- Email: [email protected]
The role of a hospital Nutrition Support Team
SYMPOSIUM: NUTRITION
The role of a hospital Nutrition Support Team
stunted growth in 2005. Strikingly, over one-third of all child deaths are linked to malnutrition. Malnutrition can be caused by inadequate/suboptimal nutrition or a disease process. Clinical malnutrition adversely affects outcome and has serious implications for recovery from disease, trauma and surgery. Morbidity and mortality due to disease, both acute and chronic, in children with background malnutrition is higher, an effect that is seen graphically in the developing world. Suboptimal nutrition leads to increased rates of infection, impaired growth, with delayed development and brain function. The Barker hypothesis recognizes the lifelong importance of nutritional programming in early life. Children born with intrauterine growth retardation and low weight at 1 year age have long-lasting consequences due to adverse nutritional programming of different organs and systems, leading to early diabetes, hypertension, and heart attacks in adult life. Boys who are small at birth but catch up by 1 year age are at lesser risk of long-term consequences compared to those who do not catch up. Interestingly, weight at 1 year age in girls had less or no such influence on long-term consequences in some studies. Poor nutrition is not only a consequence of many diseases, but also is a common feature of chronic illness, major surgery and poor oral intake or absorption. The skills required for assessment, prescription, administration and monitoring of treatment increasingly fall outside the expertise of single practitioner. Thus there is a need for multidisciplinary Nutrition Support Teams in hospitals, especially paediatric patients. Such teams require experts with complementary skills.
Murali Bhagavatula David Tuthill
Abstract Nutrition and health are so interrelated that each has a bearing on the other. Malnutrition and undernutrition make children more vulnerable to infections and chronic illness. Similarly chronic illness can affect nutritional wellbeing adversely. The prevalence of malnutrition amongst children in hospital in the developed world is between 15 and 30%. Early Nutrition Support Team involvement and intervention can prevent and/or treat malnutrition by choosing appropriate nutritional interventions and help in early identification and prevention of central line infections. In addition they facilitate the appropriate initiation of parenteral nutrition and avoid unnecessary episodes of parenteral nutrition. Staff education is also a key role. This review explores malnutrition, the role of a paediatric Nutrition Support Team in hospital along with its clinical and financial benefits.
Keywords malnutrition; malnutrition screening tool; nutrition; Nutrition Support Team; STAMP; undernutrition
Specialists in paediatric Nutrition Support Team and their roles
Poor nutrition can be defined simply as the imbalance between the provision and requirement of energy, protein and micronutrients including vitamins, minerals and trace elements, which cause measurable adverse effects on physiological functions and clinical outcome. It is a spectrum with protein energy malnutrition at one end and obesity related issues at the other. Over the past two decades the prevalence of malnutrition amongst children in hospital, has stayed the same across the developed world, between 15 and 30%, depending on the criteria used to determine malnutrition and the study patients’ characteristics. Currently around 16.8% of boys and 15.2% of girls between 2 and 15 years age are classified as obese in UK from 2008 data. Nutritional problems are still of major importance in today’s developed society. The frequency of nutritional deficits in the developing world has improved but still remains a huge challenge. Latest WHO data state that the percentage of underweight children under 5 years has dropped from 25% in 1990 to 18% in 2005 and 16% in 2010. However, globally 104 million children are still undernourished, of which 20 million suffer from severe acute malnutrition. Stunting in children less than 5 years age has decreased globally from 40% to 27% during the same period. World Health Statistics estimates that 186 million children under 5 years old are still left affected by
Paediatrician Knowledgeable in nutrition related issues and their effect on disease processes In units with high intensity surgical procedures a surgeon should be involved Nurse specialists Training and education of the hospital staff in care of gastrostomies & central venous lines. Recognizing side effects and complications of stomas/ central lines Training families for home nutrition Dietitians Evaluation of nutritional requirements for both enteral and parenteral nutrition Knowledge of nutritional supplements Training families for home enteral nutrition Pharmacist Preparing parenteral nutrition Advice on drug interactions/safety and interaction of parenteral nutrition Advice on storage and compatibility with other medical products Paediatric surgeon/radiologist Insertion of central venous lines, gastrostomies where needed Post surgical care and management skills Speech and language therapist Advice on desensitization, and the safety of oral feeding and swallowing.
Murali Bhagavatula MRCPCH is a Speciality Registrar in the University Hospital of Wales, Cardiff, UK. Competing interests: none. David Tuthill MB BCh FRCPCH is Consultant Paediatrician in the University Hospital of Wales, Cardiff, UK. Competing interests: none.
PAEDIATRICS AND CHILD HEALTH 21:9
389
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
Costs of undernutrition
Rationale for screening tool
In addition to the medical consequences of undernutrition, there is huge financial burden at the national level. In a recent estimate, the cost of adult undernutrition was estimated at £7.3 billion annually in the UK; but the potential cost of undernutrition in children has yet to be determined.
