Nutrition Screening and Assessment

Nutrition 526: 2010

Steps to Evaluating Pediatric Nutrition Problems

Screening Assessment
Data collection Evaluation and interpretation Intervention Monitor reassessment

Nutrition Screening: Purpose

To identify individuals who appear to have or be at risk for nutrition problems To identify individuals who require further assessment or evaluation

Screening: Definition
Process of identifying characteristics known to be associated with nutrition problems ASPEN, Nutri in Clin Practice 1996 (5):217-228 Simplest level of nutritional care (level 1) Baer et al, J Am Diet Assoc 1997 (10) S2:107-115

Examples of Screening risk factors

Anthropometrics: weight, length/height, BMI Growth measures < than 5th %ile Growth measures > than 90th %ile Alterations in growth patterns Change in Z-scores Change 1-2 SD Change percentiles Medical and developmental Conditions Medications Improper or inappropriate food/formula choices or preparation Psychosocial Laboratory Values

Examples of Screening risk factors

Jayden:
PG Weight gain Nutritional Practices

Mark
Newborn Weight loss Breastfeeding

Barbara:
Breastfeeding Weight changes Dietary practices Infant feeding practices

Jake
10 month old Hct: 29

Assessment
Systematic process Uses information gathered in screening Adds more in depth, comprehensive data Links information Interprets data Develops care plan monitor Reassess

Process
Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate

Goals of Nutrition Assessment

To collect information necessary to document adequacy of nutritional status or identify deficits To develop a nutritional care plan that is realistic and within family context To establish an appropriate plan for monitoring and/or reassessment

NCP: Nutrition Care Process

Provides a framework for critical thinking 4 Steps
Assessment Diagnosis Intervention Monitoring/Evaluation

NCP
Assessment
Obtain, verify, interpret information Data used might vary according to setting, individual case etc Questions to ask
Is there a problem? Define the problem? Is more information needed?

NCP
Diagnosis
Identification or labling of problem that is within RD practice to treat
Examples:
Inadequate intake Inadequate growth

Examples of Nutrition Diagnosis Options

Altered GI Function Altered nutrition related laboratory values Decreased nutrient needs Evident malnutrition Inadequate proteinenergy intake Excessive oral intake Increased energy expenditure Increased nutrient needs Involuntary weight loss Overweight/obesity Limited adherence to nutrition related recommendations (vs food and nutrition related knowledge) Underweight Food and medication interactions

NCP:
Diagnosis written as a PES statement Problem/Etiology/Signs and symptoms Must be clear and concise. 1 problem one etiology

Examples of Screening risk factors

Jayden:
PG Weight gain Nutritional Practices

Mark
Newborn Weight loss Breastfeeding

Barbara:
Breastfeeding Weight changes Dietary practices Infant feeding practices

Emma
12 months Weight @ 95th percentile Diet information

Jake
10 month old Hct: 29

NCP Process
Jayden, Barbara, Mark, Emma, Jake

NCP
Intervention
Etiology drives the intervention

Monitoring and Evaluation

Challenges and Pitfalls

Challenges
Nutrient needs influenced by: genetics, activity, body composition, medical conditions and medications Individuals anthropometric date influenced by: genetics, body composition, development, history

Challenges
Identification of etiology Weighing risk vs benefit Supportive of:
Family Individual Development/temperament

Challenges
Information Availability Accurate Representative complete Goals and expectations Available Evidence bases applicable

Comprehensive Nutrition Assessment

Collection of Nutritional data Interpretation of data Linking information Goals and expectations Individual data evidence Asking questions individualized intervention monitoring outcomes of intervention

Potential Pitfalls
Excuses Assumptions Faulty reasoning Incorrect or inaccurate information Not evidence based Biased

Information Collected: Current and Historical

Growth Dietary Medical history Diagnosis Feeding and developmental information Psychosocial and environmental information Clinical information and appearance (hair, skin, nails, eyes) Other (laboratory)

Assessment Tools

Nutrition Assessment
Tools of Assessment
Growth Measurements Growth charts Absolute size (percentile) Pattern Body composition Water, bone, muscle, fat Intake Additional information

Intake
Food record, food recall, analysis

Additional information
Medical, Development Social Laboratory Other anthropometrics etc

