SHORT REPORT

Paediatric nutrition risk scores in clinical practice: children

with inammatory bowel disease
A. E. Wiskin,* D. R. Owens, V. R. Cornelius,* S. A. Wootton* & R. M. Beattie
*NIHR Biomedical Research Unit (Nutrition, Diet & Lifestyle), Southampton, UK
University of Southampton, Faculty of Medicine, Southampton, UK
Paediatric Medical Unit, University Hospital Southampton NHS Foundation Trust, Southampton, UK
Introduction
Despite different denitions of malnutrition, nutritional
assessments based on height and weight demonstrate that
between one-fth and one-quarter (Pawellek et al., 2008;
Joosten et al., 2010) of paediatric inpatients are malnour-
ished. Recent guidance from the British Association of
Parenteral and Enteral Nutrition suggests that, in addition
to plotting growth measurements on an appropriate
growth chart, tools for detecting nutritional risk should
also be employed (Brotherton et al., 2010). This is sup-
ported by European Society for Paediatric Gastroenterol-
ogy, Hepatology and Nutrition guidance indicating that
one of the main functions of a nutrition team is to screen
for nutrition risk (Agostini et al., 2005).
Four non-disease specic nutrition screening tools
designed for paediatrics have been developed for use:
Screening Tool for the Assessment of Malnutrition in
Paediatrics (STAMP) (McCarthy et al., 2008); Screening
Tool for Risk On Nutritional status and Growth
(STRONGkids) (Hulst et al., 2010); Paediatric Yorkhill
Malnutrition Score (PYMS) (Gerasimidis et al., 2010);
Keywords
inammatory bowel disease, nutrition risk,
nutrition risk screening, paediatrics.
Correspondence
R. M. Beattie, Paediatric Medical Unit,
Southampton General Hospital, Tremona
Road, Southampton, Hampshire S016 6YD,
UK.
Tel.: +44 (0)2380 798688
Fax: +44 (0)2380 796888
E-mail mark.beattie@suht.swest.nhs.uk
How to cite this article
Wiskin A.E., Owens D.R., Cornelius V.R.,
Wootton S.A. & Beattie R.M. (2012) Paediatric
nutrition risk scores in clinical practice: children
with inammatory bowel disease. J Hum Nutr
Diet.
doi:10.1111/j.1365-277X.2012.01254.x
Abstract
Background: There has been increasing interest in the use of nutrition risk
assessment tools in paediatrics to identify those who need nutrition support.
Four non-disease specic screening tools have been developed, although there
is a paucity of data on their application in clinical practice and the degree of
inter-tool agreement.
Methods: The concurrent validity of four nutrition screening tools [Screening
Tool for the Assessment of Malnutrition in Paediatrics (STAMP), Screening
Tool for Risk On Nutritional status and Growth (STRONGkids), Paediatric
Yorkhill Malnutrition Score (PYMS) and Simple Paediatric Nutrition Risk
Score (PNRS)] was examined in 46 children with inammatory bowel disease.
Degree of malnutrition was determined by anthropometry alone using World
Health Organization International Classication of Diseases (ICD-10) criteria.
Results: There was good agreement between STAMP, STRONGkids and PNRS
(kappa > 0.6) but there was only modest agreement between PYMS and the
other scores (kappa = 0.3). No children scored low risk with STAMP,
STRONGkids or PNRS; however, 23 children scored low risk with PYMS.
There was no agreement between the risk tools and the degree of malnutrition
based on anthropometric data (kappa < 0.1). Three children had anthropome-
try consistent with malnutrition and these were all scored high risk. Four chil-
dren had body mass index SD scores < )2, one of which was scored at low
nutrition risk.
Conclusions: The relevance of nutrition screening tools for children with
chronic disease is unclear. In addition, there is the potential to under recognise
nutritional impairment (and therefore nutritional risk) in children with inam-
matory bowel disease.
Journal of Human Nutrition and Dietetics
2012 The Authors
Journal of Human Nutrition and Dietetics 2012 The British Dietetic Association Ltd. 1
and Simple Paediatric Nutrition Risk Score (PNRS)
(Sermet-Gaudelus et al., 2000). These tools all attempt to
classify children into three nutrition risk categories; low,
medium or high. The tools contain different components
and therefore may not be freely interchangeable. There is
a paucity of research on the application of these tools to
specic conditions and it is not clear which tool is best
suited for what purpose.