The earliest sign of malnutrition in children is absence of weight gain, followed by weightloss; signifying acute effects of malnutrition. Later in the course, it leads to height stunting, signifying chronic malnutrition. Malnutrition either in the background or due to illness will have an adverse effect on recovery and duration of stay in hospital. Children with chronic illnesses such as intestinal failure, inflammatory bowel disease, and cystic fibrosis have a background burden that will be exacerbated by intercurrent illness or acute flare-ups that prolong their recovery.
Screening tools for malnutrition Current practice in assessing nutritional status relies largely on clinical judgement and anthropometric data. Unfortunately clinical assessment alone is inadequate in accurately assessing nutritional status in children. Only 36% of the clinical assessments done by an experienced medical, nursing and dietetic panel were consistent with anthropometric data, with assessors uniformly poor in identifying severe malnutrition and classifying infants to appropriate group. Simple weight and height recordings may not be sufficient as growth rates and proportions vary at different ages. A variety of different paediatric screening tools have been developed. These include, Paediatric Yorkhill Malnutrition Score [PYMS], Paediatric Subjective Global Nutritional Assessment [SGNA], Screening Tool for Assessment of Malnutrition in Paediatrics [STAMP]. There exists still a lack of a universally easy to use, reliable screening tool for children. Children who are at risk of becoming malnourished or who are malnourished at admission are often suboptimally managed due to inadequate recognition and a lack of nutritional awareness/assessment combined with a poor basic knowledge about artificial nutritional support among medical and nursing teams.
Which screening tool? There is no single screening tool that is universally accepted that can be used to identify hospital malnutrition at or soon after admission. In adults, amongst the many tools that are available, “MUST e Malnutrition Universal Screening Tool”, has been approved by European Society of Parenteral and Enteral Nutrition (ESPEN) and is recommended by the British Association of Parenteral and Enteral Nutrition (BAPEN). Manchester children’s Hospitals have developed and validated a screening tool STAMP e Screening Tool for Assessment of Malnutrition in Paediatrics for children between 2 and 16 years, that is nurse administered and fulfils the criteria of a good screening tool; i.e., quick, easy to use and interpret, reliable and reproducible. To use this tool, frontline teams need some training so that all staff using the tool do so uniformly, making it reproducible and reliable. As nursing staff are the first to come in contact to children and families, it is practical and reasonable to empower them to screen for nutritional imbalances and follow the pathway developed locally or adopted regionally to initiate the cascade. STAMP has five steps; with steps 1e3 including elements that cover the background clinical condition, dietary intake by children and finally anthropometric data. All of these are scored and combined to give a nutritional risk score at Step 4. Step 5 guides through a care plan and the appropriate pathways for support. There are some limitations of STAMP: some of the terms used in screening tool are vague, highlighting need for appropriate training and good communication with regular updates and clinical governance activities (Figure 1).
Anthropometry In the 1950s Gomez described nutritional status among hospitalized children with inadequate food availability in Mexico and classified malnutrition into three groups [based on percentage weight-for-age], those in the most malnourished group [weightfor-age less than 60%] were most likely to die of infections. Two decades later, Waterlow described a new classification based on height/length criteria that has been adopted by WHO as a universal definition of malnutrition allowing meaningful comparisons. Waterlow used percentage expected weight-forheight and height-for-age that are indicative of acute and chronic malnutrition respectively. Based on definitions by Waterlow, acute malnutrition is classified as mild if weight-for-height is between 80 and 89% of expected value [expected value equates to 50th centile], moderate if between 70 and 79% and severe if less than 70%. Likewise, chronic malnutrition is classified as mild if height-forage is between 87.5 and 95%, moderate if between 80 and 87.4%, and severe malnutrition if less than 80%. Following the recently revised child growth standards, the WHO has reviewed the criteria to diagnose severe acute malnutrition in 2006, for children between 6 months and 60 months, as weight-for-height less than 3 SD reference, presence of clinical oedema and mid arm circumference [MAC] less than 115 mm [previously 110 mm]. These new standards have been endorsed by international bodies and adopted by more than 90 countries worldwide.
PAEDIATRICS AND CHILD HEALTH 21:9
Gaps with existing care The National Confidential Enquiry into Patient Outcome and Death [NCEPOD]a reviewed patients who received parenteral nutrition (PN) anytime during a 3-month period in 2008 in the UK, by sending a questionnaire to the lead clinician. A copy of
a
Glossary of abbreviations: BAPEN, British Association of Parenteral and Enteral Nutrition; ESPEN, European Society of Parenteral and Enteral Nutrition; MUST, Malnutrition Universal Screening Tool; ESPGHAN, European Society of Paediatric Gastroenterology, Hepatology and Nutrition Review; NST, Nutritional Support Team; NCEPOD, National Confidential Enquiry into Patient Outcome and Death; PN, Parenteral Nutrition; STAMP, Screening Tool for Assessment of Malnutrition; MAC, Mid Arm Circumference; PYMS, Paediatric Yorkhill Malnutrition Score; SGNA, Subjective Global Nutritional Assessment.
