Nutritional outcome of children hospitalised in the paediatric intensive care unit: A single-centre longitudinal study

INTRODUCTION

A normal nutritional state is a metabolic situation in which there is a balance between needs and intake of proteins, energy, vitamins, minerals, trace elements and water. Children are growing organisms and are particularly vulnerable in terms of nutrition. Any mismatch between nutritional needs and intake can quickly lead to undernutrition, affecting not only growth but also pubertal and cognitive development.^[1-3]

Children’s nutritional vulnerability increases during illness and hospitalisation, particularly in intensive care units.^[4] Illness, its severity, the environment and certain hospital practices are all factors in nutritional imbalance.^[4] There are many causes of undernutrition in hospitalised children. These include reduced food intake and hypercatabolism of fats and proteins, which is linked to stress caused by illness. Thus, hospital undernutrition, which occurs in hospitals, remains a reality in children. When undernutrition in hospital is not treated in time, it hinders recovery, increases morbidity and even mortality and consequently prolongs the length and increases the cost of hospitalisation.^[5-7]

The deterioration in the nutritional status of hospitalised children is very often ignored or neglected and remains under-treated because it is insufficiently investigated in clinical practice.^[8] Its exact prevalence is difficult to determine due to the absence of standardised diagnostic criteria.^[5] It has been estimated at between 6% and 30%.^[8,9] In response to the problem of nutritional risk in hospitals and its consequences, screening, prevention and management strategies have been implemented in several units.^[9,10]

At the Brazzaville Teaching Hospital Center (BTHC), the issue of nutritional risk in hospitalised children has never been studied. Therefore, we proposed to study the nutritional outcome of children hospitalised in the paediatric intensive care unit (PICU), with the primary objective of investigating their nutritional status, evolution during hospitalisation at the PICU of BTHC and specific objectives to identify risk factors for hospital-acquired undernutrition (HAUN) and to compare the outcomes of children hospitalised in the PICU based on their nutritional status.

MATERIAL AND METHODS

RESULTS

A total of 250 children were included in this study.

Nutritional outcome

Children’s height remained stable during the study. However, W/A and W/H ratios changed.

The evolution of W/A and W/H between admission and discharge is shown in Figures 1 and 2.

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Figure 1:

Evolution of the weight-age ratio of children between admission and discharge.

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Figure 2:

Evolution of the weight for height ratio between admission and discharge.

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During hospitalisation, the nutritional status remained stable for 199 (79.6%) children, improved for 6 children and 45 (18%) developed acute malnutrition (80% were under 5 years old, and 51.1% were male). HAUN affected 42.3% of children who were already malnourished at admission compared to 14% of others. The types of malnutrition occurring in the hospital included: Wasting (68.9%), severe wasting (17.8%), malnutrition with oedema (6.7%) and wasting with oedema (6.7%).

DISCUSSION

This study is one of the few in Africa and the first at the local level dedicated to evaluating nutritional status in a paediatric ward.^[14] Most previous studies have been limited to assessing nutritional status upon admission, thereby avoiding the issue of HAUN and its impact on morbidity and mortality.^[15,16] In this study, the nutritional status during hospitalisation remained stable or improved for the majority (82%) of children, while 18% developed HAUN. The prevalence of HAUN in this study was comparable to the 19.56% reported by Campanozzi et al. in Italy but lower than the rates observed by Saengnipanthkul et al. in Thailand and Pichler et al. in the UK, which were 24% and 32%, respectively.^[17,19] The differences in these studies, in terms of tools for assessing nutritional status, definitions of HAUN and patient profiles, explain these divergent results and make it difficult to compare data. Nevertheless, all these studies highlight that the prevalence of HAUN is high regardless of the country’s level of development or the methods used for evaluation. Wasting was the most observed type of undernutrition (68.9%). No cases of chronic undernutrition were observed because the children had not been in the hospital long enough for the H/A ratio to vary.

