Overview
Definition:
Malnutrition in hospitalized children is a complex condition characterized by a deficiency, excess, or imbalance of energy, protein, and other nutrients that causes measurable adverse effects on tissue function, growth, and development, leading to increased morbidity and mortality
it encompasses both undernutrition and overnutrition
Pediatric inpatient malnutrition is often iatrogenic, exacerbated by illness, inadequate intake, and metabolic stress during hospitalization.
Epidemiology:
Prevalence of malnutrition in pediatric hospitals varies widely by region and institution, often ranging from 20% to 60%
higher rates are seen in children with chronic illnesses, congenital anomalies, and those admitted to intensive care units
Undernutrition is more common, leading to delayed recovery, impaired wound healing, and increased infection risk
Overnutrition, specifically obesity, is also a growing concern in hospitalized children, contributing to metabolic complications.
Clinical Significance:
Proper management of inpatient pediatric malnutrition is critical for optimizing patient outcomes
It directly impacts recovery time, immune function, complication rates, length of hospital stay, and long-term growth and developmental trajectories
Effective collaboration with dietitians is essential for accurate assessment, tailored nutrition support, and preventing iatrogenic malnutrition, making it a high-yield area for DNB and NEET SS examinations.
Age Considerations
Infants 0 12 Months:
Critical period for growth and development
nutritional needs are high and dynamic
Emphasis on breastfeeding, appropriate formula, and introduction of complementary feeding
Risk of failure to thrive (FTT) and specific micronutrient deficiencies (e.g., iron, vitamin D).
Toddlers 1 3 Years:
Transition to family diet, often with picky eating
Increased risk of iron deficiency anemia and calcium deficiency
Impact on motor and cognitive development.
Preschoolers 3 5 Years:
Continued growth, but at a slower pace
Risk of micronutrient deficiencies and early signs of overweight/obesity due to dietary habits and activity levels.
School Aged Children 6 12 Years:
Sustained growth, increased energy demands for physical activity and learning
Potential for obesity to develop or persist
Impact on academic performance and social development.
Adolescents 13 18 Years:
Rapid growth spurt (puberty) with significantly increased nutrient needs, especially protein, calcium, and iron
Risk of eating disorders, obesity, and micronutrient deficiencies (e.g., folate, vitamin D) impacting peak bone mass and reproductive health.
Diagnostic Approach
History Taking:
Detailed dietary history including intake, preferences, intolerances, feeding methods, and appetite changes
birth weight, growth trajectory, and previous nutritional assessments
presence of gastrointestinal symptoms (vomiting, diarrhea, constipation)
chronic medical conditions and medications
socioeconomic factors affecting food security
family history of nutritional disorders or obesity.
Physical Examination:
Anthropometric measurements: weight, height, head circumference (in infants), BMI
assessment of growth charts (WHO or Indian standards)
clinical signs of malnutrition: edema, pallor, hair changes, skin lesions, muscle wasting, loss of subcutaneous fat, xerophthalmia, goiter
assessment of hydration status and signs of concurrent infections.
Nutritional Assessment Tools:
Standardized tools like the Strong Kids nutritional risk screening tool or subjective global assessment (SGA) adapted for pediatrics
anthropometric Z-scores for weight-for-age, height-for-age, weight-for-height, and BMI-for-age are crucial for classifying malnutrition (underweight, stunting, wasting, overweight/obesity).
Laboratory Investigations:
Complete blood count (CBC) to assess for anemia
serum albumin and prealbumin (markers of nutritional status, though influenced by inflammation)
electrolytes, renal function tests, liver function tests
micronutrient levels (e.g., ferritin for iron deficiency, vitamin D, zinc) as indicated by clinical suspicion
inflammatory markers (CRP, ESR) to assess the impact of illness on nutritional status.
Management And Dietitian Collaboration
Initial Management And Assessment:
Early screening for malnutrition risk upon admission using validated tools
Comprehensive nutritional assessment by a registered dietitian within 24-48 hours
Identification of nutritional deficits and needs.
Enteral Nutrition Support:
Preferred route for nutrition when the GI tract is functional
Dietitian to recommend appropriate formula (standard, specialized for renal/hepatic disease, premature infants), caloric and protein targets, and feeding method (bolus, continuous infusion)
Initiation of trophic feeds, then advancing to goal feeds
Monitoring for feeding intolerance (vomiting, abdominal distension, diarrhea).
Parenteral Nutrition Support:
Indicated when enteral feeding is not feasible or insufficient
Dietitian collaborates with the medical team to determine caloric, protein, lipid, electrolyte, and micronutrient requirements
Prescription of PN formulation, monitoring of blood glucose, liver function, and electrolyte balance
Gradual transition to enteral nutrition as tolerated.
Micronutrient Supplementation:
Specific protocols for micronutrient deficiencies identified, e.g., iron supplementation for iron deficiency anemia, vitamin D and calcium for bone health, zinc for growth and immune function
Dietitian ensures appropriate dosages and administration routes, considering potential interactions.
Transition Of Care And Discharge Planning:
Dietitian plays a key role in educating parents/caregivers on home feeding strategies, formula preparation, monitoring growth, and recognizing signs of intolerance or complications
Development of a follow-up plan with outpatient dietitians or pediatricians to ensure sustained nutritional recovery and growth post-discharge.
Complications Of Pediatric Inpatient Malnutrition
Increased Morbidity And Mortality:
Higher susceptibility to infections due to impaired immune function
delayed wound healing
prolonged recovery from illness
increased risk of organ dysfunction.
Impaired Growth And Development:
Stunting (linear growth retardation) and wasting (low weight-for-height) can lead to long-term physical and cognitive deficits, impacting academic achievement and quality of life
Failure to reach genetic potential for height and weight.
Electrolyte Imbalances And Refeeding Syndrome:
Refeeding syndrome, a potentially fatal complication when severely malnourished patients are refed too rapidly, leading to severe electrolyte shifts (hypophosphatemia, hypokalemia, hypomagnesemia) and fluid overload
Careful, gradual refeeding with electrolyte monitoring is crucial.
Iatrogenic Malnutrition:
Malnutrition developed or exacerbated during hospitalization due to inadequate nutritional assessment, delayed initiation of nutrition support, food restrictions for investigations without adequate replacement, or poor feeding practices
This highlights the importance of proactive dietitian involvement.
Key Points
Exam Focus:
Understand the definition and classification of pediatric malnutrition (stunting, wasting, underweight, overweight/obesity)
Recognize the high prevalence and impact on patient outcomes
Master the components of a comprehensive nutritional assessment and the role of anthropometry
Key aspects of enteral and parenteral nutrition support, including indications, monitoring, and potential complications like refeeding syndrome.
Clinical Pearls:
Always screen for malnutrition upon admission
early dietitian involvement is key
Prioritize enteral nutrition if the gut is functional
Monitor for refeeding syndrome meticulously in at-risk patients
Empower parents with education for successful discharge and home management
Recognize that malnutrition is multifactorial, involving disease, nutrition, and psychosocial factors.
Common Mistakes:
Underestimating the prevalence and impact of malnutrition in acutely ill children
Delaying nutritional assessment and intervention
Inadequate monitoring of feeding tolerance and electrolyte balance
Poor communication between medical teams and dietitians
Insufficient discharge planning and parental education regarding nutritional support.