It is widely considered that children with inammatory
bowel disease (IBD) are at high nutritional risk by deni-
tion. However, experience in our clinic suggests that,
although many children are underweight, most are of
normal weight, and some are overweight for their height
(Wiskin et al., 2011).
A screening tool should also be able to detect those
already malnourished, as well as detect those at nutri-
tional risk. The present study aimed to evaluate the con-
current validity of these screening tools in children with
IBD in comparison with an objective nutritional assess-
ment made by anthropometry, using WHO International
Classication of Diseases (ICD)-10 criteria.
Materials and methods
Study design and setting
This was a prospective observational study of children
recruited from the regional paediatric gastroenterology
service between December 2009 and June 2010. Children
attending outpatient clinics and those requiring inpatient
stay were recruited. Ethics approval was granted from the
local research ethics committee.
Subjects
All children had IBD, which was conrmed histologically
in accordance with international criteria (Silverberg et al.,
2005) and treated in accordance with published guidelines
(Sandhu et al., 2010).
Data collection
The four nutritional screening tools (STAMP, STRONGk-
ids, PYMS and PNRS) were consolidated into one generic
assessment from which the scores for each tool were
derived. In most cases, the original questions were used
but, in a few areas, respondents were asked to provide
numerical rather categorical answers. Nutritional risk was
determined from each tool. All observations were com-
pleted by one observer. Height and weight were recorded
and converted to SD scores (SDS) using lms growth
software (Harlow Healthcare, South Shields, UK; http://
www.healthforallchildren.co.uk) and the UK 1990 data-
sets. Malnutrition was dened using the anthropometric
component of ICD-10 into none or mild, moderate or
severe; weight SDS < )2, )2 to < )3 and )3, respec-
tively. A SDS of 2 is approximately equal to the second
centile and an SDS of 3 is less than the 0.4th centile.
Statistical analysis
Kappa values were calculated to assess the level of agree-
ment between each risk score compared to that expected
by chance. Statistical analysis was performed using spss,
version 16.0 (SPSS Inc., Chicago, IL, USA).
Results
Forty-six children (25 boys) were studied. Median age
was 14.6 years (range 317 years). Of these children, 27
had Crohns disease, 16 had ulcerative colitis and three
had indeterminate colitis. Median (25th, 75th percentile)
for height SDS, weight SDS and body mass index (BMI)
SDS were )0.19 ()1.08, 0.52), )0.3 ()0.87, 0.15) and
)0.43 ()1.09, 0.29). Three children had weight SDS < )2
(i.e were malnourished according to ICD-10). Four chil-
dren were underweight for their height (BMI SDS < )2)
and only one of these had a weight SDS < )2. In addi-
tion, two children were short for age (height SDS < )2).
No children scored low risk with STAMP, STRONGk-
ids or PNRS (Table 1) and there was good agreement
between these three tools. Similar numbers of children
(1820) were scored high risk by all four tools. Half of
the children scored low risk with PYMS and there was
only a modest level of agreement between PYMS and each
of the other scores. Of the children scored at low risk with
PYMS, one scored high risk with STAMP and four scored
high risk with PNRS. Table 2 demonstrates the kappa val-
ues for the overall agreement between the scores.
Three children had anthropometry consistent with
moderate or severe malnutrition according to ICD-10,
and these were all scored high risk. Interestingly, of the
four children with BMI SDS < )2, one was scored at low
risk by PYMS, medium risk by STRONGkids and high
risk by the other score. Two children had height for
age < )2 SDS (stunted) and were attributed high risk by
all of the tools. Children who were not malnourished
according to ICD-10 were scored mainly at medium or
high risk by the screening tools, leading to a lack of
agreement between any of the scores and the degree of
malnutrition.
Discussion
There was good agreement between STAMP (McCarthy
et al., 2008), STRONGkids (Hulst et al., 2010) and PNRS
(Sermet-Gaudelus et al., 2000) but not between PYMS
Paediatric nutrition risk scores in clinical practice A. E. Wiskin et al.
2012 The Authors
2 Journal of Human Nutrition and Dietetics 2012 The British Dietetic Association Ltd.
(Gerasimidis et al., 2010) and the other scores. There was
no agreement between the risk tools and the degree of
malnutrition based on anthropometric data. The three
scores with good agreement between each other automati-
cally scored children with IBD as at least medium nutri-
tion risk, simply on the basis of having IBD. The lack of
this element within PYMS accounts for the poor agree-
ment with the other scores. From a simple nutritional
assessment based on height and weight, several children
had obvious anthropometric abnormalities. It is of inter-
est that both PYMS and STRONGkids did not score all
these children at high nutritional risk, which is relevant
to any clinical application of the tools. Most children had
acceptable weight for height and were therefore not mal-
nourished, whereas most scores placed the majority of
children at moderate nutritional risk.
