Pediatric Nutrition in Practice

12 Puntis

cut-off have a highly elevated risk of death [7].
BMI is derived from weight in kilograms divided
by the square of the height in metres (kg/m^2 ); it is
an alternative to ‘weight-for-height’ as an assess-
ment of nutritional status [8]. In a mixed popula-
tion of hospital inpatients there will be only a
slight difference in malnutrition prevalence us-
ing the SD score for either BMI or weight-for-
height.

Classifications of Malnutrition

There is no single, universally agreed definition of
malnutrition in children [9, 10] , but the criteria
shown in table 1 are commonly used. The classi-
fication does not define a specific disease, but
rather clinical signs that may have different aeti-
ologies. Other nutrients such as iron, zinc and
copper may be deficient in addition to protein
and energy.
The Wellcome classification of malnutrition is
based on the presence or absence of oedema and
the body weight deficit ( table  2 ). Severe acute
malnutrition in children aged 6–60 months is
now defined by the WHO as weight-for-height
below –3 SD or MUAC below 115 mm [7].

When to Intervene

Malnutrition is a continuum that starts with a nu-
trient intake inadequate to meet physiological re-
quirements, followed by metabolic and function-
al alterations and, in due course, by impairment
of body composition. Malnutrition is difficult to
define and assess because of insensitive assess-
ment tools and the challenges of separating the
impact of malnutrition from that of the underly-
ing disease on markers of malnutrition (e.g. hy-
poalbuminemia is a marker of both malnutrition
and severe inflammation) and on outcome. Nu-
tritional intervention may be indicated both to
prevent and to reverse malnutrition. In general,

the simplest intervention should be followed, if

necessary, by those of increasing complexity. For

example, energy-dense foods and calorie supple-

ments before progressing to tube feeding (see

Chapter 3.3). Parenteral nutrition should be re-

served for children whose nutrient needs cannot

be met by enteral feeding (see Chapter 3.4). When

simple measures aimed at increasing energy in-

take by mouth are ineffective, tube feeding should

be considered [11] ; the following are suggested

criteria [12] :

• Inadequate growth or weight gain over >1
  month in a child aged <2 years


• Weight loss or no weight gain for >3 months
  in a child aged >2 years


• Change in weight-for-age of more than –1 SD
  within 3 months for children aged <1 year


• Change in weight-for-height of more than –1
  SD within 3 months for children aged >1 year


• Decrease in height velocity of 0.5–1 SD/year at
  an age <4 years, and of 0.25 SD/year at an age

  
  

  4 years

  
  

  
  


• Decrease in height velocity of >2 cm from the
  preceding year during midpuberty

Conclusions

• A detailed feeding history should be part of
  routine nutritional assessment


• Expert dietetic assistance is required for more
  objective assessment of nutritional intake, and
  for appropriate further management


• Accurate assessment of growth by careful
  measurement and reference to standard
  growth charts is essential to define and moni-
  tor nutritional status


• Malnutrition is a dynamic and complex pro-
  cess, without clearly agreed definitions


• The clinical status and particular needs of
  each individual child require careful evalua-
  tion when planning nutritional support

Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 6–13

DOI: 10.1159/000360311