Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Clinical nutrition

StrongKids for pediatric nutritional risk screening in Brazil: a validation study



To evaluate the validity and reproducibility of StrongKids as a pediatric nutritional screening tool in Brazil, which has no validated method for this purpose.


A cross-sectional study was conducted with 641 patients admitted to the pediatric care unit of a public hospital from 2014 to 2018. The concurrent validity was assessed by evaluating the sensitivity, specificity, and the positive and negative predictive values of StrongKids in detecting acute, chronic, and overall malnutrition. Predictive validity was determined by calculating the same indices to identify longer than median hospital stay, need of enteral nutrition, 30-day hospital readmission, transfer to hospitals with more complex procedures, and death. StrongKids was reapplied to a subsample to evaluate the inter-rater reproducibility.


Prevalence of low risk was 15.6%, moderate risk was 63.7%, and high nutritional risk was 20.7%. A positive test, corresponding to the moderate or high risk category, identified all those with acute malnutrition and showed sensitivity of 89.4% (95% CI: 76.9–96.4) and 94.0% (95% CI: 86.6–98.0) for the detection of chronic and overall malnutrition, respectively. Regarding its predictive capacity, 100% of the patients who needed enteral nutrition, who were transferred, died, or were readmitted to hospital within 30 days after discharge were considered in risk by StrongKids, and the sensitivity to identify those with prolonged hospital stays was 89.2 (95% CI: 84.6–92.7). The inter-rater agreement was excellent (PABAK: 0.87).


StrongKids had satisfactory validity and reproducibility and successfully identified nutritional deficits and predict unfavorable health outcomes. Our results support the use of StrongKids as a pediatric nutritional risk screening method in Brazil.

This is a preview of subscription content

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    Joosten KFM, Hulst JM. Prevalence of malnutrition in pediatric hospital patients. Curr Opin Pediatr. 2008;20:590–6.

    Article  Google Scholar 

  2. 2.

    Prado RCG, Santos PFB, Assis EM, Zaban ALRS. Malnutrition and subjective nutritional assessment in pediatrics. Comun Ciênc Saúde. 2010;21:61–70.

    Google Scholar 

  3. 3.

    Saunders J, Smith T. Malnutrition: causes and consequences. Clin Med. 2010;10:624–7.

    Article  Google Scholar 

  4. 4.

    Hecht C, Weber M, Grote V, Daskalou E, Dell’Era L, Flynn D, et al. Disease associated malnutrition correlates with length of hospital stay in children. Clin Nutr. 2015;34:53–9.

    Article  Google Scholar 

  5. 5.

    Kondrup J, Allison SP, Elia M, Vellas B, Plauth M. ESPEN guidelines for nutrition screening 2002. Clin Nutr. 2003;22:415–21.

    CAS  Article  Google Scholar 

  6. 6.

    Cederholm T, Barazzoni R, Austin P, Ballmer P, Biolo G, Bischoff SC, et al. ESPEN guidelines on definitions and terminology of clinical nutrition. Clin Nutr. 2017;36:49–64.

    CAS  Article  Google Scholar 

  7. 7.

    McCarthy A, Delvin E, Marcil V, Belanger V, Marchand V, Boctor D, et al. Prevalence of malnutrition in pediatric hospitals in developed and in-transition countries: the impact of hospital practices. Nutrients. 2019;11:236.

    Article  Google Scholar 

  8. 8.

    Durá-Travé T, San Martin-García I, Gallinas-Victoriano F, Vaquero Iñigo I, González-Benavides A. Prevalence of malnutrition in hospitalised children: retrospective study in a Spanish tertiary-level hospital. J R Soc Med. 2016;7:1–8.

    Google Scholar 

  9. 9.

    Hulst JM, Zwart H, Hop WC, Joosten KFM. Dutch national survey to test the STRONGkids nutritional risk screening tool in hospitalized children. Clin Nutr. 2010;29:106–11.

    Article  Google Scholar 

  10. 10.

    Ling RE, Hedges V, Sullivan PB. Nutritional risk in hospitalised children: an assessment of two instruments. e-SPEN Eur e-J Clin Nutr Metab. 2011;6:e153–7.

