Nutritional screening tools for hospitalized children: Methodological considerations

doi:10.1016/j.clnu.2013.08.002

Clinical Nutrition

Volume 33, Issue 1, February 2014, Pages 1-5

https://doi.org/10.1016/j.clnu.2013.08.002 Get rights and content

Summary

Children who are admitted to the hospital are at a risk of developing undernutrition, especially children with an underlying disease. High percentages of both acute and chronic undernutrition have been reported in various Western countries for many years. Several nutritional screening tools have been developed for hospitalized children in the last years. This review gives an overview of the nutritional screening tools that are currently available with a focus on their aims, clinical use and validity.

Introduction

Several studies in recent years have shown that the percentage of children admitted to the hospital with acute and/or chronic undernutrition remains considerable, despite advances in nutritional therapies and medical interventions.1, 2, 3, 4, 5, 6 In specific diagnostic categories the prevalence of undernutrition is even much higher.⁷ There is no accepted gold standard for the assessment of the nutritional status of a child. For the purpose of this review we use the criteria of the WHO to express acute and chronic undernutrition.⁸

Most studies have reported the prevalence of undernutrition upon admission to hospital but there are a considerable number of children who will develop undernutrition during their hospital stay. Remarkably, only a few studies have been published about this issue and they all show that in 20–50% of children the nutritional status deteriorates during admission.9, 10, 11, 12, 13

The importance of the early identification of nutritional risk and appropriate nutritional management thereafter is highlighted already for many years¹⁴ and numerous nutritional screening tools have been developed for adults and children. Over 70 screening tools for adults and children are reported in the literature.¹⁵ The question is, however, how does one choose an appropriate nutritional screening tool from such a large number available? One has to realize that all these screening tools have been designed with different goals, applications and processes. Furthermore, there is the debate about the usefulness of a screening tool. The usefulness of recommended screening tools is usually based on the aspects of predictive validity (the extent to which a screening tool predicts certain outcomes, such as mortality or body composition), concurrent validity (the extent to which screening tools agree with each other), reproducibility (reliability; agreement between users of a given tool) and practicality.

Currently, there is no consensus on the ideal screening tool to determine on admission those children who are at risk for developing undernutrition during hospital stay and will benefit from nutritional support. Such a screening tool looking at the risk is basically different from measuring the actual nutritional status with weight and height of the child.

The aim of this review is to give an overview of the currently available nutritional screening tools for children admitted to the hospital, and to discuss their aims, clinical use and validity.

Section snippets

How to design a screening tool?

It was stated by the ESPEN in 2003¹⁶ that screening tools are designed to detect protein and energy undernutrition and/or to predict whether undernutrition is likely to develop or worsen under the present and future conditions of the patient. Accordingly, screening tools should embody the following four main principles:

1.
How is the actual condition now? This item concerns the actual body composition of the patient. Height and weight can be measured to allow calculation of SD-scores or BMI.
2.
Is the

Screening tools for children admitted to the hospital and their aims

Currently there are 6 screening tools available for children admitted to the hospital;

1.
Nutrition Risk Score (NRS)¹⁷
2.
Pediatric Nutritional Risk Score (PNRS)¹³
3.
Screening Tool for the Assessment of Malnutrition in Paediatrics (STAMP)18, 19
4.
Subjective Global Nutritional Assessment (SGNA)²⁰
5.
Pediatric Yorkhill Malnutrition Score (PYMS)21, 22
6.
Screening Tool for Risk Of impaired Nutritional Status and Growth (STRONG_kids).¹⁰

Table 1 shows the characteristics of each tool and the relationship between risk

Evaluation of screening tools according to ESPEN principles

Table 3 shows an overview of the content of each of the six screening tools in relation to the four main items of a screening tool according to ESPEN.

The PYMS, the SGNA, the NRS and the STRONG_kids incorporate all these 4 items in their tool.10, 17, 20, 21, 22 Whereas the PYMS and NRS use anthropometric measurements to define the actual nutritional status, the SGNA and the STRONG_kids rely on a subjective clinical assessment. The SGNA and PNRS have included additional items (gastro-intestinal

Evaluation of the screening tools

The usefulness of the screening tools was evaluated for each screening tool using a number of different methods (Table 4).

