Original articleNutritional risk screening and its clinical significance in hospitalized children
Introduction
Hospitalized children are at risk of malnutrition,1, 2, 3 especially children with underlying disease, pain and inadequate nutritional intake. The detrimental effects of malnutrition on growth, morbidity and mortality in hospitalized children are often underappreciated. Despite major advances in the quality of care, the prevalence of malnutrition in hospitalized children has not decreased over the last 20 years. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) called for nutritional risk screening for hospitalized children in 20054 to prevent the occurrence and development of malnutrition. Nutritional risk screening is distinct from global nutritional assessment5 because nutritional risk screening combines personal nutritional status with clinical disease information, leading to a prediction of the potential nutritional dysfunction induced by the increase in stress-induced metabolic factors.6 Nutritional screening allows the physician to adjust the probability of a good or poor outcome based on nutritional factors and make the appropriate nutritional care and support plans (e.g., food, oral supplements, tube feeding, parenteral nutrition or a combination of these) to improve clinical outcomes.
With the recent growth in the awareness of the importance of adequate nutritional management,1 several nutritional risk screening tools for children have been developed in industrialized countries, such as the Netherlands, the USA and the UK. Although these risk screening tools for hospitalized children have been published, none is universally accepted. The most suitable nutritional screening tool for patients is the one that best predicts nutrition-related clinical outcomes during a hospital stay.5 Hulst's STRONGkids was developed and tested extensively in the Netherlands and used in a national wide setting.7 It consists of four parameters: (1) subjective global assessment; (2) high risk disease; (3) nutritional intake and loss; and (4) weight loss or poor weight gain. Children with high risk scores according to this tool were found to have negative standard deviation scores (SD scores) in WFH and prolonged hospital stays. The high reliability and validity of STRONGkids was confirmed in Rebecca's study.8
However, very little research has been performed on this subject, and nutritional management in hospitalized children is still poorly executed in many developing countries. In China, there is no widely accepted risk screening tool for children, nutrition risk screening is not routine carried out in most children's hospital and no investigation of nutritional risks has been reported to date. Malnutrition remains prevalent among hospitalized children in China.
The primary aims of this study were to use STRONGkids as a tool to identify nutritional risk in hospitalized children in the Nanjing Children's Hospital, to evaluate its correlation with clinical outcomes and to provide a scientific basis for further nutritional support strategies in China.
Section snippets
Subjects
This was a prospective study conducted at Nanjing Children's Hospital, which is a tertiary care centre affiliated with Nanjing Medical University in southeast China. It is one of the largest children's hospitals in China, with approximately 30,000 children admitted every year. Approximately 29,850 children were admitted to the Nanjing Children's Hospital from Feb. 2011 to Jan. 2012. The following departments were surveyed for one month (30 days): Cardiothoracic Surgery, Neurosurgery,
Patient characteristics
A total of 1325 children were enrolled according to the described inclusion criteria. Their clinical characteristics are shown in Table 1. There was no significant difference in median Z-scores for WFH, WFA, HFA, MUAC and BMI between genders. Therefore, gender was not considered in the subsequent analysis.
Risk categories in hospitalized children
Overall, 47.6% of the children were categorized as low risk, 43.3% as moderate risk and 9.1% as high risk. The differences in diagnosis and nutritional assessment among the three groups are
Discussion
To our knowledge, this is the first prospective case series study to investigate the nutritional risk among patients in a children's hospital in China. Our results showed that the children who were admitted to the hospital were exposed to nutritional risk, especially those with underlying cardiac disease, respiratory disease or oncologic disease. Higher nutritional risk was associated with malnutrition, younger age and the presence of an underlying disease, and it contributed to a longer LOS,
Statement of authorship
Conceived and designed the study: XNL. Performed the investigation: JC, LTP and RL. Analysed the data: JC and BQM. Wrote the manuscript: JC and LTP. All authors read and approved the final manuscript.
Conflict of interest
None declared.
Acknowledgements
This work was supported by grants from Project HOPE of The Abbott Fund Institute of Nutrition Science (AFINS) (AFINS-HOPE-2011-11-B) and the Nanjing Science, Technology and Development Committee (201104009). The author gratefully acknowledges the contributions of the doctors and nurses of the Nanjing Children's Hospital and the participation of the children's parents.
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Jia Cao and Luting Peng contributed equally to this work.