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Podcast episode 11: Applying Malnutrition Criteria to Neonatal and Pediatric Patients

In this episode:

NICU dietitian Patti Perks and CICU dietitian Megan Horsley:

  • Discuss published criteria for defining malnutrition in pediatric and neonatal populations
  • Identify variables that impact nutrition and growth
  • Discuss the application and challenges of malnutrition criteria
  • Identify potential outcomes of diagnosing malnutrition

Bio:

Patti Perks, MS, RDN, CNSD

Patti has been a nutrition support dietitian since 2000. For the past 16 years, she has specialized in neonatal nutrition support in the neonatal intensive care unit (NICU) at the University of Virginia (UVA) Children’s Hospital in Charlottesville, VA. In the NICU, she has been involved in numerous quality improvement initiatives, and provides nutrition education to staff and to nurse practitioner students at UVA School of Nursing. Patti provides management support for the pediatric nutrition team at UVA, Charlottesville. She is a founding board member of the Virginia Neonatal Nutrition Association, a nonprofit that provides educational and networking opportunities for healthcare providers who specialize in infant and pediatric nutrition care.

Patti earned a bachelor’s degree in nutrition science from Cornell University and a master’s degree in nutrition science from James Madison University. She completed her clinical nutrition internship at the UVA Health System.

Megan Horsley, RD, LD, CSP, CNSC

Megan is a pediatric dietitian at Cincinnati Children’s Hospital Medical Center. She has over 13 years of experience in pediatrics with a focus in cardiology and currently practices in the cardiac intensive care unit (CICU). Her most recent work has involved quality improvement in weaning heart patients off of their feeding tubes and improving maternal nutrition of moms with a fetal diagnosis of a congenital heart defect.

She is a certified nutrition support clinician and maintains her certification as a specialist in pediatric nutrition. She received her undergraduate degree from the University of Cincinnati in 2006 and completed her dietetic internship with the University of Northern Colorado in 2007. Currently, she is involved in research and quality improvement work with the National Pediatric Cardiology Quality Improvement Collaborative. She has served as a board member of the Congenital Heart Alliance of Cincinnati since 2017. She has over 13 years of professional practice in pediatric nutrition and over 16 years of personal experience of being a “heart mom” herself. Her daughter was born with congenital heart disease and required several surgeries during infancy. She concentrates her efforts on improving the nutritional care, experience, and outcomes for all children affected by heart disease.

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Show notes:

Becker P, Carney LN, Corkins MR, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Nutr Clin Pract. 2015;30(1):147-161. doi:10.1177/0884533614557642

Bouma S. Diagnosing pediatric malnutrition: paradigm shifts of etiology-related definitions and appraisal of the indicators. Nutr Clin Pract. 2017;32(1):52-67. doi:10.1177/0884533616671861

Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013;37(4):460-481. doi:10.1177/0148607113479972

About our podcast

The full potential of human milk has yet to be realized. Speaking of Human Milk provides healthcare professionals with information on the latest science and clinical research. Each episode features an interview with a thought leader passionate about uncovering the unknown potential of human milk or better understanding the science of neonatal nutrition.

About Host Keli Hawthorne MS, RD, LD

In addition to hosting Speaking of Human Milk, Keli Hawthorne is the director for clinical research for the Department of Pediatrics at the University of Texas Austin, Dell Medical School. In her current role, she trains faculty and staff on effectively executing high-quality protocols for research. She has authored more than 40 peer-reviewed publications on neonatal nutrition.


TRANSCRIPT:

