International Journal of Contemporary Pediatrics

Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

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DOI: http://dx.doi.org/10.18203/2349-3291.ijcp20180536
Original Research Article

Influence of nutritional status on clinical outcomes in

critically ill children
Chaitra K. M., Bhavya G.*, Harish S., Shruthi Patel, Syeda Kausar Anjum

Department of Paediatrics, KIMS, Bangalore, Karnataka, India

Received: 18 December 2017

Accepted: 20 January 2018

*Correspondence:
Dr. Bhavya G.,
E-mail: [email protected]

Copyright: © the author(s), publisher and licensee Medip Academy. This is an open-access article distributed under
the terms of the Creative Commons Attribution Non-Commercial License, which permits unrestricted non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.

ABSTRACT

Background: Critically-ill children have a state of metabolic stress. The nutritional needs of these patients can be
increased. Their nutritional status at admission and its possible deterioration during hospitalization can be a predictor
of worse outcome. The objective of this study was to study the influence of nutritional status on outcomes like
mortality, duration of mechanical ventilation and duration PICU stay and hospital stay, in critically ill children.
Methods: This was a prospective comparative study conducted on 60 critically ill children aged 1 month to 18 years
admitted to PICU of tertiary care, teaching hospital, Bangalore, Karnataka over a study period of 12 months. Patients
were divided into 4 categories based on Body mass index (BMI) as per WHO growth charts into: underweight,
normal, overweight and obese and outcomes was analysed.
Results: In the present study 60 children were studied. Subjects were classified as underweight (23.33%), normal
weight (45%), overweight/obese (31.67%) based on BMI Z-score at admission. The odds of prolonged hospital stay
were higher in underweight and overweight/obese children (OR-2.85, p-0.12 and OR-3.92, p-0.03 respectively).
Underweight and overweight/ obese children had higher odds for prolonged PICU stay. (OR-6, p-0.02 and OR-2.13,
p-0.36 respectively). Underweight children required prolonged ventilator support (OR-2, p-0.03). There was no
significant difference among the group.
Conclusions: There is a high prevalence of malnourishment in critically ill children compared to general population
and they are prone for poor outcome. Malnourished children must be identified at admission and optimal therapies,
nutritional strategies aimed at preventing further nutritional deterioration should be made.

Keywords: BMI, Critically ill children, Malnourishment

INTRODUCTION ill patients would not survive. Critically-ill children have

a number of organic alterations, metabolic responses
Critical illness is a life-threatening multisystem process which contribute to the maintenance of body
requiring support of failing vital organ systems without homeostasis, switching nutritional compounds towards
which survival would not be possible and also can result different functions and, at a further stage, may facilitate
in significant morbidity or mortality1. This condition can recovery.
be evoked by a variety of insults such as multiple trauma,
complicated surgery, and severe medical illnesses. The metabolic response to stress can also include
Paediatric intensive care unit (PICU) care aims at to catabolic processes that, in many circumstances, may
achieve timely diagnosis and therapeutic interventions for increase physiological instability and resource wasting.
controlling organ dysfunction and recover physiological Thus, causing an increase in nutritional requirements and
stability. Without modern critical care medicine, critically leading to state of metabolic stress.2

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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

Nutritional status can be assessed using clinical signs of were categorized as 3 nutritional groups underweight
malnutrition, biochemical indicators, and anthropometry. (BMI Z-score <-2), normal weight (BMI Z-score ≥-2 and
Anthropometry has an important advantage over other ≤1), overweight (BMI Z-score >1 and ≤2) and obese
nutritional indicators, it is non-invasive, inexpensive, and (BMI Z-score >2).5,6
relatively easy to obtain. Studies have documented that
nutritional status of critically ill children at admission and Outcomes like mortality, duration of PICU stay, duration
its possible deterioration during hospitalization can be a of hospital stay, and duration of mechanical ventilation
predictor of worse outcomes.3,4 But only a few studies were assessed in the groups.
have examined the relationships between a range of
nutritional status categories i.e. underweight, normal Statistical Analysis
weight, overweight and obesity and clinical outcomes in
critically ill children. Statistical analysis was done using Stata student’s edition
version 12.
This study was aimed to determine the influence
nutritional status at admission, as assessed by BMI Z- Continuous variables like PRISM score which followed
score, on clinical outcomes in critically ill children. The normal distribution have been summarized as mean and
objective of this study was to study the influence of standard deviation and compared between the nutrition
nutritional status on outcomes like mortality, duration of categories using one-way ANOVA test. Continuous
mechanical ventilation and duration PICU stay and variables like age, duration of hospital stay and duration
hospital stay, in critically ill children of PICU say which did not follow normal distribution
have been summarized as median and inter quartile range
METHODS and compared between the nutrition categories using
Kruskal Wallis test. Overweight and obese children were
This was a prospective comparative study conducted on assessed together because of less number. Categorical
60 critically ill children aged 1 month to 18 years variables were summarized as proportions. Comparison
admitted to PICU of tertiary care, teaching hospital, of proportions between the nutrition status categories was
Bangalore, Karnataka over a study period of 12 months. done using fisher’s exact test. To assess association of
Ethics approval for the study was obtained from the nutritional status with different morbidity and mortality
Institutional Review Board. All critically ill children related outcomes, odds ratio with 95% confidence
admitted to PICU in the age group of 1 month to 18 years interval was calculated. All statistical analysis was
were included in the study excluding the children with considered significant if p value <0.05.
chromosomal anomalies, musculoskeletal disorders or
inborn error of metabolism RESULTS

