Feature: Applying Malnutrition Indicators in the Preterm and Neonatal Population
Applying Malnutrition Indicators in the
Preterm and Neonatal Population
By: Dena L. Goldberg, PhD, RDN and Maura Sandrock, MS, RDN, CD
Guidelines for Hypoglycemia Screening and Intervention
LEARNING OBJECTIVES
Introduction
In 2014, the Academy of Nutrition and Dietetics and the American Society for Enteral and
Parenteral Nutrition published a consensus
statement on recommended indicators for the
identification and documentation of pediatric
8 | September 2019
malnutrition.1 These indicators pertain to infants and children one month of age and older.
Preterm infants and neonates were not included
for two reasons:
• The growth pattern of preterm infants
and neonates differs from older infants as
weight loss is expected after birth.
• Standards for some indicators used to
identify pediatric malnutrition, such
as mid-upper arm circumference and
weight/length z-score, are not available
for preterm infants and neonates.
As a result, another set of malnutrition indicators was developed in 2018 for the preterm
infant and neonate population.
A Vulnerable Population
Preterm infants and neonates are more vulnerable to calorie and protein deficits, which can
disrupt rapid lean body mass accretion, brain
growth, and maturation. Preterm infants may
have a harder time tolerating weight loss after
the initial postnatal diuresis because they have
low lean body mass and adipose tissue stores,
which are necessary to sustain metabolism dur-
ing periods of significant calorie and protein
deficits. For these reasons, malnutrition can
occur with nutrient intake deficits of only a
few days, given the infants’ high metabolic and
protein demands for growth.
About 50 percent of poor growth in the
preterm population has been associated with
inadequate nutrient intake.2 These deficits can
occur when infants are unable to receive optimal parenteral nutrition due to hyperglycemia
and hypertriglyceridemia. Interruptions in
feedings, delays in feeding advancement related to intolerance resulting from an immature
gastrointestinal tract, and concerns about the
development of necrotizing enterocolitis also
contribute to inadequate intake.3 Suboptimal
intake and growth failure are most likely to
occur during the transition from full or partial
parenteral nutrition to full enteral nutrition.4,5
Prematurity complications—such as necrotizing enterocolitis, sepsis, chronic lung disease,
and other medical diagnoses including congenital cardiac disease and genetic syndromes—also
contribute to poor growth.3 Medical treatments
such as fluid restriction, diuretics, and corticoPediatric Currents
steroids, can result in poor growth.6,7 Optimal
nutrition can mitigate the severity of illness and
its impact on growth.8,9 Extrauterine growth
restriction, defined as growth values <10th percentile, has been reported to exist in 28-97%
of extremely low birth weight infants.2,10–16
Growth restriction is associated with negative
neurodevelopmental outcomes of preterm infants into childhood and adolescence.17–26
Variations in infant growth rates between
neonatal intensive care units (NICUs) can
be ascribed, in part, to differences in nutrition practices10,27–38 and some due to different approaches in calculating growth rates.39
Evidence-based practices that include early
maximal parenteral nutrition and the early
introduction of feeds with rapid advancement can improve growth outcomes, cognitive development, and decrease the incidence
of necrotizing enterocolits.2,27-29,36-38,40-56 Poor
growth has been associated with poor neurocognitive development up to 19 years of age
in several studies.12,17–26,57–59
Indicators for Diagnosis of Malnutrition
Given the importance of defining the criteria
for malnutrition in this vulnerable population, a committee of experienced NICU registered dietitian nutritionists, supported by the
Academy of Nutrition and Dietetics’ Pediatric
Nutrition Dietetic Practice Group, developed
recommended indicators for diagnosing malnutrition in preterm infants and neonates in
2018.60 Preterm infants are defined as infants
born before 37 weeks. The neonatal population
includes infants 37 weeks or greater and less
than one month old. Thus, a preterm infant
now 37 weeks or greater and one month of age
or older should be screened for malnutrition using the pediatric criteria.