390
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
Figure 1 A step-by-step guide to using STAMP.
case notes was subsequently reviewed by a multidisciplinary team including clinicians, dieticians, pharmacists and nurses. Its focus was on parenteral nutrition but it also looked into nutritional care provided in adult, neonatal and paediatric patients including the role of Nutrition Support Teams. It demonstrated some concerning gaps. Good practice in PN care was seen in 24% of neonates, delay in recognizing need for PN in 28%, delay in starting in 17%, and monitoring of PN was inadequate in 19%. Only 11% of neonatal units reported having a multidisciplinary Nutrition Support Team. The need for
PAEDIATRICS AND CHILD HEALTH 21:9
Nutrition Support Team was more visible on surgical neonatal units with limited expertise regarding nutritional care among clinicians. Among children receiving PN, half received it in intensive care and HDU. About 34% received good care, in 42% of cases nutrition teams were involved in the decision to commence PN but subsequent biochemical monitoring was often not adequate. Overall the NECPOD report highlighted gaps in skills and illustrated the need for training frontline staff including junior doctors, general paediatricians and nurses caring for children in nutritional issues.
391
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
All staff have the appropriate skills and competencies needed to ensure that patient’s nutritional needs are met. All staff receive regular training on nutritional care and management Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 h a day, every day The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with home country governance frameworks Food service and nutritional care is delivered to the patient safely The hospital supports multidisciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.
Recommendations from NCEPOD review Careful and early consideration should be given to the need for PN in neonates and once the decision to commence PN is made it should be started without undue delay. The first PN given must be appropriate to the neonate’s requirements Close monitoring of the patient must be achieved so that metabolic complications can be avoided Neonatal units should have an agreed policy for nutritional requirements and use a proforma that includes this information which is tailored for each infant and placed in the case notes Hospitals in which neonates are cared for should develop a team approach to ensure safe and effective nutritional support, recognizing that this should be a multidisciplinary exercise with sharing of expertise. Depending on the type of institution and availability of personnel, the composition of these teams may vary but could include neonatologists, paediatricians, paediatric surgeons, pharmacists, dieticians and experts in nutrition. This team could also provide support to other clinical areas caring for children and have a role in education and training for those involved in PN care There is an urgent need for neonatal units across the UK to have a consensus on best PN practice based on current scientific evidence Neonatal units should undertaken regular audit of PN practice which should include the complications of PN.
European Society of Paediatric Gastroenterology, Hepatology and Nutrition Review ESPGHAN committee on nutrition, reviewed available information, between 1980 and 2004, on Nutrition Support Teams in paediatric hospital settings, highlighted major deficits in nutritional care in European hospitals and suggested recommendations to improve the situation. These recommendations include establishing Nutrition Support Teams, to optimize nutrition by both enteral and parenteral routes and training staff regarding nutrition screening to identify at risk patients early into admission (Tables 1 and 2).
Clinical benefits of Nutrition Support Teams Children with chronic illness and those hospitalized for prolonged periods are especially at high risk for nutritional compromise, which will adversely affect their long-term course and recovery from illness. Early Nutrition Support Team involvement and intervention can prevent and/or treat malnutrition by choosing appropriate nutritional intervention and help in early identification and prevention of line infections. In addition they facilitate: initiation of parenteral nutrition at the appropriate time and avoid unnecessary episodes of parenteral nutrition.
Council of Europe review The Council of Europe reviewed current practices in Europe regarding food provision and nutritional care and support of hospitalized patients. It highlighted deficiencies in: routine nutritional risk screening and assessment; use of nutritional support for undernourished patients and training and education among professionals in its recommendations. It demonstrated the need for multidisciplinary Nutrition Support Teams in hospitals that have expertise in clinical nutrition and related issues. It made over 100 recommendations that cover five broad areas as follows: [1] Nutritional assessment and treatment in hospitals [2] Nutritional care providers [3] Food services practices [4] Hospital food [5] Health economics. Ten key characteristics of good nutritional care in hospitals were identified from these recommendations: All patients screened on admission to identify the patients who are malnourished or at risk of becoming malnourished. All patients re-screened weekly All patients have a care plan which identifies their nutritional care needs and how they will be met The hospital includes specific guidance on food services and nutritional care in its clinical governance arrangements Patients are involved in planning and monitoring arrangements for food service provision The ward implements protected mealtimes to provide an environment conducive to patients enjoying and being able to eat their food
PAEDIATRICS AND CHILD HEALTH 21:9
Recommended organizational structure of Nutrition Support Teams A Nutrition Steering Committee is central to any healthcare organization and should directly explore governance issues, quality control, costs, risks, auditing and development of guidelines based on best evidence available. Such a committee should supervise and
Useful criteria for initiating nutritional support in paediatric practicea Oral intake Infants Children [>1 year] age Disabled children Insufficient oral intake
Within 3 days of lack of oral intake Within 5 days of lack of oral intake Prolonged feeding time for >6 h/day Inability to take or tolerate 60e80% of requirements for >10 days
Table 1
392
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
set up hospital Nutrition Support Teams whereever they are not available, so that a proper lead group can be developed within a healthcare organization.