    Article  Google Scholar 

  11. 11.

    Joosten KFM, Hulst JM. Nutritional screening tools for hospitalized children: methodological considerations. Clin Nutr. 2014;33:1–5.

    Article  Google Scholar 

  12. 12.

    Carvalho FC, Lopes CR, Vilela L, da C, Vieira MA, Rinaldi AEM, et al. Translation and cross-cultural adaptation of the Strongkids tool for screening of malnutrition risk in hospitalized children. Rev Paul Pediatr. 2013;31:159–65.

    Article  Google Scholar 

  13. 13.

    Teixeira AF, Viana KDAL. Nutritional screening in hospitalized pediatric patients: a systematic review. J Pediatr. 2016;92:343–52.

    Article  Google Scholar 

  14. 14.

    Santos CA, Ribeiro AQ, Rosa COB, Araújo VE, Franceschini SCC. Nutritional risk in pediatrics by StrongKids: a systematic review. Eur J Clin Nutr. 2018.

  15. 15.

    Jones JM. Validity of nutritional screening and assessment tools. Nutrition. 2004;20:312–7.

    Article  Google Scholar 

  16. 16.

    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;29:1356–61.

    Article  Google Scholar 

  17. 17.

    Bujang MA, Baharum N. Guidelines of the minimum sample size requirements for Kappa agreement test. Epidemiol Biostat Public Health. 2017;14:e12267-1–10.

    Google Scholar 

  18. 18.

    Brasil. Orientações para a coleta e análise de dados antropométricos em serviços de saúde: Norma Técnica do Sistema de Vigilância Alimentar e Nutricional—SISVAN. Brasília: Ministério da Saúde, Secretaria de Atenção à Saúde, Departamento de Atenção Básica; 2011. Accessed Feb 10, 2014.

  19. 19.

    WHO Multicentre Growth Reference Study Group. The WHO child growth standards. 2006. Accessed Jan 8, 2015.

  20. 20.

    WHO Multicentre Growth Reference Study Group. Growth reference data for 5–19 years. 2007. Accessed Jan 8, 2015.

  21. 21.

    WHO. Management of severe malnutrition: a manual for physicians and other senior health workers. Geneva: World Health Organization; 1999.

    Google Scholar 

  22. 22.

    Song T, Mu Y, Gong X, Ma W, Li L. Screening for nutritional risk in hospitalized children with liver disease. Asia Pac J Clin Nutr. 2017;26:1107–12.

    CAS  PubMed  Google Scholar 

  23. 23.

    Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159.

    CAS  Article  Google Scholar 

  24. 24.

    Moeeni V, Walls T, Day AS. Assessment of nutritional status and nutritional risk in hospitalized Iranian children. Acta Paediatr. 2012;101:446–51.

    Article  Google Scholar 

  25. 25.

    Cao J, Peng L, Li R, Chen Y, Li X, Mo B, et al. Nutritional risk screening and its clinical significance in hospitalized children. Clin Nutr. 2014;33:432–6.

    Article  Google Scholar 

  26. 26.

    Bang YK, Park MK, Ju YS, Cho KY. Clinical significance of nutritional risk screening tool for hospitalised children with acute burn injuries: a cross-sectional study. J Hum Nutr Diet. 2017;31:370–8.

    Article  Google Scholar 

  27. 27.

    Beser OF, Cokugras FC, Erkan T, Kutlu T, Yagci RV, Ertem D, et al. Evaluation of malnutrition development risk in hospitalized children. Nutrition. 2018;48:40–7.

    Article  Google Scholar 

  28. 28.

    Márquez Costa MV, Alberici Pastore C. Nutritional screening tool versus anthropometric assessment in hospitalized children: which method is better associated to clinical outcomes? Arch Latinoam Nutr. 2015;65:12–20.

    PubMed  Google Scholar 

  29. 29.

    Moeeni V, Walls T, Day AS. Nutritional status and nutrition risk screening in hospitalized children in New Zealand. Acta Paediatr. 2013;102:e419–23.

    Article  Google Scholar 

  30. 30.

