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.
Nutritional assessment of an otherwise well child at a health
maintenance examination differs from that of an infant or child
with a chronic illness (see Chapter 10). 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 Centers for Disease Control [CDC] or
World Health Organization [WHO] growth charts),
along with a routine history and physical examination. 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.1 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 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.
It is challenging to obtain an accurate nutritional history.
A 24-hour recall is the most commonly used method to obtain information
about a child’s intake and is useful as a screening tool.
Parents and other caregivers are asked to describe the types and
amounts of food eaten by the child in the previous 24-hour period.
This may not represent a typical day’s intake, so the recall
may not accurately describe a child’s nutrient intake,
and foods consumed between meals often are not recorded. Accuracy
is improved by the use of food models for estimating portion sizes,
but errors are common. The 24-hour recall is helpful during clinic
follow-up to measure adherence to dietary recommendations. A 3-day
or 7-day food record provides a more ...