Evaluating the STRONGkids Tool for Assessing Malnutrition Risk in Hospitalized Iranian Children – A Cross-Sectional Study

Document Type : Research Paper

Authors

1 Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran.

2 Metabolic Syndrome Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.

3 Student Research Committee, Varastegan Institute for Medical Sciences, Mashhad, Iran.

4 Student Research Committee, Semnan University of Medical Sciences, Semnan, Iran.

5 Service of Clinical Nutrition and Dietitian, Akbar Hospital, Mashhad University of Medical Sciences, Mashhad, Iran.

6 Department of Nutrition Improvement, Faculty of Health Center, Mashhad University of Medical Science, Mashhad, Iran.

7 Department of Pediatrics Mashhad University of Medical Sciences Mashhad Iran.

Abstract

Introduction: Malnutrition in hospitalized children can impair health outcomes. The STRONGkids screening tool requires further reliability testing across diverse healthcare providers to identify pediatric patients requiring nutritional support. This study evaluated the effectiveness of STRONGkids compared to standard anthropometric criteria in determining malnutrition risk among hospitalized Iranian children. Methods: This cross-sectional analysis evaluated 287 patients (mean age nine months) admitted for ≥4 days across all non-critical wards in a pediatric hospital in Mashhad, Iran, from November 2020 to October 2021. STRONGkids categories were compared to weight-for-age (WAZ), height-for-age (HAZ), BMI-for-age (BMIZ), and weight-for-length/height (WLZ/H) z-scores using agreement statistics. Results: The malnutrition rate exceeded previous estimates for Iranian pediatric patients. STRONGkids demonstrated statistically significant agreement with WLZ/H (p<0.001) and WAZ (p=0.014) in ruling out malnutrition risk. However, sensitivity for identifying high-risk cases was suboptimal. Conclusions: STRONGkids can reliably exclude malnutrition when agreement exists with anthropometric criteria. Standardizing training and administration of the tool could optimize sensitivity and utility for detecting hospitalized children requiring nutritional intervention.