Reproducibility (reliability) was tested in the NRS, SGNA, STAMP and PYMS tools and showed fair agreement in all the tested tools.17, 18, 19, 20, 21, 22 In the NRS all moderate and high risk patients were detected by the nurses. The inter-rater agreement for the PYMS completed by the two dieticians compared with the nursing staff concurred for 86% of patients when low and

Scoring system of screening tools

All six screening tools use a scoring system to divide the nutritional risk into 3 groups, low, moderate and high risk of malnutrition. Each item of the tools bears a certain amount of points (ranging between 0 and 2) and the total number of points (total score) reflects the degree of the nutritional risk of the patient. The allocation of points however, within each tool, and consequently the maximum total scores and cut-off points for classification of risk groups are different. Therefore,

Nutritional advice in relation to risk category

Most nutritional screening tools give some form of nutritional advice and suggestions for follow-up screening according to the risk category. For the high risk groups, PNRS, STAMP, PYMS and STRONG_kids10, 13, 18, 19, 21, 22 recommend assessment by a dietician or by a nutritional team and/or an individualized nutritional plan. These advices are comparable to the recommendations given in the adult screening tools for high nutritional risk groups, e.g. Malnutrition Universal Screening Tool (MUST)

Ease and speed of administration

In the original description of the tools, it was only mentioned for the PRNS tool that it took 48 h to complete the items of the tool. The other tools had considered in their criteria ease and speed of use. Concerning the speed, Ling et al. performed a cross-sectional study in which two trained investigators applied STAMP and STRONG_kids in 43 children. The STAMP tool took 10–15 min to apply whereas the STRONG_kids took 5 min. The reason for this is due to the addition of anthropometric

Comparison of use of screening tools

In four studies an attempt was made to compare one ore more tools in the same patient population. Ling et al. compared STAMP with STRONG_kids in a group of 43 children and concluded that STRONG_kids was superior to STAMP in terms of risk classification because STAMP over-diagnosed the number of children with nutritional risk.²⁵

Wiskin et al. compared the STAMP, PRNS, SGNA and STRONG_kids tools in 46 children with inflammatory bowel disease attending outpatient clinics and those requiring an

Discussion

Currently there are six screening tools available to screen the nutritional risk of children admitted to the hospital. Three tools, the SGNA,²⁰ the PYMS²¹ and the STRONG_kids¹⁰ were based on existing guidelines16, 28 and one tool, the NRS,¹⁷ was compared with the adult Nutritional Risk Index (NRI).²⁹ Two tools, PRNS and STAMP, were developed after multivariate analysis of a structured questionnaire that identified those factors who were significant predictors of nutrition risk.

As stated by Elia

Recommendations for clinical practice

•
Incorporate screening of nutritional risk as part of the admission procedure for each hospitalized child
•
When choosing a nutritional screening tool, consider the different purposes and applications of the tool in relation to what you want to achieve in your practice.
•
STRONG_kids seems to be the most practical, easy and reliable tool for assessment of nutritional risk
•
PYMS seems to be the most practical tool when incorporating both the determination of nutritional risk and actual nutritional status
•

Statement of authorship

KJ and JH both drafted the manuscript and read and approved the final manuscript.

Sources of funding

None.

Conflict of interest statement

None.

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ReviewNutritional screening tools for hospitalized children: Methodological considerations

Summary

Introduction

Section snippets

How to design a screening tool?

Screening tools for children admitted to the hospital and their aims

Evaluation of screening tools according to ESPEN principles

Evaluation of the screening tools

Scoring system of screening tools

Nutritional advice in relation to risk category

Ease and speed of administration

Comparison of use of screening tools

Discussion

Recommendations for clinical practice

Statement of authorship

Sources of funding

Conflict of interest statement

Arch Pediatr

Clin Nutr

Nutrition

Clin Nutr

Am J Clin Nutr

Clin Nutr

Clin Nutr

Am J Clin Nutr

Clin Nutr

Clin Nutr

e-SPEN, Eur e-Journal Clin Nutr Metab

J Nutr

Nutritional status of patients hospitalized in pediatric clinic

Turk J Gastroenterol

Malnutrition in hospitalized pediatric patients. Current prevalence

Arch Pediatr Adolesc Med

National malnutrition screening days in hospitalized children in the Netherlands

Arch Dis Child

Review
Nutritional screening tools for hospitalized children: Methodological considerations