Useful criteria for initiating nutritional support in paediatric practicea Wasting and stunting criteria
Summary
<2 years >2 years Weight-for-age criteria Others
The clear clinical and financial benefits demonstrate the need for Nutritional Support Teams that focus on the nutritional problems and care required for children in hospital and coordinate with their community teams. They can assist in providing appropriate training and education for other staff to deliver the optimal nutritional care all children deserve. A
Poor weight gain for >1 month Poor weight gain for >3 months Drop by over 2 centile lines Triceps skin fold thickness <5th percentile for age Fall in height velocity >0.3 SD/year Decrease in height velocity by >2 cm/year compared to preceding year
FURTHER READING 1 Agostino C, Axelsson I, Colomb V, et al. The need for Nutrition Support Teams in paediatric unit: a commentary by the ESPGHAN committee on nutrition. JPGN 2005; 41: 8e11. 2 Sullivan P. Malnutrition in hospital children. Arch Dis Child 2010; doi:10.1136/adc.2009.169664. online. 3 Statistics on obesity, physical activity and diet; England; 2010. 4 Millennium Development Goals. Progress towards the health-related Millennium Development Goals. WHO Fact Sheet 2010; No 290. 5 World Health Statistics. WHO 2010. 1e177. 6 Children: reducing mortality. WHO Fact Sheet 2009; No 178. 7 Barker D. Maternal and fetal origins of coronary heart disease. J R Coll Physicians Lond 1994; 28: 544e51. 8 Mcintosh N, Helms P, Smyth R. Textbook of Paediatrics, Forfar & Arneil, nutrition e principles of nutrition support. 6th Edn 2003; Chapter 14:570. 9 McCarthy H, Dixon M. Cost of hospital nutrition. Complete Nutrition 2008; 8: 1e3. 10 Cross J, Holden C, MacDonald A, et al. Clinical examination compared with anthropometry in evaluating nutritional status. Arch Dis Child 1995; 72: 60e1. 11 Joint statement by WHO & UNICEF, WHO child growth standards and identification of severe acute malnutrition in infants and children 2009. 1e11. 12 Mason D, Puntis J, McCormick, et al. Parenteral nutrition for neonates and children: a mixed bag. Arch Dis Child 2010; doi: 10.1136/adc.2010.188557. online. 13 Ncepod A. Mixed bag e an enquiry into care of hospital patients receiving parenteral nutrition 2010. 1e18. 14 Sangha E, Suchner U, Dormann A, Senkal M. An European survey of structure and organization of Nutrition Support Teams in Germany, Austria and Switzerland [Abstract]. Clin Nutr 2005; 24: 1005e13. 15 Nightingale J. Nutrition Support Teams: how they work, are set up and maintained. Frontline Gastroenterol 2010; 1: 171e7. 16 Braegger C, Decsi T, Dias J, et al. Practical approach to paediatric enteral nutrition: a comment by ESPGHAN committee on nutrition. JPGN 2010; 51: 110e22. 17 Puntis J. Malnutrition and growth. JPGN 2010; 51: S125e6.
Table 2
involve catering services, dietetic departments and the Nutritional Support Team. Members of the Nutritional Support Team are responsible for nutritional needs of their patients and also can take up an advisory role in supporting other medical teams.
Cost benefits of Nutritional Support Team The cost benefits are measurable, for both enteral and parenteral nutrition. There is a reduction of inadequate use of parenteral nutrition and increased use of enteral nutrition, minimization of catheter related sepsis and central venous thrombosis, and a faster rate of PEG insertions for enteral nutrition. In a prospective investigation of function, structure and organization of adult Nutritional Support Teams in 2004 using standardized questionnaires at 3071 hospitals in Germany, Switzerland and Austria; a reduction of complications by 88% and cost saving of 98% since establishment of NST was demonstrated. The Nutritional Support Team, through staff education programmes, can improve timing of nutritional intervention. Moreover, early involvement and support by NST can lead to early improvement and discharge thus decreasing hospital stay. All these have a positive impact on patient outcome with cost savings. Where are we currently? NICE guidelines recommend that nutritional support is provided in every hospital, but only about 60% of hospitals have an NST. Further, these NICE guidelines recommend that all acute hospital trusts employ at least one Nutrition nurse specialist and constitute a Nutrition Steering Committee.
The way forward As clinicians, it is our responsibility to develop the healthcare staff skills involved in monitoring, evaluating and implementing recommended standards for early recognition by screening, auditing and developing guidelines. These need to demonstrate long-term healthcare and cost benefits. These data can be used to
PAEDIATRICS AND CHILD HEALTH 21:9
393
Ó 2011 Published by Elsevier Ltd.
