Received: 5 May 2022 | Accepted: 30 September 2022
DOI: 10.1111/jhn.13106
NUTRITIONAL SUPPORT AND ASSESSMENT
Hospital‐acquired undernutrition and associated factors in children
and adolescents admitted to a tertiary care hospital
Marília de Fátima Viana Alves1 | Juliana Moreira da Silva Cruvel2
Marluce Alves Coutinho2 | Maria Milena Bezerra Sousa2 |
Elza Cristina Batista Barbosa2 |
1
Child and Adolescent Health Care Unit,
University Hospital of the Federal University
of Maranhão, Maranhão, Brazil
2
Clinical Nutrition Unit, University Hospital of
the Federal University of Maranhão,
Maranhão, Brazil
Correspondence
Juliana Moreira da Silva Cruvel, Clinical
Nutrition Unit, University Hospital of the
Federal University of Maranhão, São Luís,
Maranhão 65020‐560, Brazil.
Email: julimoresilva@hotmail.com
J Hum Nutr Diet. 2023;36:1359–1367.
|
Bruna Renata Fernandes Pires2
Abstract
Background: The present study aimed to verify the proportion and factors
associated with hospital‐acquired malnutrition in the paediatric unit of a
tertiary care hospital.
Methods: A retrospective study was carried out in a tertiary care hospital in
the state of Maranhão, Brazil. Demographic and clinical data on children and
adolescents were collected from medical records and the data regarding
weight, height and z‐scores of anthropometric indicators were obtained from
the World Health Organization (WHO) Anthro® and WHO Anthro Plus®
applications. Those with weight‐for‐height z‐score (< 5 years) and a body mass
index (BMI)/age z‐score (≥ 5 years) < −2 SD at admission were considered to
be malnourished. Patients who presented a decrease of > 0.25 SD between the
z‐score of BMI‐for‐age (BMIZ) at admission and at discharge were classified
as having hospital‐acquired malnutrition. Weight loss was also evaluated and
was considered significant when it was > 2% between the weight measured at
admission and the one before discharge. Logistic regression analysis was
performed to verify the factors associated with hospital‐acquired malnutrition.
Results: The median age was 4.7 years and the length of stay was 21 days;
26.8% of patients had significant weight loss during hospitalisation and a
greater proportion had hospital‐acquired malnutrition (34.9%). Gastroentero-
pathies, neuropathies and malnutrition on admission were significantly
associated with hospital‐acquired malnutrition.
Conclusions: The occurrence of hospital‐acquired malnutrition is still a
problem in paediatric patients. Thus, providing adequate nutritional support
from admission is essential when aiming to avoid deterioration of the
nutritional status of paediatric patients during hospitalisation.
KEYWORDS
hospitalisation, malnutrition, paediatrics, undernutrition
Key points
• Hospital‐acquired malnutrition comprises a further deterioration of the
patient's nutritional status in relation to their nutritional status at
admission.
• The present study was conducted with 473 children and adolescents
admitted to a tertiary care hospital.
wileyonlinelibrary.com/journal/jhn © 2022 The British Dietetic Association Ltd. | 1359
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1360 | HOSPITAL‐ACQUIRED MALNUTRITION

• In the study, during hospitalisation, it was observed that a significant

percentage of patients had a weight loss of > 2% and one‐third had hospital‐
acquired malnutrition.
• Gastroenteropathies, neuropathies and malnutrition on admission were
significantly associated with hospital‐acquired malnutrition.