Kelli Hawthorne (KH): Hey y'all. Welcome to Speaking of Human Milk where we give you bite sized episodes on the latest science and innovation surrounding human milk. This podcast is brought to you by Prolacta Bioscience, a company dedicated to advancing the science of human milk. The results and outcomes described in this episode are anecdotal and specific to the institution and its protocol. I'm your host, registered dietitian, Kelli Hawthorne. Today I will be talking to fellow dieticians, Patti Perks, and Megan Horsley on the topic of defining malnutrition in the neonatal and pediatric population, and how this can be applied in practice and some of the challenges that come along with diagnosing malnutrition. Let me go ahead and introduce the people on our podcast today. Patti Perks has been a nutrition support dietitian since 2000, and for the past 16 years has specialized in neonatal nutrition support at the neonatal ICU at the University of Virginia Children's Hospital in Charlo4ttesville, Virginia. She has been very involved in numerous quality improvement initiatives in the NICU and provides nutrition education to NICU staff, and to nurse practitioner students at the UVA School of Nursing. She is a founding board member of the Virginia Neonatal Nutrition Association, which I just love that she is, a nonprofit that provides educational and networking opportunities for healthcare providers involved in providing infant and pediatric nutrition so a great leader in our field. We also have Megan Horsley, who is a pediatric dietitian at Cincinnati Children's Hospital Medical Center. She has over 13 years of experience in pediatrics with a focus on cardiology and currently practices in the critical Cardiac Intensive Care Unit. Her most recent work has involved quality improvement and weaning heart patients off of their feeding tubes and improving maternal nutrition of moms with a fetal diagnosis of a congenital heart defect. Thank you both for talking with me with me today. I am so excited to have you on and to hear about neonatal and premature infant malnutrition guidelines. As many clinicians are aware, malnutrition in the hospital setting is a very hot topic lately. And I know there are new guidelines that have been issued to help with diagnosing and standardizing documentation of malnutrition. So can you help us all be on the same page here on our podcast, and talk about the criteria for defining malnutrition in term infants and children?

Megan Horsley (MH): Thanks, Kelli. I'm excited to be here as well. And I'm excited to talk about this topic, because certainly it's an exciting topic. There's also a lot of work being done relating to pediatric malnutrition. You asked about discussing the criteria for defining malnutrition, specifically in the term and pediatric children. Pediatric malnutrition historically, has been considered more of an issue in developing countries. There is a good amount of literature out there from countries outside of the US identifying malnourished children and the negative effects it has like, a increased risk of mortality.

The article published by Mehta et al was kind of a landmark article that summarized all the malnutrition literature from 1955, I believe, to 2011. From this paper, five domains of pediatric malnutrition were identified. And then as a response to this article in 2015, the American Academy of Nutrition and Dietetics and the American Society of Parenteral and Enteral Nutrition, published the consensus paper that really identified a basic set of indicators to use when identifying and diagnosing pediatric malnutrition. This consensus paper really helps define what malnutrition is, and it helps us to characterize undernutrition, as well as standardize how we identify it and then how we document against it.

The consensus paper identified single data points or single data indicators that can be used in infants one month of age and older. These include weight for length or height z- score, BMI for age z-score, length for height z-score, or mid upper arm circumference z-score. This paper has criteria for each of these single data point/indicators and provides the definitions. If you have a patient with a BMI z-score of negative 2.5 z-score, you could identify and classify them as moderate malnutrition.

In addition to single data point indicators, they also provide guidelines on indicators that would require a comparison of two or more data points. The indicators that require two or more data points, are: weight gain velocity in less than two years of age, weight loss if between two to 20 years of age, a deceleration in weight for length or BMI for age z-score, and nutrient intake adequacy. So, if you have that same patient that has a BMI z score of negative 2.5, as I described earlier, also has an intake that is only meeting 30% of their estimated needs, this further supports classifying that patient as moderate malnutrition. In addition to the indicators used to identify whether one is malnourished, it also addresses the chronicity of malnutrition. So, if a malnourished patient is identified, due to a severe trauma that the patient had, this might be considered an acute malnutrition, if the malnutrition is lasting one to three months in duration. Adversely, one might be chronically malnourished, which is malnutrition lasting greater than three months, resulting in more of a linear decline, or stunting as the hallmark of chronic malnutrition. So, the consensus paper provides, again, a starting point for how we assess and identify malnourished patients. Once we've identified malnutrition, we then have some guidelines on how to document it using these data points, supporting our interventions to improve their malnutrition.

KH: Patty, helps us understand what the criteria are for determining malnutrition in premature infant population?

Patti Perks (PP): Sure, as we know, the pediatric indicators have been available for several years, but they were not intended to apply to babies born prematurely, or infants who are still within the first four weeks of life. So, a team of experienced NICU dietitians collaborated, they did an extensive lit review, and patterned the criteria somewhat after the pediatric criteria for identifying malnutrition. They identified six indicators that describe growth as well as nutritional intake. One reason that criteria were needed specifically for this group is that, as we know, all babies term or preterm lose weight right after birth. It's physiologic to get rid of some of the fluid they had onboard in utero. So therefore, we're going to see weight loss initially, and it may be a week or two weeks before regaining to birth weight. So obviously, weight gain velocity isn't going to be applicable during this time which is one reason indicators needed to be specific for this group. Looking at the criteria, there's decline in weight for age z-score, weight gain velocity, nutrient intake; any of these could be single indicators. Of those, the preferred indicator in the first two weeks of life is nutrient intake. This highlights the importance of accurately assessing what the calorie and protein intake is and comparing to appropriate reference standards. Next, there are three indicators that could be used with another indicator: days to regain birth weight which is used in conjunction with nutrient intake, linear growth velocity, and decline in lenth-for-age z-score. The last two are not applicable in the first two weeks of life.