 Who is the regulator of growth? Who regulates Intake? What do measurements mean? Weight Weight gain Lab values Intake information

Growth

Growth
Growth is a dynamic process defined as an increase in the physical size of the body as a whole or any of its parts associated with increase in cell number and/or cell size Reflects changes in absolute size, mass, body composition

Growth
A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake

Growth Assessment
Progress in physical growth is one of the criteria used to assess the nutritional status of individuals

Absolute size
Absolute size Body composition Growth/changes over time

Absolute size

Other Anthropometrics
Upper arm circumference, triceps skinfolds Arm muscle area, arm fat area Sitting height, crown-rump length Arm span Segmental lengths (arm, leg)
All have limitations for CSHCN, but can be additional information for individual child

Body Mass Index for Age

Body mass index or BMI: wt/ht2 Provides a guideline based on weight, height & age to assess overweight or underweight Provides a reference for adolescents that was not previously available Tracks childhood overweight into adulthood

Guidelines to Interpretation of BMI

Underweight
BMI-for-age <5th percentile

At risk of overweight
BMI-for-age 85th percentile

Overweight
BMI-for age 95th percentile

Interpretation of BMI
BMI is useful for
screening monitoring

BMI is not useful for

diagnosis

Who might be misclassified?

BMI does not distinguish fat from muscle
Highly muscular children may have a high BMI & be classified as overweight Children with a high percentage of body fat & low muscle mass may have a healthy BMI Some CSHCN may have reduced muscle mass or atypical body composition

Nutrient Analysis
Fluid Energy Protein Calcium/Phosphorus Iron Vitamin D Other

Nutrient Needs
Recommendations established for over 43 essential and conditionally essential nutrients

Basis of recommendations
Basis Physiology
GI Renal

Preventing deficiencies Meeting nutrient needs

Water Energy Vitamin D Iron

Growth and Development

Dietary Information
Collect data Nutrient Analysis Comparison with recommendations, guidelines, evidence Link with additional information Interpret

Dietary Information
Family Food Usage 24 hour recall Diet history 3-7 day food record or diary Food frequency Other Information
Food preparation, history, feeding observation, feeding problems, likes/dislikes, feeding environment

Approaches to Estimating Nutrient Requirements

Direct experimental evidence (ie protein and amino acids) extrapolation from experimental evidence relating to human subjects of other age groups or animal models
ie thiamin--related to energy intake .3-.5 mg/1000 kcal

Breast milk as gold standard (average [] X usual intake) Metabolic balance studies (ie protein, minerals) Clinical Observation (eg: manufacturing errors B6, Cl) Factorial approach Population studies

Dietary Reference Intakes (DRI)

(including RDA, UL, and AI) are the periodically revised recommendations (or guidelines) of the National Academy of Sciences

Comparison of individual intake data to a reference or estimate of nutrient needs

DRI: Dietary Reference Intakes
expands and replaces RDAs reference values that are quantitative estimates of nutrient intakes for planning and assessing diets for healthy people

AI: Adequate Intake UL: Tolerable Upper Intake Level EER: Estimated Energy Requirement

DRI
Estimated Average Requirement (EAR): expected to satisfy the needs of 50% of the people in that age group based on review of scientific literature. Recommended Dietary Allowance (RDA): Daily dietary intake level considered sufficient by the FNB to meet the requirement of nearly all (97-98%) healthy individuals. Calculated from EAR and is usually 20% higher Adequate intake (AI): where no RDA has been established. Tolerable upper limit (UL): Caution against excess

DRI
Nutrition Recommendations from the Institute of Medicine (IOM) of the U.S> National Academy of Sciences for general public and health professionals. Hx: WWII, to investigate issues that might affect national defense Population/institutional guidelines Application to individuals.