INTRODUCTION increases morbidity and mortality, and affects growth

According to the American Society for Parenteral and
Enteral Nutrition (ASPEN), paediatric undernutrition
(malnutrition) is defined as an imbalance between
nutritional needs and intake, resulting in cumulative
deficits in energy, protein or micronutrients that can
negatively affect growth and development.1 Malnutrition
can be classified as either primary (as a result of
inadequate food intake) or secondary (as a result of an
underlying disease).2
Hospital‐acquired malnutrition comprises a further
deterioration of the patient's nutritional status in relation
to their nutritional status at admission.1 It refers to the
decline in the patient's nutritional status during hospita-
lisation, regardless of whether they were malnourished or
not at the time of admission.3
Hospital malnutrition rates in paediatrics can range
from 7.7%4 to 66%5 worldwide. When it is diagnosed in
the first 72 h of hospitalisation, it is predominantly the
result of pre‐existing factors of hospitalisation, whereas,
in the subsequent period, it the result of an insufficient
supply of nutrients during treatment.2
According to a study carried out in a public hospital
in Salvador, Brazil, which aimed to assess the evolution
of the nutritional status of paediatric patients and its
associated factors, it was observed that 25.3% of the
population was malnourished at the time of admission.
Of the total sample, 45% had weight loss during
hospitalisation, with weight loss being more prevalent
in patients > 60 months of age, those hospitalised > 28
days and those admitted with a diagnosis of acute
illness.6
Hospitalisation can favour the appearance of mal-
nutrition in children for several reasons, including
periods of prolonged fasting, insufficient oral intake
and/or delay in the indication of an alternative route of
nutritional therapy, increased energy expenditure, loss of
nutrients and changes in their use as a result of the
underlying disease.2,7 Although, on admission, children
and adolescents usually present with no previous history
of malnutrition, the presence of a massive inflammatory
response observed in the acute phase of an injury or
critical illness limits the effectiveness of nutritional
interventions and may contribute to its rapid
development.1
In hospitalised paediatric patients, malnutrition is
associated with a poor prognosis because it increases the
risk of infections, interferes with wound healing,
and development,8 in addition to increasing the hospital
stay and costs.9 In this way, assessment of the nutritional
status of hospitalised children is essential to monitor
their growth and development and thus to verify whether
they are deviating from the expected standard.10
As already mentioned, even though malnutrition
acquired after hospital admission is often associated with
a risk of adverse events, it is a problem that remains
largely underestimated and often unrecognised.1 There is
little evidence available on this type of malnutrition in
paediatrics, especially in middle‐income countries such as
Brazil. Given this scenario, the identification of mal-
nutrition in hospitalised paediatric patients from admis-
sion to discharge, together with an understanding of the
factors related to the deterioration of nutritional status
during hospitalisation, allows for early interventions in
nutritional therapy aimed at recovering the nutritional
status of patients and consequently decreasing the length
of hospital stay and the risk of clinical complications.
Therefore, the present study aimed to verify the
proportion and the factors associated with hospital‐
acquired malnutrition in paediatric patients in a tertiary
care hospital.
ME THO DS
Design
This is a longitudinal, retrospective study carried out in a
tertiary care hospital in the state of Maranhão, Brazil.
Participants and eligibility
The study population consisted of children and adoles-
cents admitted to paediatrics and evaluated by the
nutrition sector from January 2017 to March 2021. The
sample size calculation was performed based on the
number of patients hospitalised in the paediatric sector
during this period with a stay longer than 72 h (n = 4023),
considering a sampling error of 5% and a confidence level
of 95% for heterogeneous samples, thus defining a
minimum sample of 351 patients. Among the hospitali-
sations in this period, 1059 corresponded to patient
readmissions (Figure 1).
Paediatric patients of both genders, aged 0–15 years,
hospitalised for clinical and/or surgical reasons, and who