Children with IBD are a heterogenous group, some of
whom are malnourished and some are overweight and at
risk of obesity (Wiskin et al., 2011). There is therefore an
opportunity within this group to attribute different nutri-
tion risk scores and different management outcomes. In
the present study, children exhibited a range of height
SDS and weight SDS and had a range of nutrition risk
scores. Despite the small number of patients studied, the
poor agreement between risk tools and poor agreement
with anthropometry raises the question of what does it
mean to be a child at nutritional risk? The tools
employed in the present study have been designed to look
at different outcomes. The team who developed the PNRS
(Sermet-Gaudelus et al., 2000) state that their aim was to
develop a score to identify children at risk of acute mal-
nutrition during hospitalisation; however, there is no evi-
dence provided indicating that their outcome of 2%
weight loss is related to the development of acute malnu-
trition. Indeed, 45% of their study group lost >2%
weight. STRONGkids was tested in a national survey of
424 children. In their study (Hulst et al., 2010) using this
tool the prevalence of a signicant anthropometric abnor-
mality (weight for height < )2 SDS or height for
age < )2 SDS) in low risk children was 12%. Were these
children really low risk, or should they have been identi-
ed by a screening tool to enable delivery of nutritional
support? The four-stage evaluation of the PYMS tool pri-
marily determines whether nurses using the tool attrib-
uted the same nutritional risk as a dietician assessment.
As yet, STAMP has not been published, except as an
abstract, and so details of its validation are limited.
Experience in our hospital (Moon et al., 2009) and
elsewhere (Sullivan, 2010) suggests that routine height
and weight measurement is poorly performed; therefore,
it is uncertain how uniformly a nutrition screening tool
Table 1 Cross-tabulation of nutrition risk using four nutrition screening tools and the degree of malnutrition described by International Classica-
tion of Diseases (ICD)-10
STAMP STRONGkids SPNRS PYMS
Low Medium High Low Medium High Low Medium High Low Medium High
ICD-10 None/low 0 28 15 0 27 16 0 26 17 23 5 15
Moderate 0 0 2 0 0 2 0 0 2 0 0 2
Severe 0 0 1 0 0 1 0 0 1 0 0 1
STAMP Low 0 0 0 0 0 0 0 0 0
Medium 0 25 3 0 24 4 22 5 1
High 0 2 16 0 2 16 1 0 17
STRONGkids Low 0 0 0 0 0 0
Medium 0 22 5 23 3 1
High 0 4 15 0 2 17
SPNRS Low 0 0 0
Medium 19 4 3
High 4 1 15
ICD, International Classication of Diseases; PNRS, Paediatric Nutrition Risk Score; PYMS, Paediatric Yorkhill Malnutrition Score; STAMP, Screening
Tool for the Assessment of Malnutrition in Paediatrics; STRONGkids, Screening Tool for Risk On Nutritional status and Growth.
Table 2 Kappa values showing the level of agreement of nutrition
risk scores
STRONGkids SPNRS PYMS ICD10
STAMP 0.774 0.732 0.332 )0.014
STRONGkids 0.600 0.270 )0.013
SPNRS 0.236 )0.013
PYMS 0.079
A kappa value >0.6 represents a good level of agreement, <0.2 is
poor.
ICD, International Classication of Diseases; PNRS, Paediatric Nutrition
Risk Score; PYMS, Paediatric Yorkhill Malnutrition Score; STAMP,
Screening Tool for the Assessment of Malnutrition in Paediatrics;
STRONGkids, Screening Tool for Risk On Nutritional status and
Growth.
A. E. Wiskin et al. Paediatric nutrition risk scores in clinical practice
2012 The Authors
Journal of Human Nutrition and Dietetics 2012 The British Dietetic Association Ltd. 3
may be applied. Despite differences in scoring and the
subsequent suggested management of children, there is no
clear evidence of the impact of different scores on patient
outcomes. In addition, would the use of a nutrition
screening tool provide extra benet to routine height and
weight monitoring combined with a recent diet history?
Further discussion on the role of nutrition screening tools
in paediatrics is necessary (Sullivan, 2010).
Acknowledgments
A conference poster was previously presented at UEGW
2010.