Detailed history and examination were done in all the In the present study 60 children who met with inclusion
patients including the relevant investigation and the data criteria were enrolled in to the study. Mean and median
were collected at admission. Anthropometric parameters age of the study population was 4.8 and 2.5 years
including weight and height/length were taken by trained respectively with a standard deviation of 4.91. There
personnel using the standardized technique within 24 were 27 (45%) children who had normal BMI for age, 14
hours of admission. Nutritional status on admission was (23.33%) children were underweight and 19 (31.67%)
defined by BMI Z-score using the most recent World were overweight/ obese as per WHO charts.
Health Organization (WHO) growth charts. Subjects

Table 1: Characteristics of the study participants.

Underweight (n=14) Normal (n=27) Overweight or obese (n=19) P value

Median Age (IQR) 0.95 (0.25-3) 3.6 (1.3-5) 4.0 (1.7-10) 0.049
Age categories
Less than 1 year (n=10) 7 (50.0) 1 (3.7) 2 (10.5)
1-4 years (n=29) 4 (28.6) 17 (63.0) 8 (42.1) 0.006
5 years and above (n=21) 3 (21.4) 9 (33.3) 9 (47.4)
Gender
Male (n=39) 11 (78.6) 18 (66.7) 10 (52.6)
0.308
Female (n=21) 3 (21.4) 9 (33.3) 9 (47.4)
PRISM score 17.7 (7.1) 18.8 (11.5) 18.5 (8.3) 0.945
Duration of hospital stay 6.5 (5-7) 5.0 (3-7) 7.0 (4-8) 0.17
Duration of PICU stay 2.5 (1-4) 2 (1-3) 3 (2-3) 0.33

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Median age of the study population was comparable was seen that there was no statistically significant
among the groups but when age is categorised there was a difference among the groups (p value = 0.17) however
statistically significant (p-0.006) difference among the underweight and overweight/ obese children had higher
group. Gender distribution and PRISM score was odds for prolonged hospital stay compared normal
comparable among the groups (Table 1). Duration of children. (OR-2.85, p-0.12 and OR-3.92, p-0.03
hospital stay was compared among the Study groups, it respectively) (Table 2).

Table 2: Association between nutrition status and duration of hospital stay.

7-14 days <7 days

Odds ratio (95% CI) P value
N % N %
Normal 7 25.9 20 74.1 1 (Reference)
Underweight 7 50.0 7 50.0 2.85 (0.73-11.08) 0.12
Overweight or obese 11 57.9 8 42.1 3.92 (1.12-13.75) 0.03
Total 25 41.7 35 58.3

Table 3: Association between nutrition status and duration of PICU stay.

4 or more days <4 days

Odds ratio P value
N % N %
Normal 3 11.1 24 88.9 1 (Reference)
Underweight 6 42.9 8 57.1 6 (1.21-29.72) 0.02
Overweight or obese 4 21.1 15 78.9 2.13 (0.41-10.88) 0.36
Total 13 21.7 47 78.3

Table 4: Association between nutrition status and need for mechanical ventilation.

Required Not required

Odds ratio P value
N % N %
Normal 9 (33.3) 18 (66.7) 1 (Reference)
Underweight 7 (50.0) 7 (50.0) 2 (0.53-7.47) 0.03
Overweight or obese 6 (31.6) 13 (68.4) 0.92 (0.26-3.23) 0.9
Total 22 (36.7) 38 (63.3)

Table 5: Association between nutrition status and final outcome.

