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• To deepen your understanding of the difference between nutrition risk screening and nutrition assessment
• To enhance your knowledge of the use of nutrition risk screening and nutrition assessment tools in acute and primary care settings
• To read about the development of a digital nutrition awareness tool designed to support a remote or primary care-based nutrition-focused assessment
The coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented change in healthcare systems, including the swift roll-out of technology-enabled care services, such as remote consultations. Interventions such as nutrition assessments for children are likely to continue to be conducted remotely as part of an online consultation. This article considers nutrition screening and nutritional assessment in children in acute and primary care settings. The article also provides an overview of the development of the Paediatric Remote Malnutrition Application (Pedi-R-MAPP), designed to assist healthcare professionals to undertake a standardised, nutrition-focused assessment via remote consultation and/or in primary care settings. The aim of the Pedi-R-MAPP is to help identify children with declining nutritional status or new nutritional concerns and to recommend frequency of review based on the outcomes of the assessment.
Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1518
Peer reviewThis article has been subject to open peer review and checked for plagiarism using automated software
Correspondence Conflict of interestLuise Marino has received honorarium to give educational lectures for Abbott Laboratories, Danone and Nestle, who had no role in role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results. Luise Marino also reports the development of Pedi-R-MAPP was supported by an unrestricted grant from Abbott Laboratories, who had no role in role in the design of the study; data collection, analyses, or interpretation of data or writing of the manuscript the idea of which was developed by Weber Shandwick
Marino LV (2024) Development of a structured, digital nutrition awareness tool, the Pedi R-MAPP. Nursing Children and Young People. doi: 10.7748/ncyp.2024.e1518
Published online: 23 September 2024
The global health crisis that ensued as a result of the coronavirus disease 2019 (COVID-19) pandemic led to an unprecedented change in healthcare systems, including the rapid roll-out of technology-enabled care services (Baines et al 2020). A survey conducted in Israel to investigate the challenges associated with dietetic consultation during the early part of the pandemic, found that of 300 dietitians surveyed, 45% did not have formal training in undertaking remote consultations, while 25% felt that being unable to undertake in-person anthropometric (weight and height) measures was a barrier to using technology-enabled services (Kaufman-Shriqui et al 2021).
In response to the ongoing use of technology-enabled services, and healthcare professionals’ need for support to undertake remote consultations, the authors and colleagues have developed a digital nutrition awareness tool, the Paediatric Remote Malnutrition Application (Pedi-R-MAPP) (Marino et al 2022). The aim of the tool is to assist healthcare professionals to undertake a standardised, nutrition-focused assessment via remote consultation and/or in primary care settings. This article discusses the use of nutrition screening and nutritional assessment tools in acute and primary care, and describes the development and testing of the Pedi-R-MAPP.
Hospitalised children have an increased nutrition risk (Thomas et al 2016), particularly those with underlying health conditions (Joosten and Hulst 2014). Nutrition risk has been broadly defined as ‘detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measures; other documented nutritionally related medical conditions; dietary deficiencies that impair or endanger health; or conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions’ (Institute of Medicine (US) Committee on Scientific Evaluation of WIC Nutrition Risk Criteria 1996).
In the UK, the Care Quality Commission (2023) guideline on meeting patients’ nutritional and hydration needs states that service providers must ensure patients ‘have adequate nutrition and hydration to sustain life and good health and reduce the risks of malnutrition and dehydration while they receive care and treatment’ and that their nutrition and hydrations needs, and related risks, must be assessed. To adhere to regulatory guidelines, most hospitals in the UK use nutrition screening tools as a first step in identifying children who may have a nutrition risk (Huysentruyt et al 2013, 2015, Thomas et al 2016, Marino et al 2018a, Hulst et al 2022).
Most nutrition risk screening tools incorporate a series of subjective questions with or without anthropometric measurement and are designed to be quick and easy to complete (Huysentruyt et al 2013, Joosten and Hulst 2014, Wiskin et al 2015, Marino et al 2022). It is important to note, however, that nutrition risk screening is not the same as nutritional assessment. Table 1 summarises the key differences between nutrition risk screening and nutritional assessment.
