Case studies on clinical scenarios of paediatric malnutrition: Results from an international survey

Abstract

Objectives and Study: The cause and presentation of malnutrition in paediatric patients is complex; hence identification and assessment of the condition varies between health professional (HPs). This survey aimed to present different clinical scenarios regarding paediatric malnutrition to HPs and 1) investigate their nutritional risk judgement; 2) explore differences across countries and profession. Methods: A web-based questionnaire survey was sent to paediatric gastroenterologists (MD) and paediatric dieticians (RD) in seven countries (the Netherlands, Belgium, UK, Australia, Israel, Spain and Turkey). Nine brief clinical scenarios were presented and responders were asked to assess the nutritional risk as low, medium or high and to comment on need for nutritional intervention or further assessment. Decision tree algorithms were generated using the recursive partitioning algorithm. Results: In total, 569 responders (Australia: n=72; Belgium: n=26; Israel: n=90; the Netherlands: n=61; Spain: n=118; Turkey: n=73; UK: n=129) participated; 47% were MDs and 53% RDs with a different distribution of professions across countries (p< 0.001). MDs and RDs respectively, had a median of 15 (10;24) and 7 (3;13) years' experience in paediatrics. The majority worked in a tertiary (52%) and/or district general hospital (33%), with differences noted across countries. The case of a sick child with involuntary weight loss was judged at high nutrition risk with the most consensus (74.8% high risk); lowest risk was attributed to an otherwise healthy child with a low BMI (40.4% low risk). Differences existed across countries and profession. The clinical scenario which collected the most marked difference in nutrition risk interpretation among participants was a child with normal weight at risk of refeeding syndrome (71% low risk in Belgium vs 68% high risk in Turkey; p< 0.001). Agreement in nutritional risk assessment was reached across countries for a short child with chronic illness (moderate/high risk 90.4%, p=0.280) and a child with Crohn's disease in clinical remission (90.6% low/moderate risk, p=0.148). Decision tree analysis revealed that Belgium, the Netherlands and Spain clustered together in the risk assessment of 6/9 scenarios. Nutritional assessment/intervention was deemed necessary most frequently in the case of the sick child with involuntary weight loss due to illness (73.4%) and for a child with normal weight at risk of refeeding syndrome (61.9%); least frequently for the child with Crohn's disease in clinical remission (37.4%), with significant differences across countries for all. For each case study except for the short child with a chronic illness (p=0.828), there was a higher proportion of RDs than MDs that deemed an intervention was necessary (all p-values ≤0.003). Conclusions: Differences across countries were noted in judging nutritional risk in nearly all clinical paediatric scenarios, suggesting local differences in practice, beliefs, training and resource availability. The high agreement in the risk assessment of a child with on-going weight loss during illness highlights the importance of serial anthropometry measurements evaluation. There is need to formulate a uniform approach on how to assess malnutrition risk and indications for intervention in routine clinical practice.L6280937422019-06-18 <br />