Death Recovered
Odds ratio P value
N % N %
Normal 9 (33.3) 18 (66.7) 1 (Reference)
Underweight 4 (28.6) 10 (71.4) 0.8 (0.19-3.27) 0.75
Overweight or obese 5 (26.3) 14 (73.7) 0.71 (0.19-2.61) 0.61
Total 18 (30.0) 42 (70.0)

Further when duration PICU stay was analysed among Final outcome, mortality in children was compared a
the group, no statistically significant difference was shown in Table 5, and there was no significant difference
noted, however similar to Duration of hospital stay, among the group.
underweight and overweight/ obese children had higher
odds for prolonged hospital stay compared normal DISCUSSION
children. (OR-6, p-0.02 and OR-2.13, p-0.36
respectively) (Table 3). PICU is an important component of tertiary paediatric
care service in care of critically ill children including
Further when ventilator days was analysed among the timely diagnosis and treatment. The main purpose of the
group, underweight children required prolonged PICU is to prevent mortality and morbidity by intensively
ventilator support compared normal children and monitoring and treating critically ill children who are
overweight/ obese children. (OR-2, p-0.03) (Table 4). considered at high risk of mortality. The patient’s

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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

mortality not only depends on clinical characteristic of severely obese children did not have any significant
patient, ICU performance, infrastructure but also on difference in mortality, length of stay or duration of
nutritional status of the patient.7 mechanical ventilation, when compared to patients with
normal weight.19
A better understanding of the role of malnutrition in
critical illness and its effects on ultimate outcome of the Present results highlight the prevalence of malnutrition in
patient is of vital importance, in terms of the PICUs and the importance of anthropometry to allow
interpretation of anthropometric data, and subsequent early interventions to be targeted in high-risk critically ill
prioritization of intervention and targeting strategies. children. Previous studies have used only weight for age
Assessment of malnutrition is often used to determine the Z-scores to classify patients according to their nutritional
severity of morbidity and mortality.8 status. But weight alone as a marker of nutrition may be
misleading critical illness where fluid shifts are
In our study, suboptimal nutritional status was commonly present.
documented in nearly half (55%) of the critically ill
children on admission to the PICU. In that 23.33% Considering this weight for height or BMI provide a
children were underweight and 31.67% were overweight/ better assessment of nutritional status in critical ill
obese as per WHO charts, which is more compared to children. This also has recommended as primary
prevalence in general population signifying that indicators of nutritional status and growth in children.20
malnourished children are more liable for ICU care than However lean body mass may be a more accurate
normal children.9,10 indicator.21

It was also seen that being underweight or Other Anthropometric measurements such as mid-arm
overweight/obese patients was associated with circumference, triceps skinfold thickness, mid-arm
significantly higher odds of prolonged PICU stay/hospital circumference can also be used to describe fat and
stay compared to normal children which was in nutritional status.22 However, accurate measurements of
accordance to Bechard et al, a two multicenter cohort theses require expertise and experience. Despite its
studies in Boston11, Nangula et al, a prospective study limitations, BMI can be easily determined by weight and
conducted on a cohort of 400 children admitted to tertiary height measurement and may be a better indicator than
care hospital, Ludhiana.12 body weight for evaluating the proportion of fat mass
relative to lean mass in children.23
Obesity/overweight was significantly associated
prolonged PICU care. The nature of the impact of obesity Despite the prospective nature of our study, this study has
on outcomes may depend on the individual patient and several limitations. Accurate measurement of weight and
illness type. Excess fat stores may affect ventilatory particularly height may not be feasible in all critically ill
status, potentially increasing dependence on respiratory patients in addition alteration in the fluid balance during
support. Patients who are obese may also be at greater acute phase of illness may lead to erroneous measurement
risk for complications.13 of weight and thereby BMI also.

Underweight children had higher odds prolonged hospital CONCLUSION

stay. Underweight could be a symptom of an underlying
disease or reason for admission that relates to mortality Present study showed the high prevalence of
risk. Underweight children may also have impaired malnourishment in critically ill children compared to
immune function that could limit their defence against general population. After stabilization of the initial
infections.14,15 Furthermore, critically ill children are at critical phase, PICU outcome is influenced by then
risk of further nutritional deterioration during their illness nutritional status of the children. Malnourished children
course due to disease or barriers to nutrient delivery in are more prone for prolonged hospitalisation and
the intensive care unit.11 ventilation. Malnourished children (both underweight and
obese) must be identified at admission by means of
Being underweight was associated with significantly simple anthropometric measures. And optimal Therapies
higher odds mechanical ventilation (OR-2, P value-0.03) aimed at alleviating the underlying conditions and
compared normal. This in accordance to de Souza MF et nutritional strategies aimed at preventing further
al a prospective cohort study of children admitted to a nutritional deterioration should be made. Future studies
Brazilian PICU.16 In malnutrition, muscle function is examining targeted strategies and their impact on
affected, originating muscle fatigue and a reduction of up outcomes in malnourished children in the PICU are
to 75% in work intensity and hence resulting in desirable.
respiratory failure.17-18
There was no statistically significant difference in Funding: No funding sources
mortality among the 3 groups similar to a single center Conflict of interest: None declared
retrospective study conducted by Goh et al on Ethical approval: The study was approved by the
mechanically ventilated children, overweight, obese or Institutional Ethics Committee

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 Chaitra KM et al. Int J Contemp Pediatr. 2018 Mar;5(2):462-466

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