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Assessment of Nutritional Status Based on STRONGkids Tool in Iranian

Hospitalized Children

Article  in  International Journal of Child Health and Nutrition · February 2015

DOI: 10.6000/1929-4247.2015.04.01.7

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 International Journal of Child Health and Nutrition, 2015, 4, 000-000 1

Assessment of Nutritional Status Based on STRONGkids Tool in

Iranian Hospitalized Children

Zahra Gholampour1, Mina Hosseininasab1, Gholamreza Khademi2, Majid Sezavar2,

Nooshin Abdollahpour3 and Bahareh Imani2,*

1
Department of Nutrition, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
2
Department of Pediatrics, Dr. Sheikh Children Hospital, Mashhad University of Medical Sciences, Mashhad,
Iran
3
Faculty of Sciences, Young Researchers and Elite Club, Islamic Azad University of Mashhad, Mashhad, Iran
Abstract: Background & Objective: Malnutrition is very common in hospitalized children and is associated with related
clinical consequences such as increased risk of infections, increased muscle loss, impaired wound healing, longer
hospital stay and higher morbidity and mortality. The estimated prevalence of acute malnutrition in hospitalized children
varies from 6.1 to 40.9% in different countries. The current study was conducted with the aim of evaluating the efficiency
of STRONGkids (Screening Tool for Risk On Nutritional Status and Growth) tool for assessing malnutrition in hospitalized
children in Iran.
Methods: All children older than 28 days admitted to the pediatric hospital (Dr. Sheikh, Mashhad, Iran) were enrolled in
this study and the screening tool named STRONGkids was applied for them. The anthropometric measurements were
measured by a trained operator using standard methods and equipments. The children were classified in three groups of
being at high risk, moderate risk and low risk of malnutrition.
Results: According to STRONGkids score; 17% of children were classified as low risk, 75% as moderate risk and 8% as
high risk group. According to WFH, HFA and WFA z-scores31.4%, 19.2% and 28% of children were identified as
moderately and severely malnourished respectively. According to MUAC cut-offs, 3.4% of children were classified as
having moderate malnutrition and there was no child with severe malnutrition.
Conclusion: It is very important to recognize the nutritional status of the children as early as possible because of its
effects on children’s growth. Therefore, evaluating the nutritional status of the hospitalized children is an essential step in
clinical assessment. We suggest to apply the STRONGkids score aside with other clinical and anthropometric data.

Keywords: Nutritional screening, Hospitalized children, Iran, STRONGkids.

INTRODUCTION the admission, so the proper nutritional intervention

could be done as soon as possible [1].
Malnutrition is very common among hospitalized
children. It has its related health consequences such as Several screening tools had been designed for
increased risk of infections, increased muscle loss, evaluating nutritional status of hospitalized children, but
impaired wound healing, longer hospital stay and none of them has been validated properly and are
higher morbidity and mortality [1, 2]. The World Health generally admitted for common usage [1].
Organization (WHO) describes malnutrition as “the
imbalance between the supply of nutrients and energy, In 2007, Hulst et al. created a simple tool for
and the body’s demand for them to ensure growth, estimating nutritional risk. This nationwide survey was
maintenance, and specific functions [3]. Hospital conducted in Netherlands, in 44 hospitals over three
malnutrition is often a compound of cachexia (linked- consecutive days. Four hundred and twenty-four
disease) and malnutrition (insufficient utilization of patients with age of more than 30 days and
nutrients) as opposed to malnutritionalone [4]. hospitalization length of more than 1 day were
included. The screening tool was called Screening Tool
The estimated prevalence of acute malnutrition in for Risk On Nutritional Status and Growth
hospitalized children varies from 6.1 to 40.9% in (STRONGkids) and include four questions regarding
different countries. In order to intercept malnutrition and nutritional status of patients at present, presence of an
specifically hospital-acquired malnutrition, the child underlying diseases, nutritional intakes and losses, and
nutritional status should be recognized early, at best at history of recent weight loss [5, 6].

The current study was performed with the aim of

evaluating the efficiency of STRONGkids (Screening
*Address correspondence to this author at the Department of Pediatrics, Dr.
Sheikh Children Hospital, Mashhad University of Medical Sciences, Mashhad,
Tool for Risk On Nutritional Status and Growth) in
Iran; Tel: 05137276580; Fax: 05137277470; E-mail: [email protected] determining malnutrition in hospitalized children in Iran.

