Clinical Application Of Nutritional Screening And Assessment Scale In Hospitalized Children With Cerebral Palsy

BackgroundCerebral palsy(CP)is a group of persistent central motor and postural dyskinesia,activity-limited syndrome caused by non-progressive brain damage in developing fetuses or infants.Although the core problem of CP is motor disorder,its non-motor symptoms are also common,such as feeding difficulties and malnutrition,especially in children with severe motor disorders and older children.According to the epidemiological survey results of cerebral palsy in 12 provinces and cities of China in 2012 to 2013,the incidence rate was 2.48 per thousand(155/62 591),with a prevalence rate of 2.46 per thousand(797/323 858)(1 to 6 years old).Domestic and foreign literature in recent years shows that 15.6% to 94.3% of children with CP have malnutrition.Malnutrition mainly leads to poor weight gain.In addition,malnutrition can easily cause brain dysfunction,impaired immune function,increased risk of infection,prolonged wound healing time and increased risk of pressure sore.Malnutrition has great influence on nerve,physiology,psychology and movement of children with CP,and is closely related to the overall rehabilitation effect.Studies have found that adequate nutrition is beneficial to infant brain development and improves neurodevelopmental outcomes.Therefore,the expert consensus on nutritional support for children with CP points out that nutritional screening and evaluation are necessary links in nutritional support for children with CP.At present,there are many kinds of pediatric nutrition screening and evaluation tools abroad,each of which has its own characteristics and limitations.So far,there is no recognized nutrition screening and evaluation tool in the world.As the first nutritional screening tool for hospitalized children in China,the modified pediatric nutritional risk screening tool has good clinical malnutrition predictability.However,the application in hospitalized children with CP lacks clinical evidence.The Subjective Global Nutritional Assessment(SGNA),first reported in 2007 by the University of Toronto Secker and Jeejeebhoy,Canada,is a proven nutritional assessment tool for predicting nutrition-related complications and length of stay in hospitalized children.At present,there is no literature report on the clinical effectiveness of SGNA in nutritional evaluation of children with CP.This study verified the clinical effectiveness of the modified pediatric nutritional risk screening tool and SGNA in hospitalized children with CP,and combined with the Gross Motor Function Classification System(GMFCS)to grade the coarse motor function level.The malnutrition status in different GMFCS grading levels was analyzed.ObjectiveFirstly,to investigate the undernutrition of children with cerebral palsy(CP)and to verify the clinical effectiveness of SGNA in nutritional assessment of hospitalized children with CP.Secondly,a preliminary study on the relationship between GMFCS grading and malnutrition in children with cerebral palsy.Thirdly,to evaluate the clinical effectiveness of modified pediatric nutritional risk screening tool in nutritional screening of hospitalized children with cerebral palsy.MethodsThe 208 hospitalized children with cerebral palsy who came to our hospital from April to October 2019 and entered complete information with the APP of the pediatric nutrition management including the modified pediatric nutritional risk screening tool and SGNA application were selected as the subjects.The inclusion criteria included that all children met the criteria for the diagnosis of CP in the 2014 Definition,Diagnostic Criteria and Clinical Classification of CP.And children aged 1 to 17.As well as the child’s guardian agreed to participate in the study and signed an informed consent.Exclusion criteria included overweight and obese children with excess nutrition and incomplete clinical data.All hospitalized children with CP who met the selection criteria were collected general data,including the name,sex,actual age,CP classification and so on.The WHO recommended Z scoring method was used to evaluate the modified pediatric nutritional risk screening tool and SGNA,and the coarse function of hospitalized children with CP was GMFCS and graded.Then,using the Z scoring method as a reference,the reliability and criterion validity of the SGNA are evaluated comprehensively.And the GMFCS classification was carried out to analyze the distribution of malnutrition incidence in each GMFCS grading group.Evaluation of the clinical effectiveness of the modified pediatric nutritional risk screening tool through the following four aspects.Firstly,maneuverability analysis was took to receive the modified pediatric nutritional risk screening tool scale screening and scale completion time.Secondly,comparing the results of the modified pediatric nutritional risk screening tool with the results of nutritional risk assessment as malnutrition,and conduct internal consistency analysis for reliability test.At the same time,the modified pediatric nutritional risk screening tool scale was used to screen the nutritional risk of the same hospitalized children for more than one week at the interval of one week for reliability test,too.Thirdly,the two researchers rated the same child independently of each other,then calculated the Kappa coefficient and tested its stability for reliability analysis.Finally,using SGNA as the reference standard for the diagnosis of malnutrition,calculating the Kappa values of consistency test of the modified pediatric nutritional risk screening tool and SGNA methods,evaluating the sensitivity and specificity of the screening scale,Positive Predictive Value(PPV)and Negative Predictive Value(NPV)to carry on validity test.ResultsThe detection rates of undernutrition in 208 hospitalized children with CP by SGNA and Z score were 42.3% and 39.4%,respectively.There was no statistically significant difference between the two methods(χ~2=0.658,P=0.417).The application of SGNA showed a substantial agreement and statistical significance between the two evaluators(κ=0.621,P<0.001).Taking the Z score method as the reference standard,the sensitivity,specificity,PPV and NPV of SGNA were 80.5%,82.5%,75.0% and 86.7%,respectively.There was a substantial agreement between the two evaluation methods(κ=0.622),which was statistically significant(P<0.001).There was a moderate agreement between SGNA and weight-for-age Z score(WAZ(κ=0.495,P<0.001)and height/length-for-age Z score(HAZ(κ=0.478,P<0.001),but very low agreement with weight-for-height/length Z score(WHZ(κ=0.197,P=0.002).The risk of malnutrition was 60.1% in 208 hospitalized children with CP.SGNA incidence of malnutrition was 17.2%,40.0%,41.5%,58.8% and 60.0%,respectively.The incidence of malnutrition was statistically significant among the GMFCS grade groups(χ~2=13.976,P<0.001).The modified pediatric nutritional risk screening tool recovery rate was 98.9 percent and the time to complete a screening table was(3.3±0.8)minutes.The sensitivity,specificity,PPV and NPV of the modified pediatric nutritional risk screening tool regimen were 94.3%,65.0%,66.4% and 94.0%,respectively,using SGNA as reference criteria.The modified pediatric nutritional risk screening tool was screened again at one week interval between the same subjects.The correlation coefficient of the two measurements was 0.849(P<0.001),which was statistically significant.The consistency between the two researchers was good(κ=0.624,P<0.001.The consistency test results of the modified pediatric nutritional risk screening tool and SGNA that κ=0.562(95% CI:0.458 to 0.665)and P<0.001,with moderate consistency.Conclusions1.SGNA can be used as a tool to assess the nutritional status of children with cerebral palsy.2.High risk of malnutrition and incidence of malnutrition in hospitalized children with cerebral palsy.And the incidence of malnutrition increased with the GMFCS grading level.3.The modified pediatric nutritional risk screening tool can effectively screen out the occurrence of malnutrition risk,has good applicability.