A complete nutritional assessment integrates a combination of subjective medical evaluations and objective evaluation of the medical and nutritional history, including past and present dietary intake; physical examination, including anthropometric measurements and growth assessment; biochemical and metabolic parameters; and anticipation of the future medical course (including likely complications) and effects of therapy.
ROUTINE NUTRITIONAL ASSESSMENT
Nutritional assessment of an otherwise well child at a health maintenance examination differs from that of an infant or child with a chronic illness. A routine history should include a nutritional history with questions regarding family attitudes toward health foods, junk foods, dieting, fad diets, nutritional supplements, herbal remedies, and general nutrition. A healthy child on a routine visit to the doctor requires only a measurement of height, weight, and, for infants, head circumference (plotted on either the World Health Organization [WHO] growth standards or the Centers for Disease Control and Prevention [CDC] charts), along with a routine history and physical examination. It is important that either a weight for length (for ≤ 2 years) or body mass index (for > 2 years) be assessed as part of growth assessment. If growth is normal and there are no unusual dietary habits, further assessment is not required.
Both the CDC and WHO growth charts provide meaningful data, especially when tracked over time. However, assessment of normal height and weight percentiles vary slightly when applying the 5th to 95th percentile ranges to the same children. The WHO charts are more likely to suggest shortness and overweight and are less likely to suggest underweight when compared to the CDC charts when 5th and 95th percentile cutoffs for normalcy are utilized. However, when the WHO-recommended cutoff values of z-scores of –2 and +2 are applied to the WHO charts, these differences are lessened for shortness and overweight. The WHO charts consistently classify fewer children as underweight in early childhood years than do the CDC charts. The CDC growth charts are available at http://www.cdc.gov/growthcharts, and the WHO growth charts are available at http://www.who.int/childgrowth/standards/chart_catalogue/en/index.html. Computer software to facilitate calculations of anthropomorphic data using the WHO charts is available at http://www.who.int/childgrowth/software/en. The current recommendations are that the WHO growth standards be used for children younger than 2 years of age and the CDC 2000 growth reference charts be used for children older than 2 years of age. With the gradual acceptance of electronic medical records, z-score values for all anthropometric data (as opposed to percentiles) should be used.
The patient with poor growth or weight gain requires a more careful nutritional assessment. Any child with a history of poor growth or a chronic disorder placing him or her at risk for malnutrition should have periodic nutritional assessment.
MEDICAL AND NUTRITIONAL HISTORY
It is challenging to obtain an accurate nutritional history. A 24-hour recall is the most commonly used method ...