The role of a hospital Nutrition Support Team
stunted growth in 2005. Strikingly, over one-third of all child deaths are linked to malnutrition. Malnutrition can be caused by inadequate/suboptimal nutrition or a disease process. Clinical malnutrition adversely affects outcome and has serious implications for recovery from disease, trauma and surgery. Morbidity and mortality due to disease, both acute and chronic, in children with background malnutrition is higher, an effect that is seen graphically in the developing world. Suboptimal nutrition leads to increased rates of infection, impaired growth, with delayed development and brain function. The Barker hypothesis recognizes the lifelong importance of nutritional programming in early life. Children born with intrauterine growth retardation and low weight at 1 year age have long-lasting consequences due to adverse nutritional programming of different organs and systems, leading to early diabetes, hypertension, and heart attacks in adult life. Boys who are small at birth but catch up by 1 year age are at lesser risk of long-term consequences compared to those who do not catch up. Interestingly, weight at 1 year age in girls had less or no such influence on long-term consequences in some studies. Poor nutrition is not only a consequence of many diseases, but also is a common feature of chronic illness, major surgery and poor oral intake or absorption. The skills required for assessment, prescription, administration and monitoring of treatment increasingly fall outside the expertise of single practitioner. Thus there is a need for multidisciplinary Nutrition Support Teams in hospitals, especially paediatric patients. Such teams require experts with complementary skills.
Murali Bhagavatula David Tuthill
Abstract Nutrition and health are so interrelated that each has a bearing on the other. Malnutrition and undernutrition make children more vulnerable to infections and chronic illness. Similarly chronic illness can affect nutritional wellbeing adversely. The prevalence of malnutrition amongst children in hospital in the developed world is between 15 and 30%. Early Nutrition Support Team involvement and intervention can prevent and/or treat malnutrition by choosing appropriate nutritional interventions and help in early identification and prevention of central line infections. In addition they facilitate the appropriate initiation of parenteral nutrition and avoid unnecessary episodes of parenteral nutrition. Staff education is also a key role. This review explores malnutrition, the role of a paediatric Nutrition Support Team in hospital along with its clinical and financial benefits.
Keywords malnutrition; malnutrition screening tool; nutrition; Nutrition Support Team; STAMP; undernutrition
Specialists in paediatric Nutrition Support Team and their roles
Poor nutrition can be defined simply as the imbalance between the provision and requirement of energy, protein and micronutrients including vitamins, minerals and trace elements, which cause measurable adverse effects on physiological functions and clinical outcome. It is a spectrum with protein energy malnutrition at one end and obesity related issues at the other. Over the past two decades the prevalence of malnutrition amongst children in hospital, has stayed the same across the developed world, between 15 and 30%, depending on the criteria used to determine malnutrition and the study patients’ characteristics. Currently around 16.8% of boys and 15.2% of girls between 2 and 15 years age are classified as obese in UK from 2008 data. Nutritional problems are still of major importance in today’s developed society. The frequency of nutritional deficits in the developing world has improved but still remains a huge challenge. Latest WHO data state that the percentage of underweight children under 5 years has dropped from 25% in 1990 to 18% in 2005 and 16% in 2010. However, globally 104 million children are still undernourished, of which 20 million suffer from severe acute malnutrition. Stunting in children less than 5 years age has decreased globally from 40% to 27% during the same period. World Health Statistics estimates that 186 million children under 5 years old are still left affected by
Paediatrician Knowledgeable in nutrition related issues and their effect on disease processes In units with high intensity surgical procedures a surgeon should be involved Nurse specialists Training and education of the hospital staff in care of gastrostomies & central venous lines. Recognizing side effects and complications of stomas/ central lines Training families for home nutrition Dietitians Evaluation of nutritional requirements for both enteral and parenteral nutrition Knowledge of nutritional supplements Training families for home enteral nutrition Pharmacist Preparing parenteral nutrition Advice on drug interactions/safety and interaction of parenteral nutrition Advice on storage and compatibility with other medical products Paediatric surgeon/radiologist Insertion of central venous lines, gastrostomies where needed Post surgical care and management skills Speech and language therapist Advice on desensitization, and the safety of oral feeding and swallowing.
Murali Bhagavatula MRCPCH is a Speciality Registrar in the University Hospital of Wales, Cardiff, UK. Competing interests: none. David Tuthill MB BCh FRCPCH is Consultant Paediatrician in the University Hospital of Wales, Cardiff, UK. Competing interests: none.
PAEDIATRICS AND CHILD HEALTH 21:9
389
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
Costs of undernutrition
Rationale for screening tool
In addition to the medical consequences of undernutrition, there is huge financial burden at the national level. In a recent estimate, the cost of adult undernutrition was estimated at £7.3 billion annually in the UK; but the potential cost of undernutrition in children has yet to be determined.
The earliest sign of malnutrition in children is absence of weight gain, followed by weightloss; signifying acute effects of malnutrition. Later in the course, it leads to height stunting, signifying chronic malnutrition. Malnutrition either in the background or due to illness will have an adverse effect on recovery and duration of stay in hospital. Children with chronic illnesses such as intestinal failure, inflammatory bowel disease, and cystic fibrosis have a background burden that will be exacerbated by intercurrent illness or acute flare-ups that prolong their recovery.
