Handgrip strength as a surrogate marker of lean mass and risk of malnutrition in paediatric patients

Association of handgrip strength with nutritional status and clinical outcomes in hospitalized pediatric patients

BACKGROUND & AIMS

Malnutrition in children and adolescents is prevalent at hospital admission and the incidence increases with length of stay. Malnourished patients have loss of muscle mass and strength, compromising their functionality. Handgrip strength (HGS) is a nutritional marker understudied in pediatrics although it is capable of detecting nutritional deprivation before changes in body composition are observed. Therefore, this study aimed to evaluate the association between reduced HGS at hospital admission, compromised nutritional status and worse clinical outcomes of pediatric patients.

METHODS

Cohort study conducted with patients aged 6-18 years admitted to a pediatric ward. Nutritional status was assessed in the first 48 h of hospital admission using the z-score of height for age (H/A) and body mass index for age (BMI/A), percentile of mid-arm muscle circumference for age (MAMC/A) and the pediatric global subjective nutritional assessment (SGNA). HGS was measured using a digital dynamometer and considered reduced when the maximum value of three measurements was below the 5th percentile for sex and age. The clinical outcomes analyzed were length of hospital stay and frequency of readmission within 3 months after hospital discharge.

RESULTS

A total of 135 patients were evaluated (median age 10.9 years, 55.6% male) and 17.8% had reduced HGS. Patients with reduced HGS had lower H/A z-score (-0.50 vs 0.22, p = 0.012) and a higher frequency of reduced MAMC when compared to those with normal HGS (8% vs 13%, p = 0.007). Reduced HGS was not associated with malnutrition (OR = 0.63; 95%CI 0.23-1.77), prolonged hospital stay (OR = 1.89; 95%CI 0.72-4.92) or readmission to hospital 3 months after hospital discharge (OR = 1.82; 95%CI 0.67-4.93), in a model adjusted for the clinical condition.

CONCLUSION

Reduced HGS was not a predictor of malnutrition and clinical outcomes. However, it was associated with lower H/A Z-score and MAMC/A percentile values and can be used as a complementary measure in the nutritional status assessment of hospitalized pediatric patients.

Predictive value of Global Leadership Initiative on Malnutrition criteria combined with handgrip strength for postoperative outcomes in overweight colorectal cancer patients

BACKGROUND AND AIM

The Global Leadership Initiative on Malnutrition (GLIM) criteria are increasingly used to assess the nutritional status of hospitalized patients and predict the prognosis of patients with malignant tumors; however, malnutrition is often overlooked in overweight individuals, such as colorectal cancer patients. This study aimed to investigate the predictive value of the GLIM criteria combined with handgrip strength (HGS) in overweight colorectal cancer patients.

METHODS

This retrospective study enrolled overweight patients who underwent radical resection for colorectal cancer at two centers between 2015 and 2021. Malnutrition was diagnosed based on the GLIM criteria. Skeletal muscle mass was assessed using the skeletal muscle index, and skeletal muscle function was assessed using the HGS test. The risk factors for complications and survival were also evaluated.

RESULTS

A total of 850 patients were enrolled in the study. The incidence of malnutrition in the GLIM and HGS-GLIM groups was 12.4% and 6.4%, respectively. The incidence of total complications in both the malnutrition groups was significantly higher than that in the control group. Patients in the HGS-GLIM-malnutrition group had worse overall survival and disease-free survival. HGS-GLIM was independently associated with postoperative complications (P = 0.046), overall survival (P = 0.037), and disease-free survival (P = 0.047).

CONCLUSION

The GLIM criteria combined with the HGS test is an effective tool for diagnosing malnutrition. Particularly, these modalities are applicable in overweight colorectal cancer patients. Compared with the standard GLIM criteria, this tool has a better predictive value for postoperative complications and long-term survival.

Muscle Wasting among Hospitalized Children: A Narrative Review of the Feasibility and Accuracy of Diagnostic Methods

Muscle wasting is associated with a worse quality of life and increased morbidity and mortality among hospitalized children, especially those with chronic diseases. This review was conducted to summarize the data available on the most feasible and accurate diagnostic methods for detecting muscle wasting among hospitalized children, especially to review the evidence of the accuracy and feasibility of conducting assessments using handgrip strength (HGS). Many diagnostic methods are used in hospital settings to assess muscle wasting, by evaluating either muscle mass or strength, with evidentiary support for assessing muscle mass provided using ultrasonography, magnetic resonance imaging, computed tomography, dual-energy X-ray, bioelectrical impedance analysis, and anthropometry measurements. Currently, the most common diagnostic method used to detect muscle strength loss is the handheld dynamometer. Studies support using HGS among healthy and hospitalized children to assess the overall nutritional status and especially muscle function. However, almost all of these studies have been conducted in hospital settings and recruited children with different chronic diseases using a small sample size. More longitudinal cohort studies with large sample sizes are needed to assess the accuracy and feasibility of using HGS among hospitalized children.