Identifying malnutrition in preterm infants
and neonates:
1. Triggers the development of a nutrition
care plan, which provides the foundation
for optimal growth and development.
2. Establishes the prevalence of malnutrition in this population using an objective/
standardized method.61 Quality improvement projects designed to identify the
incidence of malnutrition in a NICU can
help facilitate change in nutrition support
practices to improve growth outcomes.
Pediatric Currents
3. Supports data used to justify adequate
dietitian staffing, as dietitians are key
providers to identify and document malnutrition and to establish nutrition care
plans to treat malnutrition.61,62
4. Increases reimbursement for a patient’s
hospital care, and over time increases a
facility’s acuity factor.61
5. Alerts NICU providers and post-discharge providers to intervene and monitor nutrition and growth.
The dietitian defines the nutrition goals of
preterm infants and neonates with complex
medical needs and works closely with the multidisciplinary team to coordinate nutrition care
and assess constantly changing clinical information. Early and close monitoring of growth and
nutrient intake to identify deficits of intake and
early signs of malnutrition is an important strategy for improving growth outcomes.63
The indicators for identifying malnutrition
in preterm infants and neonates include weight,
length, and nutrient intake.60 Primary indicators
used for the diagnosis of neonatal malnutrition
include: weight gain velocity, decline in weight
gain z-score, and nutrient intake. A deficit in
one of these primary indicators is sufficient for
the diagnosis of malnutrition. However, note
that weight gain velocity and decline in weight
z-scores are not appropriate indicators for the
first two weeks of life due to postnatal diuresis.2
Nutrient intake, which can be easily quantified, is the recommended indicator during this
time period. Other indicators include days to
regain birthweight, linear growth velocity, and
decline in length-for-age z-score. Deficits in
these indicators must be used in conjunction
with at least one additional indicator to diagnose malnutrition. However, linear growth
velocity and decline in length-for-age z-score
are not appropriate indicators for the first two
weeks of life. The indicators are described in
Table 1.
Growth
Growth assessment is based on established
growth curves. Either the Fenton growth
charts or the Olson growth charts are recommended for preterm infants with gestational age of 36 weeks and 6 days (6/7)
or earlier.64,65 Differences between the two
charts are discussed elsewhere.60 The World
Health Organization (WHO) growth chart
is recommended for infants born at 37
weeks or greater. Preterm infants should be
transitioned to the WHO growth charts at
about 40 weeks. The smoothing assumption
of data between the preterm and post-term
references was validated in the development
of the revised Fenton growth curves.64 Generally, z-scores rather than percentiles are
recommended for evaluating growth.1 Zscores provide a comparison to the median
of a predetermined population and are not
an absolute value. Z-scores also allow for
quantification and monitoring changes in
growth at the extremes of the growth chart
(below the 3rd and above the 97th percentiles). A change in z-scores indicates a change
in growth velocity. A decline in z-score therefore indicates growth-faltering.
Assessment of Postnatal Growth
The gold standard for weight gain in the
preterm infant population is to achieve the
rate gain of the fetus at the same postconceptional age.66 This weight gain goal is not
always easy to achieve, although at the time
of discharge most preterm infants are growing parallel to the appropriate intrauterine
growth curve.43,66 The commonly recommended weight gain goals (15-20 g/kg/day
when infant is <2,000g or 25-35 g/d when
infant is >2,000g) are not recommended for
diagnosing malnutrition as growth velocity goals change as postnatal age increases.