Children identified as having a moderate-to-high nutrition risk through nutrition risk screening require a full nutritional assessment, which would usually be completed by a dietitian or by the multidisciplinary team (Marino et al 2018a, Hulst et al 2022). This assessment would include a review of the child’s recent growth in terms of height and weight, blood laboratory results, symptoms associated with clinical conditions that affect nutrition intake and caregivers’ concerns (Joosten and Hulst 2014, Wiskin et al 2015). This information would then be used to inform the development of a nutrition care plan and nutrition support plan (Marino and Meyer 2020).
Over the last 30 years, numerous nutrition risk screening tools have been developed and used in a range of inpatient settings (Chourdakis et al 2016, Marino et al 2018b, Huysentruyt et al 2019, Klanjsek et al 2019). The most widely used tools in hospitals are the Screening Tool for Assessment of Malnutrition in Paediatrics (STAMP) (McCarthy et al 2012), the Screening Tool for Risk on Nutritional Status and Growth (STRONGkids) (Hulst et al 2010), the Paediatric Yorkhill Malnutrition Score (PYMS) (Gerasimidis et al 2011) and the Nutrition Risk Screening Tool for Children and Adolescents with Cystic Fibrosis, which can be used in specialist or outpatient settings (McDonald 2008). However, there are challenges related to the reference criteria used to validate these tools and with the anthropometrical cut-off points for indicating over-nutrition and undernutrition (World Health Organization (WHO) 2009, Klanjsek et al 2019). For example, Thomas et al (2016) found that the STAMP and PYMS tools had poor sensitivity and were difficult to interpret in the acute setting, leading to over-diagnosis of nutrition risk in children in an acute hospital.
Furthermore, there is often a disconnect between nutrition risk screening tool outcomes when compared with the WHO (2009) child growth standard cut-off points for z scores for moderate malnutrition, which may be in part due to the subjective nature of some screening tools (Chourdakis et al 2016, Thomas et al 2016). A z score system expresses an anthropometric value as a number of standard deviations (SDs) above or below the reference mean or median value; in the context of nutrition screening, a z score would be calculated for weight-for-height, weight-for-age, height-for-age and body mass index- (BMI) for-age (WHO 2009). Incorporating growth monitoring as part of a ward round may be a more effective way of identifying children with declining nutrition status in inpatient settings (Marino et al 2018a), particularly as adherence to nutrition risk screening in children in acute hospitals is often inadequate (Marino and Beattie 2018).
Systematic reviews of studies of health behaviour assessment and lifestyle screening tools for children, including diet and exercise and habits related to overweight and obesity, have shown that such tools are acceptable and feasible in primary care settings and may help to prevent the development of chronic disease in adulthood (Krijger et al 2022, Dutch et al 2024). However, validation of many of these tools is limited and most do not include actions to take based on the outcome (Krijger et al 2022, Dutch et al 2024).
Some nutrition risk screening tools which were developed for use in inpatient settings have been tested in other settings. For example, Sha et al (2023) explored the use of STRONGkids, alongside anthropometric measurements, in identifying nutrition risk in outpatients of child healthcare clinics (n=11,454, aged <2 years) in ten hospitals in Jiangsu, China. The percentages of children assessed as having high, moderate and low nutrition risk were 2% (n=228), 28% (n=3,229) and 70% (n=7,997) respectively, with moderate risk higher in children aged ≥12 months. The three top conditions associated with nutrition risk in the study cohort were premature birth (51%), food allergies (14%) and recurring respiratory disease (11%). The accuracy of STRONGkids in relation to over- or under-identifying those with nutrition risk when compared with WHO (2009) cut-off points for malnutrition was not described by the researchers. However, they concluded that STRONGkids was a useful screening tool in this setting.
In another study undertaken in China in outpatient settings, He et al (2022) designed a nutrition risk screening tool specific to preterm children (NRSP) to develop a standard way to identify feeding problems in children aged five to 36 months and to provide targeted nutritional advice. Children born pre-term often encounter feeding difficulties which may increase their nutrition risk when complementary food is introduced. The NRSP was tested with 329 children and was found to have moderate reliability and validity in predicting underweight (low weight-for-age), stunting (reduced height-for-age) and microcephaly (He et al 2022).
An assessment tool commonly used in primary care settings for a wide range of conditions, including those related to nutrition, is the WHO Integrated Management of Childhood Illnesses (WHO-IMCI) Chart Booklet (WHO 2014), which is intended to facilitate a case management process to managing illness in children aged under five years.
