Malnutrition among Hospitalized Children in the United States: Changing Prevalence, Clinical Correlates, and Practice Patterns between 2002 and 2011.

BACKGROUND: Pediatric malnutrition has been associated with adverse clinical outcomes, longer lengths of stay, and higher health care costs. OBJECTIVE: To characterize prevalence, temporal trends, and short-term clinical outcomes of coded diagnoses of pediatric malnutrition (CDM) across sociodemographic, clinical, and hospital characteristics from 2002 to 2011. DESIGN: This study is a retrospective cross-sectional analysis of nationally representative data from the Nationwide Inpatient Sample and the Kids' Inpatient Database. PARTICIPANTS/SETTING: The study sample included pediatric inpatient hospitalizations in the United States. MAIN OUTCOME MEASURES: International Classification of Diseases-9th Revision-Clinical Modification diagnosis codes were used to identify CDM and coded malnutrition subtypes based on an etiology-related definition of pediatric malnutrition. STATISTICAL ANALYSES: The national frequency and prevalence of CDM overall and across patient- and hospital-level characteristics were estimated for children aged 1 month to 17 years. Logistic regression was used to assess the association between CDM and each characteristic. Analyses evaluated conditions associated with the highest burden and risk of CDM, and compared clinical outcomes across malnutrition subtypes. Joinpoint regression was used to describe temporal trends in CDM. RESULTS: Of the 2.1 million pediatric patients hospitalized annually, more than 54,600 had CDM, a national prevalence of 2.6%. Considerable variation was observed based on primary diagnosis, with fluid and electrolyte disorders contributing the most malnutrition cases. Highest CDM rates were among patients with stomach cancer, cystic fibrosis, and human immunodeficiency virus. Patients with CDM experienced worse clinical outcomes, longer lengths of stay, and increased costs of inpatient care. The overall prevalence of CDM increased from 1.9% in 2002 to 3.7% in 2011, an 8% annual increase, and temporal increases were observed in nearly all population subgroups. CONCLUSIONS: Despite improvements, pediatric malnutrition remains underdiagnosed in inpatient settings when relying exclusively on International Classification of Diseases-based codes, which underscores the need for a national benchmarking program to estimate the true prevalence, clinical significance, and cost of pediatric malnutrition.

Optimizing Perioperative Nutrition in Pediatric Populations.

Nutrition status prior to surgery and nutrition rehabilitation after surgery can affect the morbidity and mortality of pediatric patients. A comprehensive approach to nutrition in pediatric surgical patients is important and includes preoperative assessment, perioperative nutrition considerations, and postoperative recovery. A thorough nutrition assessment to identify patients who are at nutrition risk prior to surgery is important so that the nutrition status can be optimized prior to the procedure to minimize suboptimal outcomes. Preoperative malnutrition is associated with increased complications and mean hospital days following surgery. Enteral and parenteral nutrition can be used in cases where food intake is inadequate to maintain and possibly improve nutrition status, especially in the 7-10 days prior to surgery. In the perioperative period, fasting should be limited to restricting solid foods and non-human milk 6 hours prior to the procedure and allowing clear liquids until 2 hours prior to the procedure. Postoperatively, early feeding has been shown to resolve postoperative ileus earlier, decrease infection rates, promote wound healing, and reduce length of hospital stay. If nutrition cannot be provided orally, then nutrition through either enteral or parenteral means should be initiated within 24-48 hours of surgery. Practitioners should identify those patients who are at the highest nutrition risk for postsurgical complications and provide guidance for optimal nutrition during the perioperative and postoperative period.

Pediatric Malnutrition: Putting the New Definition and Standards Into Practice.

In recent years, much effort has been directed at redefining malnutrition in the pediatric population to include the acute clinical population in addition to the more traditional ambulatory populations. In 2013, an expert panel convened to perform a critical review of available literature to craft a new approach to malnutrition. Closely thereafter, the Academy of Nutrition and Dietetics and the American Society for Parenteral and Enteral Nutrition published recommended indicators for the identification and documentation of malnutrition in pediatric populations. The purpose of this article is to review the domains within the new definition of malnutrition in pediatric practice, describe populations in which the recommended indicators for identification and management are problematic in clinical practice, give case studies that apply the new definition, and finally describe the implementation of a malnutrition identification program within a large tertiary care children's hospital.