Abstract
The appropriate assessment of nutrition and ongoing review of growth are important aspects of monitoring children. Overall, hospitalised children have higher rates of under-nutrition: this altered nutritional status may impact adversely upon morbidity during hospitalisation and length of hospital stay.
The overall hypothesis of this project was that the optimal use of Nutritional Risk Screening (NRS) tools in children will lead to earlier detection of children at risk of malnutrition, both in developed and developing countries.
Recently, three NRS tools (STRONGkids, PYMS and STAMP) have been developed in Europe for the evaluation of hospitalised children but have not been evaluated elsewhere. Therefore, these three tools were applied to 119 and 162 paediatric hospitalised patients (in Iran and NZ) respectively. The STRONGkids tool was shown to be the most reliable and feasible tool in both settings. This tool was able to recognise 83% to 100% of under-nourished patients in its at risk groups. In both studies, the nutritional state of the children (hospitalised and the comparison groups) was assessed. 9.9% of NZ hospitalised children were under-nourished, contrasting to just 3.7% of a healthy community-based group (p=0.04). An even higher rate of under-nutrition was seen in a group of children admitted to an Iranian hospital, whilst under-nutrition was again seen infrequently in the community comparison group (25.2% versus 3%; p<0.005).
The utility of the STRONGkids tool was then further evaluated, with assessment of its use by paediatric nursing staff. This tool had been designed and validated to be applied by a physician. The tool was evaluated by paired nursing and paediatrician assessments, showing substantial agreement (k=0.65). This agreement was further enhanced (k=0.86) following simplification of the tool and readjustment of the cut-off points for risk stratification. Thus, the STRONGkids tool was equally reliable and feasible when applied by a physician or paediatric nurses.
The final component of this work was to evaluate an NRS tool in children with Cystic Fibrosis (CF), along with delineation of their nutritional state. CF is associated with increased risk of developing malnutrition, and nutritional status adversely affects long-term outcomes. The use of tools to simply and easily identify children at greater risk of malnutrition could ensure earlier and more focused intervention, thereby contributing to superior disease outcomes. In this study, one previously developed NRS tool for CF patients (McDonald) was compared and contrasted with the criteria published by the Australasian Clinical Practice Guidelines for Nutrition in CF for sixty nine children with CF in Iran and NZ. These results were validated by comparison to each patient’s full evaluation by their clinical team. The McDonald tool and the Australasian guidelines both were able to recognise patients at risk of malnutrition. This data illustrated the benefits and utility of the McDonald tool, and especially indicates its potential role in developing countries lacking the resources of a complete assessment team.
In conclusion, NRS tools have the potential to significantly improve the early recognition of under-nutrition in hospitalised children and children with chronic disease.