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Nutritional Assessment in NICU/PICU Dr Abdolreza Norouzy Associate Professor in Nutrition Mashhad University of Medical Sciences 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 Malnutrition Screening Tools • PYMS • STRONGKIDS • STAMPS Growth Data Used Throughout the Nutrition Care Process • • • • Screening Assessment Diagnosis Monitoring and Evaluation Examples of Screening Risk Factors Anthropometrics: weight, length/height, BMI • measures < 5th %ile • measures > 95th %ile • alterations in growth patterns ▫ change in Z-scores ▫ change 1-2 SD ▫ change percentile channels Medical Conditions Medications Improper or inappropriate food/formula choices or preparation Psychosocial Laboratory Values Nutrition 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? How best to assess growth and nutrition? • Weight – Reflects mass of lean tissue, fat, intra- and extracellular fluid compartments • Length – More accurately reflects lean tissue mass • Head circumference – Correlates well with overall growth and developmental achievement Tools Used in Nutrition Assessment • Growth – – – – – Measurements Growth charts Absolute size (percentile) Pattern Body composition (water, bone, muscle, fat) • Intake – Food record/recall analysis • Additional information – – – – – Medical Development Social Laboratory Etc. Growth • Dynamic process • 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 • A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake Growth in the first 12 months • From birth to 1 year of age, normal human infants triple their weight and increase their length by 50%. • Growth in the first 4 months of life is the fastest of the whole lifespan - birthweight usually doubles by 4 months • 4-8 months is a time of transition to slower growth • By 8 months growth patterns more like those of 2 year old than those of newborn. Changes in Body Conformation Weight Gain (g/d) in one-month increments – Girls and Boys Age Up to 1 month 1-2 months 2-3 months 4-5 months 5-6 months 10th percentile 16 18 50th percentile 26 30 90th percentile 36 42 20 25 29 35 39 46 14 18 23 26 32 36 13 14 16 17 20 21 11 12 14 15 18 19 Guo et al, 1991 Weight Gain (g/d) in one-month increments – Girls and Boys Age Up to 1 month 1-2 months 2-3 months 4-5 months 5-6 months 10th percentile 16 18 50th percentile 26 30 90th percentile 36 42 20 25 29 35 39 46 14 18 23 26 32 36 13 14 16 17 20 21 11 12 14 15 18 19 Guo et al, 1991 Using Infant Growth Charts What are growth charts? • Growth charts are a series of percentile curves that show the distribution of body measurements in children over time. • Growth charts are not diagnostic instruments. They are screening tools that help you form an overall clinical impression for the child being measured. • The positions of the individual points on the graph are less important than the overall trajectory of the growth curve over time. How to use a growth chart • Accurately determine age (adjust for gestational age if <36 weeks) • Accurately measure weight and recumbent length • Plot measurements on appropriate chart • Use the percentile lines to assess body size and growth, and monitor growth over time • Gather additional history, exam as needed • Discuss growth pattern with parent/caregiver and agree on subsequent action if required Adjust for gestational age • A calculator to adjust for gestational age may be found at http://www.mtnstopshiv.org/node/1584 Percentile curves • Major percentile curves lie at the 2, 5, 10, 25, 50, 75, 90, 95, and 98th percentiles • Normal growth should fall between the 2nd percentile and the 98th percentile • Infants and children with a length-for-age <2nd percentile have short stature. • Infants and children with a weight-for-age <2nd percentile are underweight. • Main concern in infancy is poor growth • underweight/malnutrition, short stature/stunting Describing a plotted point - 1 • If the plotted point is right on or near the percentile line, then in practice the child is described at being at that percentile: E.g. If Point A is on or near the 50th percentile, the child is described as being “at the 50th percentile” Describing a plotted point - 2 • If the plotted point is between percentile lines, then in practice the child is described as being between the two percentiles: E.g. If Point A is between the 50th and 75th percentile, the child is described as being “between the 