Malnutrition evaluation at children who hospitalized in pediatric immunology and rheumatology department

İntroduction: Disease related malnutrition is a dynamic and multifactorial process and is closely related with inflammation, undernourishment, increased energy need and decreased take of food. The disease related malnutrition wasn't adequately studied until recently, although the nutritional abnormalities cause severe degrees of morbidity and mortality on pediatric patients. A lot of studies show 6-51% percentage of prevalence in malnutrition in pediatric patients. Although a lot of studies can be found on malnutrition of patients diagnosed with malignancy, cardiac, neurologic and infection problems and the patients in intensive care unit; malnutrition studies considering children's immunology and rheumatology diseases remains to be quite limited. Objective: In this study, we aimed to identify the malnutrition prevalence in hospitalized patients from the Children's Immunology-Rheumatology Service; to examine the effect of the treatments in consideration with the duration of hospital stay and accompanying clinical conditions (presence of fever, acute phase reactants etc.) on the period of malnutrition; to compare many available malnutrition classifications (WHO, Gomez, Waterlow, Wellcome) and malnutrition scoring methods (PeDİSMART, STAMP, PYMS) with each other and choose the most suitable classification and scoring method for the disease (Primary Immunodeficiency (PID) / Rheumatology) and for the conditions (repeated admission to hospital /long duration of hospital stay), to detect the patients with malnutrition, prevent the malnutrition which is seen especially with long duration of hospital stay and treat them all. Cases and Methods: In this prospective study; 371 children who have been admitted in Children's Immunology-Rheumatology Service between April 2017 and June 2019 with ages ranging from 1 month old to 18 years old, were included in the study. Conditions of fever, diarrhea/vomiting, usage of steroid, oral aphthae, bronchopneumonia, receiving TPN, feeding from naso-gastric catheter, albumin intake, use of enteral feeding, intravenous hydration, intravenous iron/erythrocyte, and use of insulin, use of metformin and whether edema existed or not in the physical examination were recorded for every patient at their admisson. Laboratory data on admission (protein/ albumin/ complete blood cell count/ Iron/ Total Iron Binding Capacity/ Ferritin) were recorded for patients whenever available. Once on admission and second at discharge from the hospital, and also once a week for every patient that had stayed more than two weeks in the hospital; the weight, height, mid upper arm circumference and triceps skinfold were measured with relevant devices by the same doctor (S.G.). Upon admission, WHO, Gomez, Waterlow, Wellcome malnutrition classifications and PeDİSMART, STAMP, PYMS malnutrition screening tools were applied for every patient. Malnutrition screening tools were applied once a week and at the discharge from the hospital for the patients who stayed over two weeks. Malnutrition classifications were also applied at discharge only for the patients who stayed over two weeks. These measurements and applications of malnutrition classifications and screening tools were recalculated for recurrent hospitalizations. Informed consents were taken from all patients or their parents. The study was approved by the Ethical Committee of Ege University Hospital. Results: Among the 371 patients that stayed in the Children's Immunology and Rheumatology Services,1.9% morbid obesity, 5.7% obesity, 14.8% over-weight, 7.8% under-weight, 4.3% severe under-weight, 65.5% normal BMI were determined. When a patient's admission and hospital discharge measurements would be compared, the decrease in the z-score of BMI as more than 0.25 SDS would be accepted as the criteria of hospital malnutrition. In the measurements that were conducted on among 371 patients, 50 patients (13,5%) determined a development of hospital malnutrition compared to the admission measurements as more deviation than 0.25 SDS was observed. Among the patients that developed hospital malnutrition, the average duration of hospital stay would be 13± 11,2 days; the minimum duration of stay was 3 days whereas the maximum duration of stay was 57 days. Among the 85 patients that stayed in hospital more than two weeks, 16 of them (19%) had their release BMI zscore experience a drop more than 0.25 SDS from the admission score. Especially among the top 10 patients that stayed in the hospital the longest, 67% of the patients that stayed in the hospital more than two weeks were observed to be gaining weight. Looking at the admission measurements of the 23% of patients who experienced a gain of weight, their first BMI z-scores were observed to be below -2 SDS. This situation not only demonstrated that the extended hospital stays would increase the incidence of hospital malnutrition but also showed that early diagnosis of malnutrition would provide adequate nutritional support just in time. In our study, the patients diagnosed with PID were observed with 21% acute, 17% chronic, 9% with acute malnutrition on chronic base according to Waterlow, while 23.8% had mild, 10.5% had medium and 8% had severe malnutrition according to Gomez. Confirming the of the primary immünodeficiency patients to have