Chapter 21: Nutrition

ASSESSMENT OF NUTRITIONAL STATUS

Information gathering, growth assessment, estimation of needs, determination of risk factors, identification of goals and provide recommendations and education

Assessment

• Common causes of impaired weight gain and linear growth are listed in Table 21-1 and 21-2.

• Nutrition-focused medical history

  • ✓ Usual intake including types and portion sizes of foods consumed

  • ✓ Fluid intake: Juice, milk, water over 24-hour period

  • ✓ For breast-fed children, assess minutes on each breast and frequency of feeding

  • ✓ Formula: Type, concentration, additives, changes, and response

  • ✓ Oral supplements or tube feedings (delivery method, tolerance, formula, length of time)

  • ✓ Herbal, vitamin, or mineral supplements

  • ✓ Food aversions, allergies, appetite, and religious/ethnic restrictions

  • ✓ Access to food: Food insecurity, use of Women, Infants and Children (WIC) program and food stamps

  • ✓ Note specific conditions that may affect absorption, metabolism, and digestion or increase the caloric needs of the patient (fever, increased respiratory rate and effort, cardiac disease, etc.)

  • ✓ Micronutrient deficiencies from inadequate intake or comorbidities: Vitamin D, iron, zinc

• Gastrointestinal history, including defecation patterns, nausea, vomiting, gastroesophageal reflux (GER) treatment, abdominal surgeries

• Medications and potential food/drug interactions:

  • ✓ Note side effects of drugs that may cause electrolyte wasting, change in stool patterns, or malabsorption.

  • ✓ Note whether the drug’s efficacy is reduced by food intake or whether food interferes with absorption or mechanism of action.

• Family history: Food allergies/atopic disease, celiac disease, diabetes, obesity, hypercholesterolemia

• Birth history: Prematurity, intrauterine growth retardation, small for gestational age, necrotizing enterocolitis

• Laboratory values:

  • ✓ Consider evaluating electrolytes, albumin, prealbumin, CBC, and hepatic function and lipid panels if indicated (e.g., in the setting of emesis, diarrhea, poor growth, obesity, supplemental nutrition or when otherwise warranted based on clinical evaluation)

  • ✓ Deficiencies (if diet history indicates): 25-hydroxyvitamin D, zinc, iron profile, vitamin B₁₂, vitamins E and A, fatty-acid panel

• Growth parameters:

  • ✓ Unintentional weight loss: 5–10% loss is moderate, >10% is severe.

  • ✓ Length/height, weight, head circumference (if <3 years) percentiles

    • Up to 2 years of age—Use 2006 World Health Organization (WHO) growth chart for weight, supine length, and head circumference.

    • 2–20 years of age—Use Centers for Disease Control and Prevention (CDC) 2000 growth charts for weight and standing height. Calculate Body mass index.

    • Plot on all growth measurements including calculated BMI on CDC growth chart or specialty chart (prematurity, disease-specific, etc.) until 20 years of age.

    • Correct for prematurity until 3 years of age.

  • ✓ Optional: Obtain triceps skinfold and mid-arm circumference measurements to calculate muscle and fat stores. Measure lower-leg length, knee height, or arm span (when unable to obtain accurate height).

  • ✓ Typical growth velocity presented in Table 21-3.

  • ✓ Use z-score to express individual anthropometrics in relation to population standard (i.e., 25th percentile weight-for-age = z-score of 1, indicating that weight-for-age is 1 standard deviation from the mean).