50th and 75th percentiles” Normal growth in a healthy infant • Typically follows the same growth curve or trajectory over time. • A normal growth curve is between the 2nd and 98th percentile and parallels the 50th percentile growth trajectory. • Weight should be proportional to length • An infant should regain birth weight by two weeks of age and then will typically gain 15-30 grams) per day (typical/minimal) When further investigation is needed • Unexplained growth including: – – – – Sharp upwards or downwards trend over a short period of time when child crosses one major percentile curve and may be close to crossing a second major percentile curve Growth at <2nd percentile or >98th percentile Consistent flat growth trend Concerns such as poor nutritional intake, presence of a chronic illness, etc. High concern – pediatric evaluation • Any sharp decline in growth line: – – – – This is a very significant change in the child’s growth. A sharp decline in a normal or undernourished child indicates a growth disturbance. Changes in weight or length should be investigated before a child crosses two major percentile lines. Pediatric evaluation is recommended High concern – pediatric evaluation • A flat growth line: – – – Child is not growing consistently. When growth rate is rapid during first six months of life, even a one month flat line in growth represents a possible concern. Pediatric evaluation is recommended. High concern – pediatric evaluation • Any sharp incline in the growth line: – – – – – This is a very significant change in the child’s growth. Changes in weight or length should be investigated before a child crosses two major percentile lines. An unexplained sharp incline may signal a change in feeding practices - may lead to overweight/obesity. A sharp incline in a previously ill or undernourished child may be “catch-up” growth expected in the refeeding period. Pediatric evaluation is recommended if weight gain is unexpected. Weight Gain (g/d) in one-month increments – Girls and Boys Age Up to 1 month 1-2 months 2-3 months 4-5 months 5-6 months 10th percentile 16 18 50th percentile 26 30 90th percentile 36 42 20 25 29 35 39 46 14 18 23 26 32 36 13 14 16 17 20 21 11 12 14 15 18 19 Guo et al, 1991 Evaluating Growth Evaluating Growth Overweight • Weight in infancy associated with weight in childhood – – Crossing percentiles (upward) in infancy is associated with ↑d OR of childhood obesity (Taveras, 2011) Children in upper tertile had higher risk of childhood obesity than children in lower tertile (Andersen, 2012) • Appropriate screening tool, intervention not clear; Beth’s take-home message: keep feeding babies Undernutrition • ↓ weight, no effect on length low weightfor-length • ↓ ↓ weight ↓ length or height eventually may appear proportionate Failure to Grow, Failure to Thrive • Failure to gain weight or grow at expected rates ▫ ▫ ▫ ▫ Weight-for-age <5th %ile Weight-for-length <5th %ile Decreased growth velocity (decrease over 2 SD over 3-6 months) <80% ideal body weight • 1-5% tertiary hospital admissions for <1 year olds • Prevalence varies ▫ ▫ 5-10% <3 years of age Some populations at higher risk Failure to Grow • Inadequate intake – – – Not enough food offered: Food insecurity, lack of knowledge of child’s needs Not enough food consumed: Oral-motor dysfunction, behavioral feeding problems Emesis • Malabsorption • Increased metabolic demand Figure 5: Proposed algorithm[s] for identification and assessment of possible undernutrition in infancy [and childhood] (White, 2012) Rates of weight gain: Breastfed vs. Formulafed • Rates of gain for breastfed and formula fed infants during early months of life generally have been found to be similar although some reports have demonstrated greater gains by breastfed infants and others have shown greater gains by formula fed infants – – – Dewey, Pediatrics, 1992;89:1035 Nelson, Early Human Development, 1989;19:223. Cole, Acta Paediatr, 2002;91:1296. How growth is evaluated Fetal/Neonatal Growth Charts • Intrauterine charts – Classification of newborn • • • AGA LGA SGA • Postnatal Charts Intrauterine/Fetal Growth Standards • • • • • Lubchenco Gairdner Babson/Benda Fenton Olsen Fetal Growth Data Location, Date Characteristics Number of Subjects Lubchenco Denver, 19581961 High altitude, white/Hispanic, low SES 5,635 Fenton 3 IU data sets: • Kramer • Niklasson • Beeby CDC data Olsen 33 US states, 1995-2006 Racially diverse 257,855 