E-ISSN: 1929-4247/15 © 2015 Lifescience Global

2 International Journal of Child Health and Nutrition, 2015, Vol. 4, No. 1 Gholampour et al.

METHOD & MATERIAL interpreted according to CDC (centers for disease

control and prevention) standards [9]. Z-scores were
All the children older than 28 days (n=100) who had
calculated by using a WHO software called “AnthroPlus
been admitted at Dr. Sheikh Hospital, a tertiary
1.0.4” for children below 2 years old and with the CDC
pediatric teaching hospital in Mashhad, were enrolled
software called “EPi Info 3.2.2” for children above 2
in this cross-sectional study. The study was performed
years old.
in 5 consecutive days from May20 to 25, 2014.
Patients' demographic data such as age, sex, Nutritional Status Assessment
underlying diseases, diagnosis, and length of stay in
hospital (LOS) were collected from their hospital According to WHO classification for malnutrition,
records. children with z-scores of less than -3 for weight-for-
height (WFH) and height-for-age (HFA) are classified
Participant’s age ranged from one month to 18 as severely malnourished and stunted, respectively.
years old. So we divided children into two age groups: Those with WFH or HFA z-scores between -3 and -2
(a) 1-72 months and (b) above 6 years. are classified as moderately malnourished. Weight for
height (WFH) was only calculated for those with a
The study was approved by the research committee
height <120 cm. Z-scores for WFH detects acute
of Dr. Sheikh Hospital by ethical committee number of
malnutrition and height for age (HFA) detects chronic
930452 at 2014 April. Since no intervention was
malnutrition. Weight-for-age (WFA) z-scores were also
performed on patients and only available patients` data
calculated.
were collected, the written consent was not obtained
from parents. However, the researchers stated and STRONGkids Tool
clarified the process, nature and importance of study
for parents and caregivers. The STRONGkids tool was carried out for all the
hospitalized children older than one month to evaluate
Anthropometric Measurements
nutritional status. The total score were calculated for
All measurements were performed with a standard each patient and children were classified into high,
method by a single operator (a trained MSc of moderate or low-risk groups, according to their cut-offs.
nutrition), using standard equipments. According to In addition, scores were re-arranged using adjusted
NHANES (national health and nutrition examination cut-offs proposed by Moeeni et al. [10].
survey) height was measured in two forms; recumbent
Statistical Analysis
length for all children less than 4 years of age (1- 47
month) by using an infantometer (Seca417) with a fixed
Statistical analysis was performed using SPSS
head piece and horizontal backboard and an adjustable
software 11.5 for Windows. In order to compare two
foot piece, and standing height was measured using a
independent groups, T-test or Mann-Whitney test was
stadiometer (Seca213) with a fixed vertical backboard
used (for data with normal and abnormal distribution,
and an adjustable head piece [7]. Mid-upper arm
respectively). If the numbers of independent groups
circumference (MUAC) was also measured by a color
were more than two, we applied one-way ANOVA test.
tape for all children above 2 years old. MUAC cut-off
Pearson and Spearman’s test were used to determine
points were described as less than11.5 cm (Red area),
the relationship between two quantitative variables.
11.5-12.5 cm (Yellow area) and more than 12.5 cm
The significance level was set at < 0.05.
(Green area) [8]. The registered weight in patient’s
medical record was considered as the current weight of RESULTS
child. The Seca725 mechanical baby scale for infants
and Seca760 mechanical scale for older children Characteristics of Patients at Entry to Study
weight measurement were applied formerly.
Table 1 shows the demographic characteristics of
If patients were more than 4 years old, but the study subjects. A total of 100 children (63 boys and
incapable of standing, the length was measured and 37 girls)with a mean age of27.49 months (range 1-72
0.7 cm was reduced in order to convert it to height. The months) in group 1 and mean age of 10.06 years
patient’s height was measured to the nearest 0.1 cm. (range 6-18 years) in group 2 were enrolled in the
Body Mass Index (BMI) was calculated for all the study. Overall 65 of 100 children(65%) had an
children above 2 years old and then the charts were underlying chronic disease. Figure 1 shows the
Assessment of Nutritional Status Based on STRONGkids Tool International Journal of Child Health and Nutrition, 2015, Vol. 4, No. 1 3