Screening tools for malnutrition Current practice in assessing nutritional status relies largely on clinical judgement and anthropometric data. Unfortunately clinical assessment alone is inadequate in accurately assessing nutritional status in children. Only 36% of the clinical assessments done by an experienced medical, nursing and dietetic panel were consistent with anthropometric data, with assessors uniformly poor in identifying severe malnutrition and classifying infants to appropriate group. Simple weight and height recordings may not be sufficient as growth rates and proportions vary at different ages. A variety of different paediatric screening tools have been developed. These include, Paediatric Yorkhill Malnutrition Score [PYMS], Paediatric Subjective Global Nutritional Assessment [SGNA], Screening Tool for Assessment of Malnutrition in Paediatrics [STAMP]. There exists still a lack of a universally easy to use, reliable screening tool for children. Children who are at risk of becoming malnourished or who are malnourished at admission are often suboptimally managed due to inadequate recognition and a lack of nutritional awareness/assessment combined with a poor basic knowledge about artificial nutritional support among medical and nursing teams.
Which screening tool? There is no single screening tool that is universally accepted that can be used to identify hospital malnutrition at or soon after admission. In adults, amongst the many tools that are available, “MUST e Malnutrition Universal Screening Tool”, has been approved by European Society of Parenteral and Enteral Nutrition (ESPEN) and is recommended by the British Association of Parenteral and Enteral Nutrition (BAPEN). Manchester children’s Hospitals have developed and validated a screening tool STAMP e Screening Tool for Assessment of Malnutrition in Paediatrics for children between 2 and 16 years, that is nurse administered and fulfils the criteria of a good screening tool; i.e., quick, easy to use and interpret, reliable and reproducible. To use this tool, frontline teams need some training so that all staff using the tool do so uniformly, making it reproducible and reliable. As nursing staff are the first to come in contact to children and families, it is practical and reasonable to empower them to screen for nutritional imbalances and follow the pathway developed locally or adopted regionally to initiate the cascade. STAMP has five steps; with steps 1e3 including elements that cover the background clinical condition, dietary intake by children and finally anthropometric data. All of these are scored and combined to give a nutritional risk score at Step 4. Step 5 guides through a care plan and the appropriate pathways for support. There are some limitations of STAMP: some of the terms used in screening tool are vague, highlighting need for appropriate training and good communication with regular updates and clinical governance activities (Figure 1).
Anthropometry In the 1950s Gomez described nutritional status among hospitalized children with inadequate food availability in Mexico and classified malnutrition into three groups [based on percentage weight-for-age], those in the most malnourished group [weightfor-age less than 60%] were most likely to die of infections. Two decades later, Waterlow described a new classification based on height/length criteria that has been adopted by WHO as a universal definition of malnutrition allowing meaningful comparisons. Waterlow used percentage expected weight-forheight and height-for-age that are indicative of acute and chronic malnutrition respectively. Based on definitions by Waterlow, acute malnutrition is classified as mild if weight-for-height is between 80 and 89% of expected value [expected value equates to 50th centile], moderate if between 70 and 79% and severe if less than 70%. Likewise, chronic malnutrition is classified as mild if height-forage is between 87.5 and 95%, moderate if between 80 and 87.4%, and severe malnutrition if less than 80%. Following the recently revised child growth standards, the WHO has reviewed the criteria to diagnose severe acute malnutrition in 2006, for children between 6 months and 60 months, as weight-for-height less than 3 SD reference, presence of clinical oedema and mid arm circumference [MAC] less than 115 mm [previously 110 mm]. These new standards have been endorsed by international bodies and adopted by more than 90 countries worldwide.
PAEDIATRICS AND CHILD HEALTH 21:9
Gaps with existing care The National Confidential Enquiry into Patient Outcome and Death [NCEPOD]a reviewed patients who received parenteral nutrition (PN) anytime during a 3-month period in 2008 in the UK, by sending a questionnaire to the lead clinician. A copy of
a
Glossary of abbreviations: BAPEN, British Association of Parenteral and Enteral Nutrition; ESPEN, European Society of Parenteral and Enteral Nutrition; MUST, Malnutrition Universal Screening Tool; ESPGHAN, European Society of Paediatric Gastroenterology, Hepatology and Nutrition Review; NST, Nutritional Support Team; NCEPOD, National Confidential Enquiry into Patient Outcome and Death; PN, Parenteral Nutrition; STAMP, Screening Tool for Assessment of Malnutrition; MAC, Mid Arm Circumference; PYMS, Paediatric Yorkhill Malnutrition Score; SGNA, Subjective Global Nutritional Assessment.
