Supplemental Content: Malnutrition Criteria Kwashiorkor

Supplemental Content: Malnutrition Criteria

Kwashiorkor

Four of the following criteria must be met but not all criteria are required:

Serum albumin ≤ 2.1 g/dL* (normal range 3.5-5.2 g/dL)

Total lymphocyte count (TLC) ≤ 800 mm³ **

Stable weight

Peripheral edema on physical exam

Inadequate protein intake (< 50% of estimated needs for 3 days or < 75% of estimated needs for 7 days)
Marasmus

Three of the following criteria must be met but not all criteria are required:

Significant history of weight loss (5% over one month, 7.5 over three months, 10% over six months)

85%-94% of ideal body weight

Overt muscle wasting on physical exam

Serum proteins are slightly decreased or within normal limits

Inadequate kcal intake (< 50% of estimated needs for 3 days or < 75% of estimated needs for 7 days)
Severe Protein-Energy Malnutrition

Three of the following criteria must be met but not all criteria are required:

Significant, disease-related, weight loss of > 15% of usual weight within the past six months

< 70% ideal body weight l

Serum albumin < 2.1 g/dL

TLC ≤ 800 mm³ **

Transferrin < 100 mg/dL*** (calculated: total iron binding capacity/1.45)

Overt signs of muscle wasting on physical exam

Inadequate kcal intake (< 50% of estimated needs for 3 days or < 75% of estimated needs for 7 days)

Moderate Protein-Energy Malnutrition

Two of the following criteria must be met but not all criteria are required:

Significant, disease-related, weight loss of 10%-15% of usual weight within the past six months

70%-84% of ideal body weight

Serum albumin 2.1 g/dL-2.7 g/dL*

TLC 800-1199 mm³ **

Transferrin 100-149 mg/dL***
Supplemental Content: Malnutrition Criteria (Continued)
Mild Protein-Energy Malnutrition

Two of the following criteria must be met but not all criteria are required:

Significant, disease-related, weight loss of 5%-9% of usual weight within the past six months

85%-94% of ideal body weight

Serum albumin 2.8-3.4 g/dL

TLC 1200-1499 mm³ **

Transferrin 150-199 mg/dL***
Non-Specific Protein-Energy Malnutrition

The patient has known nutritional risk with metabolic stress and/or overt signs of malnutrition without supporting anthropometric or biochemical data. Clinical judgment is required to make this classification.

Examples include:

Inadequate nutrient intake of kcal, protein, and micronutrients (< 50% of estimated needs for three days or < 75% of estimated needs for 7 days) concurrent with significant stress or injury; examples include trauma, major burn, short-bowel syndrome, severe pancreatitis, enterocutaneous fistula, inflammatory bowel disease

Overt wasting of muscle and fat stores without supporting clinical measures (e.g, anthropometric data unavailable, weight history unavailable, unreliable admission albumin)

Single nutrient deficiency

Multiple nutrient deficiencies
Note: Total lymphocyte count (TLC) = [%lymphocytes x WBC (mm³)]/100

*Only admission serum albumin is used because of difficulties in interpretation after hydration; additionally, serum albumin is not used if the patient is transferred after a prolonged stay at an outside hospital. If the admission albumin from the outside hospital is available, that may be used for evaluation.

**Excludes patients currently undergoing chemotherapy or radiation, or one month post-chemotherapy or radiation; currently receiving high-dose steroid therapy defined as ≥ 60 mg/day of prednisone or equivalent; suffering from leukemia; current infection

***Transferrin may only be used in an iron-replete patient who has not received blood transfusions.

Supplemental Content: Energy Needs Determination

Energy needs are determined by the following: For BMI < 30 kg/m², basal metabolic rate is calculated based on body surface area (1) and age, then activity and stress factors are applied based on severity of illness (patients are generally fed between 30-35 kcal/kg). For BMI 30-35 kg/m² we use adjusted weight for obesity (2), calculate resting metabolic rate, apply activity factor and stress factor based on severity of illness (patients are generally fed between 25-35 kcal/kg). Patients with BMI 35-50 kg/m² are fed at 14 kcal/kg dry weight, and those with BMI > 50 kg/m² are fed at 25 kcal/kg ideal body weight (3, 4).

References

1. Fleisch A. [Basal metabolism standard and its determination with the "metabocalculator"]. Helvetica medica acta 1951;18(1):23-44.

2. Karkeck J. Adjusted body weight for obesity. American Dietetic Association Renal Dietitians Practice Group Newsletter 1984;3:6.

3. Jacobs DG, Jacobs DO, Kudsk KA, Moore FA, Oswanski MF, Poole GV, Sacks G, Scherer LR, 3rd, Sinclair KE, Group EPMGW. Practice management guidelines for nutritional support of the trauma patient. J Trauma 2004;57(3):660-678; discussion 679.

4. McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G. , A. S. P. E. N. Board of Directors, American College of Critical Care Medicine, Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;33(3):277-316.