KH: I think it's really great that the group there decided that they were able to include that period that we know where babies are losing weight in that first couple of weeks of life, especially premature babies, since that's an important part of their physiology and not mislabeling anybody. I think I would need a cheat sheet to keep straight all of these criteria. I think that a lot of our premature babies may be born and immediately would be almost considered at-risk based on their size and intrauterine growth restriction. So I know that the indicators are more for nutrient intake in the first couple of weeks of life, as you mentioned, but do we start diagnosing malnutrition at birth? Or is there guidance to wait until a certain period of time has passed before we start to identify malnutrition in a newborn?

PP: When I think about the preterm infant, certainly by definition, they're born before getting all of the nutrient stores that they would have received if they had continued growing in utero until full term. So yes, they have been dubbed the true nutrition emergency and are in need of nutrition support right from the start. So there's a sense in which, by definition and as compared to a term infant, they are less nourished. And then an infant who experienced intrauterine growth restriction, if due to inadequate nutrient delivery, also would have nutritional needs right from the start. However, we wouldn’t apply the criteria and diagnose malnutrition at birth. The soonest I would use malnutrition indicators would be after the first two weeks of life, and that would be nutrient intake at or below 75 percent of estimated needs for the specified duration; this could be used alone, or in conjunction with days to regain birth weight. All of the criteria, whether pediatric or neonatal, require clinical judgment as we apply them. For example, judgment is needed in terms of the validity of the birth weight. Sometimes birth weight is elevated due to fluid retention or if they need fluid resuscitation, and they may not have the usual postnatal diuresis. So there's various clinical factors that I try to take into account, and I usually want to see a longer trend. I’ve been trying to apply the criteria, probably just within the last year, so I do use a cheat sheet and look at the criteria, taking all the various aspects into account.

KH: I think that's a great point about the clinical judgment. It also goes to show how complex these babies are and how, as much as we try to categorize things, there's always those babies who are outside the box. This is where clinical judgement is sometimes more than an art than a science at times. We know that there are non-nutritional factors as well that can influence growth and nutritional status, like medications and even genetic syndromes that may be present even from birth, or something that that is added on to their care, even soon after birth. Could each of you discuss how you account for non-nutritional factors as you apply these criteria in a practical setting?

PP: Sure, I'll speak for some of the NICU patients. One situation that we see sometimes is hyponatremia, whether reflecting how mature their kidneys are at retaining sodium, or sometimes depending on what their feeds are, we may see low sodium levels. If it's truly clinically significant hyponatremia, you likely aren't going to see adequate weight gain during this time, and so it's important to identify the cause of it and treat and replete sodium levels. Another common medication, dexamethasone, a steroid, is often given in hopes of weaning from the vent. And certainly, we know that the catabolic steroids block protein utilization and often linear growth in addition to weight gain is poor, during the duration of steroids.

KH: Yeah, I agree having a baby on steroids is always a struggle to get the baby to grow. And it's always a countdown to see how fast we get those babies off the steroids because, as much as I do care about their respiratory status, as a dietitian I'm interested in nutrition as well, and making sure they get the nutrition for those lungs to grow. So, it's all a combination of maybe what do you think about accounting for non-nutritional factors in this diagnostic criteria?

MH: I agree. We utilize steroids as well in the pediatric population for many reasons not just to get them off vent. But often, depending on their status like post a new organ transplant, a lot of these patients are on steroids, either acutely or chronically. There’s a lot of negative lasting side effects to that as Patty mentioned, like bone health and stunting. We’ve certainly had similar challenges of these non-nutritional factors in the world of the ICU like in the setting of diuretic use and paralytics. From my perspective, you need to prove that the patient is not malnourished and use your clinical judgment to think of all the things that could be contributing to the current state that they're in. Especially, if they're in a critical state there's going to be so much heterogeneity contributing to your assessment. These patients can be definitely sick and then they go to more of an acute care step down unit and addressing their malnutrition at each phase is really important. But when you do have a lot of non-nutritional factors that are complicating the picture, this is where utilization of the supporting indicators, as well as your physical exam comes into play. You have to support what your interventions are for that patient on how you're addressing their nutrition. This is where mid upper arms circumference might be helpful. If you have a patient that has achondroplasia, for example, they're going to appear malnourished typically with a negative three length Z-score, or height Z-score, but are they really malnourished? Is their mid upper arm circumference reassuring? Is their intake adequate? What's their physical exam look like? I think utilizing the supporting measures and physical assessment pieces is really important when you have a lot of additional non-nutritional factors to consider.

