Dena Goldberg, PhD is a registered dietitian at the neonatal intensive care unit at Carilion Children’s Hospital in Roanoke, Virginia. She has spoken at webinars and conferences and written articles on the use and implementation of malnutrition indicators with preterm infants and neonates. She chaired the AND PNPG ad hoc committee that developed the preterm/neonatal nutrition indicators. Prior to joining Carilion Children’s Hospital, Dena worked for several years in public health nutrition and academia.
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.
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. Keli is also a member of the Nutrition Advisory Committee (NAC), a group of leading registered dietitians with firsthand, clinical experience using an exclusive human milk diet with neonatal patients and the science behind it.
Keli Hawthorne (KH): Hey y’all, welcome to Speaking of Human Milk, where we give you bite-size 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. I’m your host Registered Dietitian Keli Hawthorne. Today, we will be discussing the evolution of new guidelines for pediatric malnutrition with Dr. Dena Goldberg, a registered dietitian at Carilion Children’s Hospital in Roanoke, VA. Dena Goldberg has worked at Carilion Children’s in Roanoke, VA as the NICU dietitian for the past 14 years with a focus on quality improvement and research. She chaired the AND PNPG ad hoc committee that developed the preterm/neonatal nutrition indicators. She has spoken at webinars and conferences and written professional newsletter articles on the use and implementation of the preterm/neonatal malnutrition indicators. Prior to joining Carilion Children’s Dena worked for several years in the areas of public health nutrition and academia. Thank you for joining us, Dr. Goldberg.
Dena Goldberg (DH): It’s a pleasure to be speaking with you.
KH: We’re excited to have you on and hear about neonatal and preterm infant malnutrition guidelines. As many clinicians are aware, malnutrition in the hospital setting is a hot topic lately, and there have been some new guidelines issued to help with diagnosing and standardizing documentation. In 2015, the Academy of Nutrition and Dietetics along with ASPEN, the American Society for Parenteral and Enteral Nutrition, published a consensus statement about identifying and documenting pediatric malnutrition, and as chair of the committee for this paper we’re very happy you can be here to help explain more about it. Where did this push for concern about pediatric malnutrition come from?
DG: As you aware there's been increased attention on defining and diagnosing malnutrition in clinical settings, as well on the financial impacts and outcome research. Pediatrics RDs needed a tool that was appropriate for pediatric patients and so the pediatric consensus statement was published. However, this consensus paper did not include preterm infants and neonates and in response to requests by NICU dietitians the Academy of Nutrition and Dietetics Pediatric Nutrition Practice Group formed an ad hoc committee that published recommended indicators for diagnosing malnutrition in preterm infants and neonates.
KH: So tell me Dr. Goldberg has there been any concern about dietitians making diagnoses? Is that part of our expertise? DG: Diagnosing malnutrition is within the scope of practice of the RDN. It is a nutrition diagnosis. As part of the nutrition care process RDNs assess, diagnose, intervene and monitor nutrition diagnoses. RDNs insert NG tubes, prescribe TPN components, diagnose obesity- how is this different?
KH: How does the criteria for malnutrition in premature infants and neonates differ from those developed for the general pediatric population?
DG: The preterm/neonatal malnutrition indicators take into consideration the more rapid rate of growth and the more rapid development of malnutrition in preterm infants and neonates. The preterm/neonatal malnutrition indicators do not include a decline in weight for length/height z score as an indicator. Although BMI curves have been developed for this population, they were developed to be used in conjunction with other growth measures rather than a replacement for weight or length for age curves. Additionally, research is inconclusive that BMI identifies disproportionate growth in neonates. The preterm/neonatal malnutrition indicators include a decline in weight for age z score and days to regain birth weight as indicators. The preterm/neonatal malnutrition indicators include a time period for inadequate nutrition as nutrient needs are higher and nutrient stores depleted more rapidly in this population.
KH: And how did the committee identify these criteria as the best indicators to use for diagnosing malnutrition in infants?
