanner Stage

There is a well­recognized association between normal pubertal development and nutritionalstatus; however, determinants of the age of onset of puberty are multifactorial. Although Tannerstage cannot be used as a marker of nutritional status in prepubescent children, it might be usefulas an indirect indicator in preteens and adolescents who have entered puberty, when Tannerprogression or stagnation may be influenced by nutritional status.

The onset of puberty varies from individual to individual, with a range of about 5 years. Basicinherited genetic determinants interact with environmental influences to trigger the onset ofpuberty. Pubertal development is classically staged by a set of physical parameters described byMarshall and Tanner. Reports from developing countries indicate that girls with lowerweight and height are at lower Tanner stages than their peers of the same age. US data fromthe last National Health and Nutrition Examination Survey III (1988–1994) found a significantdiscordance for Tanner staging between the physical parameters for boys and girls if the weightand BMI were above or below the mean of children in their same age group.

The use of Tanner staging as a nutrition marker is limited by the significant degree of variability ingenetic determinants for the onset of puberty from one child to another. There is also the currentlyunknown correlation of how pubertal development could be altered to a greater or lesser extentdepending on the degree of malnutrition. This is certainly a fertile area for additional research.

Classifying Pediatric Malnutrition

Historically, pediatric malnutrition related to undernutrition has been classified as a percentage ofideal body weight. This type of distribution of percentages of ideal body weight was first describedby Gomez and colleagues, who demonstrated a correlation between the severity ofundernutrition and death. The Gomez Classification and the Waterlow Criteria use thisstandard and define mild, moderate, and severe malnutrition as 76% to 90%, 61% to 75%, <60%,and 80% to 89%, 70% to 79%, and <70%, respectively.

In the past, the definitions of undernutrition and failure to thrive included decreases in two centilechannels or faltering growth as weight gain below the fifth percentile. A deceleration ofweight in time has also been used to define malnutrition. The use of z score, decline in z score,

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and negative z score to identify and document pediatric malnutrition/undernutrition is nowrecommended.

Classification of undernutrition using MUAC measures was suggested in children between theages of 6 and 60 months. Children who are severely malnourished are defined as those withmeasurements <11.5 cm, moderately malnourished is those with measurements between 11.5 and12.4 cm, and those at risk of malnutrition are those with measurements between 12.5 and 13.4 cm.

An analysis by the WHO and UNICEF showed that children with a weight for height with z scoresless than −3 SD were at a ninefold greater risk of death then were children with a z score of −1 SD.Similar studies using MUAC as a diagnostic criteria showed that risk of dying increased with

measures of 11.5 cm.

Mild malnutrition related to undernutrition is usually the result of an acute event, either due toeconomic circumstances or acute illness and presents with unintentional weight loss or weightgain velocity less than expected.

Moderate malnutrition related to undernutrition occurs due to undernutrition of significantduration that results in weight for length/height values or BMI for age values that are below thenormal range.

Severe malnutrition related to undernutrition occurs as a result of prolonged undernutrition andis most frequently quantified by declines in rates of linear growth that result in stunting.

On initial presentation, a child may have only a single data point for use as a criterion for theidentification and diagnosis of malnutrition related to undernutrition. When this is the case, theuse of z scores for weight for height/length, BMI for age, length/height for age or MUAC criteria asstated in Table 2 (tbl2) is indicated.

Table 2

Primary indicators when only a single data point is available for use as a criterion for identification and

diagnosis of malnutrition related to undernutrition: Academy of Nutrition and Dietetics/American Society of

Parenteral and Enteral Nutrition 2014 Pediatric Malnutrition Consensus Statement [object Object],[object

Object],[object Object],[object Object],[object Object]

Primaryindicators

Mild malnutrition Moderate malnutrition Severemalnutrition

Weight for height z score

−1 to −1.9 z score −2 to −2.9 z score −3 or greater z score

BMI a (hl0000388)for age z score

−1 to −1.9 z score −2 to −2.9 z score −3 or greater z score

Length/height z score

No data No data −3 z score

71

21 72 73 74 75 76

Mid­upper armcircumference

Greater than or equalto −1 to −1.9 z score

Greater than or equalto −2 to −2.9 z score

Greater than orequal to −3 z score

a BMI=body mass index.

When a child presents with historical medical information and two or more data points areavailable for use as criteria for the identification and diagnosis of malnutrition related toundernutrition, the criteria in Table 3 (tbl3) might also be used to support malnutrition’s(undernutrition) identification and diagnosis. The 1982 Foman data are still being used as growthvelocity standards, but we recommend using the WHO data for patients <2 years of age.