Malnutrition Patterns in Children with Chronic Kidney Disease

Malnutrition is frequent in children with chronic kidney disease (CKD). Apart from undernutrition and protein energy wasting (PEW), overnutrition prevalence is rising, resulting in fat mass accumulation. Sedentary behavior and unbalanced diet are the most important causal factors. Both underweight and obesity are linked to adverse outcomes regarding renal function, cardiometabolic risk and mortality rate. Muscle wasting is the cornerstone finding of PEW, preceding fat loss and may lead to fatigue, musculoskeletal decline and frailty. In addition, clinical data emphasize the growing occurrence of muscle mass and strength deficits in patients with fat mass accumulation, attributed to CKD-related wasting processes, reduced physical activity and possibly to obesity-induced inflammatory diseases, leading to sarcopenic obesity. Moreover, children with CKD are susceptible to abdominal obesity, resulting from high body fat distribution into the visceral abdomen compartment. Both sarcopenic and abdominal obesity are associated with increased cardiometabolic risk. This review analyzes the pathogenetic mechanisms, current trends and outcomes of malnutrition patterns in pediatric CKD. Moreover, it underlines the importance of body composition assessment for the nutritional evaluation and summarizes the advantages and limitations of the currently available techniques. Furthermore, it highlights the benefits of growth hormone therapy and physical activity on malnutrition management.

Hand grip strength should be normalized by weight not height for eliminating the influence of individual differences: Findings from a cross-sectional study of 1,511 healthy undergraduates

Background

Hand grip strength (HGS) is a fast, useful, and inexpensive outcome predictor of nutritional status and muscular function assessment. Numerous demographic and anthropometric factors were reported to be associated with HGS, while which one or several factors produce greater variations in HGS has not been discussed in detail. This is important for answering how should HGS be normalized for eliminating the influence of individual differences in clinical practice.

Aims

To compare the contribution of age, sex, height, weight, and forearm circumference (FCF) to variations in HGS based on a large-scale sample.

Methods

We enrolled 1,511 healthy undergraduate students aged 18-23 years. Age, weight, height, and sex were obtained. HGS was measured using a digital hand dynamometer, and FCF was measured at the point of greatest circumference using a soft ruler in both hands. Pearson's or Spearman's correlation coefficients were calculated with data of women and men separated and mixed for comparison. Partial correlation analysis and multivariate linear regression were used to compare the effect of variables on HGS.

Results

Analysis results confirmed the correlates of higher HGS include higher height, heavier weight, being men and dominant hand, and larger FCF. The correlation between HGS and FCF was the highest, and the bivariate correlation coefficient between weight and HGS was largerata of women and men were mixed, than that between height and HGS. When data of women and men were mixed, there were moderate correlations between HGS and height and weight (r = 0.633∼0.682). However, when data were separated, there were weak correlations (r = 0.246∼0.391). Notably, partial correlation analysis revealed no significant correlation between height and HGS after eliminating the weight effect, while the correlation between weight and HGS was still significant after eliminating the height effect. Multivariate linear regression analyses revealed sex was the most significant contributor to the variation in HGS (Beta = -0.541 and -0.527), followed by weight (Beta = 0.243 and 0.261) and height (Beta = 0.102 and 0.103).

Conclusion

HGS and FCF reference values of healthy college students were provided. Weight was more correlate with hand grip strength, at least among the healthy undergraduates.

Clinical trial registration

http://www.chictr.org.cn/showproj.aspx?proj=165914, identifier ChiCTR2200058586.

Impact of critical illness and withholding of early parenteral nutrition in the pediatric intensive care unit on long-term physical performance of children: a 4-year follow-up of the PEPaNIC randomized controlled trial

Background

Many critically ill children face long-term developmental impairments. The PEPaNIC trial attributed part of the problems at the level of neurocognitive and emotional/behavioral development to early use of parenteral nutrition (early-PN) in the PICU, as compared with withholding it for 1 week (late-PN). Insight in long-term daily life physical functional capacity after critical illness is limited. Also, whether timing of initiating PN affects long-term physical function of these children remained unknown.

