Disease associated malnutrition correlates with length of hospital stay in children

doi:10.1016/j.clnu.2014.01.003

Clinical Nutrition

Volume 34, Issue 1, February 2015, Pages 53-59

https://doi.org/10.1016/j.clnu.2014.01.003 Get rights and content

Summary

Background & aims

Previous studies reported a wide range of estimated malnutrition prevalence (6–30%) in paediatric inpatients based on various anthropometric criteria. We performed anthropometry in hospitalised children and assessed the relationship between malnutrition and length of hospital stay (LOS) and complication rates.

Methods

In a prospective multi-centre European study, 2567 patients aged 1 month to 18 years were assessed in 14 centres in 12 countries by standardised anthropometry within the first 24 h after admission. Body mass index (BMI) and height/length <−2 standard deviation scores (SDS, WHO reference) were related to LOS (primary outcome), frequency of gastrointestinal (diarrhoea and vomiting) and infectious complications (antibiotic use), weight change during stay (secondary outcomes) and quality of life.

Results

A BMI <−2 SDS was present in 7.0% of the patients at hospital admission (range 4.0–9.3% across countries) with a higher prevalence in infants (10.8%) and toddlers aged 1–2 years (8.3%). A BMI <−2 to ≥−3 SDS (moderate malnutrition) and a BMI <−3 SDS (severe malnutrition) was associated with a 1.3 (CI95: 1.01, 1.55) and 1.6 (CI95: 1.27, 2.10) days longer LOS, respectively (p = 0.04 and p < 0.001). Reduced BMI <−2 SDS was also associated to lower quality of life, and more frequent occurrence of diarrhoea (22% vs 12%, p < 0.001) and vomiting (26% vs 14%, p < 0.001).

Conclusion

Disease associated malnutrition in hospitalised children in Europe is common and is associated with significantly prolonged LOS and increased complications, with possible major cost implications, and reduced quality of life.

This study was registered at clinicaltrials.gov as NCT01132742.

Introduction

Diseases increase the risk of malnutrition in infants and children. Malnutrition is induced by many childhood diseases, e.g. Crohn's disease¹ or cystic fibrosis,² and many others. However, it is not possible to distinguish clearly between severity and chronicity of disease and nutritional status which interact. The prevalence of disease associated malnutrition in hospitalised children in Europe has been reported to range from 6% to 30%.3, 4 This wide variation appears mainly due to the inconsistency of criteria used for defining disease associated malnutrition in paediatric patients.³ Several different anthropometric indices have been used, which identify different groups and proportions of patients as malnourished.4, 5 The most frequently used criteria for acute malnutrition are the WHO cut-off weight for length/height (WFH) <−2 standard deviation scores (SDS) or alternatively body mass index (BMI) <−2 SDS. Height/length for age (HFA) <−2 SDS is suggestive of stunting and used as a marker of chronic malnutrition in developing countries but also in children with chronic illness.⁶

In adults, adverse effects of disease associated malnutrition defined by anthropometry, and benefits of nutritional intervention on clinical outcomes have been documented.⁷ In contrast, the relation between malnutrition in children and outcomes, e.g. length of hospital stay (LOS), has only been reported in a limited number of small paediatric studies.8, 9 Our study aimed at assessing the prevalence of disease associated malnutrition (BMI < −2 SDS) in hospitalised children across Europe and to investigate the possible impact on length of hospital stay and on complication rates.

Section snippets

Definitions

Malnutrition in this context is defined as underweight only, defined by BMI < −2 SDS. The French Paediatric Society recommends the cut-off BMI < −2 SDS or below the third centile for protein-energy malnutrition screening in children.¹⁰ In developed countries WFH standards are less available than age specific BMI standards.11, 12 For the calculation of the prevalence of malnutrition and it's relation to length of hospital stay the degree of malnutrition was classified as moderate (≥−3 to ≤ −2

Patient characteristics

During the study period 9055 of all 11,453 patients (33% surgical and 67% general) consecutively admitted to the participating wards fulfilled the inclusion criteria and were eligible for study participation. Due to limitations regarding the parental language or periods of absence from the ward during the first 24 h after admission (of parents [16%], patients [18%] or assessors [65%; on weekends or due to too many patients newly admitted to address all within the first 24 h]) 5952 patients were

Discussion

This multi-centre cohort study shows that disease associated malnutrition occurs frequently on paediatric wards in Europe and is associated with longer LOS and other adverse outcomes, with implications for the patients' quality of life. Malnutrition and stunting in European hospitalised children is associated with chronic underlying diseases, especially in those with disorders of the digestive, neurocognitive, endocrine and metabolic system.

The appreciation of nutritional teams and the

Grants/Funding

This study was financially supported in part by an ESPEN Network Grant provided to Berthold Koletzko, Univ. of Munich.

Statement of authorship

CH contributed to writing the study protocol, coordinated the study, participated in its conduction, performed the data entry, management and analyses and drafted the manuscript. MW and VG participated in the design of the study, the sample analyses and helped with the statistical analyses. BK conceived of the study, participated in its design, contributed to writing the study protocol and helped to draft the manuscript. RS, JH, KJ, HK, JK and HS participated in the initial part of study

Conflict of interest

There is no conflict of interest from authors related to this study.

Acknowledgements

We thank Dr Joachim Schweizer, Leiden NL, for his valuable contributions. Further thank for data collection goes to Kelly van der Velde and Leora van Noord Erasmus MC-Sophia Children's Hospital Rotterdam NL, Karmen Matković dipl. ing. Zagreb Children's Hospital HR, Irit Halifa and Irit Poraz Petah Tikvah IL, Cecilia Lazea Cluj-Nopacoca RO, Anne McEnroe and Louise O’Mahony University of Glasgow UK and Ghita Brekke, Karen Noes Pedersen and Karin Kok Copenhagen DK. We thank Uschi Handel, MPH, for

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^☆: Part of the data previously presented at ESPGHAN (Stockholm) and ESPEN (Barcelona) congresses 2012.

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Original articleDisease associated malnutrition correlates with length of hospital stay in children☆

Summary

Background & aims

Methods

Results

Conclusion

Introduction

Section snippets

Definitions

Patient characteristics

Discussion

Grants/Funding

Statement of authorship

Conflict of interest

Acknowledgements

Clin Nutr Edinb Scotl

Am J Clin Nutr

Clin Nutr Edinb Scotl

Arch Pediatr

Am J Clin Nutr

Am J Clin Nutr

Clin Nutr Edinb Scotl

Nutrition

Clin Nutr Edinb Scotl

The aetiology and impact of malnutrition in paediatric inflammatory bowel disease

J Hum Nutr Diet

Original article
Disease associated malnutrition correlates with length of hospital stay in children☆