common underlying chronic disease in studied patients. 45.6 % of malnourished patients were hospitalized in
The length of hospital stay varied from 1 to 81 days. PICU, 43.5% in Nephrology, 23.1%in Hematology, 35%
Thirty-three (33.9%) children were hospitalized for in Emergency and 20.2% in Surgery ward (Table 3).
more than 4 days and the mean of LOS was 7.3 days. The mean of LOS was 14 days for malnourished
children versus 5 days for non-malnourished children
Table 1: Characteristics of the 100 Patients
(p<0.001). 63% of severely malnourished children and
27% of moderately malnourished children were
Patient’s Characteristic N = 100
hospitalized for longer than 4 days (p<0.001).
Sex
Table 2: Classification of the Anthropometric Indices of
Male 63 the Patients
Female 37
Mean age Anthropometric Index (Unit) Mean ± SD
Month 27.4(1-72)
Year 10 (6-18) Weight (kg) 18.13±12.94

Mean Los 7.3 (1-81) Height (cm) 99.64±29.77

2
Underlying Disease (%) 65(65%) BMI (kg/m ) 16.32±4.03

LOS=Length of Stay (calculated with range in days). IBW (kg) 20.15±13.15

WFA Z-score -1.14±1.80
HFA Z-score -1.00±1.68
WFH Z-score -.96±2.39
BMI Z-score -.88±2.51
MUAC (cm) 17.43±4.22
BMI: Body Mass Index; IBW: Ideal Body Weight; MUAC: Mid Upper Arm
Circumference; WFA: Weight-for-Age; HFA: Height-for-Age; WFH: Weight for
Height.

Table 3: Prevalence of Moderate and Severe

Malnutrition According to Hospital Ward

Ward No. (%) Moderate and Severe

Figure 1: Distribution of children according to cause of Malnutrition (WFH)
admissions. The most common cause of admission was
cancer. Surgery 25 (25%) 20.2%
Nephrology 9 (9%) 43.5%
STRONGkids Scores and Anthropometrics
Hematology 31 (31%) 23.1%
According to the STRONGkids score, 17 (17%) of PICU 10 (10%) 45.6%
children were at low risk, 75 (75%) at moderate risk Emergency 25 (25%) 35%
and 8 (8%) at high risk of malnutrition. Twenty two
children (31.4%) were identified as moderately and
severely malnourished according to their WFH z- The Relationship between STRONGkids and
scores. Nineteen children (19.2%) were identified as Anthropometric Data
having moderate and severe malnutrition according to
their HFA z-score. According to MUAC cut-offs, 3.4% The risk stratification of STRONGkids didn't correlate
of children were classified as being moderately with MUAC (p=0.886), LOS (p=0.111) HFA (p=0.384),
malnourished and there was no child with severe WFH (p=0.314), WFA (p=0.979) and BMI z-scores
malnutrition. According to WFA z-score28% of children (p=0.569). STRONGkids classified 83% of malnourished
were identified as moderately and severely children in the moderate and high risk groups. After
malnourished. Based on BMI z-scores15.9%, 10.1% applying the adjusted cut-offs proposed by Moeeni et
and 14.5% of children were identified as having severe, al. [10], the total number of moderately and severely
moderate and mild malnutrition, respectively. Table 2 malnourished patients detected by STRONGkids
shows the nutritional status of patients. In this study, decreased from 83% to 71%.
4 International Journal of Child Health and Nutrition, 2015, Vol. 4, No. 1 Gholampour et al.

DISCUSSION about one third to half of malnourished studied children

had an underlying disease [10, 16].
The aim of this study was to evaluate the efficiency
of STRONGkids tool in assessing the malnutrition in In our study, we evaluated the STRONGkids tool that
Iranian hospitalized children. Acute (WFH) and chronic was created in a developed country hospital setting,
(HFA) malnutrition were detected in about 30.6% and because its applicability could be different in a
22.8% of our patients, respectively. In 2008 a survey developing country setting substantially. The
was performed in Tabriz, one of the cities of Iran. In STRONGkids tool does not include the patient’s weight
this study 140 children with the age of 2 to12 years old and height; accordingly make it faster and easier to
were recruited from Tabriz pediatrics hospital. They apply. This tool requires physician assessment which is
reported the prevalence of acute and chronic listed as a useful and reliable screening tool for
malnutrition as 32.2% and 30.7% respectfully [11]. pediatric patients [5].

