Disease-related undernutrition in hospitalized children in Belgium

Transcription

1 Disease-related undernutrition in hospitalized children in Belgium Koen Huysentruyt Promoters: Prof. Dr. Jean De Schepper Prof. Dr. Yvan Vandenplas Public Defense PhD May 2016

2 Aims of the thesis 1. Study current prevalence of undernutrition in Belgian hospitalized children General pediatric population Specific at-risk population 2. Validation of the STRONG kids nutritional screening tool in a Belgian population 3. Inquire about current knowledge & clinical practice of nutritional screening in Belgian paediatric departments 4. Propose practical guidelines for early detection of diseaserelated undernutrition 2

3 3 Defining under-nutrition anthropometric criteria Classification Parameter Criteria Gomez Waterlow Weight for Age (WFA) What is the WFH of a boy with a height of 100 cm and a body weight of 11 kg? Weight for Height (WFH) cm is the WHOaverage length of a 3.5 year-old boy Cole WFH BMI kg is the average weight of a 3.5 y boy Sen Mid-upper Arm Circumference (MUAC) 3. 11/16 = 69% Undernutrition 75%-90% WFA 60-74% WFA <60% WFA 80%-90% WFH 70%-80% WFH <70% WFH -2 SD < WFH -3 SD WFH < 3 SD -1 SD < BMI -2 SD -2 SD < BMI -3 SD BMI < -3 SD MUAC < -2 SD / MUAC<110 mm Gomez et al. Adv Pediatr 1955; Waterlow BMJ 1972; WHO 1995; Cole et al. BMJ 2007; Sen et al An Hum Biol 2011

4 Prevalence of undernutrition in Belgian hospitals Prospective study of 379 children (Dec 2010 Apr 2011) in four Belgian hospitals: Charleroi La Louvière Hasselt UZ Brussel WFH <-2 SD (p=0.53) HFA <-2 SD (p=0.40) Weight loss >2%* (p<0.05) Total n (%) Secondary hospitals n (%) Tertiary hospital n (%) 34 (9.0) 26 (10.0) 8 (7.8) 29 (7.7) 19 (7.0) 10 (9.5) 39 (12.5) 23 (10.2) 17 (20.0) *n=310 4 Huysentruyt et al. Acta paediatrica 2013

5 Prevalence of undernutrition in Belgian hospitals Total n (%) Secondary hospitals n (%) Tertiary hospital n (%) Nutr. Interv.** 37 (8.9) 18 (6.6) 19 (18.1) Underl. Dis.** 40 (11.1) 16 (6.3) 24 (23.1) LoS 4 days* 125 (36.2) 80 (32.5) 45 (45.5) *p<0.05; **p<0.01 Length of hospital stay: No difference in children with/without acute undernutrition (p=0.27) 1 day longer in children with chronic undernutrition (p<0.01) >2% weight loss more frequent in children with LoS 4 days (8.5% vs 21.8%; p<0.01) 5 Huysentruyt et al. Acta paediatrica 2013

6 Undernutrition & nutritional evolution in an at-risk population Retrospective study of 56 children ( ) without underlying disease and pneumonia with parapneumonic effusion in two Belgian hospitals: Hasselt UZ Brussel Specific risk factors for nutritional deterioration in this population: Chronic disease Long hospital stay Decreased intake Exsudative protein loss Inflammation Increased metabolism ( resp. effort & O 2 dependency) 6 Huysentruyt et al. Plos One 2014

7 Undernutrition & nutritional evolution in an at-risk population Minimal body weight Body weight discharge 21% 79% Yes No 50% 50% Yes No Parameter Admission (n=56) Min. weight (n=44) 2 weeks FU (n=35) 1 month FU (n=26) WFH<-2 SD 2/51 (3.9%) 4/43 (9.3%) 0 (0%) 0 (0%) WFH 13/32 (40.6%) 5/22 (22.7%) 5% weight loss 17 (38.7%) 4 (11.5%) 5 (19.2%) 10% weight loss 5 (11.4%) 1 (2.9%) 1 (3.8%) 7 Huysentruyt et al. Plos One 2014

8 Prevalence of undernutrition our results in perspective Europe ( 14): N = % BMI<-2 SD Hospital stay 1.3d France ( 13): N = % BMI <3 th centile Belgium ( 13): N = % BMI <-2 SD 8 Hecht et al. Clinical nutrition 2014; Sissaoui et al. e-spen Journal 2013; Huysentruyt et al. Acta paediatrica 2013