KH: I'm so glad you brought up the nutrition focus physical exam, because I'm going to ask you about that anyway. How does a nutrition focused physical exam fit into the assessment and diagnosis of malnutrition? I know its not a part of the malnutrition criteria. I’m also interested to know how often you do mid arm muscle circumference and mid arm circumference and what are you seeing when you when you do that and how often that occurs in your units.

MH: Yes, you’re right that the nutrition physical exam isn’t part of the consensus criteria that came out. So how do you really assess for body composition in a six-year-old that has a BMI that may be categorized as obese but really it is muscle? Or you may have a very fit adolescent that's involved in a lot of sports. The nutrition focus physical exam can complement your assessment and further drive your interventions on what you want to do to address their nutritional status, whether it be over nutrition or undernutrition.

There are many pieces of the physical exam. And now there's a ton of training on how to become proficient. I was fortunate enough to be trained by Jodi Wolf from the Academy who has been a leader in the nutrition focused physical exam. I became a kind of champion of it so I feel very comfortable doing it as a dietitian, but I know, there's such a range of comfort amongst all the dietitians that are practicing since it's really about touching and inspecting a patient. Sometimes, you can just go into the room of a patient and tell automatically if they're malnourished or not just by their physical appearance. But many times, it's more complicated than that because they have a chronic disease, and they appear proportionate, but they're stunted with other factors, and they still may be malnourished. For example, you can have an autistic child who eats four foods and appears obese, but then something acutely happens to that patient and they end up in the hospital. If you’re doing a good physical exam, you might identify that they have a vitamin C deficiency or iron deficiency by just looking at their eyelids or their nails. So, there's a lot of positives to incorporating a physical exam into your assessment. As I said, it really just kind of complements the assessment and helps direct your interventions and drives your thought process about one's nutritional status. Mid upper arm circumferences, I do them frequently with each time I'm assessing the patient if I'm able to.

Certainly, there are challenges with interpreting mid upper arm circumferences. There's a couple of different references out there. You need to standardize what references you're going to use. But if anything, it helps to trend data on somebody's nutritional status. There's also handgrip strength, as well, using the hand dynamometer (I always have a hard time saying that word) can help determine frailty. Frailty is kind of a hot topic in the literature right now. We use the hand grip strength on a lot of our liver patients, or in a lot of our chronic cardiomyopathy patients that might require ventricular assist device. There is bio electric impedance that is also being used to help really identify how much muscle versus fat versus water is making up the body weight. Some of our patients that are in rehab, are doing those bio electric impedance. We call them in-body analysis, where we can really try to monitor that frequently and see if we are making positive progress in muscle mass. So, there's many pieces to the physical exam that I think it just really makes that assessment complete, if you will.

KH: What are you seeing when it comes to physical exams in our MC use and tools like mid upper arm circumference?

PP: There's a lot of room for improving accuracy of measurements. Certainly, accuracy of anthropometrics is a challenge regardless of age, really. In our NICU population, we have not yet started with mid upper arm circumference. We want to do it and have included MUAC in our plan for identifying infants at risk of malnutrition as we continue in the future. Right now, we're trying to work with more accurate linear measurements. We recently noticed our length measurements seemed to be worse again, and we started to ask newer staff if they were using the length boards. It turned out that in rearranging equipment and supplies, someone had moved them to another closet, so they were out of sight and out of mind! The length boards really weren’t being used in the systematic way we had thought, and we realized that having equipment readily available is a huge part of measuring length accurately and training staff.

