Nutritional Status Misjudged by Pediatric Oncology Nurses


Understanding nutritional status and patient cues is crucial in ensuring patients have the proper interventions and treatment plans.

While it is known that malnutrition is associated with poorer outcomes in pediatric patients with cancer, oncology nurses were more inclined to under-rate nutritional status, according to a recent study published in the Journal of Pediatric Oncology Nursing.

The investigators sent electronic surveys to oncology nurses that included patient vignettes that examined nurses’ decision making when it came to nutritional assessment of children over the age of 2 with cancer. Factors included nutritional rating, confidence in rating, and selection of cues that support the nutritional rating. A total of 318 nurses participated.

Nurses rated the vignettes on a scale of 1 to 5, with 1 being undernourished and 5 being over-nourished. The participating nurses’ answers were then compared to the ratings of a team of experts, comprised of a master’s prepared pediatric oncology nurse, 2 pediatric oncology-registered dieticians, and an epidemiologist researcher of nutrition in pediatric oncology patients.

Nurses chose the same answers as the experts 41% of the time.

“While the mean score of the participants’ ratings were similar to the expert panel, there was considerable individual variation indicating significant differences in clinical decision making between staff nurses and experts,” the researchers wrote.

The nurses that participated were somewhat younger (average 39 years old), more educated (90% had a least a bachelor’s degree and 72% certification rate) and worked in environments known to be high performance settings (66% Magnet® institutions, 86% Children’s Oncology Group). Because of these factors, the study authors predicted that the nurse participants in the study would perform as well as, if not better, than the average nurse in the US.

Risking Over-Nutriton

“The most notable finding regarding the accuracy of participants’ ratings was nurses were significantly more likely to underrate rather than overrate nutritional status,” the authors wrote. “The participants’ ratings, on average, were below the experts’ ratings; the degree of difference increased as the patient depicted in the vignette became more nourished.”

By underrating nutritional status, nurses may be causing certain patients to undergo unnecessary nutritional interventions, putting them at risk for over-nourishment, which could lead to increased risk for morbidity and mortality, the researchers explained.

“Patients being treated for acute lymphoblastic leukemia, the largest portion of pediatric oncology patients, trend toward over-nutriton,” they wrote. “Thus, not recognizing overnutrition in this population could be placing a large percentage of pediatric oncology patients at risk.”

Cue Selection

When it came to cue selection, study participants matched the experts only 16% of the time. Notably, the nurses recognized far fewer cues.

“If participants are selecting fewer and/or different cues, it follows that they would determine a different rating of the patients’ nutritional status,” the authors wrote. “Different ratings can lead to different, or no, interventions.”

In particular, participating nurses were far less likely to consider anthropometric variables (height, growth, weight, weight loss). Not only is this important when analyzing nutritional status, but also in properly dosing chemotherapy drugs.

Another discrepancy between nurses and the experts was the consideration of albumin as supporting cues. The experts never selected albumin as a cue, while the nurses selected it more than half of the time (53%).

Improving Knowledge, Patient Care

The findings of this study outlined an important need for oncology nurses to better understand nutritional status in pediatric patients.

“Because nutrition plays a vital role in children’s growth and development as well as their health and healing, oncology nurses need to be well-versed in the nutritional assessment of their patients,” the researchers wrote.

Looking ahead, the researchers said that a standardized nutritional assessment tool for pediatric oncology patients should be implementd. “This can be done through tool development, or through widespread testing, refinement and utilization of the current tools available.”


Lulloff AJ, Vessey JA, Bashore L, Gregas M. Nutrition-Related Clinical Decision Making of Pediatric Oncology Nurses. Journal of Pediatric Oncology Nurses. 2019;36(5):352-360. doi:2083/10.1177/1043454219844233.

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