Two studies in the developing country of Thailand The current study considered 83% of children as
was performed in 1985 and with a 10 years interval in being at moderate or high nutritional risk according to
1995.In both of these surveys, the prevalence of STRONGkids but only 31.4% were actually
malnutrition in children 1-15 years old was similar and malnourished according to anthropometric
between 50%-60% [12]. measurements (WFH), which this discrepancy is
considerable. Our findings are similar to the results of a
Nevertheless in the developed countries such as prospective observational multi-centre study that was
UK, Netherlands, France and Germany, malnutrition is performed in 12 Italian hospitals and showed that70%
less prevalent with a prevalence of 6% to19% [2].
of patients were at moderate or high nutritional risk
according to STRONGkids, but only approximately 20%
These reports indicated that the developed and the
were actually malnourished according to
developing countries are very different in regard to
anthropometric measurements [2].
malnutrition prevalence.
Our study demonstrated that the risk stratification of
According to a Turkish study, prevalence of
STRONGkids didn't correlate with WFH, WFA, BMI z-
malnutrition was 55.1% [13]. In a survey in Germany
scores and MUAC. In a study that was comprised 12
malnutrition has been reported in 24.1% of children
Italian hospitals covering 144 Children of 1–18 years
admitted to a tertiary care centre [14]. A study from
old, a significant but weak correlation between the
Netherlands reported that 15% and 20% of hospitalized
STRONGkids score and the parameters of acute and
children had acute and chronic malnutrition [15]. The
chronic malnutrition was found, which is different from
differences in the prevalence of malnutrition in different
our findings [2]. Also our findings are in contrast with
countries may be related to the differences in their
another study by Ling et al. that stated STRONGkids is
population and different criteria for evaluating
significantly related with both BMI and HFA [17]. A
malnutrition.
study in Mashhad by Moeeni et al. declared that
Underlying disease in hospitalized children may be STRONGkids, but not STAMP, correlated with HFA z-
responsible for malnutrition. At least65 of total 100 score which is dissimilar from our findings [7].
children who were admitted to the pediatric hospital in
Another survey by Ling et al. [17] indicated that both
the current study had an underlying disease, most of all
STAMP and STRONGkids were able to detect all
cancer. Like our study other research also
malnourished patients. Also a survey in New Zealand
demonstrated similar outcomes? In 2013 ASPEN
by Moeeni et al. demonstrated that STRONGkids can
published a review article and declared that underlying
detect all the children with severe and moderate
disease affects malnutrition’s prevalence and its range
malnutrition (16/16) compared with PYMS (13/16) and
differs between different diseases as follow 40% in STAMP (15/16) [16]. The outcomes of above
patients with neurologic diseases, 34.5% in those with mentioned studies are in contrast with our study
infectious disease, 33.3% in patients with cystic findings, which expresses that STRONGkids can detect
fibrosis, 28.6% in those with cardiovascular disease, only 17 ⁄ 21 malnourished hospitalized children, but
27.3% in oncology patients, and 23.6% in those with GI cannot detect all malnourished patients. Findings from
diseases [3]. In two separate studies by Moeeni et al. in another study which applied current NRS tools,
2013 and 2012 in New Zealand and Iran, respectively, considering their benefits and shortcomings and
Assessment of Nutritional Status Based on STRONGkids Tool International Journal of Child Health and Nutrition, 2015, Vol. 4, No. 1 5

evaluating the potential roles of these tools, had step in clinical assessments. The screening tool that is
indicated that STRONGkids was able to detect more used should be easy and quick to administer, reliable
than half (53%) of malnourished patients (16/30,) in its and consistent, with low false positive or false negative
moderate to high risk groups, which is similar to our findings. We suggest the STRONGkids score to be
findings [5]. considered aside with other clinical and anthropometric
data because of the mismatch between prevalence of
Also Spagnuolo et al. showed that prevalence of malnutrition according to anthropometrics data and the
malnutrition is associated with cause of admission and categorization deriving from the STRONGkids
patients with Gastro-intestinal diseases were more assessment. This fact that a large number of children
likely to be at high risk group [2]
Their finding is similar with severe malnutrition according to anthropometry
to ours which demonstrated high prevalence of were classified by STRONGkids as being at low and
malnutrition in children in ICU (80% of children in ICU medium risk, decrease this tool validity.
were admitted for gastrointestinal disease).
ACKNOWLEDGEMENTS
Also Moeini et al. demonstrated that more
undernourished inpatients were male (81.2%) rather The authors would like to sincere gratitude to Vesal
than female which is similar to our findings [16]. Moeeni and her research team for applying their study
results.
Mahdavi et al. stated that there are no significant
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