# Nutritional Status as a Risk Factor for Appendiceal Perforation in Pediatric Acute Appendicitis: Systematic Review

## TL;DR

The paper finds that underweight status and certain biochemical markers, not BMI, are better predictors of severe appendicitis in children.

## Contribution

It identifies biochemical nutrition-inflammation indices as more reliable predictors of appendiceal perforation than BMI in pediatric appendicitis.

## Key findings

- Underweight status correlates with prolonged hospitalization and increased postoperative morbidity in pediatric appendicitis.
- Biochemical markers like CRP/albumin ratio and NPAR show stronger associations with perforated appendicitis than BMI.
- Standardized care pathways can mitigate disparities linked to reduced physiological reserve in underweight children.

## Abstract

What are the main findings?
Body Mass Index (BMI) percentiles do not appear to serve as consistent independent predictors of appendiceal perforation or complicated appendicitis in pediatric populations. While obesity is frequently associated with increased operative complexity and healthcare utilization, adjusted analyses have not consistently demonstrated it as an independent predictor of transmural necrosis or perforation. In contrast, underweight status emerges as a more consistent marker of clinical vulnerability, correlating with prolonged hospitalization and increased postoperative morbidity.More consistent associations were observed with biochemical nutrition–inflammation indices, such as the CRP/albumin ratio and the neutrophil percentage-to-albumin ratio (NPAR). These markers offer improved discriminatory capacity, as they reflect dynamic physiological processes including capillary leak and hepatic reprioritization during advanced appendiceal inflammation.

Body Mass Index (BMI) percentiles do not appear to serve as consistent independent predictors of appendiceal perforation or complicated appendicitis in pediatric populations. While obesity is frequently associated with increased operative complexity and healthcare utilization, adjusted analyses have not consistently demonstrated it as an independent predictor of transmural necrosis or perforation. In contrast, underweight status emerges as a more consistent marker of clinical vulnerability, correlating with prolonged hospitalization and increased postoperative morbidity.

More consistent associations were observed with biochemical nutrition–inflammation indices, such as the CRP/albumin ratio and the neutrophil percentage-to-albumin ratio (NPAR). These markers offer improved discriminatory capacity, as they reflect dynamic physiological processes including capillary leak and hepatic reprioritization during advanced appendiceal inflammation.

What are the implications of the main findings?
These findings suggest that risk stratification in pediatric appendicitis benefits from shifting emphasis from static anthropometric measures toward assessment of physiological reserve and inflammatory status. Integrating albumin-based or composite biochemical markers into existing diagnostic tools, such as the Pediatric Appendicitis Score, may enhance early identification of higher-risk patients.The age-dependent variability observed in biomarker performance further suggests that risk-stratification models could be tailored to specific pediatric developmental groups. Additionally, the review highlights that while nutritional vulnerability may influence outcomes, standardized protocol-driven care pathways appear capable of mitigating disparities associated with reduced physiological reserve.Overall, these findings support the development of integrated predictive frameworks combining biochemical indicators, clinical severity measures, and temporal factors to improve individualized management in pediatric appendicitis.

These findings suggest that risk stratification in pediatric appendicitis benefits from shifting emphasis from static anthropometric measures toward assessment of physiological reserve and inflammatory status. Integrating albumin-based or composite biochemical markers into existing diagnostic tools, such as the Pediatric Appendicitis Score, may enhance early identification of higher-risk patients.

The age-dependent variability observed in biomarker performance further suggests that risk-stratification models could be tailored to specific pediatric developmental groups. Additionally, the review highlights that while nutritional vulnerability may influence outcomes, standardized protocol-driven care pathways appear capable of mitigating disparities associated with reduced physiological reserve.

Overall, these findings support the development of integrated predictive frameworks combining biochemical indicators, clinical severity measures, and temporal factors to improve individualized management in pediatric appendicitis.

Background: The association between nutritional status and perforation or complicated appendicitis in children remains uncertain. Objective: To review evidence on anthropometric and biochemical nutritional indicators in relation to perforation and complicated appendicitis in pediatric acute appendicitis. Methods: PubMed, Scopus, and Web of Science were searched for peer-reviewed English-language studies published from 1 January 2010 to 1 January 2026, with supplementary citation searching and Google Scholar screening. Eligible studies included participants aged 0–18 years and reported BMI-based measures and/or biochemical nutritional markers (e.g., albumin, prealbumin, or derived inflammation–nutrition indices) stratified by perforation or complicated appendicitis. Risk of bias was assessed using ROBINS-E. Results: Fourteen observational studies were included. Associations between obesity and perforation or complicated appendicitis were inconsistent, and large registry-based analyses did not identify obesity as an independent predictor after adjustment. Underweight status was more consistently associated with complicated disease and adverse clinical course. Biochemical markers and inflammation–nutrition indices showed more consistent associations with perforated or complicated appendicitis than BMI categories, with several studies reporting moderate-to-high discrimination for severe disease. Conclusions: BMI-based classifications alone did not reliably predict perforation or complicated appendicitis. Albumin- and prealbumin-based indices were more consistently associated with disease severity, but the observational evidence does not establish causality and may reflect inflammatory severity at presentation. Prospective studies with standardized definitions and marker assessment are needed to evaluate incremental prognostic value beyond symptom duration and clinical severity scores.