Another limitation to physical exams in the NICU is that babies are swaddled and nurses try to bundle cares around the same time for the infant. A baby is literally growing and developing as they sleep and rest and you want to limit stimulation. That means, I don’t want to be unnecessarily interrupting that rest phase when maybe a baby just got put back to bed and swaddled. Timing really matters and a lot of close teamwork helps, regardless of whether it’s NICU or PICU or in the acute floor setting. We rely on feedback from our nurses, physical therapists, occupational therapists or speech therapists in terms of the infant’s muscle tone, oral condition, as they may be seeing more about the patient than we would such as rashes or oral thrush. So I think that's helpful to know that we don't necessarily have to be the ones to discover a physical observation, but we want to be aware of it, uncover it through the team, and through our observation, and whenever possible, to have hands on care as appropriate. Some things such as fluid status, you can look at, such as periorbital edema. I always try and look at the arms and thighs of a baby when the nurse has the baby unwrapped. A baby can look big and beefy from the neck up when they are wrapped and then you see the arms and thighs. And even without doing measurements, you can assess that they still have some repletion of stores ahead of them. And then of course, looking at the baby’s eyes, hair, and skin. We recently had a baby in extended recovery from cardiac surgery who developed chylothoraces and had a pretty long time of inadequate nutrition and his hair began to show some of the symptoms that relate to zinc deficiency. We don't routinely check zinc levels, but this baby was one that we identified as at a high risk of zinc deficiency. So there is room for the nutrition focused physical exam, although it may look a little different in the NICU. And certainly, during 2020, it's probably looked different for many of us, but it still can be done relying on team information at times.

KH: I think you make a good point about team work, especially when it comes to the NICU population. The need to bundle the baby, while also trying to do those visual evaluations at the same time can be a challenge. These babies are growing at such a mighty rate and any disruption in that can disrupt that growth. And so I think team work, as you said, is key. And I'm glad you mentioned linear growth and link boards too, because that is something that so many hospitals still struggle with. And it does seem like such a simple thing and yet, it is so foundational to the recommendations that we make and the trends that we watch. And so I think that definitely plays in very well into the other aspects of the physical exam are that you described. It’s a big complex picture to manage these babies. I think we would all agree that identifying aspects of malnutrition in our patients is important and helps us to prepare appropriate nutrition care plans and treatment strategies to assist our patients. Also, I think we would all agree that doing that as early as possible is important. But I want to give you guys a chance to verbalize to our audience of why is it so important for us to be focusing on malnutrition so early on.

PP: Great question. Every infant and every child is actively growing and developing and so therefore, each stage is a critical stage. So if they are lacking the resources for that growth and development, we really want to identify that and intervene as quickly as possible. I think the other thought is, as we look at growth measurements, and we're watching a trajectory, whether weight or length, or in some populations, head circumference, I compare it to how you aim an arrow at a target. If you're even just a little bit off, the further out you go, that distance from your target becomes greater. A lot of times when I'm teaching residents, I compare nutrition to financial debt. You can either pay it (debt) now or pay it later. And I'd rather make up a shortfall sooner and prevent a larger deficit that's more costly to the patient.

KH: That's a great analogy.

MH: I can add to that as well. As Patti mentioned growth is the forefront of what we do. And we know that it's so important to identify it early because nutrition is the building block of us. And we know the negative side effects of malnutrition are not unnoticed. Kids that are malnourished have poor wound healing, they have poor overall growth. You know, one may joke, “oh, they're just little” but that may be stunting them for further development down the road, as well as impairing their cognitive ability to develop too. We know malnutrition prolongs hospital length of stay, and kiddos do have increased risk of mortality and morbidity, if they are more malnourished. So as Patty mentioned, the healthcare cost of treating malnutrition goes up. So really identifying early can save lives, as well as cost savings, save hospital dollars. Everyone wins when we identified early.

KH: I like that everybody wins. What do you think are some of the biggest challenges to putting this into practice in the clinical setting?

MH: There are a lot of challenges. So, as we mentioned before it is understanding the utility of the guidelines and using your best clinical judgment when you're diagnosing somebody with malnutrition. When you look at the indicators, for example, weight loss, if one person has greater than 10%weight loss, the consensus doesn't really tell you in what time frame is that weight loss considered severe. So, I might have a 16-year-old that comes in with a cardiomyopathy, who has been aggressively diuresed and lost 11% of their body weight in just a week, you could diagnose them as severe malnutrition based on that. And so, making sure that we're adequately assessing the malnutrition and that your interventions and your indicators are supporting that diagnosis. This is where you would try to use multiple data points to really formulate that malnutrition diagnosis because if it is severe malnutrition, you need to add it to the problem list. It needs to be documented with the team discussion with the family and the patient. The awareness of that diagnosis for that patient is elevated and taken very seriously. I think the challenges with some of the indicators are the lack of time intervals used to diagnose. And then of course, the non-nutritional factors like if there's a genetic component to the reason why their length or height z scores are negative three, acknowledging that and including that in our clinical judgment. So those are the big challenges that we face, I think, on a daily basis when you are trying to assess and decide, okay, is this person really moderately malnourished, mild, malnourished, or severe? It's a challenge.

