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REVIEW
Nutritional screening and guidelines for managing
the child with faltering growth
K Joosten1 and R Meyer2
1
Department of Paediatric Intensive Care, Sophia Childrens Hospital, Erasmus MC, The Netherlands and 2Imperial College, London, UK
(3) Nutritional intake and losses (1 point) For both children who are at risk of developing malnutrition
Are there any of the following items present? and for those identified as being malnourished or having
Excessive diarrhoea (X5 per day) and/or vomiting (43 times/day)
the last few days?
faltering growth, nutritional treatment should commence in
Reduced food intake during the last few days before admission order to achieve better outcomes. This includes short-term
(not including fasting for an elective procedure or surgery)? outcomes such as shorter hospital stay and less infectious
Pre-existing dietetically advised nutritional intervention? complications, as well as long-term benefits such as better
Inability to consume adequate intake because of pain?
growth and development (Secker and Jeejeebhoy, 2007;
(4) Weight loss or poor weight gain? (1 point) Joosten and Hulst, 2008; Hulst et al., 2009). The nutritional
Is there weight loss or no weight gain (infants o1 year) during the management of faltering growth depends on the severity
last few weeks/months?
(that is, wasted only or wasted and stunted) and the cause of
malnutrition (that is, organic or non-organic; Shaw and
Lawson, 2007). Several guidelines have been published to
assist the clinician in making the correct decision, from oral
Table 2 Nutritional risk score and recommended nutritional
nutritional support to tube feeding and lastly to parenteral
intervention
nutrition (ASPEN Board of Directors and The Clinical
Score Risk Intervention Guidelines Task Force, 2002; Koletzko et al., 2005). The
decision with regard to the optimal route of feeding is related
45 High Consult doctor and dietitian for full diagnosis and
to the childs ability to achieve the energy requirement and
individual nutritional advice and follow-up
Start prescribing sip feeds until further diagnosis demonstrate weight gain. If a child does not achieve
13 Medium Consult doctor for full diagnosis; consider nutritional nutritional requirements orally (via oral supplements),
intervention with dietitian. Check weight twice a week then enteral feeding must be considered and in cases
and evaluate the nutritional risk after 1 week
where enteral feeding does not meet the requirements due
0 Low No intervention necessary. Check weight regularly,
conform to hospital policy and evaluate the nutritional to increased requirements, increased losses and/or poor-
risk after 1 week tolerance parenteral nutrition may be indicated. This process
should be managed by a nutritional care team (Kruizenga
et al., 2005).
Table 3 Classification of high-risk disease using the screening tool There seems to be paucity in guidelines on dietary
management for children with faltering growth requiring
Anorexia nervosa Liver disease, chronic
Burns Kidney disease, chronic
oral support. Although disease-specific guidelines exist on
Bronchopulmonary dysplasia Pancreatitis nutrient requirements, no universally accepted guidelines
(max age 2 years) exist for children with non-organic faltering growth, which
Coeliac disease Short-bowel syndrome is more commonly seen. The most common consensus
Cystic fibrosis Muscle disease
Dysmaturity/prematurity Metabolic disease
guidelines used in the United Kingdom have been produced
(corrected age 6 months) by the Great Ormond Street Hospital (Great Ormond Street
Cardiac disease, chronic Trauma Hospital for Children NHS Trust, 2009). These provide
Infectious disease (AIDS) Mental handicap/retardation guidance on energy and protein requirements in both health
Inflammatory bowel disease Expected major surgery
Cancer Not specified (classified by physician)
and disease, highlighting the importance of an optimal
protein:energy ratio. Following the recent WHO guidelines
for catch-up growth (Table 4), the focus of dietary manage-
ment during faltering growth has changed from supplement-
simplicity of the method. Many experts have attempted to ing only with energy to optimizing catch-up by providing
develop such a tool, but some tools have failed due to their adequate energy and protein (WHO/FAO/UNU expert con-
complexity or inability to detect those at risk. The STRONG- sultation, 2007). These guidelines suggest that 8.911.5% of
kids tool was developed as a simple nutritional risk-screening energy should be supplied as protein, to provide optimal
method and has been shown to work in practice (Hulst et al., catch-up growth of lean and fat mass (from 10 g/kg/day
2009). It helps to raise the clinicians awareness of the 8.9 PE% to 20 g/kg/day 11.5 PE%; 73:27 lean:fat mass).
importance of nutritional status in children. It directs the The importance of a correct protein:energy ratio has also