MalnutritionWhat nurses working with children and young people need to know and do

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AcknowledgementsThe RCN would like to thank Wendy Faulknall, Independent Nurse Consultant for revising this publication in conjunction with Karen Selwood, Advanced Nurse Practitioner, Alder Hey Children’s NHS Foundation Trust.

This publication was supported by an educational grant from Abbott Nutrition

This publication is due for review in February 2016. To provide feedback on its contents or on your experience of using the publication, please email publications.feedback@rcn.org.uk

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Nurses who work with children and young people have an important role in identifying whether children are at risk of malnutrition and monitoring it.

This publication is aimed at all such nurses in GP practices, outpatient departments, hospitals, hospices, respite services, health centres and schools.

What is malnutrition?Malnutrition is a serious condition that occurs when a person’s diet does not contain the right amount of nutrients.

It means poor nutrition and can refer to:

• under nutrition – when you don’t get enough nutrients

• over nutrition – when you get more nutrients than you need.

(NHS Choices 2013)

When a child or young person is malnourished the deficiency of energy, protein and other nutrients has consequences that might not be evident from single measurements of weight and height. They include:

• growthfailure

• delayedpuberty

• impairedneurologicaldevelopment

• alteredbehaviour

• apathyortiredness.

Good nourishment is fundamental to proper growth and development. It can prevent short-term problems such as dental caries and reduce the risk of chronic health problems such as obesity and heart disease.

Nutritional problems in children become nutritional problems in adults (BAPEN, 2005). The first five years of life are crucial as this is when dietary and food intake patterns are laid down.

Malnutrition can result from inadequate food or can be secondary to an underlying illness or disability. Nurses who work with children and young people have a key role in identifying those who are at risk.

What is adequate nutrition?Children need more energy as they have a higher metabolic rate than adults. They also have reduced body fat stores compared to adults, making them less able to cope with concurrent illness, trauma, infection or metabolic stress.

Nutritional intake must be sufficient for children to:

• maintainbodyfunctions

• engageinplayandotheractivities

• recoverfromtraumaorillness

• growanddevelop.

Standards of good nursing practiceSeveral documents describe the nurse’s role in assessing nutrition, the following are of particular relevance:

• DepartmentofHealth’sEssence of care (2010) advises undertaking a nutritional trigger assessment. This means for all children at initial contact and continuously reassessing thereafter

• theEssential standards of quality and safety (2010) as set out by the Care Quality Commission, expects patients’ individual nutritional, personal and clinical dietary requirements to be met, including help with feeding. In hospitals there should be access to food 24 hours a day.

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What every nurse should doScreening, or undertaking a nutritional trigger assessment, can identify patients who are already malnourished or are at risk of becoming so. High-risk children need a comprehensive nutritional assessment, usually undertaken by a dietitian.

Although there are no nationally-agreed screening tools for general use with children, two tools are well used and their effectiveness is subject to regular review. These are:

• STAMP(ScreeningToolfortheAssessmentofMalnutrition in Paediatrics) www.stampscreeningtool.org/stamp

• PYMS(PaediatricYorkhillMalnutritionScore)www.knowledge.scot.nhs.uk/pyms

Some basic assessments will contribute significantly to identifying children at risk. Nurses should identify slow growth patterns by:

• weighingthechildinkg(atleastweeklyifinhospital) (see Box 1)

• measuringlengthorheightincentimetreswhere there is concern about growth

• plottingthemeasurementsonacentilechart.(Note: a sustained unintentional fall in weight over more than two centiles in six months in children under two years, or 12 months in children over two years, is indicative of malnutrition)

• measuringheadcircumferenceinundertwoyear olds

• discussingthereadingswiththeparentsandchild.

Box 1: Key points when weighing children and young people• Underthreeyears–naked.

• Overthreeyears–minimalclothing.

• Choosescalessuitableforage,sizeandcondition.

• Placechildcentrallyonthescales.

• Takereadingwhenthechildisstill.

• Recordweightinkilograms.

• PlotonchartandrecordinPersonalHealthRecord where appropriate.

• Rememberscalesmustbecalibratedregularly.

Remember that accurate and reliable weighing scales and stadiometers should be available to all hospital wards, outpatient clinics, GP surgeries and other health care settings. They must be calibrated and checked regularly, and a record must be kept.

Body Mass Index (BMI) is an important measure of nutrition, but should not be used in isolation. In infants, growth trajectory should be considered, and in older children current and previous heights should be taken into account.

Age-related centile charts are available from the Child Growth Foundation (see websites for further information on page 7). The rate of weight loss is clinically more valuable than the BMI.

How to identify dietary or feeding patterns that could lead to poor nutritionIt is important to be able to recognise major or minor health problems that might be related to poor nutrition, for example constipation, dental caries or reflux, and to take appropriate action.

Reflecting on your knowledge and skills of the following might help you identify problems:

• howtoweighandmeasurechildren,youngpeople and, if necessary, their parents

• breastfeedingandproblemsthatmightresultin poor sucking or low milk production

• howtoselect,prepareandhandle age-appropriate infant feeds

• whentointroducesolidfoodsandprogressweaning

• suitablefeedingpatternsandoptimal parent-child interactions at meal times

• theappropriaterangeoffoodandportionsizesfor young children

• dietarypatternslikelytocontributetomalnutrition, such as low iron or poor vitamin intake

• culturalorethnicdietarypracticesthatcouldpredispose to malnutrition, for example vegan diets or delayed weaning

• howtorecognisesignsofmalnutrition,whichinclude short stature, thin arms and legs, skin and hair in poor condition, clearly visible vertebrae and rib cage, wasted buttocks, and, in extreme situations, oedema, wasted facial appearance or lethargy.