PP: It’s hard to add much to what you said. I think one of the things I've noticed is, I mentioned about anthropometrics, and the accuracy of the measurements, but a lot of times the measurements may be accurately obtained, but each one, linear as well as weight and even head circumference, can be influenced by edema, right? During acute illness, there could be edema that would influence the weight and you see much fluctuation, so that also speaks to the interval. What is an appropriate interval of time that truly reflects weight gain apart from edema and/or use of diuretics. So many children and infants in our ICU’s are going to have phases when they need diuresing. And so, knowing how to sort out true weight gain or not, and then the fact that everything is referenced to a standard. And especially I think, in the preterm and early term infants, the first month of life, we're still learning the validity of our standards. As you know, there's a lot being written about growth standards, and also nutritional estimations of appropriate calories. Especially for a child who's intubated and sedated, we might need to use some clinical judgment in identifying what are goal calories, and what is our goal protein intake. The indicator has a certain number of days for the neonatal criteria that the patient is below 75% of estimated needs. Your estimated needs need to be supported not only by the literature, but by your clinical assessment of the patient. So, all of those things can be like a ball of yarn, as to which comes first. There's a lot of things to take into account as you look at the whole picture of how the patient is doing, and decide what interval accurately reflects progress or lack thereof.

MH: I was going mention that Sandra Bouma published an article in 2017 reporting on their experience of using the malnutrition criteria and she talks about the burden of proof. She discusses how well-nourished children fall between negative two and positive two standard deviation and how the clinician’s job is really to prove that the child is not malnourished. So, it's an interesting article and further supports us as clinicians getting out there and continuing to do quality improvement work on how to validate and how to utilize these indicators.

KH: That's great. Thank you so much. We'll be happy to link that in our show notes. I want to ask about charting, and billing and reimbursement. And I'd love to hear from both of you about if there's ICD 10 codes linked to this diagnosis and how that's being handled. How you chart with this, and again, about billing and insurance if you're aware of those issues.

PP: Yes, I can share what we do currently at our institution at both our NICU and in pediatrics. Yes, there are ICD 10 codes, mild protein calorie malnutrition, moderate, and severe PCM. They’re an E series, E 44.1, etc. We avoid using “failure to thrive.” We’ve learned, according to our coding department, that FTT is not related to an ICD 10 code that would alter reimbursement as it's a very vague term, so it's not included. Once we identify nutrition and the severity, we do have a template for a malnutrition note. We would include our malnutrition diagnosis with, as Megan said, the etiology or symptoms and how measured. And then we add that to the patient’s problem statement. We were able at our center to gain permission for the dietitians to add a malnutrition diagnosis to the patient problem list. In the NICU we are doing currently, and again, this is our first year seeing how everything goes and looking at outcomes. We currently use “suboptimal nutrition” in our notes and in the patient's problem list. Then the attending reviews the note as well as the problem. We feel that this really helps highlight the importance as well as keeps it evident as the patient may be discharged and seen by primary care providers or specialty clinics, so they also can be aware of problem, what was done, and also what may still need to be done.

MH: And to add to Patty's response, we have a similar standardize note that includes the malnutrition indicators that we would use to document on each patient that we see. It also includes your nutrition diagnosis statement. In order for our physicians to actually bill for malnutrition, it has to be part of the problem list. You know, we can have our diagnosis statement in our note, but it has to be added to that problem list and the physician has to document on it in their note as well. We are also allowed to add malnutrition to the problem list. But again, if you're adding it to the problem list, you should be having a conversation with the medical team and the family should be aware that it has been added to the problem list. Having malnutrition as part of your problem list actually can impact the complexity score, which furthermore can potentially impact your reimbursement dollars for that patient scenario. In addition, I think adding it to the problem list is important because not only are you increasing the awareness of the problem or the patient, but the whole team is also aware across different services. This is where quality improvement work begins to flourish if you are pulling data on how many moderate malnourished patients that you have in your hospital. It may become a dashboard outcome, so I think it's really important that we document it in our note what we're doing about it what our interventions are. The physicians also have to be documenting on it too.

