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Description of a Nutrition Screening and Assessment Tool and Associations

with Clinical Outcomes in Preterm Newborns

Article in Nutrition in Clinical Practice · January 2021

DOI: 10.1002/ncp.10618

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Clinical Research

Nutrition in Clinical Practice

Volume 0 Number 0
Description of a Nutrition Screening and Assessment Tool and xxx 2020 1–10
© 2020 American Society for
Associations with Clinical Outcomes in Preterm Newborns Parenteral and Enteral Nutrition
DOI: 10.1002/ncp.10618
wileyonlinelibrary.com

Christy Hannah Sanini Belin, BS1,2 ; Roberta Aguiar Sarmento, MS, PhD2 ;
Lília Farret Refosco, MS2 ; and Juliana Rombaldi Bernardi, MS, PhD3

Background: Preterm newborns have higher nutrition risk and mortality. Nutrition risk screening enables early intervention. This
article evaluates a nutrition screening tool in a neonatal intensive care unit (NICU). Method: Retrospective longitudinal study of
preterm newborns (aged <37 weeks) in a NICU in Brazil from May 2018 to January 2019. Weight, length, and head circumference
(HC) were analyzed. Nutrition screening was defined by care levels (CLs). Outcomes analyzed were bronchopulmonary dysplasia
(BPD), peri-intraventricular hemorrhage (PIVH), retinopathy of prematurity (ROP), late sepsis, length of stay, mortality, and time
receiving enteral and parenteral nutrition. Results: Data on 110 newborns were studied, with median gestational age 34 (31–35)
weeks, mean weight 1914.92 g (±657.7), length 42.2 cm (±4.45), and HC 29.9 cm (±2.97). Most (82.7%) of them were adequate
for gestational age. Screening classifications were 41.8% (n = 46) at CL 2, 41.8% (n = 46) at CL 3, and 16.4% (n = 18) at CL 4.
CL 3 and CL 4 patients had higher frequencies of BPD (P = .003), ROP (P = .027), and PIVH (P = .006) and longer enteral time
(P < .001) and length of stay (P < .001). All mortality occurred in CL 4 patients (P < .001). Conclusions: CL 3 and CL 4 patients
had more BPD, ROP, PIVH, and mortality and longer enteral nutrition. Hospital stay was longer for CL ≥3 than CL 2 patients.
Patients classified as CL 3 and CL 4 by the nutrition screening tool may have higher nutrition risk. (Nutr Clin Pract. 2020;0:1–10)

Keywords
enteral nutrition; length of stay; neonatal intensive care unit; nutrition assessment; nutrition screening; patient outcomes; premature
infant