DG: The committee of eight experienced neonatal RDNs used an evidence informed consensus driven process similar to that used in the development of the pediatric indicators. The process included a thorough literature review and consultation with a nationally known expert in growth and nutrition assessment of preterm infants and neonates. These recommendations are not a multidisciplinary consensus statement. Rather, the indicators are objective criteria and provide practicing NICU clinicians with a starting point for data collection and evaluation of outcomes. The overall goal is thus to facilitate a multidisciplinary effort to identify those NICU patients at greatest risk for deleterious outcomes associated with early suboptimal nutrition. Without doubt, these indicators will be modified over time as new malnutrition assessment techniques become available and as NICU RDNs gain experience with the tool, collect data, fine tune the criteria, and confirm the validity
KH: What about malnutrition indicators in the NICU population? How do clinicians utilize these guidelines for our NICU babies? DG: The development of the indicators was based on the evidence that poor growth and nutrition are related. Research indicates that variations in growth rates between NICUs can be attributed to variation in nutrition practices and that Improved nutrition reduces the difference between birth and discharge weight z scores. But growth failure can also occur in the context of prematurity related illnesses such as CLD, CHD, gastrointestinal insult as well as medical treatments such fluid restriction and use of diuretics and corticosteroids. Thus, clinical judgement is required to identify malnutrition and its etiology. I cannot emphasize this enough. Not every infant with a decline in z score greater than -0.80 or growth velocity < 75% of expected is malnourished. The infant’s complete growth history and medical history should be taken into consideration. Fluid accumulation occurs in conditions such as hydrocephalus and renal or cardiac anomalies and correction of the fluid imbalance may influence weight gain velocity There are 2 categories of indicators. One category is appropriate to diagnose malnutrition based on a single indicator and the other category requires 2 or more indicators to diagnose malnutrition. For the single indicator category, a decline in either weight-for-age z-score or weight gain velocity can indicate malnutrition, but they are not appropriate for the first 2 weeks of life due to postnatal diuresis. During that time, inadequate nutrient intake should be used. For the other indicators requiring more than 1 indicator; days to regain birth weight, length growth velocity, or length-for-age z-score can be used in conjunction with nutrient intake or decline in weight for age z score or weight gain velocity to diagnose malnutrition status.
KH: Are there any guidelines attached to z-scores to identify if the baby has mild, moderate, or severe malnutrition?
DG: Yes, a decline in weight or length-for-age z-score of 0.8-1.2 indicates mild malnutrition, 1.2-2 indicates moderate malnutrition, and >2 indicates severe malnutrition. This differs from the Pediatric Consensus Statement.
KH: As we know, preterm infants have an initial period of postnatal diuresis and it can take up to 2 weeks to regain their birth weight, depending on the size and medical condition of the baby. How do these guidelines help to account for that initial weight loss?
DG: Yes, most but not all infants regain birth weight by day of life 14. To account for this, days to regain birth weight requires a second indicator to make the diagnosis of malnutrition. Inadequate nutrient intake is the recommended second indicator as it is easily quantified. And days to regain birth weight are broken down by mild malnutrition being 15-18 days to regain, moderate is 19-21 days to regain, and severe malnutrition is >21 days to regain birth weight.
KH: Growth is a key factor for every baby. How does the guidelines address the various ways we evaluate growth, such as g/kg/d velocity versus g/d versus z-scores versus percentiles?
DG: The committee recommended use of g/d rather than g/kg/d for the following reasons Z scores rather than percentile are recommended for the following reasons:
KH: How do clinicians use the nutrient intake indicator to diagnose malnutrition?
DG: Enteral and parenteral energy and protein recommendations are included in the preterm neonatal malnutrition indicator paper. For infants transitioning from parenteral to enteral nutrition estimates for protein and energy goal can be derived from the percent of kcal and protein from enteral feedings and the percent from parenteral nutrition. For example, for an infant receiving 60% of kcal and protein from parenteral nutrition and 40% from enteral nutrition the midpoint of the requirements for enteral and parenteral nutrition can be multiplied by the by the percent of each, and then added together. The degree of malnutrition depends on the length of time that the infant has been receiving <75% of their protein or energy needs. 3-5 consecutive days for mild malnutrition, 5-7 days for moderate, and equal to or greater than 7 days for severe.
KH: What’s the importance of using linear growth as an indicator of malnutrition?
DG: The relationship between linear growth, brain development and neurocognitive outcomes is well established. Preterm infants at term have greater fat mass and less lean body mass compared to term infants suggesting that a decline or deceleration in linear growth may indicate malnutrition. Since linear growth requires adequate macro and micro nutrient intake, it is recommended that linear growth be used in conjunction with another indicator such as inadequate nutrient intake. Length measurements need to be obtained using correct technique and be accurate in order to be used to diagnose malnutrition. Accurate measurements can be difficult to obtain. Length measurements may be deferred in critically ill unstable infants.
KH: Why aren’t head circumference growth or midupper arm circumference (MUAC) considered an indicator of malnutrition?
