1. Nutrition Screening and Assessment Nutrition 526: 2010

2. Steps to Evaluating Pediatric Nutrition Problems Screening Assessment –Data collection –Evaluation and interpretation –Intervention –Monitor –reassessment

3. 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

4. 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

5. Examples of Screening risk factors Anthropometrics: weight, length/height, BMI Growth measures < than 5 th %ile Growth measures > than 90 th %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

6. 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

7. Assessment –Systematic process –Uses information gathered in screening –Adds more in depth, comprehensive data –Links information –Interprets data –Develops care plan –monitor –Reassess

8. Process Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate

9. 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

10. NCP: Nutrition Care Process Provides a framework for critical thinking 4 Steps –Assessment –Diagnosis –Intervention –Monitoring/Evaluation

11. 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?

12. NCP Diagnosis –Identification or labling of problem that is within RD practice to treat Examples: –Inadequate intake –Inadequate growth

13. 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 to nutrition related recommendations (vs food and nutrition related knowledge) Underweight Food and medication interactions

14. NCP: Diagnosis written as a PES statement Problem/Etiology/Signs and symptoms “Must be clear and concise. 1 problem one etiology”

15. 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 @ 95 th percentile –Diet information Jake –10 month old –Hct: 29

16. NCP Process Jayden, Barbara, Mark, Emma, Jake

17. NCP Intervention –Etiology drives the intervention Monitoring and Evaluation

18. Challenges and Pitfalls

19. Challenges Nutrient needs influenced by: genetics, activity, body composition, medical conditions and medications Individuals anthropometric date influenced by: genetics, body composition, development, history

20. Challenges Identification of etiology Weighing risk vs benefit Supportive of: –Family –Individual –Development/temperament

21. Challenges Information –Availability –Accurate –Representative –complete Goals and expectations –Available –Evidence bases –applicable

22. 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

23. Potential Pitfalls Excuses Assumptions Faulty reasoning Incorrect or inaccurate information Not evidence based Biased

24. 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)

25. Assessment Tools

26. 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

27. Who is the regulator of growth? Who regulates Intake? What do measurements mean? –Weight –Weight gain –Lab values –Intake information

28. Growth

29. 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

30. Growth A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake

31. Growth Assessment Progress in physical growth is one of the criteria used to assess the nutritional status of individuals

32. Absolute size Body composition Growth/changes over time

33. Absolute size

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35. 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

36. Body Mass Index for Age Body mass index or BMI: wt/ht 2 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

37. 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

38. Interpretation of BMI BMI is useful for –screening –monitoring BMI is not useful for –diagnosis

39. 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

40. Nutrient Analysis Fluid Energy Protein Calcium/Phosphorus Iron Vitamin D Other

41. Nutrient Needs Recommendations established for over 43 essential and conditionally essential nutrients

42. Basis of recommendations Basis Physiology –GI –Renal Growth and Development –Preventing deficiencies –Meeting nutrient needs Water Energy Vitamin D Iron

43. Dietary Information Collect data Nutrient Analysis Comparison with recommendations, guidelines, evidence Link with additional information Interpret

44. 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

45. 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

46. Dietary Reference Intakes (DRI) (including RDA, UL, and AI) are the periodically revised recommendations (or guidelines) of the National Academy of Sciences

47. 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

48. 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

49. 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.

50. 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

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53. Other Guidelines AAP Bright Futures Educational or Professional teaching Public Policy Guidelines –Consider source –Consider Purpose –? How apply to individual

54. Examples Baby cereal at 6 months Juice Introduction of Cows milk to infants Weight gain in pregnancy Family meals

55. Energy

56. Factors that alter Energy needs Body composition Body size Gender Growth Genetics Ethnicity Environment Adaptation and accommodation Activity/work Illness/Medical conditions

57. Energy Correlate individual intake with growth

58. Medical Information

59. 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

60. 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

61. Drug-Nutrient Interaction Altered absorbtion Altered synthesis Altered appetite Altered excretion Nutrient antagonists Tolerance

62. Feeding and Developmental Information

63. Feeding and development Feeding Interactions Feeding Relationship Feeding Skills Feeding Development Feeding Behaviors

64. What factors influence food choices, eating behaviors, and acceptance?

65. Feeding Delays in feeding skills Feeding intolerance Behavioral Medical/physiological limitations Other

66. Sociology of Food Hunger Social Status Social Norms Religion/Tradition Nutrition/Health

67. Psychosocial and environmental information

68. Psychosocial and Environmental Information Family –Constellation –Dynamics –Views –Resources –other Socioeconomic status –employment/education/income/other Beliefs –Religious/cultural/other

69. Clinical and Laboratory assessment

70. Clinical Assessment General appearance Temperature Color Respiratory/WOB Skin/hair/nails/membranes Output (urine and stool) Other

71. Clinical signs of Nutrient deficiency EnergyFTT, cacexia ProteinSlow growth, edema, impaired wound healing CalciumSeizures, rickets, decreased bone density, tetany PhosphorusSeizures, decreased bone density, rickets, bone pain, decreased cardiac fx Vitamin DDecreased bone density, osteopenia, rickets Vitamin ADry scaly skin, FTT, xeropthalmia,, dry mucus membranes ZincFTT, edema, impaired wound healing, alopecia, acrodermatitis enteropathica IronPallor, tachycardia, FTT Essential fatty acidScaly dermatitis, poor growth, alopecia Vitamin CSwollen joints, impaired wound healing, swollen bleeding gums, loose teeth, petechia fluidWeight loss, decreased UOP, dry mucus membranes, altered skin turgor, sunken fontanel, tachycardia, altered BP

72. 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

73. Examples of Laboratory Tests IronHct, HgB, ferritin*, ZPPH* Protein/EnergyAlbumin, Transthyretin, RBP, other BoneCa, Ph, Alk Pho, Vit D Vitamins Minerals FluidElectrolytes, BUN, urine/serum osm, spec gravity

74. Linking Information

75. Assessment Process Linking information collected with: –Goals/expectations –Reference data/standards –Evidence –individual Asking questions

76. Case Examples YesNoNot sure or don’t know growth diet Medical, developmental, feeding Social, environmental clinical laboratory

77. 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?

78. Intervention Identify etiology Identify contributing factors Support feeding relationship Consider psychosocial factors, family choice and input Weigh risk v.s. benefit

79. Etiology: Contributing factors Inadequate Intake Fluid, energy Medical BPD, reflux, frequent illness Feeding relationship Stress, history Psychosocial

81. Adequate intake vs feeding relationship Concentrating formula vs fluid status impact on tolerance, compliance, errors, cost solution to problem vs exacerbating problem

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84. Summary: Screening Assessment Diagnosis Intervention Monitoring and reevaluation

85. Summary Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate

86. Summary: Assessment Process Collect data Interpret data –Link information –Compare to references, standards, expectations –Ask questions

87. The End Questions?