Conict of interest, source of funding and
authorship
The authors declare that they have no conict of interests.
This study was funded by the National Institute for
Health Research Biomedical Research Unit (Nutrition,
Diet & Lifestyle) in Southampton.
All authors contributed to the design and analysis of the
study and all contributed to the nal manuscript. DRO
carried out the data collection. All authors critically
reviewed the manuscript and approved the nal version
submitted for publication.
References
Agostini, C., Axelson, I., Colomb, V., Goulet, O., Koletzko, B.,
Michaelsen, K.F., Puntis, J.W.L., Rigo, J., Shamir, R.,
Szajewska, H. & Turck, D. (2005) The need for Nutrition
Support Teams in Pediatric Units: a Commentary by the
ESPGHAN Committee on Nutrition. J. Pediatr. Gastroenter-
ol. Nutr. 41, 811.
Brotherton, A., Simmonds, N. & Stroud, M. (2010) Meeting
Quality Standards in Nutritional Care: A Toolkit for Commis-
sioners and Providers in England. Worcestershire: BAPEN.
Gerasimidis, K., Keane, O., Macleod, I., Flynn, D.M. & Wright,
C.M. (2010) A four-stage evaluation of the Paediatric York-
hill Malnutrition Score in a tertiary paediatric hospital and
a district general hospital. Br. J. Nutr. 104, 751756.
Hulst, J.M., Zwart, H., Hop, W.C. & Joosten, K.F. (2010) Dutch
national survey to test the STRONGkids nutritional risk
screening tool in hospitalized children. Clin Nutr. 29, 106
111.
Joosten, K.F., Zwart, H., Hop, W.C. & Hulst, J.M. (2010)
National malnutrition screening days in hospitalised chil-
dren in The Netherlands. Arch. Dis. Child. 95, 141145.
McCarthy, H.M.H., Dixon, M. & Eaton-Evans, M.J. (2008)
Nutrition screening in children - the validation of a new
tool. J. Hum. Nutr. Diet. 21, 395396.
Moon, R.J., Wilson, P., Kirkham, F.J. & Davies, J.H. (2009)
Growth monitoring following traumatic brain injury. Arch.
Dis. Child. 94, 699701.
Pawellek, I., Dokoupil, K. & Koletzko, B. (2008) Prevalence of
malnutrition in paediatric hospital patients. Clin Nutr. 27,
7276.
Sandhu, B.K., Fell, J.M.E., Beattie, R.M., Mitton, S.G., Wilson,
D.C. & Jenkins, H. on behalf of the IBD Working Group of
the British Society of Paediatric Gastroenterology, Hepatol-
ogy, and Nutrition. (2010) Guidelines for the management
of inammatory bowel disease in children in the United
Kingdom. J. Pediatr. Gastroenterol. Nutr. 50, S1S13.
Sermet-Gaudelus, I., Poisson-Salomon, A.S., Colomb, V., Brus-
set, M.C., Mosser, F., Berrier, F. & Ricour, C. (2000) Simple
pediatric nutritional risk score to identify children at risk of
malnutrition. Am. J. Clin. Nutr. 72, 6470.
Silverberg, M.S., Satsangi, J., Ahmad, T., Arnott, I.D., Bern-
stein, C.N., Brant, S.R., Caprilli, R., Colombel, J.F., Ga-
sche, C., Geboes, K., Jewell, D.P., Karban, A., Loftus, E.V.
Jr, Pena, A.S., Riddell, R.H., Sachar, D.B., Schreiber, S.,
Steinhart, A.H., Targan, S.R., Vermeire, S. & Warren, B.F.
(2005) Toward an integrated clinical, molecular and sero-
logical classication of inammatory bowel disease: report
of a Working Party of the 2005 Montreal World Congress
of Gastroenterology. Can J Gastroenterol. 19(Suppl. A), 536.
Sullivan, P.B. (2010) Malnutrition in hospitalised children.
Arch. Dis. Child. 95, 489490.
Wiskin, A.E., Wootton, S.A., Hunt, T.M., Cornelius, V.R.,
Afzal, N.A., Jackson, A.A. & Beattie, R.M. (2011) Body
composition in childhood inammatory bowel disease. Clin
Nutr. 30, 112115.
Paediatric nutrition risk scores in clinical practice A. E. Wiskin et al.
2012 The Authors
4 Journal of Human Nutrition and Dietetics 2012 The British Dietetic Association Ltd.