Fenton Chart • Data Sets: – – – – Kramer, et al: 676,605 infants, 22-43 weeks Nicholson, et al: 376,000 Swedish infants 28-40 weeks Breeby, et al: OFC (N=29,090) and Length (N=26,973), 22-40 weeks CDC Data • Time period 1963-2001 Postnatal Growth Charts • Accounts for initial weight loss • Dancis: Data 1948, very small sample size in lowest weight group • Ehrenkranz: Pediatrics 1999:104:280 – – – – N=1660 14-16 g/kg/d weight gain 0.9 cm/week increase length 0.35 cm/week increase OFC Infant Growth Charts (References): Timeline • Stuart/Meredith Growth Charts (1946-76) – Caucasian, Boston/Iowa city, small sample size • NCHS growth charts (1976-1978) – – – Cross sectional Data from NHES, NHANES, and FELs CDC produced normalized version 1978 WHO recommended international use • CDC (2000) ▫ ▫ 5 cross sectional nationally representative surveys between 1963-1995 Included more breast fed infants • WHO (2006) ▫ ▫ ▫ ▫ ▫ Data from Brazil, Ghana, India, Norway, Oman and US Multiethnic, affluent Exclusive breastfeeding to 4 months Solids according to recommendations 6 months Continued breastfeeding to 12 months Evolution: NCHS CDC Charts NCHS infant data: Fels study • Primarily formula-fed • Underrepresented groups: largely Caucasian, middle class • Intervals of measurements (q3 months from 3-36 months) may not define dynamic patterns during rapid growth phases • Statistical smoothing procedures CDC infant data: NHANES I, II, III • Standardized data collection methods • Expanded sample • More breastfed infants • Exclusions – – VLBW infants NHANES III weight data for >6 year olds Compare the charts (<24 month olds) CDC growth reference (2000) WHO growth standard (2006) Data sources Nat’l vital statistics (birthwts), PNSS, NHANES I, II, III (19711994) MGRS longitudinal component (Brazil, Ghana, India, Norway, Oman, United States) Data type Cross-sectional starting at age 2 mo, with mathematical modeling Longitudinal: birth, 1, 2, 4, 6, 8 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, 24 months Sample size 4697 observations for 4697 children 18,973 observations for 882 children Breastfeeding among infants in sample ~50% ever breastfed ~33% breastfeeding at 3 mo 100% ever breastfed 100% predominantly breastfeeding at 4 mo 100% breastfeeding at 12 mo Complementary foods introduced at mean age 5.4 mo Source: MMWR, 2010; 59(No. RR-9):1-15. Compare the charts (<24 month olds) Exclusion criteria CDC growth reference (2000) WHO growth standard (2006) VLBW (<1500 g) • • • • • • • • • • Low socioeconomic status Birth at altitude >1500 m Birth at <37 wkor >42 wk Multiple birth Perinatal morbidities Child health conditions known to affect growth Maternal smoking during pregnancy or lactation Breastfeeding for <12 mo Complementary foods before 4 mo Wt-for-length >3 SD +/- study median Comparison of WHO and CDC Chart (weight-for-age) Girls Boys Source: MMWR, 2010; 59(No. RR-9):1-15. Comparison of WHO and CDC Chart (stature-for-age) Girls Boys Source: MMWR, 2010; 59(No. RR-9):1-15. Charts to Evaluate Growth of Infants CDC Clinical Charts http://www.cdc.gov/growthcharts/ WHO Child Growth Standards http://www.who.int/childgrowth/en • Sex-specific • Sex-specific – – – – Weight-for-age Length-for-age Weight-for-length Head circumference-forage • Choice between outer limits at 3rd and 97th percentiles, or 5th and 95th – – – – – Weight-for-age Length-for-age Weight-for-length Head circumference-forage On WHO site: BMI, other measures • Outer limits at 2nd and 98th percentiles Differences between WHO and CDC infant charts • WHO mean > CDC mean birth to 6 months • “Healthy breastfed infants track weight-for-age along WHO but falter on CDC” • Cross at 6 months and WHO mean < 6 months • On the CDC chart, children appear heavier and shorter • On the WHO chart, children appear taller • WHO charts: – Higher estimate of overweight – Lower estimates of underweight, undernutrition CDC Recommendations for infant growth charts Expert Panel (NIH, AAP) to review scientific evidence. Recommendations: • WHO charts from birth to 24 months • CDC charts for >24 months • As a screen, 2rd and 98th percentile on WHO corresponds to 5thand 95th on CDC • Clinicians should be aware that fewer individuals will be screened as “underweight” and more as “overweight” using WHO • For more, see http://www.cdc.gov/growthcharts Controversies/Issues • • • • • Screen vs. assessment Standard vs. reference Typical vs. ideal