Implementation of STRONGkids for Identifying Nutritional Risk in Pediatric Intensive Care Unit: A Survey of Chinese Practice
Malnutrition remains a critical concern in pediatric healthcare, particularly among hospitalized children, as it can exacerbate complications, prolong recovery, and increase the length of hospital stays. Early identification of nutritional risk is essential for timely interventions. The Screening Tool for Risk on Nutritional status and Growth (STRONGkids), developed in alignment with the European Society for Parenteral and Enteral Nutrition (ESPEN) guidelines, has demonstrated utility in predicting nutritional risk and hospital outcomes in European pediatric populations. However, its applicability in diverse clinical settings, such as Chinese pediatric intensive care units (PICUs), requires further validation. This study evaluates the implementation of STRONGkids in a Chinese PICU, identifies factors associated with nutritional risk, and examines the tool’s effectiveness in guiding clinical practice.
Study Design and Methodology
A cross-sectional observational study was conducted in the PICU of West China Hospital, Sichuan University, from July 2019 to May 2020. The study enrolled 1,086 consecutive patients aged <18 years with complete medical records, excluding those who declined participation. Ethical approval was obtained from the hospital’s Ethics Committee, and informed consent was secured from guardians.
Data collection involved direct observation and retrospective review of medical records. Key variables included age, sex, primary diagnosis (categorized into cardiovascular, digestive, nervous, respiratory, urinary/reproductive systems, postoperative/infections, and others such as trauma or burns), and clinical parameters such as mechanical ventilation (MV), central venous pressure (CVP) monitoring, arterial blood pressure (ABP) monitoring, physical restraint (PR), analgesia, sedation, and PICU length of stay (LOS). Nutritional risk was assessed using the STRONGkids tool, which stratifies patients into high, moderate, or low risk based on clinical and anthropometric criteria.
Statistical analyses were performed using SPSS 24.0. Descriptive statistics summarized demographic and clinical characteristics. Univariate analysis using chi-square tests identified associations between variables and nutritional risk categories. Significant factors (p < 0.05) were incorporated into a logistic regression model to determine independent predictors of high nutritional risk. Model fitness was evaluated via the Hosmer-Lemeshow test.
Key Findings
Demographic and Clinical Characteristics
Among 1,086 patients, 43.4% were aged <1 year, 53.8% were male, and 36.0% had cardiovascular system diseases. The majority (60.9%) had a PICU stay <96 hours. STRONGkids screening classified 9.6% (n = 104) as high nutritional risk and 90.4% (n = 982) as moderate risk. No patients were categorized as low risk, underscoring the universal vulnerability of critically ill children to nutritional deficits.
Univariate Analysis of Nutritional Risk
High nutritional risk was significantly associated with younger age (<1 year), digestive system diseases, and prolonged LOS (≥96 hours) (p < 0.01). Conversely, moderate-risk patients exhibited higher prevalence of MV (54.1% vs. 40.4%), CVP (32.9% vs. 23.1%), ABP (45.1% vs. 32.7%), PR (41.3% vs. 28.8%), analgesia (33.4% vs. 25.0%), and sedation (46.4% vs. 35.6%) compared to the high-risk group (p < 0.05). These findings suggest that invasive interventions and supportive therapies are more frequently applied to moderately malnourished patients, possibly reflecting clinical prioritization of stabilizing acute conditions before addressing nutritional needs.
Multivariate Logistic Regression
Logistic regression identified five independent predictors of high nutritional risk (Table 1):
- Age: Compared to infants <1 year, older age groups had lower odds of high risk: 1–3 years (OR = 0.460, 95% CI: 0.239–0.883, p = 0.020), 3–6 years (OR = 0.252, 95% CI: 0.101–0.625, p = 0.003), and 6–18 years (OR = 0.236, 95% CI: 0.094–0.595, p = 0.002).
- Physical Restraint (PR): Absence of PR increased risk (OR = 0.449, 95% CI: 0.282–0.714, p = 0.001).
- Sedation: Lack of sedation was linked to higher risk (OR = 0.597, 95% CI: 0.361–0.988, p = 0.045).
- LOS ≥96 hours: Prolonged stay doubled the risk (OR = 1.801, 95% CI: 1.135–2.858, p = 0.012).
- Digestive System Disease: Patients with digestive disorders faced twice the risk compared to cardiovascular cases (OR = 2.028, 95% CI: 1.093–3.763, p = 0.025).
The model demonstrated good fit (Hosmer-Lemeshow χ² = 6.806, p = 0.558) and 90.5% accuracy in predicting risk categories.
Clinical Implications and Discussion
Age and Developmental Vulnerability
Infants <1 year emerged as the most nutritionally vulnerable group, aligning with global evidence highlighting rapid growth and limited nutrient reserves in early life. Preterm infants and those with congenital conditions are particularly susceptible, necessitating aggressive nutritional monitoring and supplementation in PICUs.
Paradoxical Role of Physical Restraint and Sedation
Contrary to studies linking PR to complications like deep vein thrombosis, this study found restrained patients had lower nutritional risk. This may reflect reduced metabolic demand from limited mobility, though ethical and safety considerations warrant cautious application. Similarly, sedation’s association with moderate risk suggests metabolic stabilization, though over-sedation risks must be balanced.
LOS and Disease-Specific Risk
Prolonged hospitalization (≥96 hours) independently predicted high risk, likely due to cumulative nutrient deficits and disease severity. Digestive system diseases, impairing absorption and intake, doubled nutritional risk compared to cardiovascular conditions, emphasizing the need for tailored nutritional strategies in gastroenterology patients.
STRONGkids in Chinese PICU Context
The absence of low-risk patients highlights the universal need for nutritional support in critically ill children. STRONGkids proved feasible and effective, correlating with clinical outcomes like LOS, consistent with Dutch and British validations. However, its sensitivity to age and disease-specific factors underscores the importance of contextual adaptation in diverse populations.
Conclusion
This study confirms the high prevalence of nutritional risk in Chinese PICUs, with nearly all patients requiring intervention. STRONGkids serves as a practical tool for early risk stratification, guiding resource allocation and personalized care plans. Key risk factors—infancy, digestive disorders, prolonged hospitalization, and limited use of PR or sedation—provide actionable insights for clinicians. Future research should explore longitudinal outcomes of nutrition-focused interventions and validate tool modifications for regional variability.
doi.org/10.1097/CM9.0000000000001330
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