Screening n 526 Hand Out

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Nutrition Screening and AssessmentNutrition 526: 2010



Steps to Evaluating Pediatric Nutrition

Problems

• Screening

• Assessment

– Data collection

– Evaluation andinterpretation

– Intervention

– Monitor

– reassessment



Nutrition Screening: Purpose

• To identify individuals who appear to

have or be at risk for nutrition problems

• To identify individuals who requirefurther 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 < than5th %ile

• Growth measures > than90th %ile

• Alterations in growthpatterns

– Change in Z-scores – Change 1-2 SD

– Change percentiles

• Medical anddevelopmentalConditions

• Medications

• Improper or inappropriatefood/formula choices or preparation

• Psychosocial

• Laboratory Values




• 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 andReevaluate



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 tonutrition 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 problemone etiology”




• 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

C h i N t iti



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 inaccurateinformation

Not evidence based

Biased

I f i C ll d C d



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 nutritionalstatus of individuals



Absolute size

• Absolute size


• Growth/changes over time



Absolute size



Other Anthropometrics

• Upper arm circumference, tricepsskinfolds

• 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



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 essentialnutrients



Basis of recommendations

• Basis

• Physiology

– GI

– Renal

• Growth and

Development

– Preventing

deficiencies

– Meeting nutrientneeds

• 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

A h t E ti ti N t i t



Approaches to Estimating Nutrient

Requirements

• Direct experimental evidence (ie protein and aminoacids)

• 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



Comparison of individual intake data to a

reference or estimate of nutrient needs

• DRI: DietaryReference Intakes

– expands and replaces

RDA‟s

– reference values that

are quantitative

estimates of nutrient

intakes for planning

and assessing dietsfor healthy people

• AI: Adequate Intake

• UL: Tolerable Upper

Intake Level

• EER: EstimatedEnergy Requirement



DRI

• Estimated Average Requirement (EAR): expected tosatisfy 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 therequirement 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



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 size

• Gender

• Growth

• Genetics

• Ethnicity

• Environment

• Adaptation and

accommodation• Activity/work

• Illness/Medical

conditions



Energy

• Correlate

individual intakewith growth

f



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



Feeding and Developmental

Information



Feeding and development

• Feeding Interactions

• Feeding Relationship

• Feeding Skills• Feeding Development

• Feeding Behaviors



• What factorsinfluence food

choices, eating

behaviors, and

acceptance?

F di



Feeding

• Delays in feeding skills

• Feeding intolerance

• Behavioral

• Medical/physiological limitations

• Other

S i l f F d



Sociology of Food

• Hunger

• Social Status

• Social Norms

• Religion/Tradition• Nutrition/Health

P h i l d i t l i f ti



Psychosocial and environmental information

Psychosocial and



y

Environmental Information• Family

– Constellation

– Dynamics

– Views

– Resources – other

• Socioeconomic status

– employment/education/income/other

• Beliefs

– Religious/cultural/other



Clinical and Laboratory

assessment

Cli i l A t



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 mucusmembranes

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



Linking Information



Assessment Process

• Linking informationcollected with: – Goals/expectations

– Reference data/standards

– Evidence

– individual

• Asking questions

Case Examples



Case Examples

Yes No Not sure or don‟t know

growth

dietMedical, developmental,

feeding

Social, environmentalclinical

laboratory

I t t ti A ki



Interpretation: Asking

QuestionsIs there a problem?

Was there a problem?

Does information makesense?

What are goals and

expectations?

What is etiology of theproblem?



Intervention

• Identify etiology

• Identify contributing

factors• Support feeding

relationship

• Consider psychosocialfactors, family choice

and input

• Weigh risk v.s. benefit

Weighing Risks and Benefits



Etiology: Contributing factors

Inadequate Intake

Fluid, energy

Medical

BPD, reflux, frequent illness

Feeding relationship

Stress, historyPsychosocial




• Adequate intake vs

feeding relationship• Concentrating

formula vs fluid

status

• impact on tolerance,

compliance, errors,

cost

• solution to problemvs exacerbating

problem



Summary:

Screening

Assessment

Diagnosis

Intervention

Monitoring and

reevaluation



Summary

• Identify Problemor risk

• Identify Etiology

• Determineintervention

• Monitor andReevaluate

S A t



Summary: Assessment

Process• Collect data

• Interpret data

– Link information – Compare to references,

standards, expectations

– Ask questions

Screening n 526 Hand Out

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