390
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
Figure 1 A step-by-step guide to using STAMP.
case notes was subsequently reviewed by a multidisciplinary team including clinicians, dieticians, pharmacists and nurses. Its focus was on parenteral nutrition but it also looked into nutritional care provided in adult, neonatal and paediatric patients including the role of Nutrition Support Teams. It demonstrated some concerning gaps. Good practice in PN care was seen in 24% of neonates, delay in recognizing need for PN in 28%, delay in starting in 17%, and monitoring of PN was inadequate in 19%. Only 11% of neonatal units reported having a multidisciplinary Nutrition Support Team. The need for
PAEDIATRICS AND CHILD HEALTH 21:9
Nutrition Support Team was more visible on surgical neonatal units with limited expertise regarding nutritional care among clinicians. Among children receiving PN, half received it in intensive care and HDU. About 34% received good care, in 42% of cases nutrition teams were involved in the decision to commence PN but subsequent biochemical monitoring was often not adequate. Overall the NECPOD report highlighted gaps in skills and illustrated the need for training frontline staff including junior doctors, general paediatricians and nurses caring for children in nutritional issues.
391
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
All staff have the appropriate skills and competencies needed to ensure that patient’s nutritional needs are met. All staff receive regular training on nutritional care and management Hospital facilities are designed to be flexible and patient centred with the aim of providing and delivering an excellent experience of food service and nutritional care 24 h a day, every day The hospital has a policy for food service and nutritional care which is patient centred and performance managed in line with home country governance frameworks Food service and nutritional care is delivered to the patient safely The hospital supports multidisciplinary approach to nutritional care and values the contribution of all staff groups working in partnership with patients and users.
Recommendations from NCEPOD review Careful and early consideration should be given to the need for PN in neonates and once the decision to commence PN is made it should be started without undue delay. The first PN given must be appropriate to the neonate’s requirements Close monitoring of the patient must be achieved so that metabolic complications can be avoided Neonatal units should have an agreed policy for nutritional requirements and use a proforma that includes this information which is tailored for each infant and placed in the case notes Hospitals in which neonates are cared for should develop a team approach to ensure safe and effective nutritional support, recognizing that this should be a multidisciplinary exercise with sharing of expertise. Depending on the type of institution and availability of personnel, the composition of these teams may vary but could include neonatologists, paediatricians, paediatric surgeons, pharmacists, dieticians and experts in nutrition. This team could also provide support to other clinical areas caring for children and have a role in education and training for those involved in PN care There is an urgent need for neonatal units across the UK to have a consensus on best PN practice based on current scientific evidence Neonatal units should undertaken regular audit of PN practice which should include the complications of PN.
European Society of Paediatric Gastroenterology, Hepatology and Nutrition Review ESPGHAN committee on nutrition, reviewed available information, between 1980 and 2004, on Nutrition Support Teams in paediatric hospital settings, highlighted major deficits in nutritional care in European hospitals and suggested recommendations to improve the situation. These recommendations include establishing Nutrition Support Teams, to optimize nutrition by both enteral and parenteral routes and training staff regarding nutrition screening to identify at risk patients early into admission (Tables 1 and 2).
Clinical benefits of Nutrition Support Teams Children with chronic illness and those hospitalized for prolonged periods are especially at high risk for nutritional compromise, which will adversely affect their long-term course and recovery from illness. Early Nutrition Support Team involvement and intervention can prevent and/or treat malnutrition by choosing appropriate nutritional intervention and help in early identification and prevention of line infections. In addition they facilitate: initiation of parenteral nutrition at the appropriate time and avoid unnecessary episodes of parenteral nutrition.
Council of Europe review The Council of Europe reviewed current practices in Europe regarding food provision and nutritional care and support of hospitalized patients. It highlighted deficiencies in: routine nutritional risk screening and assessment; use of nutritional support for undernourished patients and training and education among professionals in its recommendations. It demonstrated the need for multidisciplinary Nutrition Support Teams in hospitals that have expertise in clinical nutrition and related issues. It made over 100 recommendations that cover five broad areas as follows: [1] Nutritional assessment and treatment in hospitals [2] Nutritional care providers [3] Food services practices [4] Hospital food [5] Health economics. Ten key characteristics of good nutritional care in hospitals were identified from these recommendations: All patients screened on admission to identify the patients who are malnourished or at risk of becoming malnourished. All patients re-screened weekly All patients have a care plan which identifies their nutritional care needs and how they will be met The hospital includes specific guidance on food services and nutritional care in its clinical governance arrangements Patients are involved in planning and monitoring arrangements for food service provision The ward implements protected mealtimes to provide an environment conducive to patients enjoying and being able to eat their food
PAEDIATRICS AND CHILD HEALTH 21:9
Recommended organizational structure of Nutrition Support Teams A Nutrition Steering Committee is central to any healthcare organization and should directly explore governance issues, quality control, costs, risks, auditing and development of guidelines based on best evidence available. Such a committee should supervise and
Useful criteria for initiating nutritional support in paediatric practicea Oral intake Infants Children [>1 year] age Disabled children Insufficient oral intake
Within 3 days of lack of oral intake Within 5 days of lack of oral intake Prolonged feeding time for >6 h/day Inability to take or tolerate 60e80% of requirements for >10 days
Table 1
392
Ó 2011 Published by Elsevier Ltd.
