Malnutrition

Definition

As defined by A.S.P.E.N. (American Society for Parenteral and Enteral Nutrition), pediatric malnutrition (undernutrition) is “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.”

Chronically ill and hospitalized patients have an exceedingly higher risk for developing malnutrition, with prevalence rates 24% to 50% worldwide , yet in routine practice only 4% of patients are recognized

Basic Assessment Criteria for Malnutrition:

Any of the following can be indicators of malnutrition, and must be investigated further to deduce if malnutrition exists, severity of diagnosis, and need for consultation/implementation of interventions:

High risk factors including any chronic disease, infection, trauma, malabsorption, malignancy, cystic fibrosis, gastrointestinal disease, neurological impairment
Weight loss or decline in weight gain velocity/inadequate weight gain velocity
Inadequate nutrient intake either via mouth or nutrition support
Fat loss and/or muscle wasting

Malnutrition Severity


Severe Protein Calorie Malnutrition
Single Data Point Indicators: Weight-for-Length OR BMI-for-age z-score of ≤ -3 Length/Height-for-age z-score of ≤ -3 *MUAC z-score of ≤ -3
Multiple Data Point Indicators(2 or more): Weight Gain Velocity (<2 years of age): <25% of the norm expected weight gain for age Weight Loss (2-20 years of age): ≥10% of usual body weight Decrease in z-score Weight-for-Length or BMI-for-age of ≥3 ≤25% Estimated Energy/Protein needs for at least 2 weeks Presence of both Fat Loss and Muscle Wasting


Moderate Malnutrition
Single Data Point Indicators: Weight-for-Length OR BMI-for-age z-score of -2 to -2.9 *MUAC z-score of -2 to -2.9
Multiple Data Point Indicators(2 or more): Weight Gain Velocity (<2 years of age): 25%-50% of the norm expected weight gain for age Weight Loss (2-20 years of age): 7.5%-9.9% of usual body weight Decrease in z-score Weight-for-Length or BMI-for-age of 2 to 2.9 26%-50% Estimated Energy/Protein needs for at least 2 weeks Observed/Presence of Fat Loss and/or Muscle Wasting


Mild Malnutrition
Single Data Point Indicators: Weight-for-Length OR BMI-for-age z-score of -1 to -1.9 *MUAC z-score of -1 to -1.9
Multiple Data Point Indicators (2 or more): Weight Gain Velocity (<2 years of age): 50%-75% of the norm for expected weight gain Weight Loss (2-20 years of age): 5%-7.4% of usual body weight Decrease in z-score Weight-for-Length or BMI-for-age of 1 to 1.9 51%-75% Estimated Energy/Protein needs for at least 2 weeks Observed/Presence of Fat Loss and/or Muscle Wasting

Tips For Documentation

Diagnosis Document Code:

Dietitian to document malnutrition chronicity, severity and supporting evidence
Physician to document severity of malnutrition in progress note and add diagnosis to hospital problem list

“Failure to Thrive” codes at the same level as “Mild Malnutrition”
“Severe Failure to Thrive” does NOT equate to “Severe Protein-Calorie Malnutrition”
Documenting “Poor Feeding” and/or “Poor Weight Gain” does NOT equate to a malnutrition diagnosis for the patient.

When documenting, remember:

Severity of Illness (SOI) AND Risk of Mortality (ROM) increase with worsening MALNUTRITION
Check MUAC z-scores on Compass growth chart “TABLES” to help assess the degree of malnutrition
*MUAC = Mid-Upper Arm Circumference

Finding a Z-Score

Units of standard deviation from the “normal range”

A statistical measure that tells how a single data point compares with normative data

Found in EMR under growth charts if you click on “Table”. The table will populate the z-score. (Refer to images beside and below to become familiar with the format)

Malnutrition Indicators for Cystic Fibrosis


	Weight-for-Length on WHO Growth Chart (0-2 years) OR Body Mass Index (BMI) on CDC Growth Chart (2-20 years)	Percentage of Weight Loss Based on Usual Body Weight
Mild Malnutrition	> 25th – 50th percentile	< 2.5%
Moderate Malnutrition	> 10th – 25th percentile	2.5 - 5%
Severe Malnutrition	<= 10th percentile	> 5%

Quick Tips!

Failure to Thrive vs. Malnutrition
**Failure to Thrive EQUALS Malnutrition**


MUAC Z-score	Degree of Malnutrition
-1 to -1.9	Mid (FTT)
-2 to -2.9	Moderate
<= -3	Severe

When documenting, remember:
Severity of Illness (SOI) AND Risk of Mortality (ROM) increase with worsening MALNUTRITION

Check MUAC z-scores on Compass growth chart “TABLES” to help assess the degree of malnutrition
*MUAC = Mid-Upper Arm Circumference