VOL: 96, ISSUE: 49, PAGE NO: 2
Jamil Khair, RGN, RSCN, DipChildDev, is a paediatric nutrition nurse, The Royal Hospitals NHS Trust
Louise Morton, RSCN, is clinical nurse specialist in chronic granulomatous disease, Great Ormond Street Hospital for Children NHS Trust, London
Under-nutrition is usually described as protein-energy malnutrition or PEM. In children, PEM is often perceived as a problem particular to the developing world, with a reported incidence of about 39% of the world’s pre-school children and associated mortality in up to 20 % of these children (Suskind et al, 1990).
While this may be true of primary PEM (resulting from inadequate food supply), PEM related to underlying illness (secondary PEM) is a common problem in modern hospitals.
The short-tern implications of failure to address secondary PEM in children include increased susceptibility to infection, poor healing, perioperative complications and reduced response to treatment. The long-term implications include stunting, developmental delay and an overall increase in morbidity and mortality (Fuchs, 1990).
The significance of PEM in children becomes clearer when we consider the role of nutrition in the paediatric patient and how it differs from the nutritional needs of the mature, adult patient.
The five pillars of paediatric nutrition
Adequate nutrition in the paediatric patient must provide for all of the following factors:
Maintenance of body function
A child’s metabolic rate is higher per kilogram of bodyweight than that of an adult and, therefore, energy requirements are also proportionately greater (Poskitt, 1988). These requirements are further increased by physiological stresses, such as trauma and infection, and psychological stresses, such as separation and anxiety.
In addition, children (particularly neonates) may have much smaller fat stores than adults, severely reducing their ability to survive periods of starvation or under-nutrition.
Play and activity are essential to a child’s social and physical development. It is important that nutrition provides sufficient energy to allow for this (Grantham-McGregor, 1988). Even a short period of immobility or inactivity can prove detrimental.
As in adults, the body’s initial response to trauma is to deplete body stores - glycogen, protein and fat - in order to preserve body function (Fuchs, 1990). The body’s reserves of energy are more rapidly depleted in the younger/smaller child. Neonates, therefore, are at particular risk of nutritional problems and consequent growth delay (BAPEN, 2000). Trauma causes a loss of protein and fat from damaged tissue. Healing requires increased provision of energy, nitrogen and certain micronutrients, such as zinc (Golden and Golden, 1981). Estimation of nutritional requirements following trauma must take these factors into account.
Normal growth occurs only when more nutrition is provided than that required for body function, healing, metabolic stress and energy expenditure. A child’s rate of growth is not linear, but occurs in stages with periods of accelerated growth, such as infancy or puberty, driven by a combination of nutrition and endocrine function. Any nutritional defect during a critical growth period could prevent the child from achieving his or her growth potential (Waterlow, 1988).
When children have experienced an extended period of weight loss or failure to thrive, estimating their nutritional requirements on the basis of current weight may not be sufficient to allow them to achieve their growth potential. Extra calories and protein must be provided to allow for accelerated growth and weight gain (Lewinter-Suskind, 1990). The centile chart can be used to monitor the child’s growth until he or she has regained acceptable levels in terms of weight and height.
The nurse has a key role in identifying children who might be at risk of PEM. The ability to assess a child’s nutritional status using anthropometry, observation and history is vital, but it is also as important for the nurse to have an understanding of the implications of information gained during an assessment.
Anthropometry, the measurement of the human body, can give useful information about growth and current nutritional status when compared with established norms. However, an assessment of nutritional status or growth should not rely on these measurements alone. Consideration must also be given to other factors, such as feeding history (Poskitt, 1988).
Although other anthropometric measurements may be indicated, height/length, weight and head circumference constitute a minimum requirement in paediatrics.
Equipment scales should be available for different age groups of children - for instance, baby scales, chair or standing scales. They should be calibrated regularly, centrally purchased and designed for clinical use.
Children should be weighed on admission to hospital and subsequently at least once a week. Frequency of weighing requires adjustment according to clinical condition on discussion with the multidisciplinary team. Repeat weights should be recorded under similar conditions and at the same time of day as the original measurement.
Infants and toddlers (up to three years) should always be weighed naked. Older children should be weighed with a minimum of clothing. The choice of scales will be determined by the child’s age, size and general condition. Care should be taken when positioning the child on the scales to ensure an accurate measurement - the child should be placed centrally and the measurement should not be recorded until the child is still. All weights should be recorded in kilograms.