ALVES ET AL.
F I G U R E 1 Patient selection flowchart.
HAZ, height‐for‐age z‐score; PICU, paediatric
intensive care unit
had the initial anthropometric assessment within 72 h of
hospital admission and an assessment record at dis-
charge, were included in the study.
Patients with a syndrome that alters the growth
pattern (such as Down's, Potter type IV or Turner
syndrome), cerebral palsy, hydrocephalus and those with
ascites, anasarca, oedema, hepatomegaly or splenomeg-
aly were not included. Patients with a height‐for‐age
z‐score (HAZ) of less than −6 SD, extreme (i.e., biologically
implausible)11 and patients readmitted during the research
period were also not included in the research. The exclusion
factor was patients who were first admitted to the
paediatric intensive care unit.
Data collection
Electronic medical records were used to collect demo-
graphic and clinical data on patients. Data referring to
weight, height and z‐scores of weight‐for‐height (WHZ)
and body mass index‐for‐age (BMIZ) were collected
from the World Health Organization (WHO) Anthro®,
version 3.2.2 (children < 5 years old) and WHO Anthro
Plus®, version 1.0.4 (children > 5 years old) applications,
available from the Clinical Nutrition Service.
Classification of the nutritional status of the patients
was performed using the z‐scores for WHZ (0–5 years)
and BMIZ (0–15 years). For children born prematurely
(gestational age < 37 weeks), a corrected age of up to 2
years was used. Anthropometric indicators were classi-
fied according to the WHO.11 Those with WHZ (< 5
years) and BMIZ (≥ 5 years) scores < −2 SD were
considered to be malnourished. Patients who presented a
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| 1361
decrease of > 0.25 SD between the BMIZ at admission
and at discharge were classified as having hospital‐
acquired malnutrition.12 Weight loss was also assessed,
and a reduction of > 2% between the weights measured
at admission and before discharge was considered
significant.13
The explanatory variables of the study were: gender, age
(< 5 years and ≥ 5 years), character of hospitalisation
(clinical/surgical), diseases that led to hospital admission
(uropathies, gastroenteropathies, heart diseases, lung dis-
eases, neuropathies, nephropathies, infectious and parasitic
diseases, endocrinopathies, orthopedic diseases, haematopa-
thies) and length of stay. The response variable was hospital‐
acquired malnutrition (decreased BMIZ).
Statistical analysis
Data analysis was performed using SPSS, version 28 (IBM
Corp.). Descriptive statistics were used for continuous and
categorical variables. The Shapiro–Wilk test was used to
determine whether variables had a normal distribution or
not. Continuous variables are presented as the median and
interquartile range (Q1–Q3, 25%–75%) because they are not
normally distributed. Categorical variables were expressed as
absolute values and percentages. A simple logistic regression
analysis was performed to verify the association of the study
response variable with the explanatory variables. The disease
that led to hospitalisation was the only variable with more
than two levels, and so it was included in the model as a
dummy variable. Variables with p < 0.20 were then included
in the multiple (adjusted) logistic regression analysis. The
Akaike information criterion (AIC) was used to determine