The booklet provides a systematic process for undertaking assessment, including nutritional assessment, with the aim of standardising practice and promoting optimal care in settings with constrained resources (WHO 2014). The charts in the booklet guide the healthcare professional through a series of questions in a stepwise method to assess, classify, identify and provide treatment, share information with the parent and determine a follow up period. Answers to the questions within the charts are categorised and colour coded to provide an illustrative view of areas of concern (green=none, amber=possible, red=urgent) (WHO 2014, 2024). The principles of the WHO-IMCI chart booklet have been incorporated into several nutritional pathways, including for congenital heart disease (Marino et al 2018b).
• To adhere to regulatory guidelines, most hospitals in the UK use nutrition screening tools as a first step in identifying children who may have a nutrition risk
• Children identified as having a moderate-to-high nutrition risk through nutrition risk screening require a full nutrition assessment
• The Peri R-MAPP is a nutrition awareness tool intended to support healthcare professionals working remotely and/or working in primary care to complete a nutrition-focused assessment
• Standardisation based on the use of protocols and decision aids may reduce variation in practice and improve nutrition-related outcomes
The development of the Pedi R-MAPP was prompted by the need to better support healthcare professionals working remotely and/or working in community settings to undertake standardised nutritional assessments. Learning from the COVID-19 pandemic included that such tools may help healthcare professionals feel more confident when undertaking remote consultations or when working independently in primary care settings (Kaufman-Shriqui et al 2021, Kelly et al 2021, Armstrong et al 2022). In addition, standardisation based on the use of protocols and decision aids has been shown to reduce variation in practice and improve nutrition-related outcomes (Tume et al 2020, 2021, Rungsattatharm et al 2022, Stefanescu et al 2022).
The Pedi R-MAPP is a nutrition awareness tool and is not intended to replace clinical judgement. A nutrition awareness tool can be described as a consistent, stepwise process to support information gathering by asking a series of questions to inform the development of a nutrition care plan for individual children with a range of nutrition statuses (for example, undernutrition, normal nutrition or over-nutrition) and with different social circumstances (Marino et al 2022). The Pedi R-MAPP provides a structured approach to undertaking a nutrition-focused assessment for children seen in the community or via remote consultation and includes colour-coded actions for recommended frequency of review based on responses to the questions: green (no concerns – discharge); amber (some concerns – review in 1-3 months); red (significant concern – urgent review or review in 1-2 weeks); purple (over-nutrition concerns – review in 3-6 months); and/or whether the child requires a face-to-face consultation (Marino et al 2022).
The tool draws on the WHO-IMCI Chart Booklet (WHO 2014, 2024) and the British Dietetic Association (2023) Model and Process for Nutrition and Dietetic Practice, which provides a framework for the development of nutrition care plans.
The Pedi R-MAPP was developed between 2021 and 2022 using a multi-stage process, which included:
• A comprehensive literature review relating to child nutrition in community settings, food security, growth monitoring as part of a remote consultation and the principles outlined in the WHO-IMCI (WHO 2014).
• An international survey of 463 healthcare professionals, including nurses (n=19), to better understand the effects of the pandemic on their ability to provide remote consultations about nutrition support for children.
• Development of a draft paper version of the Pedi-R-MAPP (Table 2).
• A modified Delphi consensus on the paper version of the tool, involving international nutrition experts.
• Surveys to confirm the content of the tool.
• Iteration of the paper version of the tool to inform the content of the digital version.
• Development of the digital version of the tool.
• Testing and re-testing of the digital Pedi-R-MAPP by paediatric dietitians.
For full details of the development process see Marino et al (2022).