Therefore, the recommended growth velocity (in g/kg/d) varies with the denominator
used in the calculation.67 Additionally, postnatal growth rate may need to be greater
than 15-20 g/kg/d to maintain a current
z-score. Pedi Tools (peditools.org) provides
exact weight z-scores, percentiles, and the
weight gain needed to maintain weight zscore over the following week. There are
reports of improved neurodevelopmental
outcomes with weight gains of >18 g/kg/
d25 and of maintaining or exceeding birth
weight z-score with weight gains of 20-30
g/kg/d.80
After initial diuresis, infants should
achieve a rate of weight gain that parallels fetal growth. According to Zeigler and
Carlson, weight loss after birth decreases the
September 2019 | 9
Feature: Applying Malnutrition Indicators in the Preterm and Neonatal Population
Table 1: P
rimary Indicators of Neonatal Malnutrition*
Primary Indicator
Mild Malnutrition
Moderate Malnutrition
Severe Malnutrition
Use of Indicator
Decline of >1.2–2 SDb
Decline of >2 SDb
Not appropriate for first two weeks
of life
Primary Indicators requiring one indicator
Decline in weightfor-age z-scorea
Decline of 0.8–1.2 SDb
Weight gain
velocitya
<75% of expected
rate of weight gain to
maintain growth rate
growth rate
maintain growth rate
≥3–5 consecutive
≥5–7 consecutive days
>7 consecutive days
of protein/energy
intake ≤75% of estimated needs
Preferred indicator during the first two
weeks of life
Nutrient Intake
<50% of expected rate of
<25% of expected
Not appropriate for first two weeks
Guidelines for
Intervention
weightHypoglycemia
gain to maintain
rate ofScreening
weight gain to
ofand
life
days of protein/energy intake ≤75% of
estimated needs
of protein/energy intake
≤75% of estimated needs
Primary Indicators requiring two or more indicators
Days to regain
birth weight
15–18 days
19–21 days
>21 days
Use in conjunction with nutrient intake
Linear growth
velocitya
<75% of expected
rate of linear gain to
maintain expected
growth rate
<75% of expected rate
of linear gain to maintain
expected growth rate
<25% of expected
rate of linear gain to
maintain expected
growth rate
Not appropriate for first two weeks
of life
May be deferred in critically ill
unstable infants
Use in conjunction with another
indicator when accurate length
measurement available
Decline in lengthfor-age z-scorea
Decline of 0.8–1.2 SDb
Decline of >1.2–2 SDb
Decline of >2 SDb
Not appropriate for first two weeks
of life
May be deferred in critically ill
unstable infants
Use in conjunction with another
indicator when accurate length
measurement available
*Reprinted with permission from the Academy of Nutrition and Dietetics JAND. 2018. doi:10.1016/j.jand.2017.10.006
a Expected weight linear growth velocity and z-scores can be determined using the online calculator pedi tools www.peditools.org
b SD=standard deviation
z-score by about 0.6 standard deviation.68
Andrews, et al. reported that infants born
at 24 to 31 weeks gestation had an average change in weight z-score from birth of
-0.27 at 36 weeks; whereas infants born at
23 weeks gestation had a change in weight
z-score from birth of -1.02 at 36 weeks.69
A large study by Rochow, et al. found that
infants grew at 0.8 standard deviation below
birth weight z-scores at 21 days of age.43 A
similar observation by Cole and colleagues
led them to recommend using this lower percentile as a growth goal rather than the birth
10 | September 2019
percentile, which would necessitate rapid
weight gain which carries its own risks.70 Using recommended growth velocities would
allow infants to grow at an intrauterine rate
– although parallel to their birth percentile.
Days to Regain Birth Weight
Infants are expected to lose around 7 to 10%
of birth weight due to postnatal diuresis.71
Up to 20% weight loss can occur in the first
3 to 5 days of life.71 Although the amount of
weight loss is variable, optimal water balance
and nutrient intake can lessen the severity of
weight loss and aid in the regaining of birth
weight.71–73 The majority of infants regain
birth weight within the first 2 weeks of life,
though this is not consistent.27,31,74–76 Therefore, to be used as an indicator of malnutrition, days to regain birth weight must be
used in conjunction with a second indicator,
nutrient intake.