1362 | HOSPITAL‐ACQUIRED MALNUTRITION
the best model corresponding to AIC values for multivariate
logistic analysis. A category with p < 0.20 was included in
the final model as a dummy variable. The results were
presented in the form of an odds ratio (OR) with a 95%
confidence interval (CI).
RESULTS
In total, 473 patients were included in the present study,
as shown in Figure 1. The baseline characteristics of
these patients are shown in Table 1. The percentage of
male paediatric patients was higher (51.4%), half of the
patients were < 5 years old (50.7%), the median age was
4.7 years and the length of stay was 21 days. Regarding
the reason for hospitalisation, 74.2% were hospitalised
for clinical reasons, among which gastroenteropathies
(18.4%), uropathies (12.7%), neuropathies (12.5%) and
lung diseases (12.1%) were the main pathologies that led
to hospitalisation (Table 1).
We found that almost half of the patients lost weight
(42.5%) and among these 63.2% had significant weight loss
(> 2%) during hospitalisation. The percentage of significant
weight loss (>2%) among all patients was 26.8%. When
analysing the criterion for hospital malnutrition, the
proportion was smaller (34.9%) (Table 1).
It is important to highlight that 15.2% of the study
sample had a diagnosis of malnutrition at the time of
admission according to the WHZ in children < 5 years of
age or the BMIZ in older patients. A higher percentage of
patients (17.1%) were malnourished at discharge (Table 1).
The classifications of anthropometric indicators
evaluated at admission and discharge are shown in
Table 2. At hospital admission, according to the WHZ,
10% were moderately wasted and 5.8% were severely
wasted. For the BMIZ, 10.6% were moderately wasted
and 5.3% were severely wasted. At hospital discharge, it
was observed that, according to the WHZ, 10.4% had
moderately wasted and 5.4% had severely wasted,
whereas the BMZI showed that 11.8% were moderately
acute malnutrition and 6.3% were severely wasted.
Regarding the factors associated with hospital‐
acquired malnutrition, according to the unadjusted
analysis, neuropathies, endocrinopathies and the pres-
ence of malnutrition at the time of admission were
associated with a reduction of > 0.25 SD in the BMIZ
during hospitalisation (Table 3).
Patients who had neuropathies were 66% less likely to
have a reduction of > 0.25 SD (OR = 0.34, CI = 0.16–0.69,
p = 0.003), whereas those with endocrinopathies were 78%
less likely (OR = 0.22, CI = 0.05–0.98, p = 0.048). Mal-
nourished patients at the time of admission were 51% less
likely to have a reduction of > 0.25 SD (OR = 0.49,
CI = 0.27–0.89, p = 0.020) (Table 3).
After the adjusted analysis, it was observed that
endocrinopathies and the lung diseases were not associ-
ated with hospital‐acquired malnutrition (Table 4).
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The presence of gastroenteropathy increased the
chance of the patient being malnourished during
hospitalisation by 1.6 times (OR = 1.68, CI = 1.02–2.75,
p = 0.040). On the other hand, those hospitalised for
neuropathies were 65% less likely to have a reduction of
> 0.25 SD (OR = 0.35, CI = 0.17–0.74, p = 0.006). Pa-
tients classified as malnourished at admission were 49%
less likely to have a reduction of > 0.25 SD from the
BMIZ (OR = 0.51, CI = 0.27–0.94, p = 0.033) (Table 4).
DISCUSSION
In the present study, during hospitalisation, it was
observed that a significant percentage of patients had a
weight loss of > 2% (63.2%) and one‐third had hospital‐
acquired malnutrition. There was an association between
hospital‐acquired malnutrition and gastroenteropathies,
neuropathies and the presence of malnutrition at the time
of admission.
In previous studies carried out in tertiary and
secondary hospitals, the prevalence of malnutrition at
admission was 9%–27% 4,12,14,15 and, at discharge, it was
32%–39.1%.15,16 Similar results were found in the present
study. We observed that malnutrition percentages were
15.8% (WHZ) and 15.9% (BMZI). We found lower
percentages at hospital discharge, between 15.8% and
18.1%, according to the anthropometric indices WHZ
and BMZI, respectively.
The disparity in the reported prevalence of mal-
nutrition in hospitalised children stems from the studied
population, clinical environments and instruments used
to define malnutrition because there is still no consensus
on the best definition of paediatric malnutrition17,18 and
its diagnosis can be difficult because of the many
contributing factors, the aetiology of the diseases and
the absence of reliable serum diagnostic markers. For
these reasons, current criteria for diagnosing mal-
nutrition are primarily based on the z‐scores of
anthropometric indicators and on nutritional intake.19
Corroborating the present results, a multicentre
prospective cohort study carried out in Canadian
university hospitals showed that, at admission, 19.5%
of the patients were malnourished. Of the total study
population, almost half of the patients (48.5%) lost
weight during hospitalisation and, of these, 25.4% lost ≥
5% of their admission weight. When evaluating the
factors associated with this ≥ 5% weight loss, the
researchers found that patients admitted with a haema-
tological or oncological diagnosis were less likely to lose
weight compared to those with gastrointestinal or liver
problems. Participants were considered to be mal-
nourished if they had at least one growth indicator
(WAZ, HAZ, WHZ or BMIZ) that was < −2 SD at the
time of admission.14 If we used this same parameter to
identify the malnourished, it is likely that the prevalence
recorded in our study would be higher because we used
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ALVES ET AL.
| 1363

TABLE 1 Baseline characteristics of paediatric patients admitted to a tertiary care hospital

All < 5 years (n = 228) > 5 years (n = 245)

Variables (n = 473) Median (n) Q1–Q3 (%) Median (n) Q1–Q3 (%) Median (n) Q1–Q3 (%)
Length of stay (days) 21 14.0–33.5 28.1 14.0–33.0 29.3 14.0–35.0

Gender

Female 230 48.6 110 48.3 120 48.9

Male 243 51.4 118 51.7 125 51.1

Reason for hospitalisation

Clinical 351 74.2 169 74.1 182 74.3

Surgical 122 25.8 59 25.9 63 25.7

Illness that led to hospitalisation

Uropathies 60 12.7 35 15.4 25 10.2

Gastroenteropathies 87 18.4 52 22.8 35 14.3

Neuropathies 38 8.0 25 10.9 34 13.9

Lung diseases 57 12.1 39 17.1 18 7.4

Heart diseases 59 12.5 16 7.0 22 8.9

Nephropathies 22 4.7 7 3.1 15 6.1

Infectious parasitic diseases 41 8.7 11 4.8 30 12.2

Endocrinopathies 18 3.8 3 1.4 15 6.1

Orthopaedic diseases 26 5.5 6 2.7 20 8.2

Haematopathies 30 6.3 9 3.9 21 8.6

Others 35 7.4 25 10.9 10 4.1

Weight loss

Yes 201 42.5 86 37.7 115 46.9

No 272 57.5 142 62.3 130 53.1

a
Significant weight loss (n = 201)

