Advancing early identification of at-risk children: a consensus-based refinement and validation roadmap for the pediatric malnutrition screening algorithm

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Introduction: Mild malnutrition risk remains an underrecognized yet clinically important contributor to impaired growth and development in children aged 1-10 years across the Middle East. Regional estimates indicate that 15-25% of children in the Gulf Cooperation Council (GCC) fall within the mild malnutrition risk category (Weight-for-Height Z-score [WHZ] between -1 and -2 SD), a subgroup vulnerable to progressive growth faltering yet excluded from conventional malnutrition diagnostic thresholds (WHZ < -2 SD). The Pediatric Malnutrition Screening Algorithm (PMSA-2025) was refined through a structured regional expert consensus process to enable early, standardized detection of these at-risk children in outpatient and community healthcare settings. Methods: A 14-member multidisciplinary expert panel from different countries (KSA, UAE, Egypt, Kuwait, Oman, Russia, United States, and Türkiye) refined the PMSA-2025 using a three-round, hybrid modified Delphi approach conducted in September 2025. Expert selection criteria included a minimum of 10 years of clinical or academic experience in pediatric nutrition or gastroenterology, active involvement in malnutrition-related clinical practice or research, and representation of diverse regional healthcare contexts. Content validity was assessed using the Item-level Content Validity Index (I-CVI), with a threshold of ≥0.80 for domain retention. Six clinical domains were retained from an initial pool of eight candidate domains after Delphi-based consensus: perinatal history, growth trajectory, prior nutritional diagnosis, hospitalization frequency, infection recurrence, and feeding behavior. Each domain was operationalized with measurable, age-appropriate criteria and incorporated into a binary (Yes/No) scoring system (total score: 0-6). The tool is designed for use by pediatricians, family physicians, nurses, and trained community health workers in children aged 1-10 years with WHZ between -1 and -2 SD. Exclusion criteria include children with primary chronic systemic disease driving growth impairment and those already receiving formal nutritional support. Results: All six retained domains achieved an Item-level CVI (I-CVI) ≥ 0.85 in the final consensus round. Two initial candidate domains (dietary diversity score, caregiver nutritional literacy) were excluded due to insufficient agreement (I-CVI < 0.70). Three domains required definitional refinement during Round 2, achieving ≥90% final agreement in Round 3. The PMSA-2025 stratifies mild malnutrition risk across three tiers: low (0-1), moderate (2-3), and high (4-6). It requires no specialized equipment beyond a standard scale and can be completed within routine consultations. Conclusion: The PMSA-2025 represents a consensus-based, multidimensional screening tool with established content validity designed to address the unmet need for early mild malnutrition risk identification in outpatient and community pediatric settings across the Middle East.

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