Additional factors that impact on the accuracy of weight measurements are presence of intravenous splints/lines, stoma devices, dressings/drains, timing of bolus/continuous feeds and intravenous therapy. Weights should be recorded on a weight chart, observation chart and on the centile chart in the medical notes and in parent-held records.
A single weight is of limited value in assessing a child’s nutritional status. Similarly, daily weights may reflect hydration rather than nutrition. A measurement of weight is of nutritional value only when reviewed in the light of previous weights and clinical history.
It should be noted that a measurement of weight should not be relied on as an accurate indication of nutritional status in children with significant oedema or solid tumours. Weight should always be interpreted in conjunction with height/length and age, for which an understanding of the centile chart is vital. Although not definitive, comparing weight, height and age can give useful clues to potential problems (Box 1).
Equipment should be available for measuring the height/length of different age groups of children - for instance, a measuring mat with head and foot boards for infants and a stadiometer for older children, It is not appropriate to use a tape measure.
Height/length should be measured on admission and subsequently at least once a month.
Infants should be measured naked and by two people, using an appropriate measuring mat with head and footboard. The child should be placed supinely with the head held against the headboard and gentle downward pressure applied to the knees to ensure that the legs are straight and flat against the mat. Length is then measured by bringing the footboard into contact with the child’s heels.
The standing height of an older child should be measured using an appropriate stadiometer. Shoes should be removed and the child asked to stand with feet together and heels, buttocks and shoulder blades in contact with the vertical measure.
Measurement of height/length is inappropriate for children who are unable to stand or bear weight or with conditions that impede correct positioning - for instance, curvature of the spine.
Measurements of length/height should be recorded in centimetres and documented as for weight.
Length/height can provide a useful indication of growth in children. Impaired growth may indicate inadequate feeding, diet or malabsorbtion, where poor weight gain is also evident. In the presence of adequate weight gain, impaired height may be indicative of metabolic or endocrine disease. Measurements of parental height constitute a useful guide to target height in a child. However, it should be remembered that the parents themselves may not have achieved their full growth potential due to socio-economic factors or illness.
Pubertal development is accompanied by a period of rapid growth acceleration. Any assessment of growth in adolescence should include evaluation of pubertal staging.
A thin metal or plastic tape measure should be used to measure head circumference. It is not appropriate to use paper or sewing tape for this purpose.
Head circumference is monitored in children under two and should be recorded on admission. The tape is placed so that it lies midway between the eyebrows and hairline at the front of the head and meets with the occipital prominence at the back. A second person is required to hold the child’s head still. Measurements of head circumference should be recorded in centimetres.
If a child’s clinical condition is such that standard anthropometric measurements are inappropriate or misleading - for instance, if there is oedema, ascites or solid tumours - other techniques are available for measuring growth (Box 2).
The performance of anthropometric measurements provides the nurse with an ideal opportunity to observe the child’s general appearance. With experience a paediatric nurse will be able detect specific signs of poor nutritional status/growth, such as the following:
- Short stature;
- Thin arms and legs;
- Poor skin condition/skin lesions;
- Poor hair condition;
- Clearly visible spinal processes or rib cage;
- Wasted buttocks;
- Oedema, wasted facial appearance, lethargy.
A nursing assessment interview conducted on admission should elicit useful information pertaining to feeding history and parental concerns regarding feeding and growth/weight gain (Box 3).
In order to assess the adequacy of a child’s nutritional intake, dietitians require detailed information about all food and drink consumed. As all children admitted to hospital are at risk of nutritional deficit, a dietary record should be started on all in-patients, although this may subsequently be discontinued when deemed appropriate. The dietary record should include details of food and fluids offered and consumed, with quantities expressed in terms of teaspoons, tablespoons and so on. Owing to the difficulties of providing for the likes and dislikes of individual children any record of dietary intake completed during admission is unlikely to provide an ideal reflection of a child’s customary intake.
A number of psychosocial factors may impact on nutritional status, such as family income, family support systems, parenting skills and so on. As with any other aspect of nutritional assessment, psychosocial factors should be interpreted only in the light of other findings.
Nutritional risk factors
If any of the following problems are identified during the assessment process the child may he considered to be at increased risk of nutritional deficiency:
- Predisposing medical condition;
- Static weight;
- Documented weight loss;
- Perceived weight loss;
- Poor intake;
- Poor feeding;
- Short stature;
- Pubertal delay;
- Developmental delay.
The short-term implications of failure to address PEM can lead to multiple complications. The long-term implications can be devastating and include stunting, developmental delay and an overall increase in morbidity and mortality.