Nutrition Screening and Assessment
Nutrition 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 proteinenergy 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 Tests
Iron
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
Weighing Risks and Benefits
• Identify etiology
• Identify contributing
factors
• Support feeding
relationship
• Consider psychosocial
factors, family choice
and input
• Weigh risk v.s. benefit
Etiology: Contributing factors
Inadequate Intake
Fluid, energy
Medical
BPD, reflux, frequent illness
Feeding relationship
Stress, 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