Malnutrition
What nurses working with children and young people
need to know and do
This publication is supported by a global health care company
Acknowledgements
The 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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ROYAL COLLEGE OF NURSING
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?
What is adequate nutrition?
Malnutrition is a serious condition that occurs
when a person’s diet does not contain the right
amount of nutrients.
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.
It means poor nutrition and can refer to:
• under nutrition – when you don’t get enough
nutrients
Nutritional intake must be sufficient for children to:
• maintain body functions
• over nutrition – when you get more nutrients
than you need.
• engage in play and other activities
(NHS Choices 2013)
• recover from trauma or illness
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:
• grow and develop.
Standards of good nursing
practice
• growth failure
Several documents describe the nurse’s role
in assessing nutrition, the following are of
particular relevance:
• delayed puberty
• impaired neurological development
• Department of Health’s Essence of care (2010)
advises undertaking a nutritional trigger
assessment. This means for all children at
initial contact and continuously reassessing
thereafter
• altered behaviour
• apathy or tiredness.
Good nourishment is fundamental to proper
growth and development. It can prevent shortterm problems such as dental caries and reduce
the risk of chronic health problems such as
obesity and heart disease.
• the Essential 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.
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.
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MALNUTRITION
What every nurse should do
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.
Screening, or undertaking a nutritional trigger
assessment, can identify patients who are already
malnourished or are at risk of becoming so. Highrisk children need a comprehensive nutritional
assessment, usually undertaken by a dietitian.
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.
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:
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.
• STAMP (Screening Tool for the Assessment of
Malnutrition in Paediatrics)
www.stampscreeningtool.org/stamp
• PYMS (Paediatric Yorkhill Malnutrition Score)
www.knowledge.scot.nhs.uk/pyms
How to identify dietary or
feeding patterns that could
lead to poor nutrition
Some basic assessments will contribute
significantly to identifying children at risk. Nurses
should identify slow growth patterns by:
It 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.
• weighing the child in kg (at least weekly if in
hospital) (see Box 1)
• measuring length or height in centimetres
where there is concern about growth
Reflecting on your knowledge and skills of the
following might help you identify problems:
• plotting the measurements on a centile chart.
(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)
• how to weigh and measure children, young
people and, if necessary, their parents
• breastfeeding and problems that might result
in poor sucking or low milk production
• measuring head circumference in under two
year olds
• how to select, prepare and handle
age-appropriate infant feeds
• discussing the readings with the parents and
child.
• when to introduce solid foods and progress
weaning
• suitable feeding patterns and optimal
parent-child interactions at meal times
Box 1: Key points when weighing children
and young people
• the appropriate range of food and portion sizes
for young children
• Under three years – naked.
• Over three years – minimal clothing.
• dietary patterns likely to contribute to
malnutrition, such as low iron or poor vitamin
intake
• Choose scales suitable for age, size and
condition.
• cultural or ethnic dietary practices that could
predispose to malnutrition, for example vegan
diets or delayed weaning
• Place child centrally on the scales.
• Take reading when the child is still.
• Record weight in kilograms.
• how to recognise signs of malnutrition, which
include 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.
• Plot on chart and record in Personal Health
Record where appropriate.
• Remember scales must be calibrated regularly.
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ROYAL COLLEGE OF NURSING
Asking questions
What to do next
Basic 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).
If 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.
You should also ensure the information is passed
to an appropriate specialist for example:
• breastfeeding counsellor
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:
• health visitor for normal feeding problems
• paediatrician for elimination of an underlying
medical problem
• be clear about why you need the information
• GP
• ask open questions, for example: “Tell me how
often you eat a piece of fruit” or “Tell me about
the food you eat at school”
• paediatric dietitian for advice on nutritional
support, for example nutritional drinks, dietary
modification and feeding problems
• answer any questions they might have
truthfully
• speech and language therapist for help
with feeding difficulties such as chewing or
swallowing.
• give guidance if needed or requested.
Some indicators or problems to look out for are
given in box 2.
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.
Box 2: Some clues to a problem
• Parents have anxieties about food.
• Parents are too focused on healthy eating
for their children, so they become deprived
of calories.
• Parents are overweight – children may be
deliberately kept thin to avoid bullying.
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MALNUTRITION
References
Brotherton 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).
More J (2008) Don’t forget the undernourished
children 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).
Care Quality Commission (2010) Essential Standards
of Quality and Safety, London: CQC. Available at:
www.cqc.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).
Department of Health (2010b) Essence of Care
2010: benchmarks for the fundamental aspects
of care. London: DH. Available at: www.gov.uk/
government (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.
Department of Health (2008) High quality care for
all: NHS next stage review final report, London:
DH (CM 7432). Available at: 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).
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).
Department of Health (2010a) Equity and
excellence: liberating the NHS. London: DH
(Cm 7881). Available at: www.official-documents.
gov.uk/document/cm78/7881/7881.pdf
(accessed 27 November 2013).
Shaw NJ and Mughal MZ (2013) Vitamin D and
Child Health Part 1 (skeletal aspects) Archives of
Disease in Childhood 98 (5) pp.363-367.
Elia M and Stratton RJ (2012) An analytic appraisal
of nutrition screening tools supported by original
data with particular reference to age. Nutrition 28
(5) pp.477-494.
Shaw NJ and Mughal MZ (2013) Vitamin D and
Child Health Part 2 (extraskeletal and other
aspects) Archives of Disease in Childhood 98 (5)
pp.368-372.
Gerasimidis K et al., (2011) Performance of the
novel Paediatric Yorkhill Malnutrition Score
(PYMS) in hospital practice. Clinical Nutrition
30(4) pp.430-435.
Shepherd A (2009) Nutrition in infancy and
childhood: a healthy start means a health future.
Primary Health Care 19 (1) pp.41-48.
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.
Shipway L (2010) Providing nutritional support
for patients during cancer treatment. Paediatric
Nursing 22 (4) pp.20-25.
Hall D and Elliman D (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
Paediatric Yorkhil Malnutrition Score: challenges
and impact on nursing practice. Journal of Clinical
Nursing 21 (23-24) pp.3583-3586.
More J (2013) Evidence-based portion sizes for
children aged 1-4 years. Community Practitioner
86 (5) pp.43-46.
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ROYAL COLLEGE OF NURSING
Websites for further information
British 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
7
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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