Accepted Article
Article Type: Regular Article
More training and awareness are needed to improve the recognition of under-nutrition in hospitalised children Koen Huysentruyt1, Philippe Goyens2, Philippe Alliet3, Patrick Bontems4, Hilde Van Hautem5, Pierre Philippet6, Yvan Vandenplas1, Jean De Schepper1. 1
Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels,
Belgium 2
Nutrition and Metabolism Unit, Department of Paediatrics, University Children’s hospital Queen
Fabiola, Brussels, Belgium 3
Department of Paediatrics, Jessa Hospital, Hasselt, Belgium
4
Department of Paediatrics, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
5
Department of Paediatrics, Sint-Maria Hospital, Halle, Belgium; for VVK (Vlaamse Vereniging voor
Kindergeneeskunde) 6
Department of Paediatrics, CHC - Espérance, Liège, Belgium; for GBPF (Groupement Belge des
Pédiatres de Langue Française) Short title: Nutritional screening in hospitalised children
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/apa.13014 This article is protected by copyright. All rights reserved.
Accepted Article
Corresponding author & request for reprints: Dr. K. Huysentruyt Department of Paediatrics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium Tel: +32 2 477 57 81, Fax: +32 2 477 57 83 E-mail: [email protected]
ABSTRACT Aim: Reports suggest that 10% of hospitalised children in Europe are undernourished. We investigated if nutritional screening tools (NST) were used in Belgian secondary-level hospitals, examined strategies for detecting under-nutrition and identified barriers preventing the systematic management of under-nutrition. Methods: A nationwide questionnaire-based survey of paediatric departments in Belgian secondarylevel hospitals was carried out from September 2013 to February 2014. Respondents were dived into French-speaking (Walloon + Brussels) and Dutch-speaking (Flemish) departments. Results: We received replies from 71 of the 97 (73.2%) departments. Half of the departments – 39.5% Flemish speaking and 71.4% Walloon speaking - carried out nutritional screening. Undernutrition was identified by measuring weight and length or height (92.7% of cases), clinical appraisal (74.7%) mid-upper arm circumference and, or, skin fold thickness (19.7%). There was no protocol for under-nutrition in many Flemish (60.5%) and Walloon (28.6%) speaking departments. Reasons given for not screening were: lack of training (46.9%), ignorance of NST (42.2%) and lack of time (29.7%). Conclusion: Half of the paediatric departments in Belgian secondary-level hospitals did not carry out nutritional screening and differences in current practices and attitudes may be due to cultural and, or, educational differences.
This article is protected by copyright. All rights reserved.
Accepted Article
screening tools and these were used by 25% of the departments, followed by the STRONGkids nutritional screening tool, which was used by 21.4%. Screening was performed by paediatricians in 80% of cases, alone (19/28) or with the help of other staff (9/28). Nurses performed screening in 15 departments and in seven of these, all in the French speaking part of the country, they were solely responsible for screening.
DISCUSSION This was the first nationwide study to evaluate the extent to which nutritional screening in hospitalised children was an established clinical practice. Our survey demonstrated that nutritional screening had not been widely adopted in the paediatric departments of Belgian secondary-level hospitals during the six-month study period from September 2013 to February 2014. The most common barriers that prevented nutritional screening were a lack of training, especially in the smaller departments, and a lack of awareness. Another important finding was that a paediatric dietician or PNST was present in less than half of the departments. Lastly, no protocol or action plan for managing under-nutrition was adopted in half of the paediatric departments.
While half of the paediatricians were unaware of nutritional screening tools, their opinions about the necessity of nutritional screening in hospitalised children differed greatly. Only two respondents did not believe in the merit of nutritional screening. On the other hand, 37% felt that screening would benefit all children, while the majority would only screen children that they suspected were nutritionally at risk. This opinion was not associated with ward size or the presence of paediatric dieticians, but differed between the Dutch and French speaking areas of Belgium. We suspect that cultural and, or educational differences might have been responsible for this striking difference. In addition, the Dutch speaking community tended to favour gentler measures to raise the priority of
This article is protected by copyright. All rights reserved.
Accepted Article
Therefore, the aims of our study were: 1) to investigate the extent to which screening for undernutrition in hospitalised children was established in the paediatric departments of Belgium’s secondary-level hospitals; ii) to list the strategies used to identify under-nutrition and iii) to list barriers hindering the systematic detection of paediatric under-nutrition.
MATERIALS AND METHODS Data collection Our survey was derived from a review of the available literature on nutritional screening and current recommendations on best clinical practice for nutritional assessment and management. A first draft was considered by a group of experts in the field during a face-to-face meeting and the revised version was independently approved by all the experts. An English translation of this version is available online in Table S1. The original Dutch questionnaire was translated into French by a native French speaking expert and then translated back into Dutch. The 97 heads of all Belgian secondary-level paediatric departments were invited to participate in this survey and respond to the postal or online questionnaire (7). Tertiary-level university hospitals were not invited to take part, because their structure is more complex and nutritional management is likely to be different. The questionnaire was distributed to all paediatric department heads through the post and by email on 14 November 2013. A reminder was sent to non-responders, again through the post and by email, on 6 January 2014, with a deadline of 9 February 2014. No incentives or compensation, financial or otherwise, were offered and anonymity was guaranteed to all respondents. The responses to the electronic questionnaire were blinded to the investigators through the survey software and The Belgian Nutrition Congress Secretary was the trusted third party who collected and
This article is protected by copyright. All rights reserved.