9 Defining undernutrition Need for a consensus n = 46 (12%) 9 Huysentruyt et al. Acta paediatrica 2013

10 Defining undernutrition Need for a consensus 100,0% 90,0% 80,0% 70,0% 60,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% Methods for the evaluation of undernutrition Weight & height Clinical appraisal MUAC and/or SFT Serum protein levels Other 22.5% based judgement on 1 criterion: Weight & length (81.3%) Clinical appraisal (4.0%) MUAC and/or SFT (6.3%) Lack of uniform definition could play a role in under-recognition Current terminology: Mere description of undernutrition No insight in etiology and interactions associated with pediatric undernutrition 10 Huysentruyt et al. Acta Paediatr 2015

11 Key concepts of the new definition Anthropometry Outcome Growth Undernutrition Chronicity Etiology 11 Mehta et al. JPEN 2013

12 Weight loss during hospital stay Country N Nutritional status at diagnosis Fr ( 00) % with weight loss >5% Poor nutritional status on admission no significant predictor of weight loss Trk ( 03) 170 Well-nourished: no deterioration Undernutrition: Significant %BMI on discharge B ( 13) % with weight loss >2% No correlation with WFH on admission Eur ( 14) % of children lost weight 3.7% with weight Nutritional loss >5% 6.8% of malnourished riskchildren lost weight 12 Sermet Gaudelus et al. Am J Clin Nutr 2000; Ozturk et al. J Trop Pediatr2003; Huysentruyt et al. Acta Paediatr 2003; Hecht et al. Clin Nutr 2014

13 Guidelines nutritional screening (adults) Screening for malnutrition: Result in diagnosis of malnutrition and adverse outcome Result in improved outcome by nutritional treatment ESPEN guidelines nutrition screening tools: High predictive & content validity Reliable Practical Should be linked to specified protocols for action Should lead to nutritional care 13 Kondrup et al. Clinical nutrition 2003

14 The STRONG kids nutritional screening tool Question Is there an underlying illness with the risk for malnutrition or expected major surgery? Is the patient in a poor nutritional status judged with subjective clinical assessment? Is one of the following items present? 1. Excessive diarrhea ( 5x/day) and/or vomiting (>3x/day) 2. Reduced food intake during the last few days 3. Pre-existing nutritional intervention 4. Inability to consume adequate nutritional intake because of pain Is there weight loss or no weight loss increase (infants <1 year) during the last few weeks-months? Score No: 0 Yes: 2 No: 0 Yes: 1 None: 0 1 item: 1 No: 0 Yes: 1 Low risk Moderate risk High risk 0 points 1-3 points 4-5 points 14 Hulst et al. Clin Nutr 2010

15 STRONG kids nutritional screening tool Belgian validation study Prospective study of 368 children (Dec 2010 Apr 2011) in four Belgian hospitals: Charleroi La Louvière Hasselt UZ Brussel Pilot study (n=29) Inter-rater: κ= 0.61 (p<0.01) Intra-rater: κ= 0.66 (p<0.01) Ease of use 97% completion rate <5 minutes 15 Huysentruyt et al. Nutrition 2013

16 STRONG kids nutritional screening tool Belgian validation study Concurrent validity ρ Sens Spec NPV PPV OR (95% CI) WFH -0.23** ( )** HFA ( ) Children classified as 'low risk' have a 5% probability of being acutely undernourished, Prospective with only validity a 1% probability of a nutritional intervention during hospitalization *p<0.05; **p<0.01 ρ Sens Spec NPV PPV OR (95% CI) LoS 0.25** ( )** Wt loss ( ) Ntr Intv 0.48** ( )** *p<0.05; **p< Huysentruyt et al. Nutrition 2013