Table 3

Primary indicators when two or more data points are available for use as criteria for identification and

diagnosis of malnutrition related to undernutrition: Academy of Nutrition and Dietetics/American Society of

Parenteral and Enteral Nutrition 2014 Pediatric Malnutrition Consensus Statement [object Object],[object

Object],[object Object],[object Object],[object Object]

Primaryindicators

Mild malnutrition Moderate malnutrition Severe malnutrition

Weight gainvelocity (<2 y ofage)

<75% a (hl0000445) ofthe norm b (hl0000450)for expected weight gain

<50% a (hl0000445) ofthe norm b (hl0000450)for expected weight gain

<25% a (hl0000445) ofthe norm b (hl0000450)for expected weight gain

Weight loss (2to 20 y of age)

5% usual body weight 7.5% usual body weight 10% usual body weight

Deceleration inweight forlength/height z score

Decline of 1 z score Decline of 2 z score Decline of 3 z score

Inadequatenutrient intake

51% to 75% estimatedenergy/protein need

26% to 50% estimatedenergy/protein need

≤25% estimatedenergy/protein need

a From Guo et al.

b World Health Organization data for patients younger than 2 y old.

Nutrition Surveillance and Continuity of Care

Once the diagnosis of pediatric undernutrition is made, it is crucial to determine how oftennutritional status should be monitored and what processes will be established to ensure continuityof care between settings. These questions require answers that ensure improved outcomes for thechild with this diagnosis.

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One of the mandates of the Affordable Care Act and “meaningful use” is to facilitate care transitionacross the health care system. The Centers for Medicare and Medicaid Services will requiremonitoring and re­evaluation of patients’ health conditions and that continuation of care isplanned, executed, and documented (see www.HealthIT.gov (http://www.healthit.gov) ). A specifictimeframe for these requirements has yet to be delineated. Providing nutrition surveillance willundoubtedly improve outcomes and reduce hospital readmission rates. The nutrition care processprovides guidelines for monitoring and evaluation of nutrition therapy provided. The ideal

frequency for nutrition surveillance, however, remains elusive.

It will be difficult to standardize follow­up surveillance intervals because of the great variation inseverity of growth failure, nutritional habits, and in coexisting morbidities, chronic disease(s),social situations, etc. Optimally, follow­up intervals for pediatric malnutrition(undernutrition), like any other medical condition, should be individualized.

Call to Action: Next Steps

This consensus statement represents a starting point in the effort to standardize a diagnosticapproach to the identification and documentation of pediatric undernutrition. It is important thatall clinicians caring for pediatric patients use the recommended diagnostic indicators to identifyand document nutritional status in children and adolescents. It is also imperative that cliniciansmake every effort to obtain and enter numerical data into searchable fields in the electronicmedical record, in order to make tracking within and among institutions feasible.

Members of the health care team should come together to determine strategies forimplementation compatible with their own institution’s policies and practices. Standardizedformats for the collection of data associated with each indicator’s use are needed in order tovalidate and determine which characteristics are the most or least reliable in the identification ofpediatric undernutrition and its treatment. Uniform data collection across facilities at local,regional, and national levels would facilitate feasibility testing on a broad scale. The indicatorsrecommended in this consensus statement should be reviewed and revised at regular intervals toreflect validation data that offers evidence of efficacy.

We also need to begin to develop systems that track the diseases or conditions, and environmentalor socioeconomic circumstances that contribute to, or that are routinely associated with, thedevelopment of pediatric undernutrition. The human and financial impact of the routine use ofthe recommended indicators in such areas as resource utilization, revenue generation, andpersonnel needed to adequately address the needs of undernourished children and adolescents inacute, ambulatory, home, and residential care settings should also be tracked.

The education and training needs of nutrition, medical, and allied health professionals should bedetermined, with appropriate outreach initiated to remediate identified deficits. Additionaltraining in the nutrition assessment protocol is recommended and in the development andutilization of electronic systems that facilitate data collection in this highly vulnerable and costlysegment of our population should be offered in multiple venues as specific identified needs arise.

Summary

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The recommended indicators to diagnose pediatric undernutrition delineated in this consensusstatement are a work in progress. Clinicians should expect to see an evolution of theserecommendations as data regarding their use are systematically collected, analyzed, anddisseminated to research and clinical communities. Periodic review and revision of ourrecommendations will ensure that the health of the public is optimized and that utilization ofhealth care resources proceeds with maximum efficiency.

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