growth Environmental influence Variety of diets may result in acceptable growth and nutrition status • Normal population diversity Plot individuals on both CDC and WHO. Does your assessment change? • Absolute size vs. pattern Problems with Growth • Underweight • Overweight • Failure to Grow • “Overfat” Screening Assessment • Screening identifies nutritional risk and/or need for further assessment. Assessment: • Collect data • Interpret data ▫ ▫ ▫ Link information Compare to references, standards, expectations Ask questions 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? Undernutrition • ↓ weight, no effect on length low weightfor-length • ↓ ↓ weight ↓ length or height eventually may appear proportionate Failure to Grow, Failure to Thrive • Failure to gain weight or grow at expected rates ▫ ▫ ▫ ▫ Weight-for-age <5th %ile Weight-for-length <5th %ile Decreased growth velocity (decrease over 2 SD over 36 months) <80% ideal body weight • 1-5% tertiary hospital admissions for <1 year olds • Prevalence varies ▫ ▫ 5-10% <3 years of age Some populations at higher risk Failure to Thrive • Inadequate intake – – – Not enough food offered: Food insecurity, lack of knowledge of child’s needs Not enough food consumed: Oral-motor dysfunction, behavioral feeding problems Emesis • Malabsorption • Increased metabolic demand Prematurity in the U.S. • In the year 2010: – – – 7.6% of infants born weighed less than 2500 grams 1.4% weighed less than 1500 grams Infant mortality dropped to 6.9 per 1000 births • Last 8 years, prematurity rates have increased – Role of multiples (IVF) General Principles The goal of nutritional management of the sick or premature infant in the first months of life is to promote normal growth velocity and body composition relative to age matched, healthy infants • Prematures: Evidence for PostDischarge Nutrient Deficits • Poor first year growth (protein-energy) • Poorer developmental outcome-related to growth failure • Persistant ostepenia (calcium, phosphorus) • Anemia (Iron) • Little data on other nutrients Canadian Pediatric Society: Stages of Growth in Preterms • Stage 1: Transition (0-10d) • Stage 2: Stable premie grower (10d-d/c) • Stage 3: Post-discharge (d/c-?) Is there evidence for different nutritional requirements at each stage ? Physiology of the infant at each stage would suggest YES! 3. Post-discharge 2. Premie Grower 1.Early Transition • First days of life • Sick • Catabolic - Negative N balance; increased energy needs - ?insulin resistant; counter-regulatory hormones • Nutrient sources TPN+minimal feeds • Goal: Reduce losses - Can they grow? How We Get To Stage 3: Effects of Stage 1 • Neonatal illness affects protein, energy, calcium, phosphorus, Na/K/CI, iron status • Energy requirements increase proportionately to respiratory distress • Protein losses increase with sepsis • Preemie Growth Phase • 10 days to 34 weeks post-conception - Start time varies based on severity of illness (maybe 30 days or more) • Stable, post-neonatal illness (e.g. RDS) • Anabolic-unique gut physiology • Effects of Stage 2 • Current recommendation likely to be underestimates - Reference fetal growth rate likely to be low (18-20 v. 10-15 g/kg/d) - Higher energy delivery needed to achieve true fetal growth rate (>130 kcal/kg/d) - Higher protein delivery needed to support higher energy delivery (3.2-3.8 g/kg/d) • Estimates assume no interruption of growth during Phase 1 Nutritional Status at Discharge: Effects of Stage 1 + 2 • Protein-energy malnutrition - Cumulative energy deficit: 1000 kcal/kg - Cumulative protein deficit: 25 grams/kg - 2000 grams at 37 weeks • Demineralization - Cumulative calcium deficit • Variable iron status • Undocumented nutrients - Cu, Zn, Mg, I, Se, vitamins Can this pattern of postnatal growth failure be reversed? • Very preterm infants have minimal nutritional reserves • Once a preterm infant develops growth failure it is very difficult to recoup the growth loss Post-Discharge Phase • After 34 weeks • Healthy, stable • Anabolic-gut physiology more typical of term infant • Nutrient Source: Several possibilities - Unfortified HM, fortified HM, term formula, PT formula, follow-up formula • Continued growth at term infant rates +recovery from deficits A TALL ORDER Nutritional Screening Assessment Performed 4 - 6 weeks post -hospital D/C: Growth Action Values Weight gain < 25 g/day Length growth < 1 cm/wk HC growth < 0.5 cm/wk (from Hall, 