Introduction In these patients, nutrition assessment aims to record

Premature birth (defined as birth before 37 weeks of gesta-
tion) is considered a global problem by the World Health
Organization (WHO), mainly because of its association
with neonatal mortality.1 Brazil is 1 of 10 countries with
the highest rates of premature birth, which between them
are responsible for 60% of premature births worldwide.1
Prematurity has consequences associated with higher rates
of infant morbidity and factors related to survival and
quality of life in these patients, such as increased risk of
long-term medical complications and impaired neurode-
velopment, and prematurity also increases hospital costs.2
Hospitalized premature children are also at increased risk
of malnutrition and often have stunting.3
In addition to growth deficit, inadequate nutrition, and
high infection rates, which are all related to longer hospital
stay,4,5 the literature also shows that retinopathy of pre-
maturity (ROP), peri-intraventricular hemorrhage (PIVH),
bronchopulmonary dysplasia (BPD), and sepsis are com-
monly found in preterm newborns and are considered
risk factors for morbidity and/or mortality.6–10 Moreover,
preterm newborns have a high likelihood of developing
nutrition deficiencies, mainly because of their rapid growth
rate, the immaturity of various organs and systems, and
difficulties with providing adequate nutrition.11
nutrition parameters, identify nutrition deficits, and estab-
lish nutrition needs.12 Nutrition screening is understood as
a way of identifying patients at higher nutrition risk and
is currently recommended by the European Society of Pe-
diatric Gastroenterology and Hepatology and Nutrition.12
Identification of patients at nutrition risk or already mal-
nourished is a predictor of complications and enables
From the 1 Child and Adolescent Health Program, Department of
Nutrition, Medical School, Universidade Federal do Rio Grande do
Sul, Porto Alegre, Brazil 2 Nutrition and Dietetic Service, Hospital de
Clínicas de Porto Alegre, Universidade Federal do Rio Grande do
Sul, Porto Alegre, Brazil; and the 3 Child and Adolescent Health
Program, Food, Nutrition and Health Program, Department of
Nutrition, Medical School, Hospital de Clínicas de Porto Alegre,
Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil.
Financial disclosure: The study was funded by the Research Incentive
Fund (FIPE) of Hospital de Clínicas de Porto Alegre (HCPA),
number 2018-0634.
Conflicts of interest: None declared.
Corresponding Author:
Christy Hannah Sanini Belin, BS, Child and Adolescent Health
Program, Department of Nutrition, Medical School, Universidade
Federal do Rio Grande do Sul, Rua Ramiro Barcelos, 2400, 4°floor,
CEP 90035-003, Porto Alegre, Rio Grande do Sul, Brazil.
Email: christy.sbelin@gmail.com
2 Nutrition in Clinical Practice 0(0)
early intervention and provision of timely and effective
nutrition support.13 It is, therefore, clearly important to
develop nutrition screening and assessment tools and to
enable identification of individuals at risk and preparation
and design of nutrition management plans14 . In addition,
they are practical and quick tools for systematic use at
hospital admission to detect nutritionally malnourished
patients.13 However, there is no validated nutrition screening
and assessment tool for newborns, especially for premature
infants.12 Risk screening, nutrition assessment, interven-
tion, and monitoring of results are all involved in the
nutrition care process and must be provided in a systematic
sequence,15 with patients classified at different nutrition care
levels (CLs) according to their degree of nutrition risk and
the complexity of care neeeded.16
The development of an instrument for nutrition screen-
ing in the neonatal intensive care unit (NICU) was con-
ducted at the institution’s Nutrition and Dietetic Service.
This tool uses nutrition status classification and nutrition
and disease severity diagnoses. Analysis of these factors
determines each patient’s CL, which can be classified as
CL 1, CL 2, CL 3, or CL 4. CL 1 was not considered in
the neonatal hospitalization unit because of the need for
systematic monitoring of the hospitalized child, regardless
of an excellent condition on admission. The need for
nutrition monitoring ranges from ≥1 time a week to 3 times
a week, depending on the CL grade. After creation of this
instrument, a study was deemed necessary to assess the
association between CL grades and clinical outcomes in the
preterm infants admitted to the NICU.
Methods
Patients
A retrospective, quantitative longitudinal study was con-
ducted with data from patients admitted between May 2018
and January 2019 to a university hospital. The sample size
comprised 110 newborns of both sexes hospitalized in the
NICU, born at the gestational age (GA) of <37 weeks,
with a maximum age of 3 months, and discharged from
the hospital up to January 2019. Patients were excluded
if anthropometric measurements for nutrition assessment
could not be obtained. Data were collected from patients’
electronic medical records, at admission and at hospital
discharge.
Nutrition Screening Tool
The nutrition screening tool used daily in the institution’s
NICU was utilized to assess risk in all the hospitalized
infants on the basis of GA and clinical status at birth.
Figure 1 shows the nutrition screening tool proposed in the
study. The tool was developed on the basis of the service’s
demand to have an effective nutrition screening tool to
assess nutrition risk. The nutrition screening tool consisted
of the following items.
Item A: anthropometric measurements. On admission, and
also at discharge, weight measurements were taken. The
following anthropometric measurements analyzed were
weight, length, and head circumference (HC). Newborns
were weighed (without clothes) on an electronic pediatric
scale, with a maximum load of 15 kg and variation of 5
grams. A Filizola brand electronic scale (São Paulo, Brazil)
was used for patients admitted to the intermediate care
units, and the Giraffe Omni Bed Warm Crib Incubator
(Ohmeda Medical; Gurnee, IL, USA) was used in the
NICU. Length measurements were collected using a board
with a fixed plastic blade at one end and a movable one at the
other (the top of the head was placed against the fixed part).
Length was determined in the supine position by measuring
with a ruler attached to the board, in accordance with the
unit’s routine practice. HC was measured using inextensible
metric tape, in accordance with the unit’s routine practice.
Weight for GA was used to assess nutrition status, ac-
cording to Fenton curves (2013), with the aid of the Fenton
growth chart calculator (online calculator available at http://
www.ucalgary.ca/fenton). Newborns with weight above the
90th percentile were classified as large for GA (LGA); those
whose weight was between the 10th and 90th percentile were
classified as adequate for GA (AGA); and newborns with
weight below the 10th percentile were classified as small for
GA (SGA).17
Item B: nutrition intake and outcomes. Time receiving par-
enteral nutrition in days, time receiving enteral nutrition
in days, and time until starting breastfeeding (for patients
who were in clinical condition to start oral feeding) were
recorded.
The following outcomes and their degrees of severity,
as diagnosed and described in the medical records of
each hospitalized patient assessed, were BPD, PIVH, ROP,
necrotizing enterocolitis (NEC), late sepsis (after 72 hours
of life [diagnosed by blood culture with positive results]),18
length of hospital stay, and mortality.
Item C: nutrition diagnoses. Nutrition diagnoses are the
critical connection between assessment and intervention
and are descriptions of nutrition conditions observed in the
patient. There is a possibility of resolving every nutrition
diagnosis, which are problems that already exist, rather
than potential risks of occurrence. Starting from a health
problem, the nutrition diagnostic process involves the col-
lection of data considered relevant and interrelated. First, a
diagnostic hypothesis is raised and the problem is named.
The list of diagnoses comprises a classification system
(or taxonomy). In this taxonomy, standardized nutrition
Belin et al 3

