TOPIC OF THE MONTH
Identification and Management of Acute Malnutrition in
Hospitalized Children: Developed Country Perspective
Juliana F. Vaughan and George J. Fuchs
(JPGN 2015;61: 610612)
D uring the past 3 decades, there has been an increased
awareness of malnutrition (undernutrition) in developed
countries. In contrast to developing countries where most of the
childhood malnutrition is related to food insecurity and poverty, a
majority of malnourished children in developed countries are
secondarily malnourished because of a specific, usually chronic
disorder. Severe acute malnutrition constitutes a small proportion of
all malnutrition in this setting, yet accounts for a disproportionately
high risk of morbidity and mortality and, once identified, is
considered a medical emergency. This review focuses on the
identification and management of acute malnutrition in hospitalized
children in developed countries.
METHODS
A search was conducted of PubMed and Cochrane databases
for studies and reviews on the topic of acute malnutrition in
hospitalized children in developed countries. The search was lim-
ited to articles in English published in the past 5 years. Articles that
were published more than 5 years ago were included if relevant. The
authors focused their search and included all the studies that
contained the following key words: prevalence of malnutrition in
developed countries, definition of malnutrition, outcomes,
and management.
PREVALENCE
Several malnutrition-screening tools have been developed
for hospitalized children; however, validation is usually proble-
matic (1,2). This is in contrast to nutritional status for which
anthropometric indices of deficiency have an established progress-
ive (mild to moderate to severe malnutrition) association with
increasing risk of abnormal physiologic states (eg, impaired immu-
nity, metabolic disturbances) and risk of mortality (3,4). Regardless
of the parameter used, surveys of hospitalized children reveal a
substantial prevalence of malnutrition (Table 1). Huysentruyt et al
in 2013, their review of the literature for the 15 years prior, reported
rates of moderate-to-severe undernutrition to be 3% to 20% and
2.5% to 18% for acute and chronic undernutrition, respectively (5).
From the Pediatric Gastroenterology, Hepatology, and Nutrition, Uni-
versity of Arkansas for Medical Sciences and Arkansas Childrens
Hospital, Little Rock, AR.
Address correspondence and reprint requests to George Fuchs, MD,
University of Arkansas for Medical Sciences, Little Rock, AR (e-mail:
fuchsgeorgej@uams.edu).
The authors report no conflicts of interest.
Copyright # 2015 by European Society for Pediatric Gastroenterology,
Hepatology, and Nutrition and North American Society for Pediatric
Gastroenterology, Hepatology, and Nutrition
DOI: 10.1097/MPG.0000000000000987
610 JPGN  Volume 61, Number 6, December 2015
Copyright 2015 by ESPGHAN and NASPGHAN. Unauthorized reproduction of this article is prohibited.
A discharge diagnosis of malnutrition in the United States increased
from 1.4% to 3.2% from 1993 to 2010, among all age groups (6). A
European multicenter study in 12 countries reported 7% of the
hospitalized children were malnourished upon admission (7). In this
and other surveys, rates of malnutrition are higher in association
with specific disease conditions including psychiatric disorders,
gastrointestinal disease, congenital heart disease, among others
(3,7). Notably, many and sometimes most hospitalized malnour-
ished children do not receive nutrition support (5).
DEFINITION
The most widely accepted and validated definition of mal-
nutrition is based on the World Health Organization (WHO) criteria
using anthropometric z scores. In the clinical context, indices of
weight-for-length/weight-for-height or, in children older than 2
years of age, body mass index (wasting) and height-for-age (stunt-
ing) generally reflect acute and past or chronic malnutrition,
respectively (Table 2) (8). A weight-for-length/weight-for-height
or BMI <
2.0 SD or edematous malnutrition indicates the need for
short-term or immediate therapeutic intervention.
The American Society for Parenteral and Enteral Nutrition
proposed a more expansive definition of pediatric malnutrition
(undernutrition) as an imbalance between nutrient requirement
and intake, resulting in cumulative deficits of energy, protein, or
micronutrients that may negatively affect growth, development, and
other relevant outcomes and categorized it further by etiology,
severity, mechanism, and chronicity (9). The authors conceptual
framework attempts to integrate elements of established nutrition
pathophysiology and disease context, nutritional screening (risk),
and nutritional status, the latter using the WHO anthropometric
definitions as the quantified correlates of risk of morbidity and
mortality. The practical application and a closer association with
outcome of combining these elements in this manner remain to
be validated.
Effect on Hospitalization or Outcome
Acute malnutrition is associated with longer hospital stays
(5,7). In a 12-country multicenter study, moderate malnutrition
(BMI <
2 to
3 SDs) and severe malnutrition (BMI <
3 SDs)
were associated with a 1.3 (95% confidence interval [CI] 1.01
1.55) and 1.6 (95% CI 1.272.10) days longer hospitalizations,
respectively. Reduced BMI <
2 SDs was also associated with
lower quality of life and more frequent occurrence of diarrhea (22%
vs 12%, P < 0.001) and vomiting (26% vs 14%, P < 0.001) (7).
Offering oral nutritional supplements reduced length of hospital
stay by 1.1 days and lowered the cost by 9.7% (10). In view of the
significant prevalence of malnutrition in hospitalized children and its
impact on outcomes, a nutrition screen upon admission has become
standard practice. Use of a computerized malnutrition screening
system in a cluster randomized trial enabled early nutrition support
team intervention and facilitated improved clinical practices (11).
 JPGN  Volume 61, Number 6, December 2015 Identification and Management of Acute Malnutrition in Children

