Lisa Grentz, MS, RDN, CD, LDN, FAND
Pediatric malnutrition (undernutrition) has been defined by the Academy of Nutrition and Dietetics and American Society for Parenteral and Enteral Nutrition as “an imbalance between nutrient requirements and intake that results in cumulative deficits of energy, protein, or micronutrients that may negatively affect growth, development, and other relevant outcomes.” Together, these organizations published a standardized set of diagnostic indicators used to identify malnutrition in the pediatric population. If your child has been identified as mildly, moderately, or severely malnourished, you are probably wondering what indicators were used to support the documentation of this diagnosis.
A child is considered to be nutritionally at risk when their energy and nutrient intake is inadequate to maintain body composition and growth. Children deemed at risk are screened for malnutrition as part of routine pediatric care, and a growth assessment is just one of the several domains used to evaluate for malnutrition. According to consensus guidelines 1, when a single data point is available, the recommended indicators are z-score weight for length, BMI for age, length/height for age, or mid-upper arm circumference. For example, if your child’s weight for length or BMI for age z-score is between -1.0 to -1.9 this is classified as mildly malnourished, a z-score between -2.0 to -2.9 is moderately malnourished, and a z-score of -3.0 or greater is severely malnourished. The diagnosis and degree of malnutrition is further strengthened and supported when data points are available that show a decline in weight gain velocity (for children <2 years of age) or percent of weight loss (for children 2-20 years of age), deceleration in weight for length or BMI z-score, and inadequate energy/protein intake.
However, the diagnosis of pediatric malnutrition is more complex than just looking at growth parameters. A nutrition-focused physical exam (NFPE) is another component of nutrition assessment that involves a head-to-toe examination in order to identify muscle wasting, subcutaneous fat loss, and edema. A general inspection of hair, skin, and nails as part of the NFPE can be useful in identifying micronutrient deficiencies. Other domains evaluated in the diagnostic process for malnutrition are etiology, chronicity, and impact on functional status. Etiology looks at the reason for inadequate nutrient intake that results in nutrient imbalance preventing normal growth. Etiologies can be from secondary factors (i.e., socioeconomic, behavioral, or environmental) or non-illness related where the mechanism is decreased energy intake (i.e., unintentionally induced poor appetite/weight loss from feeding interruptions or intolerance resulting from medical treatments) or illness-related where the mechanism is increased nutrient requirements (i.e., malabsorption or excessive losses from vomiting and diarrhea). The chronicity of malnutrition is categorized as acute (<3 months) or chronic (lasting > 3 months).
Ultimately, a functional assessment looks at physical, immune, and cognitive function. Clinicians can ascertain information about functional status by observing physical activity or play, measuring handgrip strength, interviewing the family for information about frequency of illness and school attendance, learning difficulties, or delayed milestones. Together, the Information gathered from the growth assessment, physical examination, medical status, chronicity, and functional outcomes are used to make a nutrition diagnosis statement. An example of this type of statement would be – “Moderate protein-calorie malnutrition (chronic) related to increased nutrient losses associated with malabsorption secondary to SBS as evidenced by weight for length z-score -2.24, rate of weight gain at less than 50% of the norm for expected weight gain, reduced muscle mass (quadriceps and calf), and moderate loss of subcutaneous fat (orbital area, ribs, and spine)”.
[1] Becker, P., Carney, L.N., Corkins, M.R., Monczka, J., Smith, E., Smith, S.E., Spear, B.A., White, J.V., and (2015), Consensus Statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition. Nutrition in Clinical Practice, 30: 147-161.
https://aspenjournals.onlinelibrary.wiley.com/doi/10.1177/0884533614557642