Malnutrition Indicators for Preterm and Sick Neonates

By:  Suzanne Smith, MS, RD, LDN, IBCLC and Caroline Steele, MS, RD, IBCLC, FAND

Premature and sick neonates are at high risk of malnutrition due to nutrition deficits. The malnutrition risk stems from reduced nutrient stores at birth, immature digestion and absorption, organ immaturity, and delayed initiation or advancement of nutrition.1 These infants depend on health care providers adequately identifying and effectively providing needed nutrients during this period of rapid growth and development.1  Complications related to prematurity, such as necrotizing enterocolitis or chronic lung disease, may worsen the degree of malnutrition by limiting the provision of adequate nutrition.

Malnutrition results in poor growth and neurocognitive development impacting a child far beyond infancy, with deficits up to 19 years of age.2,3  Because extrauterine growth restriction is common in infants born before 31 weeks gestation, frequent evaluation of nutrition and growth are crucial in the overall medical management. Implementing protocols that promote adequate nutrient provision and assessing malnutrition risk factors allows clinicians to take a more proactive nutritional approach, which could reduce the risk or degree of malnutrition.

Prior to 2018, there was not an accepted, validated tool for diagnosing malnutrition in hospitalized neonates. The Pediatric Nutrition Practice Group (PNPG) of the Academy of Nutrition and Dietetics (AND) published recommended indications for identifying malnutrition in infants and neonates.1

The goal of these indicators is to identify malnutrition sooner, intervene earlier, and prevent adverse outcomes in those patients at greatest risk.1 The indicators:

  • include a time-period for inadequate nutrition as nutrients needs are higher and nutrient stores are depleted more rapidly in this population
  • account for rapid rates of growth and development in preterm infants and neonates
  • advocate for clinical judgment to identify malnutrition as not all declines in growth velocity are secondary to malnutrition (i.e. medical conditions requiring fluid restriction, diuretics, corticosteroids, etc.).

Growth measurements are compared to a standard and are described using the z-score which indicates the standard deviation from the mean or average measurement.  The indicators for identifying malnutrition are weight (z-score and weight gain velocity), length (z-score and linear growth velocity), and nutrient intake. Documentation of enteral and parenteral intake as well as growth anthropometrics are vital in assessing malnutrition. Growth assessment is based on preterm specific growth charts (Fenton or Olson). Various tools can be used to assess nutrient intake.

Billing and Reimbursement

Diagnosing malnutrition may impact hospital reimbursement.  Provider documentation of malnutrition (including the degree of malnutrition) signals coding departments to translate into codes for billing claims which is important because malnourished infants may have longer hospital stays resulting in higher costs.

Further, malnutrition impacts the severity of the illness and risk of mortality scores, which can influence the hospitals’ performance on required quality-reporting dashboards and have a downstream influence on reimbursement.

At Timeless Medical Systems, we created a program to help clinicians quickly analyze a patient’s enteral and parenteral intake. The Timeless Medical Parenteral and Enteral Nutrition System (PENS) helps make daily workflow more efficient by analyzing nutrition and anthropometrics, identifying malnutrition, and giving access to the industry’s most comprehensive database of nutrition products. This program is brought to clinicians as a value-added service by Reckitt Mead Johnson. For more information, contact your Reckitt Mead Johnson representative or Timeless Medical Systems at


  1. Goldberg, (2018) Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. JAND, 118:9. 1571-1581.
  2. Bhutta ZA, Gurrant RL, Nelson CA. (2017) Neurodevelopment, nutrition and inflammation: the evolving global child health landscape. Pediatr.139(suppl 1):S12-22.
  3. Scharf RJ, Rogawski ET, Murray-Kolb LE, et al. (2018) Early childhood growth and cognitive outcomes: findings from the MAL-ED study. Maternal Child Nutr. 14(3):e12584

Learn more about Timeless Medical Systems

The Timeless Medical Systems bar code scanning system offers a variety of reports that can help healthcare organizations evaluate their near-miss data and turn that knowledge into process change. In addition, Timeless Medical Systems also offers preparation room consulting services. Our very experienced and skilled Clinical Team Members have 1st hand experience in creating and implementing centralized preparation rooms and processes in some of the largest most prestigious hospitals throughout North America and are experts in workflows designed to minimize risk of error. If you are interested in learning more about these consulting services, please contact

The material presented in this blog represents the opinion of the author(s) and not necessarily the views of Synova Associates. Synova Associates does not endorse any specific products or organizations but strives to connect its industry partners with leaders interested in product/educational innovation.