Case Study 1: AJ - Days to Regain Birth Weight
AJ is a preterm male born at 24 5/7 weeks;
birth weight 590 grams. Parenteral nutrition
was initiated shortly after birth. Trophic
Pediatric Currents
Table 2: Case Study 1 - AJ Weight History
DOL
Date
Gestational Age
(weeks)
Weight (g)
Weight-for-Age
(%tile, z-score)
Change in
Z-score
(from birth)
Weight
Changes
(g past week)
% Goal
Goal Weight
Gain
(g/week)
Birth
9/2/18
24 5/7
590
16th
-1.00
8
9/10/18
25 6/7
600
8th
-1.42
-0.42
+10
1.7%
above birth
weight
60
16
9/17/18
26 6/7
560
3rd
-1.89
-0.89
-40
0
47
Table 3: Case Study 2 - ES Weight History
DOL
Date
Gestational Age
(weeks)
Weight (g)
Weight-for-Age
(%tile, z-score)
Change in
Z-score
(from birth)
Weight
Changes
(g past week)
Birth
9/23/18
24 5/7
540
13th
-1.12
7
9/29/18
25 5/7
550
13
10/5/18
26 4/7
20
10/12/18
27
7th
-1.44
-0.32
10
620
10th
-1.28
-0.16
110
229
62
27 4/7
690
11th
-1.25
-0.13
70
113
77
10/19/18
28 4/7
740
9th
-1.35
-0.23
50
65
94
34
10/26/18
29 4/7
840
9th
-1.33
-0.21
100
106
122
41
11/2/18
30 4/7
970
10th
-1.31
-0.19
130
107
155
feeds of human milk were started on day of
life (DOL) 3 at 20 mL/kg/day and advanced
to 60 mL/kg/day on DOL 7. The feeding
advancement was then held because of feeding intolerance. On DOL 10, AJ developed
necrotizing enterocolitis and was made NPO.
Goal parenteral nutrition of GIR 10 mg/kg/
min (glucose infusion rate), 3.5 g/kg protein, 3
g/kg lipid and 50 ml/kg fluid was provided. On
DOL 12, triglyceride levels reached 390 mg/dL
and intravenous lipids were held for 24 hours.
Follow-up evaluation revealed triglyceride levels of 170 mg/dL, and lipids were resumed at 2
g/kg. Subsequently, due to continued hypertriglyceridemia, lipid dosing was held at 1 g/kg/d.
On DOL 14, the dextrose concentration in
Pediatric Currents
the parenteral nutrition was decreased due to
glucose levels greater than 250 mg/dL despite a
high dose of insulin. Caloric intake met 68% of
goal of 90 kcal/kg and protein intake met 100%
of goal of 3.5 g/kg protein from DOL 11 to
16. Table 2 describes AJ’s weight history. Does
this infant meet criteria for malnutrition?
See test question 3 in the Post-test on page 15.
(Infant meets criteria for mild malnutrition
due to failure to regain birth weight by 15-18
DOL and caloric intake of less than 75% of
goal for 5 days.)
Weight Gain Velocity
Weight gain velocity is a short-term indicator for a time period up to 2 weeks after
% Goal
Goal Weight
Gain
(g/week)
48
DOL 14. Pedi Tools provides the expected
weekly weight gain to maintain weight-forage z-score.
Case Study 2: ES - Weight Gain Velocity
ES is a preterm female born at 24 5/7 weeks
gestation; birth weight 540 grams. Enteral
feeds were started on DOL 2 and feedings
were advanced per protocol. Parenteral nutrition was discontinued on DOL 14. At this
time ES was on feeds of human milk, fortified with a human-milk-based fortifier to 26
kcal per ounce at 140 mL/kg. From DOL
21-41 she was on feeds of human milk with
the human-milk-based fortifier plus donor
human milk cream to 28 kcal per ounce
September 2019 | 11
Feature: Applying Malnutrition Indicators in the Preterm and Neonatal Population
at 140-150 mL/kg. Table 3 describes ES’s
weight history. Does ES meet criteria for
malnutrition based on her weight gain velocity? See test question 4. (Although weight
gain velocity for the week ending DOL 27
was low, her weight gain velocity at all other
times did not meet criteria for malnutrition.)