| Section | Content/considerations |
|---|---|
| Information on the child’s general condition | This section requires:
|
| Does the child have a long-term health condition | This section is classified into health conditions which involve: |
| Is an in-person review required | This section includes a series of questions that detect ‘red flags’ that indicate the need for an immediate in-person hospital assessment. These red flags include (Haimi et al 2020, Hulst et al 2022):
|
| Assess recent changes in growth | This section involves identifying if the healthcare professional or the child’s parents have noticed any changes by determining, for example: |
| Review the child’s dietary intake | This section involves considering the child’s usual eating patterns by determining, for example: |
| Is there enough food at home | Asking this question directly can provide insight into whether food insecurity is a concern. Food insecurity can be defined as eating less or going for a day without eating because an individual is unable to access or afford food (Gitterman et al 2015, Food Foundation 2024) |
| Have there been changes in physical activity | This section involves identifying whether the child is undertaking less or more physical activity than normal, for example due to feeling unwell or a result of low mood |
(Adapted from Marino et al 2022)
A digital version of the Pedi R-MAPP was developed using the IDEAS (integrate, design, assess, share) framework for the development of effective digital interventions (Mummah et al 2016). Healthcare professionals (n=22) from England, Scotland, Ireland, Europe, South Africa and the US attended focus groups to refine the content for the digital version.
Limited testing of a beta (pre-release) version of the Pedi R-MAPP was undertaken by one paediatric dietitian who conducted 80 nutrition reviews using the tool. Following this, three changes were made to the logic of the tool (that is, the interaction between the end user and the app) in the general condition, clinical conditions and changes in growth sections.
Extensive testing of the revised version of the Pedi R-MAPP was undertaken between November and December 2022 by 15 paediatric dietitians who conducted 745 nutrition reviews across a range of acute and chronic disease groups, including:
• Congenital heart disease (31%, n=229).
• Allergy (14%, n=101).
• Cystic fibrosis (14%, n=103).
• Gastroenterology (9%, n=64).
• General paediatrics (7%, n=49).
• Neurological disorders (8%, n=61).
• Inherited metabolic disease/ketogenic conditions (5%, n=34).
• Neonatology (including premature infants) (2%, n=16).
• Primary ciliary dyskinaesia (6%, n=45).
• Endocrine conditions (6%, n=43).
The average age of the children reviewed (n=745) was 65.3 ±62.7 months; average weight-for-age z (WAZ) score was -0.6 ±1.5; average height-for-age z (HAZ) score was -0.5 ±1.5; and average BMI for age z (BMIZ) score was -0.2 ±1.4. The percentage of undernourished children, as identified using WHO (2009) child growth standards cut off points, was 13% WAZ (underweight), 7% HAZ (lower height than average) and 12% BMIZ (excess weight).
The paediatric dietitians were requested to log agreement with the Pedi R-MAPP final recommendations for frequency of review compared with the nutrition review they would usually undertake in person or virtually; agreement was logged for 86% (n=640) of reviews.
Following this testing, further changes were made to the tool, including: rules about the WAZ score; clinical conditions (to ensure they included all high-risk children); what and how much a child eats and drinks (to ensure those who require nutrition support or have a restricted diet continued to be reviewed); recommended frequency of review for amber and purple; and the information buttons (which provide additional information about the questions) to make them more prominent. Once these changes had been made, the paediatric dietitians re-reviewed the Peri R-MAPP nutrition reviews they had undertaken and logged agreement for 98% (n=730). The paediatric dietitians also reported that the Pedi R-MAPP was easy and quick to complete, with a mean time of less than two minutes to complete the tool.
The Pedi R-MAPP, which can be accessed at pedi-rmappnutrition.com/welcome, may be suitable for use in different clinical areas, including GP practices and other primary care settings, at home as part of a health visitor assessment and in schools as part of a school nurse assessment. The tool may act as an aide memoire to support healthcare professionals when completing a nutrition-focused assessment, with the aim of reducing variation in practice. The Pedi R-MAPP does not retain any data and no personal information such as date of birth are collected (Marino et al 2022).
The Pedi R-MAPP is a newly developed tool that has not been widely used by healthcare professionals in primary care settings. Despite good agreement with the frequency for review by paediatric dietitians, local standards of nutrition practice may have influenced the outcomes. Therefore, further testing in primary care settings is required.
The ongoing use of technology-enabled care services, and healthcare professionals’ need for support to undertake remote consultations, prompted the development of the Pedi R-MAPP. The Pedi R-MAPP has been designed as a nutrition awareness tool intended to support healthcare professionals working remotely and/or working in primary care to complete a nutrition-focused assessment. The digital tool, which was developed using the IDEAS framework, has undergone extensive testing and re-testing by paediatric dietitians and has shown good agreement with recommended frequency of review, however further research in primary care settings is required. The Pedi R-MAPP may act as an aide memoire for healthcare professionals when completing a nutrition-focused assessment.
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