17 Overview of paediatric screening tools NRS PNRS STAMP PYMS STRONG kids Present weight Present weight Present weight Poor nutrition status Expected WFH 0 WFA-HFA 1 ctles apart 0 BMI below cut-off value? (subjective assessment) 90-99% of expected WFH 2 WFA-HFA 2-3 ctles apart 1 No 0 No % of expected WFH 4 WFA-HFA 3 ctles apart 79% of expected WFH 6 (or WFA < 2 nd ctle) 3 Yes 2 Yes 1 Appetite Recent weight loss Poor weight gain (<1y) or weight loss Good: eats most of meals 0 Looser clothes/poor w. gain (<2y) Poor: leaves >½ of meals 2 No 0 No 0 ± None: during >4 meals 3 Yes 1 Yes 1 Ability to eat/retain Which Eating <½ of usual Recent screening nutritional Intake past week tool Ability to eat/retain food food 48h No difficulties No diarrhoea/vomiting Problems handling food Vomiting/mild diarrhoea Difficulty swallowing Dental/chewing problems Vomiting/diarrhoea (1-2/d) Needs help with feeding Unable to take food orally Unable to swallow Vomiting/diarrhoea (>2/d) Malabsorption 0 None of the above 0 Good, no change 0 No, usual intake 0 None of the items listed below 0 should we use? present 1 1 of the above 1 Poor or recently 2 Yes, of usual intake 1 1 of the items listed below 1 present 2 Both of the above 2 ± No intake 3 Yes, ± no intake 2 List of items: - Diarrhoea ( 5x/d) 1-3 days - Vomiting (>3x/d) 1-3 days - Pre-existing advised nutr. Interv. 3 - Adequate intake not possible (pain) Stress factor Stress factor Diagnosis with nutr. implications Will condition affect nutrition next week? Expected major surgery /underlying disease? None 0 Minor 0 No 0 No 0 No 0 Mild 1 Mild 1 Possible implication 2 intake or losses/needs 1 Yes 2 Moderate 2 Severe 3 Definite implication 3 ± no intake 2 Severe 3 LOW RISK: <5/15 LOW RISK: 0/5 LOW RISK: 0-1/9 LOW RISK: 0/7 LOW RISK: 0/5 MODERATE RISK: 5-9/15 MODERATE RISK: 1-2/5 MODERATE RISK: 2-3/9 MODERATE RISK: 1/7 MODERATE RISK: 1-3/ HIGH RISK: 10/15 HIGH RISK: 3/5 HIGH RISK: 4/9 HIGH RISK: 2/7 HIGH RISK: 4/5

18 Systematic review screening tools Search strategy PICO search question: P: hospitalized children in developed countries I+C: Paediatric nutritional screening tools O: Nutritional risk No language or time restrictions Hand searching of references from included articles and narrative reviews Contact with panel of international experts for identification of additional articles Developed country : International Statistical Institute (ISI) Based on country s Gross National Income 18 Huysentruyt et al. JPGN 2015

19 Systematic review screening tools Study selection records identified via MEDLINE, EMBASE and Cochrane Central Database (until ) records screened 54 full-text articles assessed for eligibility 18 papers included in detailed assessment 11 studies included in qualitative synthesis 19 Huysentruyt et al. JPGN 2015

20 Systematic review screening tools Study selection Validation methods of nutritional risk : Weight loss Full dietetic assessment Clinical decision for nutritional intervention Clinical decision for dietetic referral WFA/BMI/HFA z-scores Description of nutritional risk without validation Length of hospital stay 20 Huysentruyt et al. JPGN 2015

21 22 Huysentruyt et al. JPGN 2015 Systematic review screening tools Validation against weight loss

22 23 Huysentruyt et al. JPGN 2015 Systematic review screening tools Validation against dietetic referral

23 Systematic review screening tools Conclusion Four validated nutritional screening tools STAMP PYMS PNRS STRONG kids Choice of cut-off values greatly influences sens & spec of screening tools Choice of screening tool will depend on other factors such as local validation, ease of use and reliability 26 Huysentruyt et al. JPGN 2015

24 Belgian survey screening for undernutrition Nationwide survey (Sept 13 Febr 14) Department heads of all Belgian, non-university hospitals with paediatric department Postal or electronic questionnaire Dutch and French version of the questionnaire 1 reminder was sent to non-responders Respondents blinded for investigators 78.2% 66.7% Overall response: 71/97 (73.2%) p= Huysentruyt et al. Acta paediatrica 2015

25 Belgian survey Respondent characteristics Total N (%) Flemish N (%) Walloon N (%) Significance (p-value) Number of beds on ward <20 beds 31 (43.7) 17 (39.5) 14 (50.0) 20 beds 40 (56.3) 26 (60.5) 14 (50.0) Median (range) 20 (10-72) 20 (15-48) 19 (10-72) Admission undernourished children Never 1 (1.4) 1 (2.3) 0 (0.0) <1x/month 56 (78.9) 35 (81.4) 21 (75.0) 1x/week 1x/month 12 (16.9) 6 (14.0) 6 (21.4) 1x/week 2 (2.8) 1 (2.3) 1 (3.6) Total N (%) Small centre N (%) Large centre N (%) Significance (p-value) Paediatric NST/dietician present No 38 (53.5) 20 (64.5) 18 (45.0) Yes 33 (46.5) 11 (35.5) 22 (55.0) Number of dieticians No dieticians 39 (58.2) 22 (71.0) 17 (47.2) >0-1 full time dieticians 25 (37.3) 9 (29.0) 16 (44.4) >1 full time dieticians 3 (4.5) 0 (0.0) 3 (8.3) Missing Huysentruyt et al. Acta paediatrica 2015