NUTRITION SCREENING TOOL - PRETERM

Name: _______________________________________________ Medical Record: ______________

Date of Birth: ____/____/____ Apgar: ________Admission Date: ____/____/____ Sex: ( ) Female ( ) Male
Birth Weight: ___________Birth Length: ________ Birth Head Circumference: _________ Gestational Age: _______
Reason for hospitalization: _____________________________________________________________
( ) Parenteral Nutrition - Beginning: ____/____/____ End: ____/____/____
( ) Enteral Nutrition - Beginning: ____/____/____ End: ____/____/____
( ) Oral Feeding - Beginning ____/____/____ ( ) Breastfeeding - Beginning: ____/____/____
Discharge Date from NICU: ____/____/____

Mother’s age:______________ Type of delivery: ( ) Vaginal delivery ( ) Cesarean section

Prenatal consultations: _________________

Admission assessment:

Weight: ___________ Length: ___________ Head Circumference: _____________

Type of feeding:_____________________________________ Type of oral feeding: _______________________

Fenton PERCENTILE
W/GA
L/GA
HC/GA

Nutrition Status: ( ) SGA ( ) AGA ( ) LGA

Severity Disease:__________________________
Nutrition Diagnoses: ______________________
CL: ( ) 2 ( ) 3 ( ) 4

Reassessment (every 14 days or 21 days):

Weight: ___________ Length: ___________ Head Circumference: ______________

Type of feeding:_____________________________________ Type of oral feeding: _______________________

Fenton PERCENTILE
W/GA
L/GA
HC/GA
Nutrition Status: ( ) SGA ( ) AGA ( ) LGA
Disease Severity:__________________________
Nutrition Diagnoses: ______________________
CL: ( ) 2 ( ) 3 ( ) 4

Hospital Discharge:

Weight: ___________ Length: ___________ Head Circumference: _____________

Type of feeding:_____________________________________ Type of oral feeding: _______________________

Fenton PERCENTILE
W/GA
L/GA
HC/GA

Nutrition Status: ( ) SGA ( ) AGA ( ) LGA

Disease Severity:__________________________
Nutrition Diagnoses: ______________________
CL: ( ) 2 ( ) 3 ( ) 4