Yes 127 63.2 46 53.5 81 70.4

No 74 36.8 40 46.5 34 29.6

Hospital‐acquired malnutritionb

Yes 165 34.9 82 35.9 83 33.9

No 308 65.1 146 64.1 162 66.1

Malnutrition at admission (< −2 SD) c

Yes 72 15.2 33 14.5 38 15.5

No 401 84.8 195 85.5 207 84.5

Malnutrition at discharge (< −2 SD) c

Yes 81 17.1 33 14.5 48 19.5

No 392 82.9 195 85.5 197 80.5

a
Considered significant when > 2%.
b
When the difference between the body mass index‐for‐age (BMIZ) was > 0.25 SD.
c
The indicator used as a reference in those < 5 years old was the weight‐for‐height (WHZ); in the older patients, the reference indicator was the BMIZ.
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1364 | HOSPITAL‐ACQUIRED MALNUTRITION

T A B L E 2 Classification of nutritional status according to T A B L E 3 Crude analysis of the association between hospital‐
anthropometric indices of paediatric patients at the time of hospital acquired malnutrition and patient demographic and clinical
admission and discharge characteristics

Malnutrition at Malnutrition at Crude analysis

Indices (n = 473) admission, N (%) discharge, N (%)
Variable OR 95% CI p
WHZ (n = 240)
Gender
Severely wasted 14 (5.8%) 13 (5.4%)
Female 1.00
Moderately wasted 24 (10%) 25 (10.4%)
Male 0.79 0.54–1.15 0.229
Normal 172 (71.7%) 171 (71.3%)
Age
At risk of overweight 23 (9.6%) 26 (10.8%)
≥ 5 years 1.00
Overweight 6 (2.5%) 5 (2.1%)
< 5 years 1.01 0.69–1.47 0.957
Obese 1 (0.4%) 0 (0.0%)
Length of stay 0.99 0.99–1.00 0.351
BMIZ (n = 473)
Character of hospitalisation
Severe acute 25 (5.3%) 30 (6.3%)
Surgical 1.00
malnutrition
Clinical 0.77 0.50–1.18 0.231
Moderate acute 50 (10.6%) 56 (11.8%)
malnutrition Illness that led to hospitalisation
Normal 337 (71.2%) 321 (67.9%) Uropathies 1.18 0.67–2.07 0.549
At risk of overweight 25 (5.3%) 27 (5.7%) Gastroenteropathy 2.11 1.31–3.38 0.002
Overweight 27 (5.7%) 28 (5.9%) Heart diseases 1.23 0.62–2.44 0.536
Obese 4 (0.8%) 7 (1.5%) Lung diseases 0.69 0.37–1.28 0.252
Severe obesity 5 (1.1%) 4 (0.8%) Neuropathies 0.34 0.16–0.69 0.003
Note: Due to missing data, N is not always equal to 473. Nephropathies 1.30 0.54–3.13 0.545
Abbreviations: BMIZ, z‐score of body‐mass‐index‐for‐age; WHZ, z‐score of
weight‐for‐height. Infectious parasitic diseases 0.96 0.49–1.89 0.917

Endocrinopathies 0.22 0.05–0.98 0.048

Orthopaedic 0.67 0.27–1.63 0.384

only one indicator per patient (WHZ or BMIZ)
according to age. Haematopathies 1.46 0.69–3.09 0.318
In another study carried out in Belgian hospitals, Others 0.95 0.40–2.24 0.908
malnutrition was stratified into acute or chronic by
considering the WHZ and HAZ, respectively. It was Malnutrition at admission
identified that, on admission, 7.7% of the patients had No 1.00
chronic malnutrition and 9% had acute malnutrition.
Yes 0.49 0.27–0.89 0.020
The frequency of weight loss in the sample, regardless of
nutritional status at admission, was 32.3% and, of these, Note: The adjustment variables, n = 473.
12.5% lost > 2% of their body weight; these are smaller Abbreviations: CI, confidence interval; OR, odds ratio.