SYMPOSIUM: NUTRITION
set up hospital Nutrition Support Teams whereever they are not available, so that a proper lead group can be developed within a healthcare organization.
Useful criteria for initiating nutritional support in paediatric practicea Wasting and stunting criteria
Summary
<2 years >2 years Weight-for-age criteria Others
The clear clinical and financial benefits demonstrate the need for Nutritional Support Teams that focus on the nutritional problems and care required for children in hospital and coordinate with their community teams. They can assist in providing appropriate training and education for other staff to deliver the optimal nutritional care all children deserve. A
Poor weight gain for >1 month Poor weight gain for >3 months Drop by over 2 centile lines Triceps skin fold thickness <5th percentile for age Fall in height velocity >0.3 SD/year Decrease in height velocity by >2 cm/year compared to preceding year
FURTHER READING 1 Agostino C, Axelsson I, Colomb V, et al. The need for Nutrition Support Teams in paediatric unit: a commentary by the ESPGHAN committee on nutrition. JPGN 2005; 41: 8e11. 2 Sullivan P. Malnutrition in hospital children. Arch Dis Child 2010; doi:10.1136/adc.2009.169664. online. 3 Statistics on obesity, physical activity and diet; England; 2010. 4 Millennium Development Goals. Progress towards the health-related Millennium Development Goals. WHO Fact Sheet 2010; No 290. 5 World Health Statistics. WHO 2010. 1e177. 6 Children: reducing mortality. WHO Fact Sheet 2009; No 178. 7 Barker D. Maternal and fetal origins of coronary heart disease. J R Coll Physicians Lond 1994; 28: 544e51. 8 Mcintosh N, Helms P, Smyth R. Textbook of Paediatrics, Forfar & Arneil, nutrition e principles of nutrition support. 6th Edn 2003; Chapter 14:570. 9 McCarthy H, Dixon M. Cost of hospital nutrition. Complete Nutrition 2008; 8: 1e3. 10 Cross J, Holden C, MacDonald A, et al. Clinical examination compared with anthropometry in evaluating nutritional status. Arch Dis Child 1995; 72: 60e1. 11 Joint statement by WHO & UNICEF, WHO child growth standards and identification of severe acute malnutrition in infants and children 2009. 1e11. 12 Mason D, Puntis J, McCormick, et al. Parenteral nutrition for neonates and children: a mixed bag. Arch Dis Child 2010; doi: 10.1136/adc.2010.188557. online. 13 Ncepod A. Mixed bag e an enquiry into care of hospital patients receiving parenteral nutrition 2010. 1e18. 14 Sangha E, Suchner U, Dormann A, Senkal M. An European survey of structure and organization of Nutrition Support Teams in Germany, Austria and Switzerland [Abstract]. Clin Nutr 2005; 24: 1005e13. 15 Nightingale J. Nutrition Support Teams: how they work, are set up and maintained. Frontline Gastroenterol 2010; 1: 171e7. 16 Braegger C, Decsi T, Dias J, et al. Practical approach to paediatric enteral nutrition: a comment by ESPGHAN committee on nutrition. JPGN 2010; 51: 110e22. 17 Puntis J. Malnutrition and growth. JPGN 2010; 51: S125e6.
Table 2
involve catering services, dietetic departments and the Nutritional Support Team. Members of the Nutritional Support Team are responsible for nutritional needs of their patients and also can take up an advisory role in supporting other medical teams.
Cost benefits of Nutritional Support Team The cost benefits are measurable, for both enteral and parenteral nutrition. There is a reduction of inadequate use of parenteral nutrition and increased use of enteral nutrition, minimization of catheter related sepsis and central venous thrombosis, and a faster rate of PEG insertions for enteral nutrition. In a prospective investigation of function, structure and organization of adult Nutritional Support Teams in 2004 using standardized questionnaires at 3071 hospitals in Germany, Switzerland and Austria; a reduction of complications by 88% and cost saving of 98% since establishment of NST was demonstrated. The Nutritional Support Team, through staff education programmes, can improve timing of nutritional intervention. Moreover, early involvement and support by NST can lead to early improvement and discharge thus decreasing hospital stay. All these have a positive impact on patient outcome with cost savings. Where are we currently? NICE guidelines recommend that nutritional support is provided in every hospital, but only about 60% of hospitals have an NST. Further, these NICE guidelines recommend that all acute hospital trusts employ at least one Nutrition nurse specialist and constitute a Nutrition Steering Committee.
The way forward As clinicians, it is our responsibility to develop the healthcare staff skills involved in monitoring, evaluating and implementing recommended standards for early recognition by screening, auditing and developing guidelines. These need to demonstrate long-term healthcare and cost benefits. These data can be used to
PAEDIATRICS AND CHILD HEALTH 21:9
393
Ó 2011 Published by Elsevier Ltd.