Figure 1. Neonatal Screening tool proposed for hospitalized preterm. AGA: adequate for gestational age; CL: care level; DS:
disease severity; GA: gestational age; HC/GA: head circumference for gestational age; LGA: large for gestational age; L/GA:
length for gestational age; ND: newborn date of birth; NICU: neonatal intensive care unit; SGA: small for gestational age;
W/GA: weight for gestational age.
4 Nutrition in Clinical Practice 0(0)
diagnoses are divided into 3 categories: (1) ingestion, (2)
clinical nutrition, and (3) behavior/nutrition environment.
The category “other” is used when the patient does not have
a nutrition diagnosis that requires intervention. The follow-
ing nutrition diagnoses used in the NICU were suboptimal
energy intake, composition of enteral nutrition inappropri-
ate for needs, suboptimal or excessive protein intake, diffi-
culty breastfeeding, low weight, unintentional weight loss,
overweight/obesity, growth rate below expectations, and no
nutrition diagnosis at the moment. Nutrition interventions
generate important results not only for nutrition status
but for the overall health and life of a patient. Nutrition
diagnosis is a diagnostic component of the care process.19
Item D: disease severity. The disease severity is an item
used in nutrition screening as one of the criteria for
defining the patient’s CL. Disease severity is identified by
consulting the patient’s online medical record, based on
a medical diagnosis, and includes diseases or complica-
tions that may interfere with the patient’s nutrition status.
Diseases and/or complications that should be identified in
the first or subsequent nutrition assessment were surgery
and/or immediate postoperative period, NEC, congenital
heart disease, invasive mechanical ventilation, therapeutic
hypothermia protocol, BPD, intraventricular hemorrhage,
and hospitalization postcardiorespiratory arrest.20
Item E: CLs. The pediatric protocol for nutrition care and
monitoring through CL was developed to systematize and
optimize the nutrition care of hospitalized children.21 After
nutrition assessment and diagnosis, the nutritionist classifies
the patient’s CL to determine follow-up. Three levels of
nutrition assistance were defined in the neonatology service
(CLs 2, 3, and 4), and care protocols were created on
the basis of nutrition status and frequency of nutrition
screening. Patients classified as CL 2 are followed up at least
once a week and reassessed after 21 days; patients classified
as CL 3 are followed up at least twice a week and reassessed
after 14 days; and patients classified as CL 4 are followed
up at least 3 times a week and reassessed after 14 days.
According to the screening tool, patients with GA < 34
weeks are classified as CL 3 or CL 4, according to their
nutrition status and the presence or absence and disease
severity. Newborns with GA ≥ 34 weeks are classified as CL
2 or CL 3, according to nutrition status and the presence or
absence and disease severity. Nutrition monitoring of the
patient is conducted until hospital discharge. The neonatal
care flow diagram used in the present study for preterm
infants aged <34 weeks and >34 weeks is shown in Figure 2.
Data Collection
Nutrition and clinical data were collected by reviewing
the patients’ electronic medical records and were recorded
on a nutrition assessment form that includes neonatal
nutrition screening. Data recorded include date of birth,
date of admission to the NICU, birth weight (grams),
length at birth (centimeters), HC at birth (centimeters), GA
(weeks + days), reason for hospitalization, Apgar at 1 and
5 minutes, mother’s age (years), type of feeding at the time
of assessment, nutrition diagnoses, presence or absence and
disease severity, nutrition status according to Fenton curves,
and CL.17
Statistical Analysis
WinPEPI, version 11.65, was used to calculate the sample
size on the basis of data from a study by Johnson (2014),
estimating a need for 160 patients.22 Results were analyzed
using IBM Predictive Analytics Software version 22.0. Cat-
egorical variables were expressed as absolute and relative
percentages. Quantitative variables were expressed as means
and standard deviations. The Shapiro-Wilk test was used to
assess the adequacy of normal distribution of quantitative
variables. To compare the outcomes between CL categories,
we used a Kruskal-Wallis nonparametric test followed by
pairwise comparisons that were performed using Dunn pro-
cedure, with a post hoc Bonferroni correction for multiple
comparisons. Pearson χ 2 test or Fisher exact test were used
to detect associations between categorical outcomes and CL
levels at admission. A 5% significance level was adopted
(P ≤ .05).
Ethical Considerations
The study was approved by the research ethics committee
(approval number 2018-0634) and is in compliance with
Resolution 466/12 of the National Health Council and the
Declaration of Helsinki. The researchers signed a data use
agreement.
Results
The sample comprised 110 patients, with a median GA of
34 (31–35) weeks, 54.5% (n = 60) of whom were male. With
regard to birth characteristics, 63.6% (n = 70) were born
by cesarean delivery; mean (±SD) birth weight was 1924 ±
4.38 g; mean first minute Apgar score was 6.79 ± 2.09; and
mean fifth-minute Apgar score was 7.92 ± 1.63. Mean age
of mothers was 27.9 ± 6.86 years, and they attended 6 ±
3.25 prenatal consultations. The most prevalent reason for
hospitalization was prematurity (73.6%; n = 81), followed
by early respiratory dysfunction (52.7%; n = 58). Addi-
tional clinical and demographic characteristics are listed in
Table 1.
Table 2 shows the composition of the proposed
tool for premature newborns. At the time of nutrition
assessment at admission, mean (±SD) weight was
Belin et al 5