2000) Nutritional Screening Assessment Performed 4 - 6 weeks post -hospital D/C: Biochemical Test Action Values Phosphorus < 4.5 mg/dL Alkaline phosphatase > 450 IU/L BUN < 5 mg/dL Prealbumin < 10 mg/dL Retinol binding protein < 2.5 mg/dL (from Hall, 2000) 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 Normal output Daily stool and urine output guidance Day 0 1 wet nappy and meconium at least once a day Day 1 2 wet nappies and meconium at least once a day Day 2 & 3 3 or 4 wet nappies and changing stools at least once a day Day 4+ 5 or 6 heavy wet nappies and yellow stools at least once daily A baby who is passing meconium at 3 or 4 days old may not be getting enough milk. A baby who does not have yellow stools by day 5 may not be getting enough milk. A baby who is not doing as many wet nappies each day as expected may not be getting enough milk. Catch-up Growth • Enhanced nutritional intake sufficient to allow ‘catch-up’ growth improves long term neurodevelopmental outcome Body composition differences • Compared to term infants, ex-preterm infants fed at 120 kcal/kg/day – – Have more body fat Have a different fat distribution Laboratory assessment • TPN requires regular monitoring of acid base status, liver function, bone profile and electrolytes • In enterally fed infants, monitoring albumin, transferrin, total protein, urea, alkaline phosphatase and phosphate may be useful Feeding development • Swallowing first detected at 11 weeks • Sucking reflex at 24 weeks • Coordinated suck-swallowing not present till 32-34 weeks • Swallowing to coordinate with respiration – – Respiration>60-80 NG feeding Respiration>80 high risk for aspiration (NPO) Gastrointestinal Development • • • • • Fetal swallowing, motility in 2nd trimester – 18 week fetus swallows 18-50ml/kg/day – Term 300-700ml/day – Fetal swallowing regulates the volume of amniotic fluid and controls somatic growth of the GI tract Intestines double in length from 25-40 weeks Functionally mature gut by 33-34 weeks Intestine in final anatomic position by 20 weeks Premature Infant GI tract: – Delayed gastric emptying seen in preterm • Breast milk, glucose polymers, prone positioning facilitate gastric emptying – Total gut transit time in preterm 1-5 days – Stooling delayed until after 3 days – feeding volume ’s motility Growth – General Facts • Last trimester of pregnancy – Fat and glycogen storing – Iron reserves – Calcium and phosphoruos deposits • Premature babies more fluid (85%-95%), 10% protein, 0.1% fat. – No glycogen stores • The growth of VLBW infants lags considerably after birth Growth Goals • Weight: 20-30 g/day • Length: ~1cm/week • HC: 0.5cm/week – Correlates with brain growth and later development Tools Used for Determination • • • • • Indirect calorimetry Underlying disease process Biochemistrys and nitrogen balance Published papers (reference charts) Nutritional status Parenteral Metabolic Complications: • Amino acids – toxic • Carbohydrate – – Hepatic stenosis Cholestasis - alk phos - GGT - bili • Fat – depressed immune function – Reduced bacterial clearance – Increased triglycerides Biochemistries in PICU • Serum albumin, urea, triglycerides, magnesium – ↓ Mg – 20% – ↑ trig – 25% – ↑ urea – 30% – ↓ albumin – 52% • ↑ uremia → ↓ SD scores for weight and arm circumference between admission and discharge • ↑ triglycerides → > ventilator dependence days and length of stay than children with triglyceride levels Journal of Nutritional Biochemistry 17 (2006) 57-62 Getting Started • Verify patient – National Patient Safety Goal • Introduce self – tell purpose of assessment/ interview • Use open-ended questions • Ask only one question at a time • Direct the question to the child when appropriate • Obtain feedback from parents to confirm understanding • Talk in soothing voice. Initial Interview • Statistical information – – – Childs name, nickname, age, sex, ethnic origin Birth date, religion Important phone number and parent contact information • General Appearance – – Note parent-child interaction Note clues about child’s behavior and health status History Taking • Problem-oriented History – gather data regarding the current Chief Complaint – major focus • Health History • Family History • Lifestyle and Life Patterns History of Present Illness or Injury Characteristic Defining Variables • Onset • Sudden or gradual, date and time began • Type of Symptom • • Location • Pain, itching, cough, vomiting, runny