DG: Microcephaly and macrocephaly are often due to an underlying pathophysiology. Head circumference growth that differs significantly from expected may indicate complications of prematurity such as IVH with hydrocephalus or other brain anomalies. The definition of microcephaly is inconsistent in the literature. Furthermore, head circumference is believed to be spared during periods of undernutrition. Faltering head circumference growth may support the diagnosis of moderate to severe malnutrition based on weight and length. A head growth velocity that falters independently of weight and length should be investigated for causes other than inadequate nutrition intake. MUAC does provide information regarding body composition and therefore may be useful in making a diagnosis of malnutrition. Due to lack of appropriate references, the preterm/neonatal ad hoc malnutrition committee did not include MUAC as an indicator of malnutrition.
KH: I’d definitely need a cheat sheet to get started with all this. I would think that a lot of our premature babies may be born and immediately would be at risk based on their size and intrauterine growth restriction. Do we start diagnosing malnutrition at birth or is there guidance to wait a certain period of time before starting to identify malnutrition in a newborn?
DG: The indicators do not identify malnutrition at birth as the information to determine whether intrauterine growth retardation was due to malnutrition is not always available. An infant can be small for gestational age but not malnourished due to genetics. Likewise, an AGA infant could have experienced IUGR. Nutrient intake is the most appropriate indicator during the first 2 weeks of life, but the infant will not immediately meet recommended nutrient intake
KH: Are there ICD-10 codes linked to this diagnosis? How’s that being handled? And how is this charted?
DG: Yes, there are ICD -10 Codes for the diagnosis of malnutrition. They are Failure to thrive is not recognized as malnutrition by insurance companies and thus will not be coded as malnutrition Keep in mind that It is not common for the diagnosis of malnutrition to impact severity of illness/risk of mortality and thus reimbursement In my institution, the coders will query the provider if my diagnosis of malnutrition is not included in the progress notes if they believe the diagnosis of malnutrition will increase severity of illness/risk of mortality and thus reimbursement Even if the diagnosis of malnutrition does not increase reimbursement, malnutrition on the problem list keeps the nutrition care plan in the fore front and alerts the post discharge provider to the need to monitor nutrition and growth closely The RDN should document all indicators to support the diagnosis in the assessment, as well as the etiology, in case insurance companies question the malnutrition diagnosis
KH: What’s the next step for clinicians once malnutrition has been identified? Are there any changes to a nutrition care plan or does this just bring more attention to the patient’s nutritional status than we’ve had in the past?
DG: Once the diagnosis has been made, the nutrition care plan should be evaluated to ensure that nutrition is optimized given any medical complications. The impact of the intervention should be revaluated and adjusted as indicated. Nurses and care givers play an important role in the implementation and evaluation of the care plan and they should be involved.
KH: How often should clinicians re-evaluate malnutrition status? Is there a difference in acute vs chronic malnutrition when it comes to re-evaluting?
DG: Malnutrition status should be reevaluated weekly as the NICU infant’s nutritional and medical status can change quickly. The preterm/neonatal malnutrition indicators do not differentiate between acute and chronic malnutrition. The preterm/neonatal indicators do not diagnose malnutrition at birth as the information to make the diagnosis is often not available.
KH: Is there anything else you want to make sure our listeners know about diagnosing malnutrition in the premature and neonate populations?
DG: I want to again emphasize the importance of clinical judgement taking into consideration clinical status, medical treatment, nutrient intake and growth pattern. Although the NICU RDN may not be able to observe fat and muscle store, abdominal protuberance, and skin integrity especially in a critically ill infant needing minimal stimulation, input can be obtained from the bedside nurse, physician, or neonatal nurse practitioner. It is also important to emphasize to the health care team that a diagnosis of malnutrition does not mean suboptimal care. Due to complications of prematurity such as chronic lung disease, feeding intolerance and gastrointestinal issues and medical management that necessitates fluid restriction, use of diuretics, and steroids, it may not be possible to optimize nutrition and growth. There are recent publications on the implementation and use of the preterm/ neonatal malnutrition indicators with case studies in last winter’s PNPG Building Block for Life and the most recent Pediatric Currents. More materials are being developed. Feel free to contact me with questions.
KH: It’s been great speaking with you Dr. Goldberg and I appreciate you talking with us about such an important topic that affects our practice. To our listeners, thank you for listening to this week’s episode of Speaking of Human Milk, powered by Prolacta Bioscience, a company dedicated to Advancing the Science of Human Milk. For more information on the company visit www.prolacta.com. As always, links to resources discussed in this episode are in the description. Thanks again for listening.