Figure 2. Neonatal Care Flow Diagram for preterm aged below 34 weeks and preterm aged above 34 weeks. AGA: adequate for
gestational age; CL: care level; DS: disease severity; GA: gestational age; HC: head circumference; LGA: large for gestational age;
ND: newborn date of birth; SGA: small for gestational age.

1914.92 ± 657.7 g, mean length was 42.2 ± 4.45 cm,
and mean HC was 29.9 ± 2.97 cm. The most
prevalent nutrition status category was AGA (82.7%;
n = 91). Most patients did not have any nutrition diagnoses
at the time of admission (70.9%; n = 78). The most prevalent
diet at the time of admission was a combination of human
milk and artificial formula (43.6%; n = 48), followed by
parenteral nutrition (22.7%; n = 25). Only 5.5% (n = 6)
were exclusively fed human milk at admission. Moreover,
30 of the patients assessed were on an oral diet, 14.5%
6 Nutrition in Clinical Practice 0(0)

Table 1. Clinical and Demographic Characteristics of Table 2. Composition of the Proposed Tool for Assessing
Patients. Premature Newborns at the Time of Admission to a Neonatal
Unit.
Variables N = 110 (%)
Variables (N = 110) Mean SD
Sex
Male 60 (54.5) Weight, g 1914.92 ±657.7
Type of delivery Length, cm 42.2 ±4.45
Cesarean 70 (63.6) Head circumference, mcm 29.9 ±2.97
Gestational age W/GA percentile 43.4 ±26.5
<34 wk 54 (49.1) L/GA percentile 44.7 ±30.0
>34 wk 56 (50.9) HC/GA percentile 48.3 ±29.4
Reason for hospitalization Variables N Percentage (%)
Preterm 81 (73.6) Nutrition status (n = 110)
Respiratory dysfunction 58 (52.7) SGA 15 13.6
Congenital syphilis 6 (5.5) AGA 91 82.7
Intrauterine growth restriction 7 (6.4) LGA 4 3.6
Hypoglycemia 6 (5.5) Disease severity (n = 110)
Invasive mechanical ventilation 16 14.5
Nutrition diagnoses (n = 110)
Growth rate below expectations 17 15.5
Low weight 15 13.6
(n = 16) were on mixed breastfeeding and bottle feeding Difficulty breastfeeding 8 7.3
with artificial formula, and 12.7% (n = 14) were on bottle Weight loss 1 0.9
feeding with artificial formula. At admission, nutrition CL Suboptimal energy intake 1 0.9
Overweight/obesity 1 0.9
was as follows: 41.8% (n = 46) of the children were at level
No nutrition diagnosis at the 78 70.9
2, 41.8% (n = 46) were at level 3, and 16.4% (n = 18) were moment
at level 4. Type of diet (n = 110)
Patients classified as CL 2 were not given parenteral Breast milk + formula 48 43.6
nutrition and had shorter enteral nutrition time; therefore, Nothing by mouth + 25 22.7
there is no statistically significant difference (P = .123) parenteral nutrition
compared with those classified as CL 3 and CL 4. Patients Nothing by mouth 17 15.5
Formula 14 12.7
classified as CL 3 and CL 4 started breastfeeding later than
Exclusively breast milk 6 5.5
patients classified as CL 2 (P < .001). Table 3 shows the Type of oral diet (n = 110)
nutrition parameters of the sample studied. Mixed breastfeeding 16 14.5
Table 4 shows the clinical outcomes and their associa- Artificial feeding 14 12.7
tions with the CL of the sample studied. Patients classified Care Level (n = 110)
as CL 3 and CL 4 had a higher frequency of complications 2 46 41.8
or comorbidities (CL 2: 4.3%, CL 3: 19.6%, CL 4: 55.6%; 3 46 41.8
4 18 16.4
P < .001). Furthermore, BPD was more prevalent in pa-
tients classified as CL 3 and CL 4 (P = .003); all patients Values are expressed as mean ± SD.
with ROP were at CL grade 4 (P = .027); most patients AGA, adequate for gestational age; HC/GA, head circumference for
with PIVH were classified as CL grade 4 (P = .006); and gestational age; LGA, large for gestational age; L/GA, length for
late sepsis was more prevalent in CL 3 patients. However, gestational age; SGA, small for gestational age; W/GA, weight for
gestational age.
there was no statistical difference (P = .070), and all patients
who died had been classified as CL 4 (P < .001). There
was no statistically significant difference in presence of NEC
Discussion
between the groups of patients classified as CL 2, CL 3, and This study described and evaluated a nutrition screening
CL 4 (P = .278). and assessment tool for premature newborns in a neonatal
With regard to length of hospital stay, as illustrated unit at a university hospital and analyzed associations
in Figure 3, patients classified as CL 3 and CL 4 by between CL classification at admission and these newborns’
the nutrition assessment at admission had a significantly outcomes. It is evident that nutrition screening and assess-
longer hospital stay than those classified as CL 2 (P < ment should be performed routinely for any infant born
.001). Median stay for CL 2 patients was 10.5 (2–51) prematurely and/or with low birth weight.23 The tool is
days; the median stay for CL 3 patients was 33.0 (5–83) performed on admission to the hospital, and it will help
days; and the median stay for CL 4 patients was 32.5 to raise the clinician’s awareness of nutrition risks. To our
(5–126) days. knowledge, this is the first Brazilian study designed with the
Belin et al 7