DRIs for infants

Macronutrients based on average intake of breast milk Protein less than earlier RDA AAP Recommendations Vitamin D: 200 IU supplement for breastfed infants and infants taking <500 cc infant formula Iron: Iron fortified formula (4-12 mg/L), Breastfed Infants supplemented 1mg/kg/d by 4-6 months

Other Guidelines
AAP Bright Futures Educational or Professional teaching Public Policy Guidelines
Consider source Consider Purpose ? How apply to individual

Examples
Baby cereal at 6 months Juice Introduction of Cows milk to infants Weight gain in pregnancy Family meals

Factors that alter Energy needs

Body composition Body size Gender Growth Genetics Ethnicity Environment Adaptation and accommodation Activity/work Illness/Medical conditions

Energy
Correlate individual intake with growth

Medical Information

Medical Information and History

Conditions that may impact growth, nutritional status, feeding Medications that may impact nutrient needs, absorbtion, utilization, or tolerance Illness, treatments, proceedures

Medical Conditions Congenital Heart Disease Cystic Fibrosis Liver disorders Short gut syndrome or other conditions of malabsorbtion Respiratory disorders Neuromuscular Renal Prematurity Recent illness Others

Drug-Nutrient Interaction

Altered absorbtion Altered synthesis Altered appetite Altered excretion Nutrient antagonists Tolerance

Feeding and Developmental Information

Feeding and development

Feeding Interactions Feeding Relationship Feeding Skills Feeding Development Feeding Behaviors

 What factors influence food choices, eating behaviors, and acceptance?

Feeding
Delays in feeding skills Feeding intolerance Behavioral Medical/physiological limitations Other

Sociology of Food
Hunger Social Status Social Norms Religion/Tradition Nutrition/Health

Psychosocial and environmental information

Psychosocial and Environmental Information

Family Constellation Dynamics Views Resources other Socioeconomic status employment/education/income/other Beliefs Religious/cultural/other

Clinical and Laboratory assessment

Clinical Assessment
General appearance Temperature Color Respiratory/WOB Skin/hair/nails/membranes Output (urine and stool) Other

Clinical signs of Nutrient deficiency

Energy Protein Calcium Phosphorus Vitamin D Vitamin A Zinc Iron Essential fatty acid FTT, cacexia Slow growth, edema, impaired wound healing Seizures, rickets, decreased bone density, tetany Seizures, decreased bone density, rickets, bone pain, decreased cardiac fx Decreased bone density, osteopenia, rickets Dry scaly skin, FTT, xeropthalmia,, dry mucus membranes FTT, edema, impaired wound healing, alopecia, acrodermatitis enteropathica Pallor, tachycardia, FTT Scaly dermatitis, poor growth, alopecia

Vitamin C
fluid

Swollen joints, impaired wound healing, swollen bleeding gums, loose teeth, petechia
Weight loss, decreased UOP, dry mucus membranes, altered skin turgor, sunken fontanel, tachycardia, altered BP

Laboratory Assessmet
Laboratory tests can be specific and may detect deficiencies or excess prior to clinical symptomotology. Useful for assess status, response to tx, tolerance Validity effected by handling, lab method, technician accuracy, disease state, medical therapies Complements other components of process

Examples of Laboratory Tests

Iron Protein/Energy Bone Hct, HgB, ferritin*, ZPPH* Albumin, Transthyretin, RBP, other Ca, Ph, Alk Pho, Vit D

Vitamins
Minerals

Fluid

Electrolytes, BUN, urine/serum osm, spec gravity

Linking Information

Assessment Process
Linking information collected with:
Goals/expectations Reference data/standards Evidence individual

Asking questions

Case Examples
Yes No Not sure or dont know growth diet Medical, developmental, feeding Social, environmental

clinical
laboratory

Interpretation: Asking Questions

Is there a problem? Was there a problem? Does information make sense? What are goals and expectations? What is etiology of the problem?

Intervention
Weighing Risks and Benefits
Identify etiology Identify contributing factors Support feeding relationship Consider psychosocial factors, family choice and input Weigh risk v.s. benefit

Etiology: Contributing factors

Inadequate Intake Fluid, energy

Medical BPD, reflux, frequent illness

Feeding relationship Stress, history

Psychosocial

Weighing Risks and Benefits

 Adequate intake vs feeding relationship Concentrating formula vs fluid status impact on tolerance, compliance, errors, cost solution to problem vs exacerbating problem

Summary:
Screening Assessment Diagnosis Intervention Monitoring and reevaluation

Summary
Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate

Summary: Assessment Process

Collect data Interpret data
Link information Compare to references, standards, expectations Ask questions