Keywords

Main Subjects


1. Hajhir M. Diseases Induced by Malnutrition. Tehran: Andisheh Farda. 2004.
2. Mohseni M, Aryankhesal A, Kalantari N. Prevention of malnutrition among children under 5 years old in Iran: A policy analysis. PloS One. 2019;14(3):e0213136.
3. Kruger HS, Visser M, Malan L, Zandberg L, Wicks M, Ricci C, Faber M. Anthropometric nutritional status of children (0-18 years) in South Africa 1997-2022: a systematic review and meta-analysis. Public Health Nutrition. 2023;1-7
4. Organization wH. WHO. 2021.
5. Singh S, Srivastava S, Upadhyay AK. Socio-economic inequality in malnutrition among children in India: an analysis of 640 districts from National Family Health Survey (2015–16). International Journal for Equity in Health. 2019;18:1-9.
6. Chen S, Richardson S, Kong Y, Ma N, Zhao A, Song Y, et al. Association Between Parental Education and Simultaneous Malnutrition Among Parents and Children in 45 Low- and Middle-Income JAMA Network Open. 2023;6(1):e2251727-e.
7. Parkash O, Jamil S, Chudzinski V, Tahir N, Gole S, Deleon J, et al. Academy for Quality and Safety Improvement (AQSI) project to improve diagnosis and documentation of malnutrition in a community hospital. BMJ Open Quality. 2023;12(4).
8. Baratta R, Degano C, Leonardi D, Vigneri R, Frittitta L. High prevalence of overweight and obesity in 11–15-year-old children from Sicily. Nutrition, metabolism and cardiovascular diseases. 2006;16(4):249-55.
9. Mohseni M, Ahmadi S, Asadi H, Mohammadian ED, Asgarlou Z, Ghazanfari F, Moosavi A. A Systematic Review and Meta-Analysis of the Prevalence of Malnutrition Among 6-14-Year-Old Children in Iran. International Journal of Preventive Medicine. 2022;13:138.
10. Imanzadeh F, Olang B, Khatami K, Hosseini A, Dara N, Rohani P, et al. Assessing the Prevalence and Treatment of Malnutrition in Hospitalized Children in Mofid Children's Hospital During 2015-2016. Arch Iran Med. 2018;21(7):302-9.
11. Gerasimidis K, Macleod I, Maclean A, Buchanan E, McGrogan P, Swinbank I, et al. Performance of the novel Paediatric Yorkhill Malnutrition Score (PYMS) in hospital practice. Clinical Nutrition (Edinburgh, Scotland). 2011;30(4):430-5.
12. O'Connor J, Youde LS, Allen JR, Hanson RM, Baur LA. Outcomes of a nutrition audit in a tertiary paediatric hospital: implications for service improvement. Journal of Paediatrics and Child Health. 2004;40(5-6):295-8.
13. Pawellek I, Dokoupil K, Koletzko B. Prevalence of malnutrition in paediatric hospital patients. Clinical nutrition (Edinburgh, Scotland). 2008;27(1):72-6.
14. Malekiantaghi A, AsnaAshari K, Shabani-Mirzaee H, Vigeh M, Sadatinezhad M, Eftekhari K. Evaluation of the risk of malnutrition in hospitalized children by PYMS, STAMP, and STRONGkids tools and comparison with their anthropometric indices: a cross-sectional study. BMC Nutrition. 2022;8(1):33.
15. Aurangzeb B, Whitten KE, Harrison B, Mitchell M, Kepreotes H, Sidler M, et al. Prevalence of malnutrition and risk of under-nutrition in hospitalized children. Clinical nutrition (Edinburgh, Scotland). 2012;31(1):35-40.
16. Edington J, Boorman J, Durrant ER, Perkins A, Giffin CV, James R, et al. Prevalence of malnutrition on admission to four hospitals in England. The Malnutrition Prevalence Group. Clinical Nutrition (Edinburgh, Scotland). 2000;19(3):191-5.
17. Hulst JM, Zwart H, Hop WC, Joosten KF. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clinical Nutrition (Edinburgh, Scotland). 2010;29(1):106-11.
18. Joosten KF, Hulst JM. Nutritional screening tools for hospitalized children: methodological considerations. Clinical nutrition (Edinburgh, Scotland). 2014;33(1):1-5.
19. Spagnuolo MI, Liguoro I, Chiatto F, Mambretti D, Guarino A. Application of a score system to evaluate the risk of malnutrition in a multiple hospital setting. Italian Journal of Pediatrics. 2013;39:81.
20. Durakbaşa Ç U, Fettahoğlu S, Bayar A, Mutus M, Okur H. The Prevalence of Malnutrition and Effectiveness of STRONGkids Tool in the Identification of Malnutrition Risks among Pediatric Surgical Patients. Balkan Medical Journal. 2014;31(4):313-21.
21. Castro JDS, Santos CAD, Rosa COB, Firmino HH, Ribeiro AQ. STRONGkids nutrition screening tool in pediatrics: An analysis of cutoff points in Brazil. Nutr Clin Pract. 2022;37(5):1225-32.
22. McHugh ML. Interrater reliability: the kappa statistic. Biochemia medica. 2012;22(3):276-82.
23. Chotard S, Mason JB, Oliphant NP, Mebrahtu S, Hailey P. Fluctuations in wasting in vulnerable child populations in the Greater Horn of Africa. Food and Nutrition Bulletin. 2010;31(3 Suppl):S219-33.
24. Nimpagaritse M, Korachais C, Nsengiyumva G, Macq J, Meessen B. Addressing malnutrition among children in routine care: how is the Integrated Management of Childhood Illnesses strategy implemented at health centre level in Burundi? BMC Nutr. 2019;5:22.
25. Namiiro FB, Batte A, Rujumba J, Nabukeera-Barungi N, Kayom VO, Munabi IG, et al. Nutritional status of young children born with low birthweight in a low resource setting: an observational study. BMC Pediatr. 2023;23(1):520.
26. Rafisa A, Sarilita E, Delage B, Munger RG, Mossey PA. Situational analysis of nutritional status among 1899 children presenting with cleft lip and/or palate in Indonesia. Journal of Global Health. 2023;13:04127.
27. Gupta PM, Wieck E, Conkle J, Betters KA, Cooley A, Yamasaki S, et al. Improving assessment of child growth in a pediatric hospital setting. BMC Pediatrics. 2020;20(1):419.
28. Bharati S, Pal M, Bharati P. Determinants of nutritional status of pre-school children in india. Journal of Biosocial Science. 2008;40(6):801-14.
29. Siddiqui F, Salam RA, Lassi ZS, Das JK. The intertwined relationship between malnutrition and poverty. Frontiers in Public Health. 2020;8:453.
30. Panda BK, Mohanty SK, Nayak I, Shastri VD, Subramanian SV. Malnutrition and poverty in India: does the use of public distribution system matter? BMC Nutr. 2020;6:41.
31. Rahman MA, Halder HR, Rahman MS, Parvez M. Correction: Poverty and childhood malnutrition: Evidence-based on a nationally representative survey of Bangladesh. PloS One. 2021;16(12):e0261420.
32. Kapçı N, Akçam M, Koca T, Dereci S, Kapcı M. The nutritional status of hospitalized children: Has this subject been overlooked? The Turkish Journal of Gastroenterology. 2015;26(4):351-5.
33. Moeeni V, Walls T, Day AS. Nutritional status and nutrition risk screening in hospitalized children in New Zealand. Acta Paediatrica (Oslo, Norway : 1992). 2013;102(9):e419-23.
34. Huysentruyt K, Alliet P, Muyshont L, Rossignol R, Devreker T, Bontems P, et al. The STRONG(kids) nutritional screening tool in hospitalized children: a validation study. Nutrition (Burbank, Los Angeles County, Calif). 2013;29(11-12):1356-61.
35. da Cruz Gouveia MA, Tassitano RM, da Silva GAP. STRONGkids: Predictive Validation in Brazilian Children. Journal of Pediatric Gastroenterology and Nutrition. 2018;67(3):e51-e6.
36. Maciel JRV, Nakano EY, Carvalho KMBd, Dutra ES. STRONGkids validation: tool accuracy. Jornal de Pediatria (English Edition). 2020;96(3):371-8.
37. Huysentruyt K, Alliet P, Muyshont L, Rossignol R, Devreker T, Bontems P, et al. The STRONGkids nutritional screening tool in hospitalized children: a validation study. Nutrition. 2013;29(11-12):1356-61.
38. Pars H, Açıkgöz A, Erdoğan BD. Validity and reliability of the Turkish version of three screening tools (PYMS, STAMP, and STRONG-kids) in hospitalized children. Clinical Nutrition ESPEN. 2020;39:96-103.