malnutrition; patients were scored with PeDİSMART at admission; 74% of them was at low risk, 17.4% of them was at medium risk and 8.5% was at the severe risk of malnutrition; with STAMP, 51.3% had low risk, 30.6% had medium risk, and 18% had severe risk of malnutrition; with PYMS, 55% of the patients scored 0, 13.7% scored 1 whereas 31.2% scored 2 points and was characterized with a malnutrition risk. Based on the measurements of rheumatology patients, 25.2% mild, 9.3% middle and 1.6% severe malnutrition wad detected according to Gomez. According to Waterlow, 28% of the patients had acute, 12.6% had chronic, 5% had acute malnutrition on chronic base. Confirming the fact that 1/3 of the rheumatology patients had malnutrition, patients were scored with PeDİSMART at admission; 88% mild risk, 10.4% medium risk and 1.6% severe risk of malnutrition; by STAMP, 67% low risk, 23.7% medium risk and 9.3% severe risk of malnutrition; by PYMS, 71% of the patients scored 0 points, 12% scored 1 and 17% of them scored 2 points and was characterized with a malnutrition risk. Among the patients with repeated stays at the hospital, PeDİSMART and STAMP were found to be more suitable screening tools for the PID patients, whereas PYMS was a more suitable for rheumatology patients. Among the patients that stayed at the hospital more than two weeks, PYMS was found to be more useful than the rest of the malnutrition screening tools. We detected that, primer immunodeficiency patients who had malnutrition according to Wellcome and Gomez were hospitalized more than once wheras there was no such difference for Rheumatology patients. Also, there is no association between hospitalization rate and the other (WHO, Waterlow) classifications. PYMS and PedİSMART fall behind at diagnosing malnutrition when patients have edema. STAMP showed parallelism with Wellcome as the malnutrition got more serious: it continued to score up. While PYMS, STAMP and PeDİSMART seemed to be compatible with Gomez and qualified enough for diagnosing acute malnutrition; they were not qualified enough at diagnosing chronic malnutrition. Conclusion: In this study we aimed to determine the malnutrition prevalence in Children's Immunology and Rheumatology patients; to examine the effect of the duration of hospital stay, accompanying disease, clinical condition and given treatments for malnutrition control; and to choose the most optimal malnutrition classification and screening tool according to the diseases and conditions by comparing many malnutrition classifications (WHO, Gomez, Waterlow, Wellcome) and screening tools (PeDİSMART, STAMP, PYMS). In our study, we detected 21.3% acute and 17.5% chronic malnutrition with Waterlow among the patients who were admitted to Children's Immunology and Rheumatology Service. In all the patients that were admitted to inpatient clinics, 13.5% was found to develop malnutrition, and the average of their hospitalization time was calculated to be 13 days. We considered that hospitalization more than two weeks is a risk factor for hospital malnutrition. When we evaluated within patient groups, half of PID patients and one-thirds of rheumatology patients were found to have malnutrition. In the literature, there isn't any study which defines and compares malnutrition of PID and rheumatology patients or compares different malnutrition classifications (WHO, Gomez, Waterlow, Wellcome) and malnutrition screening tools (PeDİSMART, PYMS, STAMP) with each other. In this study; we detected that 1/2 of PID patients and 1/3 of rheaumatology patients had malnutrition and malnutrition screening tools were good enough to detect acute malnutrition but adequate to detect chronic malnutiriton. While half of the patients with PID had malnutrion; on guessing the weight loss and nutritional support need, PeDİSMART's sensitivity found as 52%, while STAMP's sensitivity was 97% and PYMS' sensitivity was 89%. While approximately one-thirds of the rheumatology patients had malnutrition, on guessing the loss of weight and nutritional support need, PeDİSMART's sensitivity was 37%, STAMP was 99% and PYMS was 88%. Considering the patients with more than two weeks of stay, PYMS is more suitable than other malnutrition screening tools. At repeated hospitalizations; for PID patients PeDİSMART and STAMP, for rheumatology patients PYMS is more convenient as a malnutrition screening tool. Alongside the modern malnutrition screening tools, considering their inadequacy to diagnose chronic malnutrition and to be able to classify malnutrition (mild /medium/ severe; acute/ chronic/ acute on chronic base or low weight / marasmus/ kwashiorkor); malnutrition classifications were found to be still reliable. According to our study's results, we advise being considerate on progression of hospital malnutrition of hospitalized patients. While using WHO, Gomez, Waterlow, Wellcome classifications on diagnosis of malnutrition, we should also use the most convenient malnutrition screening tool considering the patient and accompanying conditions (disease, repeating stay count etc.). Thus, we not only advise detecting malnutrition fastly and prevent the progression of the malnutrition but also control the patients regularly and see their clinical progress closely and cure malnutrition with the guidance of the malnutrition screening tools. Key words: primary immunodeficiency, rheumatology, children, malnutrition, hospital malnutrition