Decline in Weight Z-Score
Decline in weight z-score is a long-term
(greater than two weeks) indicator for malnutrition when the infant is greater than 2
weeks of age.
Case Study 3: EF - Decline in Weight Z-Score
EF is a preterm male born at 26 3/7 weeks
gestation, birth weight 780 grams. He has a
complex history. On DOL 1 he had an intestinal perforation and a drain was placed.
On DOL 16 an exploratory laparotomy was
performed for extensive lysis of adhesions,
partial resection of the proximal ileum,
ileostomy and mucous fistula creation. A
right upper quadrant abscess was drained.
On DOL 30 trophic feeds of donor human
milk were started. On DOL 46 he was made
NPO because of abdominal distention.
Trophic feeds of donor human milk were restarted, and he was advanced to full feeds of
26 kcal per ounce donor human milk with a
human-milk-based fortifier. Later, donor human milk cream was added to increase caloric density of feeds to 28 kcal per ounce. EF
was transitioned from fortified donor human
milk to an elemental formula concentrated
to 24 kcal per ounce. On DOL 69 caloric
density of feeds was increased to 27 kcal per
ounce. Table 4 provides EF’s weight history.
Does EF meet criteria for malnutrition
based on decline in weight z-score? See test
question 5. (The infant meets criteria for severe malnutrition based on decline in z-score
from birth.)
Length Growth Velocity and Decline in Z-Score
Length assessment requires using a length
board and proper technique to obtain an accurate measurement. Length measurements
obtained using a nonstandard length board
or a tape measure are inaccurate when compared with measurements obtained using the
recommended equipment and technique.77, 78
Measurement for length can be deferred in
infants less than 2 weeks of age, as well as in
very critically-ill infants. Pedi Tools provide
exact length percentiles, z-scores, and expected linear growth to maintain length z-score.
Linear growth velocity and decline in length
z-score require a second indicator to diagnose
malnutrition. Weight gain velocity and nutrient
intake would be appropriate second indicators
with linear growth, as linear growth faltering
related to malnutrition does not occur independently of weight faltering.
Case Study 4: MT - Linear Growth Velocity
MT is a 1-month old male born at 25 0/7
weeks gestation corrected to 29 0/7 weeks
gestation with a birth weight of 652 grams.
Medical diagnoses include respiratory failure
requiring intubation, necrotizing enterocolitis, and bilateral grade II intraventricular
hemorrhage.
Parenteral nutrition was started on DOL 1
and advanced to goal on DOL 6. Trophic feeds
of breast milk at 20 ml/kg/d were initiated on
DOL 5. Feeds were stopped on DOL 8 for necrotizing enterocolitis and sepsis. Hyperglycemia
Table 4: Case Study 3 - EF Weight History
DOL
Date
Gestational Age
(weeks)
Weight (g)
Weight-for-Age
(%tile, z-score)
Change in
Z-score
(from birth)
Weight
Changes
(g past week)
Birth
8/25/18
26 3/7
780
27th
-0.61
9
9/3/18
27 5/7
770
16
9/10/18
28 5/7
23
9/17/18
30
11th
-1.20
-0.59
1.3% below
birth weight
880
13th
-1.14
-0.53
110
118
116
29 5/7
990
12th
-1.16
-0.55
110
95
142
9/24/18
30 5/7
1080
10th
-1.30
-0.69
90
63
167
37
10/1/18
31 5/7
1170
7th
-1.50
-0.89
90
54
191
44
10/8/18
32 5/7
1240
4th
-1.79
-1.18
70
37
210
51
10/15/18
33 5/7
1230
1st
-2.31
-1.70
-10
0
227
58
10/22/18
34 5/7
1270
0
-2.75
-2.14
40
18
235
12 | September 2019
% Goal
Goal Weight
Gain
(g/week)
93
Pediatric Currents
Table 5: Case Study 4 - MT Weight History
Age
(days)
Date
Gestational Age
(weeks)
Weight (g)
Weight-for-Age
(z-score)
Change in
z-score
Weight
Changes
(g past week)