KH: Oh, I totally agree, I think having it in that problem list and then having it in a place where it can be easily pulled through retrospective chart reviews for research and QA projects is, is so critical to help us with these milestones to show what our rates are, and the incidence of malnutrition and different severities of malnutrition in the units, and then where those improvements have been happening, and to show trends over time. So that's very exciting to see, once malnutrition has been identified by you communicated with the team added to that problem list. What are some of the next steps that clinicians can take? And are there any real changes to a nutrition care plan? Is there something that a dietitian would focus on differently? Or does this just bring yet more attention to the patient's nutritional status to the rest of the team involved than we've had in the past?

PP: Again, that's a great question. And I think that starts upon admission with the nutrition screen by the nurse. There's been quality improvement projects looking at what screening tool is in place, and how well is it capturing patients who really need to be seen? Or are there too many false positives and perhaps dietitian resources are being stretched thin and not able to see the patients who really need them? So starting right from the beginning with the screening tool, I think it's important that this whole work of highlighting and focusing on identifying malnutrition and doing it well is important each step along the way, including nurse training in application of the screening tool. And then how is that screening result communicated to the dietitians? How do they know to prioritize which patients they see? When you identify malnutrition in a patient and identify that in your note, and in the problem statement, communicating with the team, as Megan said, which is always vital, this all can shine a light on the problem of malnutrition, which has characteristically been underdiagnosed both worldwide as well as in the US. So, it increases visibility to all members of the medical team. And helps I think families to understand why an intervention is important. I know in the NICU, when we need to fortify or increase calories, or maybe increase volumes, sometimes that's hard for families to understand. They may see it as a barrier to their baby progressing, right? Or they're afraid of a change they haven't heard of, such as fortification? What's that mean? What does it look like? Will they tolerate it? And so, the more that we talk about the interventions to help correct undernutrition, the more support you have in all aspects, and families also can be become part of the solution. So, I think that's a benefit of having a quantifiable way to talk about the infant’s nutritional needs, instead of just saying they're “growing pretty well” or “growth is fair.” Instead of using subjective terms, it enables us to quantify and have more specific targets, and then be able to measure the progress and also to know when we need to revisit and alter the plan.

MH: Well, Patti, I think you said it all. I don't have too much to add other than that it just causes you to act, once you've identified the malnutrition, your next step is how are you going to improve that malnutrition and prevent any negative side effects of the malnutrition? I mentioned already that how much awareness is gained from that, but the biggest thing is that it causes you to act. And I think the more support you have as a whole team and with the family, your family becomes part of the solution and things improve.

KH: I love getting the families involved. How often should we be reevaluating malnutrition status? And when we are doing that reevaluation, is there a difference in that acute versus chronic malnutrition that you've talked about?

MH: I think you should be reevaluating malnutrition, especially in a hospitalized patient, every time you go to assess that patient or reassess that patient. For majority of us, I believe it's anywhere from seven to 10 days that you are seeing that patient so I think it should be reassessed every time, especially if you're creating interventions or if you're monitoring interventions. If they were ineffective, or no longer appropriate you need to modify and change those interventions. In the setting of critical illness, your needs are changing every day. When we talk about metabolic monitoring, the gold standard for metabolic testing would be every three days. I'm constantly reassessing, especially in a critical care setting. The more stable that patient gets maybe your interval time in between your assessment gets a little bit longer but there's always opportunity, I think, with every assessment to improve the nutrition of a patient, whether its education related or actual physically making a change. Regarding your question about acute versus chronic malnutrition – certainly if they have a chronic disease, like cystic fibrosis, or if they were just diagnosed, those patients may be acutely malnourished and change over to more chronic and that's where you'll see more of that stunting or linear effect in the linear growth. Certainly, you need to be cognizant of that and really trying to prevent the negative effects of that happening.

PP: Well said Megan. I'll just add a little more about the outpatient setting. We've had NICU grads who we know have not been able to be reevaluated and seen in follow up as closely as we might want. So that was actually what gave a large push to our being able to identify malnutrition and add it to the problem list in hopes of identifying who was at risk of undernutrition after they leave the NICU. They may need closer follow up than our usual timeframe for either NICU follow up clinic or through a specialty clinic or primary care provider. We've not yet been able to track this outcome, but it is one of our data collection plans to answer if the patients that we identified during the NICU stay do indeed have closer follow up, and fewer readmissions in their future. So that's part of encouraging closer outpatient follow up of these nutrition-related measurements.