nose, diarrhea, etc General or localized • Severity • Influencing factors • Previous and Current Treatment • • • Effect on daily activities – interrupted sleep, decreased appetite What relieves or aggravates symptoms, what precipitated the problem Medications used, treatments used (heat, ice, rest), response to treatment A Health History Data is gathered from birth to current status and includes: – – – – – – – – Birth history including condition of baby at birth Health maintenance – child’s primary provider, dentist, and other healthcare providers Medications Allergies Immunizations Activities and exercise Nutrition Sleep Family History • Focuses on health status of parents, siblings, and specific blood relatives. • Purpose is to gather data about any hereditary factors that are likely to affect the child’s health. Lifestyle / Psychosocial Data • • • • Family composition Housing / home environment School or childcare arrangements Daily Routines – very important Potential Indicators of Child Abuse • • • • • • Dress - Inappropriate for weather; excessively dirty Hygiene- dirty teeth, matted hair, broken fingernails Posture and Movement – crouching in corner, slow, concentrated movements Communication – using one syllable words, seeking approval for answers; waiting for someone else to answer question Facial characteristics – fearful, anxious, tearful, sad Psychological state – demanding, bizarre, overly dramatic or condescending Summary • During the first contact with the child and parent, the nurse forms an initial impression by making a general survey. • It will give the nurse a subjective impression of the: – – – – – – – Physical appearance State of nutrition Behavior and Personality Interactions with parents and nurse Posture Development Speech Vital Signs Temperature • Normal temperature runs around 37.2degrees until > 36 months. • A variance of 0.2 degrees is OK. • A temperature <37degrees in an infant and > 37.5 degrees is indicative of a problem and should be noted. • Temperatures are taken Vital Signs Pulse • Apical pulse rates are most commonly taken in children; especially in those under 2. • Assess based on limits for age and norms for that child. Normal Heart Rates for Children of Different Ages Vital Signs Respirations • Assess the rate, depth, and ease of respiration in the child. Varies with age of child. Respirations should be quiet and effortless • Infants are abdominal breathers / nose breathers 4 weeks to 4 months. • By age 7 – costal breathers Normal Respiratory Rate Ranges for Different Age Groups Measurements • • • • Height Weight Head Circumference Chest Circumference • Growth Charts 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 Interpretation of BMI • BMI is useful for – – screening monitoring • BMI is not useful for – diagnosis CLINICAL ASSESSMENT/2 • Good nutritional history should be obtained • General clinical examination, with special attention to organs like hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland. • Detection of relevant signs helps in establishing the nutritional diagnosis CLINICAL ASSESSMENT/3 • ADVANTAGES – – – Fast & Easy to perform Inexpensive Non-invasive • LIMITATIONS – Did not detect early cases Clinical signs of nutritional deficiency HAIR Spare & thin Protein, zinc, biotin deficiency Easy to pull out Protein deficiency Corkscrew Coiled hair Vit C & Vit A deficiency Clinical signs of nutritional deficiency MOUTH Glossitis Bleeding & spongy gums Riboflavin, niacin, folic acid, B12 , pr. Vit. C,A, K, folic acid & niacin Angular stomatitis, cheilosis & fissured tongue leukoplakia B 2,6,& niacin Sore mouth & tongue Vit B12,6,c, niacin ,folic acid & iron Vit.A,B12, B-complex, folic acid & niacin Clinical signs of nutritional deficiency EYES Night blindness, exophthalmia Vitamin A deficiency Photophobiablurring, conjunctival inflammation Vit B2 & vit A deficiencies Clinical signs of nutritional deficiency NAILS Spooning Iron deficiency Transverse lines Protein deficiency Clinical signs of nutritional deficiency SKIN Pallor Folic acid, iron, B12 Follicular hyperkeratosis Flaking dermatitis Vitamin B & Vitamin C Pigmentation, desquamation Bruising, purpura PEM, Vit B2, Vitamin A, Zinc & Niacin Niacin & PEM Vit K ,Vit C & folic acid Clinical signs of nutritional deficiency Joins & bones • Help detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency (Scurvy) 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