The prevalence of HAUN varied according to initial nutritional status, being higher in children already malnourished at admission (42.9% vs. 14%). Campanozzi et al. made the same observation.^[17]

In this study, nutritional management was primarily the responsibility of the parents. They had not received any tip from a dietician, except in the case of severe malnutrition. This situation could account for the high number of children with inadequate nutritional intake (47.2%) and for the high prevalence of HAUN. These results raise the issue of the organisation of nutritional care in the PICU and, more generally, of nutritional care policy at the BTHC. In Europe, the Nutrition Committee of the European Society of Paediatric Gastroenterology, Hepatology and Nutrition recommended in 2005 that nutritional support teams be established in paediatric units, in response to the growing prevalence of malnutrition and the significant gaps in nutritional care in hospitals.^[10] Deme/Ly et al. in Senegal have reported the benefits of having a nutritional recovery and education centre within the hospital for nutritional outcomes.^[14] The benefits of early and appropriate nutritional intervention for the nutritional outcomes of hospitalised children have also been documented by other authors.^[19,20]

Many factors influencing the nutritional status of hospitalised children have been described in the literature. However, most of these factors identified in Western countries are not necessarily applicable to our context.^[4,17] Therefore, it was crucial to identify factors that correspond to our reality. In this study, the identified risk factors for HAUN were: an unemployed father and primary-level education, maternal age between 15 and 25 years, insufficient nutritional intake, hospitalisation duration of more than 7 days, severe conditions (shock, coma, respiratory distress), and certain pathologies (severe bronchopneumonia, measles). Campanozzi identified the following risk factors: age under 24 months, hospital stay longer than 5 days, fever and nocturnal abdominal pain.^[17]

Hubert et al. found dyspnoea to be the only risk factor.^[21] Families where the father is unemployed often face financial hardship, as the father is usually the family’s primary provider. These families often struggle to provide their hospitalised children with regular and sufficient nutritional intake.

Regarding the fathers’ low education level and young mothers (15–25 years), financial difficulties often accompany their status, compounded by a lack of knowledge about children’s nutritional needs. However, some researchers suggest that the mother’s education level, rather than the father’s, correlates more with the child’s nutritional status.^[22] Many researchers have cited prolonged hospitalisation as a risk factor for malnutrition. Hospitalisation is a condition conducive to malnutrition, primarily due to illness-related factors but also the hospital environment, which does not always allow for optimal nutritional intake.^[7,17,23] In this study, hospitalisation lasting more than 7 days increased the risk of malnutrition fivefold. For Campanozzi et al., the risk of undernutrition appeared after 5 days of hospitalisation and 4 days for Hetch et al.^[17,23] The link between undernutrition and prolonged hospitalisation constitutes a veritable vicious cycle. Hospital undernutrition also has an impact on the length of hospital stay.^[7]

In the present study, severe conditions such as shock, coma, severe bronchopneumonia and measles favoured the onset of undernutrition in the PICU. Due to their severity, these pathologies often lead to prolonged cessation of oral feeding, without any real relevant scientific evidence; in addition, they are sources of major inflammation and energy loss. All these factors combined contribute to the onset of undernutrition if optimal nutritional support by alternative means (enteral or parenteral nutrition) is not provided.

Undernutrition is an important prognostic factor. In our study, undernourished children died more often than others (P < 0.0001). Deme/Ly et al. found a 4 times higher risk of death in malnourished children.^[14] Malnourished children are often exposed to multiple serious complications and have a low capacity for resistance to disease, which explains their higher mortality rate.

CONCLUSION

Most children hospitalised in the PICU maintained their nutritional status on discharge. However, the prevalence of HAUN was significant (18%), predominantly manifested by wasting. Nutritional care was not integrated into the medical care and was left to the parents. HAUN increases both mortality rates and prolongs hospital stay. Contributing factors to its occurrence include paternal unemployment, low paternal level of education, maternal age between 15 and 25 years, inadequate meal quality, hospitalisation stay of more than 7 days, shock, coma, severe bronchopneumonia and measles.

The extent of HAUN in the PICU and its consequences require the establishment of a nutritional support team, including dieticians, the development of a nutritional care protocol adapted to the local context, and the implementation of preventive measures based on the factors identified in this study.