% Goal
Goal Weight
Gain
(g/week)
14
01/22
27 0/7
652
-1.50
-0.81
+52
21
01/29
28 0/7
701
-1.57
-0.07
+49
71
81
28
02/05
29 0/7
772
-1.60
-0.03
+71
88
104
69
Table 6: Case Study 4 - MT Length History
Age
(days)
Date
Gestational Age
(weeks)
Length
(cm)
Length-for-Age
(z-score)
Change in
z-score
Length Change
(cm past week)
% Goal
Goal Linear
Growth
14
01/22
27 0/7
32.0
-1.32
-0.56
0
0
1.27
21
01/29
28 0/7
32.4
-1.68
-0.36
0.4
31
1.28
28
02/05
29 0/7
32.6
-2.12
-0.44
0.2
16
1.30
Table 7: C
ase Study 4
- MT Nutrient
Intake History
Week
Calories
(% goal)
Protein
(% goal)
1
71
95
2
86
100
3
85
100
4
75
85
with blood glucose levels greater than 250 mg/
dL was managed with Y-in fluid of D5 (dextrose
5%) with ¼ NS (normal saline) to avoid use of
insulin. GIR in the parenteral nutrition was reduced to maintain blood glucose levels less than
200 mg/dL. On DOL 14, trophic feeds were
restarted at 20 ml/kg/d and advanced by 20 ml/
kg/d to 150 ml/kg/d. Breast milk was fortified
to 22 kcal per ounce with a human milk fortifier
on DOL 18. Feeds were held on DOL 19 for
abdominal distention and emesis. Feeds were restarted on DOL 20 and parenteral nutrition discontinued on DOL 21. Breast milk was fortified
to 24 kcal per ounce with a human milk fortifier
on DOL 25 and advanced to 26 kcal per ounce
on DOL 28. MT’s weight history is reviewed in
Table 5, linear growth reviewed in Table 6, and
nutrient intake in Table 7. Does MT meet criteria for malnutrition based on linear growth
Pediatric Currents
Table 8: R
ecommended Parenteral and Enteral Energy
and Protein*
Parenteral
Enteral
Energy Goals:
(kcal/kg)
Protein Goals:
(g/kg)
Energy Goals:
(kcal/kg)
Protein Goals:
(g/kg)
85–111
3–4
110–130
3.5–4.5
Late Preterm Infant33
34 0/7 weeks - 36
6/7 weeks
100–110
3–3.5
120–135
3–3.2
Term Infant31,32
> 37 0/7 weeks
90–108
2.5–3
105–120
2–2.5
Preterm Infant31,32
< 34 0/7 weeks
*Reprinted with permission from the Academy of Nutrition and Dietetics. JAND. 2018
doi:10.1016/j.jand.2017.10.006
velocity? See test question 7. (MT meets criteria
for moderate malnutrition, based on declines in
weight z-score and length z-score.)
Nutrient Intake
Nutrient intake provides an objective assessment of intake in relation to nutrition goals
and is the preferred indicator during the first
2 weeks of life when weight loss is expected.
Nutrient intake is also important beyond the
first 2 weeks of life, especially when accurate
growth measurements may be difficult to obtain due to medical conditions. Such conditions can result in positive fluid balance and
edema (e.g. septic shock or oliguric renal
failure), or negative fluid balance with high
output renal failure or rapid diuresis. Table 8
provides calorie and protein goals based on
gestational age.
Many factors affect the calorie and protein
requirements of preterm infants and term
neonates. Nutrient requirements change as
the preterm infant’s gestational age increases
towards term. Medical conditions must also be
considered when determining calorie and protein goals, as they may impact requirements.
The nutrient needs of the small-for-gestational-age infant are discussed in detail elsewhere.79
In preterm infants, the period of transition
from parenteral to enteral nutrition is when
September 2019 | 13
Feature: Applying Malnutrition Indicators in the Preterm and Neonatal Population
calorie and protein deficits are most likely to
occur, resulting in growth faltering.5 As with
the weight and length indicators, clinical judgement is important when assessing nutrient intake, as there are no specific caloric and protein
recommendations for the transition phase of
nutrition support.
