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Almost a fifth of children admitted to Dutch hospitals have acute or chronic malnutrition; risk factors include underlying disease and non-white ethnicity

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Definition and prevalence of malnutrition

This very important study examined the prevalence of malnutrition in children in Dutch hospitals. Malnutrition includes disorders of nutrition status resulting from a deficiency of nutrient intake, impaired nutrient metabolism, or overnutrition.1 In this article, the authors specifically examined undernutrition.

Undernutrition in children is a common problem around the world. In low-income countries, the prevalence of undernutrition is estimated at 8–43%.2 In hospitals, the rate is even higher. In high-income countries, the prevalence of undernutrition in hospitalized children is around 6–19%.3,4 Undernourished children are at higher risk for improper physical and psychological development2,5 and may have permanent mental and physical disabilities as they age.6

Review of study

In this article, researchers investigated the prevalence of undernutrition in hospitalized children in the Netherlands. The study included 424 children older than 1 month (63% male, 86% white, median age 3.5 years). Undernourished children were identified by World Health Organization (WHO) criteria7: standard deviation (SD) scores <–2 for weight/height to identify acute undernutrition and SD scores <–2 for height/age to identify chronic undernutrition (stunting). The study found that 19% were undernourished, 11% (95 confidence interval [CI]: 8%–15%) acutely undernourished, and 9% (95% CI: 6%–12%) chronically undernourished. Underlying disease was identified as a risk factor for undernutrition. Risk factors for chronic undernutrition were underlying disease and non-white ethnicity. Acutely undernourished children were hospitalized on average 45% (95% CI: 7%–95%) longer than children who were not undernourished.

Suggested anthropometric measurements

The authors used weight/height as an indicator of acute undernutrition and height/age for chronic undernutrition. Some researchers prefer using body mass index (BMI) because it indicates weight related to both height and age. Another accurate and cheap indicator of nutritional status is the combination of mid-upper arm muscle circumference and triceps skin fold. Weight can be influenced by the patient's body composition, fluid status, medication use, organ enlargement, or tumour mass. Arm anthropometry is useful in assessing nutritional status, especially in children with underlying medical conditions such as tumor mass, chromosomal abnormalities, cerebral palsy, or cystic fibrosis. Arm anthropometry is also a good technique to be used for children with diverse ethnic backgrounds. Triceps and subscapular skinfold thickness provide an index of body fat, and muscle circumference provides a measure of muscle mass. Fat folds can be used to objectively and directly assess body fat reserves.

Implications of the study

This research supports previous findings that undernutrition in hospitalized children is common, even in high-income countries, and that it lengthens hospital stays. The benefit of this study is its large sample size, screening for both acute and chronic undernutrition and identifying risk factors for undernutrition of hospitalized children.

The implications of the study are multiple. Since those measurements were done at admission, we can conclude that children were already malnourished before they were admitted. Children in the community who are at risk, children with underlying conditions, and non-white children should be assessed for undernutrition by a pediatrician, nurse, or dietitian. Children with underlying medical conditions and non-white children should be evaluated for access to food and nutrition support plans.

Clinical practice guidelines for hospital treatment of undernourished children should be developed and followed with a plan for long-term follow up after hospital discharge.

Suggestions for future research

These findings reinforce that undernourishment lengthens hospital stays. It is disturbing that even in such a high-income county as the Netherlands, 19% of hospitalized children are acutely or chronically undernourished. With respect to the global obesity epidemic, it will be interesting to see how many hospitalized children are overnourished and whether that affects the length of hospital stays. Malnutrition of children is a serious global problem that can cause permanent physical and psychological disabilities. It also poses a financial burden for hospitals due to prolonged stays and for the community.


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