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Asking questionsBasic screening of a child’s nutritional status should be a routine part of a nursing assessment. In fact, National Institute for Health and Care Excellence (NICE) guidance for patients tells them to expect to be examined for malnutrition when attending hospital (2006).

Important information can come from asking the child’s mother, carer and the child about their eating habits. To help you do this you should adhere to some key communication principles:

• beclearaboutwhyyouneedtheinformation

• askopenquestions,forexample:“Tellmehowoftenyoueatapieceoffruit”or“Tellmeaboutthe food you eat at school”

• answeranyquestionstheymighthavetruthfully

• giveguidanceifneededorrequested.

Some indicators or problems to look out for are given in box 2.

Box 2: Some clues to a problem• Parentshaveanxietiesaboutfood.

• Parentsaretoofocusedonhealthyeating for their children, so they become deprived of calories.

• Parentsareoverweight–childrenmaybedeliberately kept thin to avoid bullying.

What to do nextIf your assessment flags up some areas of concern you should ensure these are discussed with the parents/carers and noted in the child’s care plan. Youshouldalsoensuretheinformationispassedto an appropriate specialist for example:

• breastfeedingcounsellor

• healthvisitorfornormalfeedingproblems

• paediatricianforeliminationofanunderlyingmedical problem

• GP

• paediatricdietitianforadviceonnutritionalsupport, for example nutritional drinks, dietary modification and feeding problems

• speechandlanguagetherapistforhelpwith feeding difficulties such as chewing or swallowing.

Ensuring that children receive optimum nutrition is everybody’s business and nurses in contact with children are in a prime position to identify nutritional problems and take appropriate steps aimed at rectifying these.

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ReferencesBrotherton A, Simmonds N, Stroud M (2010) Malnutrition matters: meeting quality standards in nutritional care: a toolkit for commissioners and providers in England, Redditch: British Association for Parenteral and Enteral Nutrition (BAPEN).

Care Quality Commission (2010) Essential Standards of Quality and Safety, London: CQC. Available at: www.cqc.org.uk (accessed 27 November 2013).

DepartmentofHealth(2010b)Essence of Care 2010: benchmarks for the fundamental aspects of care.London:DH.Availableat:www.gov.uk/government (accessed 27 November 2013).

DepartmentofHealth(2008)High quality care for all: NHS next stage review final report, London: DH(CM7432).Availableat:http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_085828.pdf (accessed 27 November 2013).

DepartmentofHealth(2010a)Equity and excellence: liberating the NHS.London:DH (Cm7881).Availableat:www.official-documents.gov.uk/document/cm78/7881/7881.pdf (accessed 27 November 2013).

Elia M and Stratton RJ (2012) An analytic appraisal of nutrition screening tools supported by original data with particular reference to age. Nutrition28(5) pp.477-494.

Gerasimidis K et al., (2011) Performance of the novelPaediatricYorkhillMalnutritionScore(PYMS)inhospitalpractice.Clinical Nutrition 30(4) pp.430-435.

Gibson F et al., (2012) What it’s like when you find eating difficult: children’s’ and parents’ experiences of food intake. Cancer Nursing 35 (4) pp.265-277.

HallDandEllimanD(2003)Health for all children (4th edition.), Oxford: Oxford University Press.

Houlston A, et al., (2009) Cook to order: meeting the nutritional needs of children with cancer in hospital. Paediatric Nursing 21 (4) pp.25-27.

Konstantinos G et al., (2012) Introduction of PaediatricYorkhilMalnutritionScore:challengesand impact on nursing practice. Journal of Clinical Nursing21(23-24)pp.3583-3586.

MoreJ(2013)Evidence-basedportionsizesforchildren aged 1-4 years. Community Practitioner 86(5)pp.43-46.

MoreJ(2008)Don’tforgettheundernourishedchildren in our midst. Journal of Family Health Care 18(5)pp.159-160.

National Institute for Health and Clinical Excellence (2006) Nutrition support in adults: Clinical guideline 32, London: NICE. Available at www.nice.org.uk (accessed 27 November 2013).

National Institute for Health and Clinical Excellence(2008)Maternal and child nutrition (PH11). London: NICE. Available from www.nice.org.uk (accessed 27 November 2013).

Picot J et al (2012) The effectiveness of interventions to treat severe acute malnutrition in young children: a systematic review. Health Technology Assessment 16 (19) pp.1-316.

Rabbitt A & Coyne I (2012) Childhood Obesity: nurses’ role in addressing the epidemic. British Journal of Nursing 21 (12) pp.731-735.

Royal College of Nursing (2013) Nutrition – core nutritional care resources, London: RCN. Available at: www.rcn.org.uk/development/practice (accessed 27 November 2013).

ShawNJandMughalMZ(2013)VitaminDandChild Health Part 1 (skeletal aspects) Archives of Disease in Childhood98(5)pp.363-367.

ShawNJandMughalMZ(2013)VitaminDandChild Health Part 2 (extraskeletal and other aspects) Archives of Disease in Childhood98(5)pp.368-372.

Shepherd A (2009) Nutrition in infancy and childhood: a healthy start means a health future. Primary Health Care19(1)pp.41-48.

Shipway L (2010) Providing nutritional support for patients during cancer treatment. Paediatric Nursing 22 (4) pp.20-25.

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Websites for further informationBritish Association for Parenteral and Enteral Nutrition (BAPEN) www.bapen.org.uk

Child Growth Foundation www.childgrowthfoundation.org

Department of Health www.dh.gov.uk

National Institute for Health and Care Excellence (NICE) www.nice.org.uk

National Health Choices: your health, your choices www.nhs.uk

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Second edition, February 2014 Review date February 2016

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This publication was supported by an educational grant from Abbott Nutrition