Estimates can be based on the percent of calories and protein from parenteral feedings and
the percent of calories and protein from enteral
feedings. The mid-points of requirements from
the enteral and parenteral can be multiplied by
the percent for each, and then added together.
Example: TW is a 3-week-old late preterm
infant with respiratory failure. Parenteral nutrition (PN) provides 60% of nutrition and enteral
nutrition (EN) provides 40% of nutrition.
The PN goal range is 100-110 kcal/kg. The
mid-point is 105 kcal/kg x 60% =63kcal/kg.
The EN goal range is 120-135 kcal/kg. The
mid-point is 128 kcal/kg x 40% =51 kcal/kg.
The calorie goal for this patient is 63 + 51 or
114 kcal/kg/day.
The PN protein goal range is 3-3.5g/kg and
EN protein goal range is 3-3.2g/kg. The goal of
3g/kg protein for this patient is reasonable.
Term Infant
Case Study 5: SH - Term Infant
Below is a case study of a term infant, using the
preterm infant/neonatal malnutrition criteria.
SH is a term 39 2/7 weeks female with severe hypoxic ischemic encephalopathy. Feeding
complications include gastroesophageal reflux
without esophagitis, absent gag reflex and poor
gastric emptying requiring gastrojejunal tube
placement. Continuous feeds are being slowly
advanced, and she is on parenteral nutrition and
human milk. Caloric and protein intakes meet
recommendations and do not meet criteria for
malnutrition. Her weight history is included in
Table 9.
Does SH meet criteria for malnutrition
on DOL 22? See test question 9. (Weight gain
velocity, when evaluated from DOL 8 to DOL
22, does not meet criteria for malnutrition. Decline in weight z-score and nutrient intake also
do not meet criteria for malnutrition.)
When should SH be transitioned to the
pediatric malnutrition criteria? See test question 10. (On DOL 29, when the infant is one
month old, the pediatric malnutrition criteria
would be used to assess for malnutrition.)
need to closely monitor nutrition and growth
for deficits. Good clinical judgement is as important as factors other than nutrition (such
as fluid balance, environmental conditions,
and medical diagnoses) can influence growth,
development and long-term outcomes.
ABOUT THE AUTHORS
Dena L. Goldberg, PhD, RDN is a Clinical Dietitian II
at Carilion Children’s Hospital in Roanoke, VA.
Maura Sandrock, MS, RDN, CD is a Pediatric Clinical
Dietitian at Seattle Children’s Hospital, Seattle, WA.
REFERENCES FOR THIS ARTICLE MAY
BE FOUND IN THE ONLINE VERSION
AT WWW.ANHI.ORG (All URLs listed
in these articles were active at the time
of publication)
Conclusion
Diagnosing malnutrition in the preterm and
neonatal population using standardized, objective criteria is important because adequate
nutrition is essential for promoting optimum
physical and neurocognitive development. A
diagnosis of malnutrition alerts NICU providers and post-discharge providers of the
Table 9: Case Study 5 - SH Weight History
DOL
Date
Gestational Age
(weeks)
Weight (g)
Weight-for-Age
(%tile, z-score)
Change in
Z-score
(from birth)
Weight
Changes
(g past week)
Birth
10/10/18
39 2/7
3590
78th
0.76
8
10/18/18
40 3/7
3450
15
10/25/18
41 3/7
22
11/1/18
29
48th
-0.06
-0.82
-140
3730
52nd
0.06
-0.70
280
128
221
42 3/7
3580
26th
-0.65
1.41
-150
0
205
11/8/18
43 3/7
3987
39th
-0.27
-1.03
407
199
214
36
11/15/18
44 4/7
4300
46th
-0.10
-0.86
313
146
207
43
11/22/18
45 4/7
4231
30th
-0.52
-1.28
-69
0
188
14 | September 2019
% Goal
Goal Weight
Gain
(g/week)
219
Pediatric Currents
Post-Test: Applying Malnutrition
Indicators in the Preterm and Neonatal
Population
Complete the quiz online at www.anhi.org at no charge. Enter the title into the key word search to find the course. Please note online questions or answers are randomized and may not appear in the sequence below. Do not assume that the “letter” preceding the correct response
will be identical to the online version.