Table 3. Nutrition Parameters for the Population Studied.

Variable CL 2 CL 3 CL 4 P-value

Days of parenteral nutrition, N = 53 0 6.5 (0–12.25) 9.5 (5.5–13.5) .123*

Days of enteral nutrition, N = 85 1.5 (0.7–6.25)a 23.5 (9–37)b 23 (2.25–34.25)b <.001*
Days of life before starting breastfeeding, N = 94 1.0 (0–26)a 16 (0–59)b 35.5 (8–90)b <.001*

Statistical significance: P ≤ .05. Values are expressed as median (IQR).

CL, care level; IQR, interquartile range
* Kruskal-Wallis test; post hoc Bonferroni test: groups with same letter superscript (a,b ) show statistically significant difference.

Table 4. Clinical Outcomes and Association With the Care Level of the Population Studied.

Clinical Outcomes CL 2 N = 46 (%) CL 3 N = 46 (%) CL 4 N = 18 (%) P-value

Outcome(s) present (N = 21) 2 (4.3)a 9 (19.6)ab 10 (55.6)b <.001+

BPD (N = 6) 0 2 (4.3) 4 (22.2) .003*
ROP (N = 2) 0 0 2 (11.1) .027*
PIVH (N = 6) 1 (2.2) 1 (2.2) 4 (22.2) .006*
Late sepsis (N = 10) 0 7 (15.2) 3 (16.7) .070*
NEC (N = 4) 1 (2.2) 1 (2.2) 2 (11.1) .278*
Mortality (N = 5) 0a 0a 5 (27.8)b <.001*

Statistical significance: P ≤ .05.

BPD, bronchopulmonary dysplasia; CL, care level; NEC, necrotizing enterocolitis; PIVH, peri-intraventricular hemorrhage; ROP, retinopathy of
prematurity.
* Fisher exact test.
+ Pearson χ 2 test.
a,b: Different letters represent statistically different means.