Methods

This preplanned follow-up study of the multicenter PEPaNIC randomized controlled trial subjected 521 former critically ill children (253 early-PN, 268 late-PN) to quantitative physical function tests 4 years after PICU admission in Leuven or Rotterdam, in comparison with 346 age- and sex-matched healthy children. Tests included handgrip strength measurement, timed up-and-go test, 6-min walk test, and evaluation of everyday overall physical activity with an accelerometer. We compared these functional measures for the former critically ill and healthy children and for former critically ill children randomized to late-PN versus early-PN, with multivariable linear or logistic regression analyses adjusting for risk factors.

Results

As compared with healthy children, former critically ill children showed less handgrip strength (p < 0.0001), completed the timed up-and-go test more slowly (p < 0.0001), walked a shorter distance in 6 min (p < 0.0001) during which they experienced a larger drop in peripheral oxygen saturation (p ≤ 0.026), showed a lower energy expenditure (p ≤ 0.024), performed more light and less moderate physical activity (p ≤ 0.047), and walked fewer steps per day (p = 0.0074). Late-PN as compared with early-PN did not significantly affect these outcomes.

Conclusions

Four years after PICU admission, former critically ill children showed worse physical performance as compared with healthy children, without impact of timing of supplemental PN in the PICU. This study provides further support for de-implementing the early use of PN in the PICU.

Trial registration ClinicalTrials.gov, NCT01536275; registered on February 22, 2012.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-022-04010-3.

A Practical Approach to Identifying Pediatric Disease-Associated Undernutrition: A Position Statement from the ESPGHAN Special Interest Group on Clinical Malnutrition

ABSTRACT

Disease-associated undernutrition (DAU) is still common in hospitalized children and is generally accepted to be associated with adverse effects on disease outcomes; hence making proper identification and assessment essential in the management of the sick child. There are however several barriers to routine screening, assessment, and treatment of sick children with poor nutritional status or DAU, including limited resources, lack of nutritional awareness, and lack of agreed nutrition policies. We recommend all pediatric facilities to 1) implement procedures for identification of children with (risk of) DAU, including nutritional screening, criteria for further assessment to establish diagnosis of DAU, and follow-up, 2) assess weight and height in all children asa minimum, and 3) have the opportunity for children at risk to be assessed by a hospital dietitian. An updated descriptive definition of pediatric DAU is proposed as "Undernutrition is a condition resulting from imbalanced nutrition or abnormal utilization of nutrients which causes clinically meaningful adverse effects on tissue function and/or body size/composition with subsequent impact on health outcomes." To facilitate comparison of undernutrition data, it is advised that in addition to commonly used criteria for undernutrition such as z score < -2 for weight-for-age, weight-for-length, or body mass index <-2, an unintentional decline of >1inthese z scores over time should be considered as an indicator requiring further assessment to establish DAU diagnosis. Since the etiology of DAU is multifactorial, clinical evaluation and anthropometry should ideally be complemented by measurements of body composition, assessment of nutritional intake, requirements, and losses, and considering disease specific factors.

Sarcopenia in Children with Solid Organ Tumors: An Instrumental Era

Sarcopenia has recently been studied in both adults and children and was found to be a prognostic marker for adverse outcome in a variety of patient groups. Our research showed that sarcopenia is a relevant marker in predicting outcome in children with solid organ tumors, such as hepatoblastoma and neuroblastoma. This was especially true in very ill, high-risk groups. Children with cancer have a higher likelihood of ongoing loss of skeletal muscle mass due to a mismatch in energy intake and expenditure. Additionally, the effects of cancer therapy, hormonal alterations, chronic inflammation, multi-organ dysfunction, and a hypermetabolic state all contribute to a loss of skeletal muscle mass. Sarcopenia seems to be able to pinpoint this waste to a high degree in a new and objective way, making it an additional tool in predicting and improving outcome in children. This article focuses on the current state of sarcopenia in children with solid organ tumors. It details the pathophysiological mechanisms behind sarcopenia, highlighting the technical features of the available methods for measuring muscle mass, strength, and function, including artificial intelligence (AI)-based techniques. It also reviews the latest research on sarcopenia in children, focusing on children with solid organ tumors.