1.Both the Fenton and Olson growth
charts can be used for assessing preterm
infant growth.
a. True
b. False
2.For an infant with a gestational age of
36 5/7 weeks, the weight and length
should be plotted on the WHO growth
chart.
a. True
b. False
3.Does AJ in Case Study 1 meet the
criteria for malnutrition?
a. Yes, the patient meets criteria for mild
malnutrition, based on calorie/protein intake and days to regain birth
weight.
b. Yes, mild malnutrition based on days
to regain birth weight.
c. Yes, moderate malnutrition based on
calorie/protein intake and days to
regain birth weight.
d. No, infant does not meet criteria for
malnutrition.
4. D
oes ES in Case Study 2 meet the
criteria for malnutrition based on her
weight gain velocity?
a. Yes, ES meets criteria for mild
malnutrition.
b. Yes, ES meets criteria for moderate
malnutrition.
c. Yes, ES meets criteria for severe
malnutrition.
d. No, ES does not meet criteria for
malnutrition.
5.Does EF in Case Study 3 meet the
criteria for malnutrition on DOL 58,
based on decline in z-score?
a. Yes, EF meets criteria for mild
malnutrition.
b. Yes, EF meets criteria for moderate
malnutrition.
c. Yes, EF meets criteria for severe
malnutrition.
d. No, EF does not meet criteria for
malnutrition.
8.A 31 2/7 weeks infant weighing 1250
g is receiving 50% of his calories from
parenteral nutrition and 50% from
enteral nutrition. His PN goal range is
85-111 kcal/kg and his EN goal range
is 110-130 kcal/kg. What is his calorie
goal?
a. 105 kcal/kg
b. 98 kcal/kg
c. 109 kcal/kg
d. None of the above
6.Length is a primary indicator and
does not require a second indicator to
diagnose malnutrition.
a. True
b. False
9.Does SH in Case Study 5 meet criteria
for malnutrition on DOL 22?
a.Yes, SH meets criteria for mild
malnutrition.
b.Yes, SH meets criteria for moderate
malnutrition.
c.Yes, SH meets criteria for severe
malnutrition.
d.No, SH does not meet criteria for
malnutrition.
7.Does MT in Case Study 4 meet the
criteria for malnutrition based on linear
growth velocity?
a. Yes, MT meets criteria for mild
malnutrition.
b. Yes, MT meets criteria for moderate
malnutrition.
c. Yes, MT meets criteria for severe
malnutrition.
d. No, MT does not meet criteria for
malnutrition.
10.When should SH be transitioned to
pediatric malnutrition criteria?
a. DOL 15
b. DOL 22
c. DOL 29
d. DOL 36
CREDIT: 1 CONTACT HOUR Abbott Nutrition Health Institute, is an approved provider of continuing nursing education by the California
Board of Registered Nursing Provider #CEP 11213.
Abbott Nutrition Health Institute (RO002), is a Continuing Professional Education (CPE) Accredited Provider with the Commission on
Dietetic Registration (CDR). Registered dietitians (RDs) and dietetic technicians, registered (DTRs) will receive 1 continuing professional
does | not
Pediatric Currents education units (CPEU) for completion of this program/material. Continuing Professional Education Provider Accreditation
September 2019
15
constitute endorsement by CDR of a provider, program, or materials.
Feature: Screening for Malnutrition Risk in Pediatrics
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Feature: Applying Malnutrition Indicators in the Preterm and Neonatal Population
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20 | September 2019
Pediatric Currents