KH: So, Megan, I know you mentioned that other study previously, but I was interested into seeing if anybody has published anything about validating these guidelines and criteria yet and what are other people finding?

MH: So the article I mentioned by Bouma does talk about reviewing and providing their experience to date on the criteria. There is an AND study going on. It's called the Validation of the Malnutrition Clinical Characteristics and Staffing Optimization Study.” It's not complete so the data is not there yet, but I believe it's around 95% complete is what I've heard. We are a part of it here at Cincinnati Children's but there's like six aims to the study and it's looking at both pediatric and adult malnutrition criteria. So, I believe there's 160- 60 adult and 60 pediatric hospitals and just a couple of the aims are assessing the inter-rate reliability of the malnutrition and clinical characteristics, as well as the training of the actual dieticians. So it's very complex of a study, but it is an ongoing study. And that's all I'm aware about as far as any other validation studies. I'm not sure if Patti is aware of more.

PP: No, I don't know of other studies. I think the mid upper arm circumference as a criteria is part of this study that you just referred to, and I think although it’s not in the neonatal indicators, that using it is part of our plan going forward, to incorporate mid upper arm circumference more often as we work with identifying malnutrition in our unit. The hope is that evaluation of all of these criteria will be able to provide more data and feedback for all of us going forward.

KH: Well, I'm always a proponent of doing more research and getting more data. So I'm excited to be look forward. Looking forward for that. So as we close up today, I just want to make sure that we haven't missed anything. And if there's anything in particular that you'd like to make our listeners know about when it comes to diagnosing and addressing malnutrition.

PP: I'll go ahead and jump in. I think that I’ve just started to work with the neonatal indicators, and also have talked with Dena Goldberg, the lead author of the consensus statement, who is a fellow founding board member of the Virginia neonatal group, so time to time, I get to pick her brain, which is a wonderful opportunity. And Dena emphasizes that it's the neonatal indicators are a place to begin. And there's much that we are still learning; it's a work in progress. I think many, many people will continue to contribute towards that. I just read an article, “Counting the Weighs” which provides growth velocity tables for preterm infants, by Jacqueline Keller, and it's excellent! I think it's brilliant. And this will help to provide other references for our measurements so that we can eventually know that what we are comparing infant’s growth to, really is an appropriate standard for that particular infant. So, there is much to learn, and I look forward to that!

MH: I would agree, and I certainly get excited about identifying and diagnosing malnutrition. You know, a lot of times the dietitian is the first provider that might find something like a micronutrient deficiency identified as part of your focused exam. You raise concerns to the medical team, and you've identified that this patient has a deficiency. Don't be afraid to utilize the criteria and test them out. You can always reevaluate what you're testing out. It's like Patty mentioned, it's kind of a moving target, you're learning as we go. But dietitians can have such an impactful outcome on a patient if they are assessing that patient for malnutrition and identify malnutrition early. There's so much excitement and work around this. There's so much opportunity to have dietitians be part and drive this research so I think the takeaways from my standpoint are to really practice and act on it. Continue to ask questions and grow in learning about this malnutrition criteria and how to diagnose.

KH: Well, thank you so much to both of you for your time today. It has just been a pleasure to talk with you about malnutrition, and helping our listeners understand a little bit more about the criteria and what's involved with that. And then and then how we can take steps to utilize that criteria and really making an impact in the baby's care or pediatric care as well. So, thank you so much and to our listeners. links to information discussed will be available in the show notes. And as always, we look forward to bringing you future topics on the science of human milk

References:

Becker P, Carney LN, Corkins MR, et al. Consensus statement of the Academy of Nutrition and Dietetics/American Society for Parenteral and Enteral Nutrition: indicators recommended for the identification and documentation of pediatric malnutrition (undernutrition). Nutr Clin Pract. 2015;30(1):147-161. doi:10.1177/0884533614557642

Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr. 2013;37(4):460-481. doi:10.1177/0148607113479972

Bouma S. Diagnosing Pediatric Malnutrition: Paradigm Shifts of Etiology-Related Definitions and Appraisal of the Indicators. Nutr Clin Pract. 2017;32(1):52-67. doi:10.1177/0884533616671861