26 Belgian survey Opinions regarding screening Total N (%) Small centres N (%) Large centres N (%) Significance (p-value) Aware of nutritional screening tools Yes 35 (49.3) 15 (48.4) 20 (50.0) No 36 (50.7) 16 (51.6) 20 (50.0) Necessity of nutritional screening All hospitalized children 26 (36.6) 9 (29.0) 17 (42.5) Only in case of suspicion 43 (60.6) 20 (64.5) 23 (57.5) Unnecessary, clinical judgement sufficient 2 (2.8) 2 (6.5) 0 (0.0) Dangerous, may lead to decreased skills of staff 0 (0.0) 0 (0.0) 0 (0.0) Total N (%) Flemish N (%) Walloon N (%) Significance (p-value) Aware of nutritional screening tools Yes 35 (49.3) 18 (41.9) 17 (60.7) No 36 (50.7) 25 (58.1) 11 (39.3) Necessity of nutritional screening All hospitalized children 26 (36.6) 10 (23.3) 16 (57.1) Only in case of suspicion 43 (60.6) 31 (72.1) 12 (42.9) Unnecessary, clinical judgement sufficient 2 (2.8) 2 (4.7) 0 (0.0) Dangerous, may lead to decreased skills of staff 0 (0.0) 0 (0.0) 0 (0.0) 29 Huysentruyt et al. Acta paediatrica 2015

27 Belgian survey Options to raise priority Other More attention for nutrition management in general More training about screening Walloon Flemish Obliged by department head p=0.005 Obliged by governement p= % 20% 40% 60% 80% 100% Missing: n=2 30 Huysentruyt et al. Acta paediatrica 2015

28 Belgian survey Barriers preventing screening 80,0% 70,0% p= ,0% 50,0% 40,0% 30,0% 20,0% 10,0% 0,0% p= Small centres Large centres Missing: n=7 31 Huysentruyt et al. Acta paediatrica 2015

29 Belgian survey Current clinical practice Current screening in Wallonia Current screening in Flanders 11% p= % 28% 16% 43% 18% 16% 61% Currently used screening method Total N (%) Growth charts/wfh/bmi 7 (25.0) STRONG kids 6 (21.4) Own tool 5 (17.9) No systematic method 4 (14.3) More elaborate assessment 3 (10.7) Other 3 (10.7) Missing 9 32 Huysentruyt et al. Acta paediatrica 2015

30 Early detection of undernutrition Proposal for practical algorithm 33 Huysentruyt et al. JPGN 2016 (accepted for publication)

31 Limitations of this work 1. No association length of hospital stay and acute undernutrition In contrast with other, larger studies Underpowered? Interaction with other factors? 2. Static anthropometric definitions used What about constitutional thin children... What about children with weight loss but still above cut-off values Short duration of hospital stay Difficult to correlate with nutritional outcome Interventions need to be carried on after discharge 4. Study on children with parapneumonic effusion Retrospective, small sample size, high number of drop-outs 5. Lack of golden standard for defining nutritional risk Each measure has its own strengths and weaknesses Complication of finding the ideal screening tool 6. Lack of evidence-based practice for validation of algorithm 34

32 Overall conclusion Undernutrition in hospitalized children also exists in Belgian hospitals Lack of recognition of undernutrition Increased nutritional risk for children with more severe conditions and those hospitalized for longer time periods STRONG kids is a validated screening tool and easy to use in everyday practice Nutritional screening is not yet common practice Major barriers for nutritional screening were a lack of awereness and a lack of training We proposed a nutritional algorithm for use in everyday practice 35

33 What next? Validation of the algorithm in a broader, multicentric population Search for anthropometric criteria that are linked with disease-specific outcome parameters Role of body composition? Further raising awereness on nutritional screening and a good nutritional policy The use of screening as a quality indicator? Screening in other settings? 36

34 Special thanks to... Prof. Vandenplas Dr. Devreker Prof. De Schepper Prof. Cools Dr. Alliet Dr. Bontems Dr. Muyshondt Mrs. Vandecandelaere Mr. Descheemaeker 37