proportions compared to our study.4 This can be

explained by the fact that Belgium is a high‐income
country and consequently is expected to have a higher
level of healthcare.
Although the study by Pichler et al.15 was carried out in
a high‐income country, a similar percentage of malnutrition
was identified in their prospective study, carried out in a
high‐complexity paediatric hospital in London. At admis-
sion, 27% were malnourished, with this percentage increasing
to 32% at discharge. When analysing weight loss during
hospitalisation, it was concluded that 23% of the sample lost
weight. In addition, children under 2 years of age and those
with multiple health problems were more likely to be
malnourished. The justification presented by Pichler et al.15
for the proportions of malnutrition was the probability of
overestimation of malnutrition because it did not relate
weight to height in that the criterion for malnutrition was
based only on the WAZ. This indicator reflects either low
weight for height or stunting for age (short children may
weigh less than taller children), or a combination of both.20
Muñoz‐Esparza et al.,16 in a longitudinal study,
divided the study sample into two groups: Group 1,
discharged from hospital within 7–10 days, and Group 2,
discharged after 10 days. It was identified that, according
to the BMIZ, 21.9% of patients in group 1 were
malnourished at admission and discharge, whereas, in
group 2, 36.9% of patients were malnourished on
admission and 39.1% on discharge. Patients with longer
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ALVES ET AL.
| 1365

T A B L E 4 Adjusted analysis of the association between hospital‐ consequence of reduced absorption, reduced intake or
acquired malnutrition and clinical characteristics of patients increased catabolism of nutrient stores, malnutrition is a
Adjusted analysis very common occurrence in most gastroenteropathies.22
Variable OR 95% CI p
On the other hand, neuropathies were related to a
reduced risk of in‐hospital malnutrition in our study. A
Malnutrition at admission previous study showed that children diagnosed with
No 1.00 craniopharyngioma (brain tumor) have a high incidence
of obesity as a result of an interruption of hypothalamic
Yes 0.51 0.27–0.94 0.033
function caused by the tumour or by treatment (surgery
Gastroenteropathy or cranial radiation) and this can lead to abnormalities in
No 1.00 both the satiety and hunger control mechanisms, which
in turn cause a dysregulation in energy balance.23
Yes 1.68 1.02–2.75 0.040
Another important finding in the present study was
Neuropathies that patients classified as malnourished at admission had
No 1.00 a lower chance of worsening nutritional status during
hospitalisation. Generally, patients identified as mal-
Yes 0.35 0.17–0.74 0.006 nourished at hospital admission receive early nutritional
Endocrinopathies intervention, either through supplementation or an
enteral diet associated or not with the oral diet. It has
No 1.00
been shown that early nutritional intervention results in a
Yes 0.23 0.05–1.04 0.057 lower incidence of nutritional deterioration during
Lung diseases hospitalisation,12 as well as a reduction in hospital
costs.24 Furthermore, in the hospital where this study
No 1.00
was carried out, patients identified as malnourished on
Yes 0.62 0.33–1.18 0.152 admission are classified as having a higher level of care,
Note: The adjustment variables, n = 473. with greater priority to attention in relation to others,
Abbreviations: CI, confidence interval; OR, odds ratio. such as more frequent monitoring of weight and
p < 0.05 statistically significant. acceptance of the hospital diet.
In the present study, we aimed to identify mal-
nutrition during hospitalisation in paediatrics at a
hospital stays (> 10 days) had increased deficits in tertiary care hospital. A possible explanation for the
anthropometric indices at admission. When analysing the significant incidence of deterioration in nutritional status
association of pathologies with the BMIZ, they observed could be the severity of the diseases and the complica-
a lower mean z‐score at admission in patients with tions of these pathologies observed in this type of
respiratory diseases and gastroenteropathy. However, hospital. It is noteworthy that more complex diagnoses
during hospitalisation, worsening of the BMIZ occurred require further investigations and interventions by the
in patients with surgical pathology and infectious or team and, as a result, the patients undergo more frequent
neurological diseases, whereas patients with gastroen- fasting because of examinations or surgical procedures.
teropathies tended to improve during hospitalisation. Hospital‐acquired malnutrition in paediatric patients
A prospective multicentre study carried out with should be monitored and may also be related to lack of
patients aged 1 month to 18 years in Thailand showed appetite, aversion to hospital food,2,3,25 diet intolerance
that, at admission, 19% of the sample was malnourished manifested by vomiting and abdominal distension,2 use of
according to the BMIZ. The same criteria as in our study medications that may alter intake and/or metabolism of
were used to identify hospital‐acquired malnutrition nutrients,14 lengthening of hospital stay, interruptions
(reduction > 0.25 SD BMIZ), where a proportion of 24% at mealtimes,14,26 and effects of disease or treatment.25
was observed; furthermore, 25% of the patients had Thus, various strategies are suggested, such as nutritional
significant weight loss (i.e., > 2% of their reference weight) screening on admission and throughout hospitalisation,
during hospitalisation. The factors associated with hospital‐ regular weighing, additional nutritional support to improve
acquired malnutrition were moderate to severe medical nutritional intake, reassessment of nutritional status at
conditions, pneumonia, seizures and surgery.12 Therefore, it hospital discharge,27 adding oral supplementation to the
is observed that the proportion of hospital‐acquired meals of undernourished patients and those at risk for
malnutrition was lower compared to our results. malnutrition,28 implementation of hospital gastronomy that
According to our findings, gastroenteropathies are risk aims to improve the sensory quality of the preparations
factors for hospital‐acquired malnutrition. Gastrointestinal served in the hospital,29,30 and implementation of fasting
diseases are often related to nutritional deficiencies21 because abbreviation protocols and the protection of mealtimes.3
malabsorption, inflammation and anorexia are characteristic The present study has two weaknesses: the retrospec-
of many of these diseases. Because malnutrition is usually a tive type of design and the parameter used for identifying