Accepted Article
anonymised the questionnaires returned through the post. The study protocol was approved by Commissie Medische Ethiek UZ Brussel, the ethical committee of UZ Brussel.
Statistical analysis Language, and the differences in culture that accompany it, was deemed an important factor in this study, as there is a north-south divide in Belgium. Dutch is the dominant language in the north of the country (which is called the Flemish region), while French, dominates the south (which is called the Walloon region). French is also the most common language spoken in Brussels (the central region of the country). Department heads were divided into French and Dutch speaking respondents, based on their geographical origin. Because all of the responding departments from Brussels were French speaking, they were included with the French respondents. Statistical analysis was performed using SAS v9.4. Differences in proportions between the groups were analysed using a χ²-test or a Fisher’s exact test where appropriate. The medians of continuous variables were compared using a Wilcoxon Mann-Whitney test. Missing values were reported separately. A p-value of 1 full time dieticians
Total (N=97) N (%)
Dutch speaking (N=55) N (%)
French speaking (N=42) N (%)
26 (26.8) 28 (28.9) 43 (44.3)
12 (21.8) 15 (27.3) 28 (50.9)
14 (33.3) 13 (31.0) 15 (35.7)
31 (43.7) 40 (56.3) 20 (10 - 72)
17 (39.5) 26 (60.5) 20 (15 - 48)
14 (50.0) 14 (50.0) 19 (10 - 72)
38 (53.5) 33 (46.5)
24 (55.8) 19 (44.2)
14 (50.0) 14 (50.0)
39 (58.2) 25 (37.3) 3 (4.5)
25 (62.5) 13 (32.5) 2 (5.0)
14 (51.9) 12 (44.4) 1 (3.7)
Significance* p-value 0.282
0.385
0.445 0.631
0.692
This article is protected by copyright. All rights reserved.
Accepted Article
Missing 4 3 1 Admission of undernourished children Never 1 (1.4) 1 (2.3) 0 (0.0)
Article Type: Regular Article
More training and awareness are needed to improve the recognition of under-nutrition in hospitalised children Koen Huysentruyt1, Philippe Goyens2, Philippe Alliet3, Patrick Bontems4, Hilde Van Hautem5, Pierre Philippet6, Yvan Vandenplas1, Jean De Schepper1. 1
Department of Paediatrics, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels,
Belgium 2
Nutrition and Metabolism Unit, Department of Paediatrics, University Children’s hospital Queen
Fabiola, Brussels, Belgium 3
Department of Paediatrics, Jessa Hospital, Hasselt, Belgium
4
Department of Paediatrics, Centre Hospitalier Universitaire Tivoli, La Louvière, Belgium
5
Department of Paediatrics, Sint-Maria Hospital, Halle, Belgium; for VVK (Vlaamse Vereniging voor
Kindergeneeskunde) 6
Department of Paediatrics, CHC - Espérance, Liège, Belgium; for GBPF (Groupement Belge des
Pédiatres de Langue Française) Short title: Nutritional screening in hospitalised children
This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process, which may lead to differences between this version and the Version of Record. Please cite this article as doi: 10.1111/apa.13014 This article is protected by copyright. All rights reserved.
Accepted Article
Corresponding author & request for reprints: Dr. K. Huysentruyt Department of Paediatrics, UZ Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium Tel: +32 2 477 57 81, Fax: +32 2 477 57 83 E-mail: [email protected]
ABSTRACT Aim: Reports suggest that 10% of hospitalised children in Europe are undernourished. We investigated if nutritional screening tools (NST) were used in Belgian secondary-level hospitals, examined strategies for detecting under-nutrition and identified barriers preventing the systematic management of under-nutrition. Methods: A nationwide questionnaire-based survey of paediatric departments in Belgian secondarylevel hospitals was carried out from September 2013 to February 2014. Respondents were dived into French-speaking (Walloon + Brussels) and Dutch-speaking (Flemish) departments. Results: We received replies from 71 of the 97 (73.2%) departments. Half of the departments – 39.5% Flemish speaking and 71.4% Walloon speaking - carried out nutritional screening. Undernutrition was identified by measuring weight and length or height (92.7% of cases), clinical appraisal (74.7%) mid-upper arm circumference and, or, skin fold thickness (19.7%). There was no protocol for under-nutrition in many Flemish (60.5%) and Walloon (28.6%) speaking departments. Reasons given for not screening were: lack of training (46.9%), ignorance of NST (42.2%) and lack of time (29.7%). Conclusion: Half of the paediatric departments in Belgian secondary-level hospitals did not carry out nutritional screening and differences in current practices and attitudes may be due to cultural and, or, educational differences.
