title: Is undernutrition prognostic of infection complications in children undergoing surgery? A systematic review.
abstract: BACKGROUND
  Healthcare-associated infections are costly and are increasingly viewed as an indicator of the quality of care. Although strategies to reduce infections have become widespread, few studies have formally investigated the role of undernutrition on the development of infection-related complications in children after surgery.
  
  
  OBJECTIVE
  To perform a systematic review of the literature to determine if undernutrition is prognostic of postoperative infection complications in children.
  
  
  METHODS
  Electronic bibliographic and research databases were searched from 1950 to 2014. Inclusion criteria were studies in children (age <18 years) evaluating pre-operative nutritional status and reporting postoperative infection complications. Quality assessment was performed independently by two reviewers, with disagreements resolved by a third reviewer. The quality of the evidence was judged to be low in the majority of studies.
  
  
  RESULTS
  Ten cohort and two case-control studies met the inclusion criteria. Five studies reported an outcome combining infection-related complications, with the remainder reporting individual infection complications. Six studies reported surgical site infection (SSI) alone or in combination with other infection complications. Direct comparison between studies was difficult due to clinical and diagnostic heterogeneity. Unadjusted analyses (for patient or clinical variables) were suggestive of a relationship between undernutrition and infection complications. In studies controlling for other variables, the analyses did not remain significant for SSI.
  
  
  CONCLUSIONS
  There was low-quality evidence that undernutrition may be predictive of postoperative infection complications in children, with the exception of SSI. However, inconsistencies in nutritional and outcome assessments made it difficult to draw conclusions. Larger, high-quality studies are warranted to further investigate a potential prognostic relationship.
authors.affiliation: Department of Paediatric Cardiology and Cardiac Surgery, Alder Hey Children's NHS Foundation Trust, Liverpool, UK. Electronic address: rebecca.hill@alderhey.nhs.uk.
authors.forename: R
authors.initials: R
authors.lastname: Hill
authors.affiliation: Department of Infectious Diseases, Alder Hey Children's NHS Foundation Trust, Liverpool, UK; Institute of Infection and Global Health, University of Liverpool, Liverpool, UK.
authors.forename: S
authors.initials: S
authors.lastname: Paulus
authors.affiliation: College of Clinical and Biomedical Science, University of Central Lancashire, Preston, UK.
authors.forename: P
authors.initials: P
authors.lastname: Dey
authors.affiliation: College of Health and Wellbeing, University of Central Lancashire, Preston, UK.
authors.forename: M A
authors.initials: MA
authors.lastname: Hurley
authors.affiliation: Children's Nursing Research Unit, Alder Hey Children's NHS Foundation Trust, Liverpool, UK; Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK.
authors.forename: B
authors.initials: B
authors.lastname: Carter
mesh_terms: D000293:Adolescent; D002648:Child; D002675:Child, Preschool; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D044342:Malnutrition / Q000150:complications*; D013530:Surgical Wound Infection / Q000453:epidemiology*
keywords: Healthcare-associated infection; Nutritional assessment; Paediatric surgery; Postoperative infection; Undernutrition