TABLE 1. Rates of malnutrition reported in developed countries 19952015


References Patients with acute malnutrition, % Weight-for-height or BMI Comments

Huysentruyt et al (5) 9 <
2 SD Children in Belgian hospitals

Marteletti et al (17) 11 <
2 SD Children in French hospitals
Pawellek et al (18) 6.1 <80% median Children in German hospitals
Hecht et al (7) 7 <
2 SD Children in European hospitals
Hendricks et al (19) 7.1 <80% median Children in US hospitals
Corkins et al (6) 3.2 <
1 SD Children and adults in US hospitals
Baxter et al (20) 6.9 <
2 SD Children in a Canadian hospital
Groleau et al (21) 11 <3%ile Children in a Canadian hospital

BMI body mass index; SD standard deviation; US United States.


All values are moderate to severe malnutrition except for reference (6).

Management
Once an acutely malnourished child is identified, nutritional
rehabilitation (preferably oral or enteral) is implemented without
delay. The composition of therapeutic feeds and the mode of
nutrient delivery often need to be modified in context of specific
underlying conditions. For example, children with renal failure
require less potassium, and certain children with short bowel
syndrome or Crohn disease may require enteral tube feeding or
total parenteral nutrition.
In general, children with mild and moderate acute malnu-
trition require approximately twice the protein and 1.5 times the
energy requirements as well as specific micronutrients to enable a
minimum of 5 g  kg
1  day
1 catch-up weight gain that results in
complete catch-up growth by 1 month or less (12).
Children with severe acute malnutrition present unique
challenges. Refeeding syndrome is a set of metabolic abnorm-
alities that occur upon the initiation of nutritional therapy and is not
only the result of isolated metabolic abnormalities, especially
phosphate depletion, but also the combined effect of various
disturbances including deficiencies of phosphate, potassium, mag-
nesium, fluid, vitamins, and/or micronutrients that lead to life-
threatening pathophysiologic states (13). In addition to slowly
increasing caloric intake, standard treatment in developed countries
and prevention of refeeding syndrome have emphasized close and
frequent monitoring of laboratory data with subsequent correction
of abnormal values.
The WHO developed guidelines for the protocolized man-
agement of complicated severe acute malnutrition of hospitalized
children older than 6 months of age in developing countries that has
resulted in a marked reduction in case fatality rates. Principles of
these guidelines are based on 10 essential steps divided into 3
phases of management: stabilization, rehabilitation, and eventual
follow-up (14,15). The initial phase focuses on the stabilization of
metabolic imbalances, stabilization of electrolyte imbalances, and
treatment of infection as well as any associated complications such
as shock, anemia, and associated illnesses. Energy intake in younger
children in this phase does not exceed 100 kcal  kg
1  day
1
because this is the phase in which children are at the greatest risk of
refeeding syndrome. The rehabilitation phase is clinically identified
by return of appetite, progressive weight gain, reduction of apathy,
and increasing social interaction. Emphasis in this stage is on
intensive refeeding with 150 to 220 kcal  kg
1  day
1 to attain
catch-up growth.
A major reason for the success of the guidelines is that, by
being prescriptive in nature, they prevent the exercise of discretion
by physicians and health workers that is unnecessary and often
dangerous (16). For example, although severely malnourished
children often do not have obvious signs of infections such as
fever and tachypnea because of impaired immunity, the prevalence
of infections is high and with a high associated mortality; the WHO
protocol, therefore, promotes the use of immediate anticipatory
antibiotic treatment in all severely malnourished children for pre-
sumed infection. Severely malnourished children are typically
depleted in several essential micronutrients including phosphorus,
magnesium, potassium, zinc, among others even with normal blood
concentrations of these elements (Table 3); supplemental, not
maintenance, amounts are provided rather than being withheld
until there is an abnormal laboratory value. Somewhat analogous
to the premature newborn, severely malnourished children have
unique stereotypical pathophysiologic abnormalities that require
both anticipatory and special management. Although the prescrip-
tive nature of the guidelines is an essential characteristic that
accounts for its success, it may also be a point of conflict on the
part of some health care providers who are either uninformed about
the guidelines or unconvinced of the superiority of decision making
by an algorithm instead of clinical judgment and discretionary
management. Furthermore, it advocates only a few select laboratory
tests and instead largely addresses refeeding syndrome in a pre-
ventive rather than reactive way. If severe acute malnutrition in a
child is identified, the conceptual approach of the WHO guidelines
is relevant and applicable to the developed country setting, unless
controlled trials, which are lacking, indicate otherwise. Not all
components of the WHO guidelines can, however, be easily or

TABLE 2. Classification of malnutrition using z scores


Nutritional status Weight-for-height Height-for-age Weight-for-age

Adequate >
1.0 >
1.0 >
1.0

Mild 
1.0 to >
2.0 
1.0 to >
2.0 
1.0 to >
2.0
Moderate 
2.0 to >
3.0 
2.0 to >
3.0 
2.0 to >
3.0
Severe 
3.0y 
3.0 
3.0y

Or BMI in children >2 years of age.
y
Or edema, regardless of weight.

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 Vaughan and Fuchs JPGN  Volume 61, Number 6, December 2015

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