Figure 3. Box-plot diagram for the relationship between length of stay and association with the level of care provided.
8 Nutrition in Clinical Practice 0(0)
objective of describing and evaluating a nutrition screening
and assessment tool for preterm newborns.
The present study observed a 54.5% prevalence of
male infants. Findings confirm that males have a slower
pulmonary maturation process, compounding premature
birth.24 Thus, greater attention is recommended for male
infants because of their fragility acquired at conception.25
Cesarean delivery is a direct consequence of prematurity
rates. This was the main method of delivery in this study
(63.6%), confirming findings reported by Damian (2016).25
The Apgar score is calculated at the first and fifth minutes of
life, assessing 5 aspects (heart rate, breathing, color, muscle
tone, and reflex irritability) and resulting in a score ranging
from 0 to 10. According to a cohort study in Sweden, low
Apgar scores within the reference range (7–10) were strongly
associated with neonatal morbidity and mortality, and these
associations are considerably stronger with increasing time
after birth.26 Apgar scores for the first and fifth minutes
were classified as high if ≥ 7 and as low if < 7. A
median score of 8.0 was observed for the first and fifth
minutes.
Apgar scores, birth weight, and GA are highly associ-
ated with survival and, in combination, are a measure of
the newborn’s well-being, size, and maturity.25 Insufficient
prenatal care, low Apgar score, prematurity, and low weight
are associated with mortality.27
As expected, prematurity was the main cause of hos-
pitalization, and it is considered a risk factor for infant
mortality, especially in the first months of life.24 In addition
to prematurity, respiratory disorders constitute the most
common complications in this period, resulting from the
immaturity of the respiratory system and its inability to
produce surfactant.28
With regard to the composition of the tool used, anthro-
pometry is useful for several purposes in preterm infants, in-
cluding diagnosis of malnutrition and assessment of the risk
of early metabolic complications, for monitoring growth
during hospitalization and for identifying a need to review
routines related to the diet, illustrating the importance of
systematic use of a nutrition protocol to avoid malnutrition
after hospital discharge.29,30
In the sample studied, there was a high prevalence of
newborns with adequate weight, length, and HC (between
the 10th and 90th percentiles). HC is an important measure
that is strongly linked to brain development, enabling identi-
fication of adequate growth in children born prematurely.31
Practical assessments of the nutrition status of premature
infants in intensive care (IC) must include valid anthropo-
metric measures, which are easy to obtain and inexpensive.31
Weight is the anthropometric measure most used for nu-
trition assessment of newborns and is strongly related to
growth.32 Length is the best indicator of linear growth and
is less influenced by inadequate fetal nutrition, in addition
to not changing with hydration status.11,32
Regarding nutrition status, most newborns were assessed
as AGA (82.7%), whereas 13.6% of the sample was SGA,
confirming findings by Holzbach (2019) in which there was
a prevalence of AGA weight newborns.33 Nutrition status
is not always correlated with current nutrition risk, which at
the time of hospitalization may not yet be affected, although
there is a high risk of malnutrition.34
Thus, this type of screening is essential and crucial for
the surveillance of nutrition status in patients at risk of
malnutrition.34 Monitoring of anthropometric parameters,
such as measurements and periodic recording of weight,
height, and HC, contributes to health promotion and
protection through detection of children at higher risk
of morbidity and mortality and through diagnosis and
treatment of nutrition problems.32 According to Kondrup
and colleagues (2003), disease severity can be used to predict
the risk of malnutrition, as an indicator that can influence
nutrition status and predict risk.34 In our study, mechanical
ventilation was considered an element of disease severity
because it alters patients’ energy expenditure.16
In the present study, exclusive human milk feeding
was practically absent among these infants; 6 (5.5%) were
exclusively fed using human milk, and the majority were
given both human milk and artificial formula at assessment
(43.63%). There is evidence that mothers of premature
infants have lower breastfeeding success rates, and therefore,
adoption of practices aimed at establishing and maintaining
the supply of breast milk as the first choice for feeding
of premature infants must be continually reinforced and
reviewed.35–37 It is known that median duration of breast-
feeding is below the recommended 6 months in premature
infants and weaning is associated with a GA of <32 weeks.37
Patients at nutrition risk should undergo a more de-
tailed nutrition assessment to identify and quantify specific
nutrition problems.13 A higher proportion of CL 3 and
CL 4 patients had presence of clinical outcomes such as
prolonged hospital stay, BPD, ROP, PIVH, and mortality,
so the tool proved to be useful for identifying more severe