This article is protected by copyright. All rights reserved.
Accepted Article
screening tools and these were used by 25% of the departments, followed by the STRONGkids nutritional screening tool, which was used by 21.4%. Screening was performed by paediatricians in 80% of cases, alone (19/28) or with the help of other staff (9/28). Nurses performed screening in 15 departments and in seven of these, all in the French speaking part of the country, they were solely responsible for screening.
DISCUSSION This was the first nationwide study to evaluate the extent to which nutritional screening in hospitalised children was an established clinical practice. Our survey demonstrated that nutritional screening had not been widely adopted in the paediatric departments of Belgian secondary-level hospitals during the six-month study period from September 2013 to February 2014. The most common barriers that prevented nutritional screening were a lack of training, especially in the smaller departments, and a lack of awareness. Another important finding was that a paediatric dietician or PNST was present in less than half of the departments. Lastly, no protocol or action plan for managing under-nutrition was adopted in half of the paediatric departments.
While half of the paediatricians were unaware of nutritional screening tools, their opinions about the necessity of nutritional screening in hospitalised children differed greatly. Only two respondents did not believe in the merit of nutritional screening. On the other hand, 37% felt that screening would benefit all children, while the majority would only screen children that they suspected were nutritionally at risk. This opinion was not associated with ward size or the presence of paediatric dieticians, but differed between the Dutch and French speaking areas of Belgium. We suspect that cultural and, or educational differences might have been responsible for this striking difference. In addition, the Dutch speaking community tended to favour gentler measures to raise the priority of
This article is protected by copyright. All rights reserved.
Accepted Article
Therefore, the aims of our study were: 1) to investigate the extent to which screening for undernutrition in hospitalised children was established in the paediatric departments of Belgium’s secondary-level hospitals; ii) to list the strategies used to identify under-nutrition and iii) to list barriers hindering the systematic detection of paediatric under-nutrition.
MATERIALS AND METHODS Data collection Our survey was derived from a review of the available literature on nutritional screening and current recommendations on best clinical practice for nutritional assessment and management. A first draft was considered by a group of experts in the field during a face-to-face meeting and the revised version was independently approved by all the experts. An English translation of this version is available online in Table S1. The original Dutch questionnaire was translated into French by a native French speaking expert and then translated back into Dutch. The 97 heads of all Belgian secondary-level paediatric departments were invited to participate in this survey and respond to the postal or online questionnaire (7). Tertiary-level university hospitals were not invited to take part, because their structure is more complex and nutritional management is likely to be different. The questionnaire was distributed to all paediatric department heads through the post and by email on 14 November 2013. A reminder was sent to non-responders, again through the post and by email, on 6 January 2014, with a deadline of 9 February 2014. No incentives or compensation, financial or otherwise, were offered and anonymity was guaranteed to all respondents. The responses to the electronic questionnaire were blinded to the investigators through the survey software and The Belgian Nutrition Congress Secretary was the trusted third party who collected and
This article is protected by copyright. All rights reserved.
Accepted Article
anonymised the questionnaires returned through the post. The study protocol was approved by Commissie Medische Ethiek UZ Brussel, the ethical committee of UZ Brussel.
Statistical analysis Language, and the differences in culture that accompany it, was deemed an important factor in this study, as there is a north-south divide in Belgium. Dutch is the dominant language in the north of the country (which is called the Flemish region), while French, dominates the south (which is called the Walloon region). French is also the most common language spoken in Brussels (the central region of the country). Department heads were divided into French and Dutch speaking respondents, based on their geographical origin. Because all of the responding departments from Brussels were French speaking, they were included with the French respondents. Statistical analysis was performed using SAS v9.4. Differences in proportions between the groups were analysed using a χ²-test or a Fisher’s exact test where appropriate. The medians of continuous variables were compared using a Wilcoxon Mann-Whitney test. Missing values were reported separately. A p-value of 1 full time dieticians
Total (N=97) N (%)
Dutch speaking (N=55) N (%)
French speaking (N=42) N (%)
26 (26.8) 28 (28.9) 43 (44.3)
12 (21.8) 15 (27.3) 28 (50.9)
14 (33.3) 13 (31.0) 15 (35.7)
31 (43.7) 40 (56.3) 20 (10 - 72)
17 (39.5) 26 (60.5) 20 (15 - 48)
14 (50.0) 14 (50.0) 19 (10 - 72)
38 (53.5) 33 (46.5)
24 (55.8) 19 (44.2)
14 (50.0) 14 (50.0)
39 (58.2) 25 (37.3) 3 (4.5)
25 (62.5) 13 (32.5) 2 (5.0)
14 (51.9) 12 (44.4) 1 (3.7)
Significance* p-value 0.282
0.385
0.445 0.631
0.692
This article is protected by copyright. All rights reserved.
Accepted Article
Missing 4 3 1 Admission of undernourished children Never 1 (1.4) 1 (2.3) 0 (0.0)