1366 | HOSPITAL‐ACQUIRED MALNUTRITION
hospital‐acquired malnutrition (BMIZ ≥ 0.25 SD). Using
the BMIZ as a response criterion can result in under‐
identification of malnutrition because of the lack of
application of other anthropometric measures and an
assessment of body composition.31 However, there are
few studies on the development of malnutrition in
paediatrics during hospitalisation because most studies,
especially in Brazil, emphasise malnutrition at the time of
admission, making the present study relevant to the
scientific community.
CONCLUSIONS
Our study describes the presence of malnutrition at
hospital admission of paediatric patients, as well as its
significant worsening during the hospitalisation period.
The main risk factor was the presence of gastroentero-
pathies. Therefore, strategies to reduce hospital‐acquired
malnutrition are necessary to avoid its negative impacts.
We hope that our findings will serve as a basis for
further research in this area, to be carried out with the
view to improving healthcare and especially the quality
of life of paediatric patients.
A U T H O R C ON T R I B U T I O N S
Marília de Fátima Viana Alves was involved in the
conception and design of the study and the collection and
interpretation of the data. Juliana Moreira da Silva Cruvel
was involved in the conception and design of the study and
analysis and interpretation of the data. Marluce Alves
Coutinho, Maria Milena Bezerra Sousa, Elza Cristina
Batista Barbosa and Bruna Renata Fernandes Pires were
involved in data collection. All authors contributed to the
writing, critical review and approval of the final version of
the manuscript submitted for publication.
AC KNOWLE DGEME NT S
The work was conducted at the University Hospital of
the Federal University of Maranhão.
CONFLI CT S O F I NT ERE ST
The authors declare that there are no conflicts of interest.
ET HICAL STATEM ENT
The study was carried out in accordance with the Code
of Ethics of the World Medical Association (Declaration
of Helsinki) and was approved by the Research Ethics
Committee of the University Hospital of the Federal
University of Maranhão (Protocol Number 4,853,350
and CAAE 49004921.0.0000.5086).
T R AN S P A RE NC Y DE CLA RA T I ON
The lead author affirms that this manuscript is an honest,
accurate and transparent account of the study being
reported. The reporting of this work is compliant with
STROBE guidelines. The lead author affirms that no
1365277x, 2023, 4, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jhn.13106 by Suleyman Demirel University, Wiley Online Library on [10/10/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
important aspects of the study have been omitted and
that any discrepancies from the study as planned have
been explained.
OR CI D
Juliana Moreira da Silva Cruvel http://orcid.org/0000-
0003-1087-7095
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