patients and those at higher nutrition risk. BPD has a
significant short- and long-term morbidity of extremely
low birth weight infants38 and is associated with significant
healthcare use in infancy and beyond.39 Thereby, infants
who developed BPD had a significantly lower amount of
enteral nutrition during the first 2 weeks of life, and an ade-
quate amount of protein and caloric intake is recommended
to prevent the development of BPD. Our findings suggested
that those who were classified as CL ≥3 in the admission
assessment had more comorbidities, requiring more care
during hospitalization.
The neonatal nutrition screening tool described by John-
son (2014) classifies newborns as high, moderate, or low
risk, and only those at high risk or with growth deficit are
defined as having positive screening results, requiring review
by the nutrition support team, since the tool is administered
Belin et al
daily by the nursing team.22 Our tool is only administered by
nutritionists and requires weekly monitoring and frequent
reassessments of the patient; if classified as CL 3 and CL
4, reassessments are conducted every 14 days. The only
tool to identify hospitalized children at a higher nutrition
risk designed specifically for ICUs is the Ohio Neona-
tal Nutritionists criteria.40 This incorporates nutrition as-
sessment but considers newborns with a birth weight of
<1 kg, with low growth (<10 g/kg/d after 2 weeks of age),
and with NEC, chronic lung disease, or gastrointestinal
surgical conditions to be at high nutrition risk.22 The
STRONG kids tool is currently used with children aged
>1 month who are admitted to a pediatric ward (excluded
IC patients), with an expected stay of ≥1 day. Children
at risk had significantly higher prevalence of acute malnu-
trition, longer hospital stay, and lower standard deviation
scores for weight-for-height compared with children with-
out nutrition risk.41
Our nutrition screening tool incorporates objective and
subjective measures, including the nutrition diagnoses,
which require individual assessment. It permits nutritionists
to apply their clinical knowledge based on a wide range
of variables focused on nutrition to assess the nutrition
status of hospitalized preterm infants. These items are also
important indicators for diagnosing those at risk of mal-
nutrition, who are often difficult to identify with objective
anthropometric measures alone.42
Survival rates continue to improve gradually for preterm
infants.43 Decreasing GA is moderately associated with
major neonatal morbidity and strongly associated with
mortality.44 Regarding mortality in the present sample, all
patients who died (27.8%) had been classified as CL 4 and
were all born at <34 weeks. This sample studied had a
mortality rate similar to that in another study conducted in
Brazil using data from the Live Birth Information System
(Sistema de Informações de Nascidos Vivos) and from the
Mortality Information System (Sistema de Informações de
Mortalidade) of Porto Alegre, including preterm infants.
The study found that neonatal death was 21.64% and the
neonatal mortality rate for this group tended to decrease,
with a total of 1845 infants who died during the first
27 days of life, with 21% of deaths occurring on the birthday,
45% between days 1 and 6, and 33% between days 7 and
27.45
The main limitations of this study were the sample size,
which possibly explains the lack of significance in some
of the parameters evaluated, use of online patient medical
records, and loss from the sample of patients for whom
it was not possible to conduct anthropometry. Another
limitation is the absence of a gold standard for nutrition
screening to enable comparison with the instrument tested.
To adopt intensive nutrition strategies during hospital-
ization, early identification of patients at high nutrition risk
should be performed. The study’s standout strong point is its
9
originality, describing and evaluating a nutrition screening
and assessment tool for preterm infants.
Conclusion
Newborns classified as CL 4 by the nutrition screening
protocol used at the institution had the highest propor-
tions of outcomes such as BPD, ROP, PIVH, death, and
extended length of hospital stay, in addition to longer use
of enteral nutrition. The nutrition screening and assessment
tool showed that patients classified as CL 3 and CL 4 on
admission are in fact the most serious and may be at the
greatest nutrition risk. Early identification of patients at
high risk of low weight, growth deficit, and unfavorable
clinical outcomes is necessary for adoption of intensive
nutrition strategies during hospitalization, and, therefore,
it is necessary to evaluate the effectiveness of the strategies
adopted.
Statement of Authorship
C. H. S. Belin and J. R. Bernardi equally contributed to the
conception and design of the research; R. A. Sarmento and
L. F. Refosco contributed to the research design; C. H. S.
Belin and L. F. Refosco contributed to the acquisition and
analysis of the data; R. A. Sarmento and J. R. Bernardi
contributed to the interpretation of the data; and C. H. S.
Belin drafted the manuscript. All authors critically revised
the manuscript, agree to be fully accountable for ensuring
the integrity of the work, and read and approved the final
manuscript.
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