    Chourdakis M, Hecht C, Gerasimidis K, Joosten KFM, Karagiozoglou-Lampoudi T, Koetse HA, et al. Malnutrition risk in hospitalized children: use of 3 screening tools in a large European population. Am J Clin Nutr. 2016;103:1301–10.

    CAS  Article  Google Scholar 

  31. 31.

    Leppin AL, Gionfriddo MR, Kessler M, Brito JP, Mair FS, Gallacher K, et al. Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials. JAMA Intern Med. 2014;174:1095–107.

    Article  Google Scholar 

  32. 32.

    Berry JG, Gay JC, Joynt Maddox K, Coleman EA, Bucholz EM, O’Neill MR, et al. Age trends in 30 day hospital readmissions: US national retrospective analysis. BMJ. 2018;360:k497.

    Article  Google Scholar 

  33. 33.

    Syed MH, Hussain MA, Khoshhal Z, Salata K, Altuwaijri B, Hughes B, et al. Thirty-day hospital readmission and emergency department visits after vascular surgery: a Canadian prospective cohort study. Can J Surg. 2018;61:257–63.

    Article  Google Scholar 

  34. 34.

    Cederholm T, Bosaeus I, Barazzoni R, Bauer J, Van Gossum A, Klek S, et al. Diagnostic criteria for malnutrition—an ESPEN Consensus Statement. Clin Nutr. 2015;34:335–40.

    CAS  Article  Google Scholar 

  35. 35.

    Charney P. Nutrition screening vs nutrition assessment: how do they differ? Nutr Clin Pract. 2008;23:366–72.

    Article  Google Scholar 

  36. 36.

    Mueller C, Compher C, Ellen DM. A.S.P.E.N. clinical guidelines: nutrition screening, assessment, and intervention in adults. J Parenter Enter Nutr. 2011;35:16–24.

    Article  Google Scholar 

  37. 37.

    Ortíz-Gutiérrez S, Pérez-Cruz E, Lara-Pompa NE, Serralde-Zúñiga AE, Fewtrell M, Peralta-Pedrero ML, et al. Validation and adaptation of the Spanish Version of the STRONGkids nutrition screening tool. Nutr Clin Pract. 2019;34:589–96.

  38. 38.

    Galera-Martínez R, Moráis-López A, Rivero De La Rosa MD, Escartn-Madurga L, López-Ruzafa E, Ros-Arnal I, et al. Reproducibility and inter-rater reliability of 2 paediatric nutritional screening tools. J Pediatr Gastroenterol Nutr. 2017;64:e65–70.

    Article  Google Scholar 

  39. 39.

    Moeeni V, Walls T, Day AS. The STRONGkids nutritional risk screening tool can be used by paediatric nurses to identify hospitalised children at risk. Acta Paediatr. 2014;103:e528–31.

    Article  Google Scholar 

  40. 40.

    Mustapha M, Callan J, Champion H, Radbone L. Making the best use of a hospital Dietitian. Paediatr Child Health. 2013;23:342–5.

    Article  Google Scholar 

  41. 41.

    Skipper A, Ferguson M, Thompson K, Castellanos VH, Porcari J. Nutrition screening tools: an analysis of the evidence. J Parenter Enter Nutr. 2012;36:292–8.

    Article  Google Scholar 

Download references


The authors gratefully acknowledge all the participating children and their parents/caregivers, as well the doctors and nurses of the pediatric unit of São Sebastião Hospital. We also thank the participating students AL Wendling, LO Possa, and AP Floriano.

Author information




The authors worked on the following stages: CAS: conceptualization; methodology; formal analysis; investigation; writing. COBR: conceptualization; methodology; writing. SCCF: conceptualization; methodology; writing. JSC: formal analysis; investigation. IBMC: formal analysis; investigation. HHF: methodology; resources; writing. AQR: conceptualization; methodology; formal analysis; reviewing and editing. All authors have read and approved the final version of the paper.

Corresponding author

Correspondence to Carolina Araújo dos Santos.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Santos, C.A.d., Rosa, C.d.O.B., Franceschini, S.d.C.C. et al. StrongKids for pediatric nutritional risk screening in Brazil: a validation study. Eur J Clin Nutr 74, 1299–1305 (2020).

Download citation


Quick links