Nutrition Screening and AssessmentNutrition 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

• Barbara:– Breastfeeding– Weight changes– Dietary practices– Infant feeding

practices

• Mark– Newborn– Weight loss– Breastfeeding

• 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 protein-

energy 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

• Barbara:– Breastfeeding– Weight changes– Dietary practices– Infant feeding practices

• Mark– Newborn– Weight loss– Breastfeeding

• 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

• Growth and Development

– Preventing deficiencies

– Meeting nutrient needs

• Water• Energy• Vitamin D• Iron

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

RDA’s– 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 agains’t 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.

DRI’s 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 FTT, cacexia

Protein Slow growth, edema, impaired wound healing

Calcium Seizures, rickets, decreased bone density, tetany

Phosphorus Seizures, decreased bone density, rickets, bone pain, decreased cardiac fx

Vitamin D Decreased bone density, osteopenia, rickets

Vitamin A Dry scaly skin, FTT, xeropthalmia,, dry mucus membranes

Zinc FTT, edema, impaired wound healing, alopecia, acrodermatitis enteropathica

Iron Pallor, tachycardia, FTT

Essential fatty acid Scaly dermatitis, poor growth, alopecia

Vitamin C Swollen joints, impaired wound healing, swollen bleeding gums, loose teeth, petechia

fluid 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 TestsIron Hct, HgB, ferritin*, ZPPH*

Protein/Energy Albumin, Transthyretin, RBP, other

Bone 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 don’t 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

• Identify etiology• Identify contributing

factors• Support feeding

relationship• Consider psychosocial

factors, family choice and input

• Weigh risk v.s. benefit

Weighing Risks and Benefits

Etiology: Contributing factors

Inadequate IntakeFluid, energy

MedicalBPD, reflux, frequent illness

Feeding relationshipStress, 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