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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.

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Steps to evaluating pediatric nutrition problems
Steps to Evaluating Pediatric Nutrition Problems

  • Screening

  • Assessment

    • Data collection

    • Evaluation and interpretation

    • Intervention

    • Monitor

    • reassessment

Nutrition screening purpose
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
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


Improper or inappropriate food/formula choices or preparation


Laboratory Values

Examples of Screening risk factors

Examples of screening risk factors1



Weight gain

Nutritional Practices



Weight changes

Dietary practices

Infant feeding practices



Weight loss



10 month old

Hct: 29

Examples of Screening risk factors


Systematic process

Uses information gathered in screening

Adds more in depth, comprehensive data

Links information

Interprets data

Develops care plan




Identify Problem or risk

Identify Etiology

Determine intervention

Monitor and Reevaluate


Goals of nutrition assessment
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
NCP: Nutrition Care Process

  • Provides a framework for critical thinking

  • 4 Steps

    • Assessment

    • Diagnosis

    • Intervention

    • Monitoring/Evaluation


  • 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?


  • 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 protein-energy intake

Excessive oral intake

Increased energy expenditure

Increased nutrient needs

Involuntary weight loss


Limited adherence to nutrition related recommendations (vs food and nutrition related knowledge)


Food and medication interactions

Examples of Nutrition Diagnosis Options


  • Diagnosis written as a PES statement

    Problem/Etiology/Signs and symptoms

    “Must be clear and concise. 1 problem

    one etiology”

Examples of screening risk factors2



Weight gain

Nutritional Practices



Weight changes

Dietary practices

Infant feeding practices



Weight loss



12 months

Weight @ 95th percentile

Diet information


10 month old

Hct: 29

Examples of Screening risk factors

Ncp process

NCP Process

Jayden, Barbara, Mark, Emma, Jake


  • Intervention

    • Etiology drives the intervention

  • Monitoring and Evaluation


Nutrient needs influenced by:

genetics, activity, body composition, medical conditions and medications

Individuals anthropometric date influenced by:

genetics, body composition, development, history


Identification of etiology

Weighing risk vs benefit

Supportive of:





  • Information

    • Availability

    • Accurate

    • Representative

    • complete

  • Goals and expectations

    • Available

    • Evidence bases

    • applicable

Comprehensive nutrition assessment
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
Potential Pitfalls



Faulty reasoning

Incorrect or inaccurate information

Not evidence based


Information collected current and historical
Information Collected: Current and Historical



Medical history


Feeding and developmental information

Psychosocial and environmental information

Clinical information and appearance (hair, skin, nails, eyes)

Other (laboratory)

Nutrition assessment

Tools of Assessment



Growth charts

Absolute size (percentile)


Body composition

Water, bone, muscle, fat


Additional information


Food record, food recall, analysis

Additional information





Other anthropometrics


Nutrition Assessment

Who is the regulator of growth?

Who regulates Intake?

What do measurements mean?


Weight gain

Lab values

Intake information


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


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

Growth assessment
Growth Assessment

Progress in physical growth is one of the criteria used to assess the nutritional status of individuals

Absolute size
Absolute size

  • Absolute size

  • Body composition

  • Growth/changes over time

Other anthropometrics
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 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
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
    Interpretation of BMI

    • BMI is useful for

      • screening

      • monitoring

    • BMI is not useful for

      • diagnosis

    Who might be misclassified
    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
    Nutrient Analysis

    • Fluid

    • Energy

    • Protein

    • Calcium/Phosphorus

    • Iron

    • Vitamin D

    • Other

    Nutrient needs

    Recommendations established for over 43 essential and conditionally essential nutrients

    Nutrient Needs

    Basis of recommendations
    Basis of recommendations conditionally essential nutrients

    • Basis

    • Physiology

      • GI

      • Renal

    • Growth and Development

    • Preventing deficiencies

    • Meeting nutrient needs

      • Water

      • Energy

      • Vitamin D

      • Iron

    Dietary information
    Dietary Information conditionally essential nutrients

    Collect data

    Nutrient Analysis

    Comparison with recommendations, guidelines, evidence

    Link with additional information


    Dietary information1
    Dietary Information conditionally essential nutrients

    • 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
    Approaches to Estimating Nutrient Requirements conditionally essential nutrients

    • 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) conditionally essential nutrients(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 conditionally essential nutrients

    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

    Comparison of individual intake data to a reference or estimate of nutrient needs

    DRI conditionally essential nutrients

    • 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 conditionally essential nutrients

    • 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
    DRI’s for infants conditionally essential nutrients

    • 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

    Adam conditionally essential nutrients

    Adam conditionally essential nutrients

    Other guidelines
    Other Guidelines conditionally essential nutrients

    • AAP

    • Bright Futures

    • Educational or Professional teaching

    • Public Policy Guidelines

      • Consider source

      • Consider Purpose

      • ? How apply to individual

    Examples conditionally essential nutrients

    • Baby cereal at 6 months

    • Juice

    • Introduction of Cows milk to infants

    • Weight gain in pregnancy

    • Family meals

    Energy conditionally essential nutrients

    Factors that alter energy needs

    Body composition conditionally essential nutrients

    Body size






    Adaptation and accommodation


    Illness/Medical conditions

    Factors that alter Energy needs

    Energy conditionally essential nutrients

    Correlate individual intake with growth

    Medical information
    Medical Information conditionally essential nutrients

    Medical information and history
    Medical Information and History conditionally essential nutrients

    Conditions that may impact growth, nutritional status, feeding

    Medications that may impact nutrient needs, absorbtion, utilization, or tolerance

    Illness, treatments, proceedures

    Medical conditions
    Medical Conditions conditionally essential nutrients

    • 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
    Drug-Nutrient Interaction conditionally essential nutrients

    Altered absorbtion

    Altered synthesis

    Altered appetite

    Altered excretion

    Nutrient antagonists


    Feeding and developmental information
    Feeding and Developmental Information conditionally essential nutrients

    Feeding and development
    Feeding and development conditionally essential nutrients

    Feeding Interactions

    Feeding Relationship

    Feeding Skills

    Feeding Development

    Feeding Behaviors

    Feeding acceptance?

    Delays in feeding skills

    Feeding intolerance


    Medical/physiological limitations


    Sociology of food
    Sociology of Food acceptance?

    • Hunger

    • Social Status

    • Social Norms

    • Religion/Tradition

    • Nutrition/Health

    Psychosocial and environmental information1
    Psychosocial and Environmental Information acceptance?

    • Family

      • Constellation

      • Dynamics

      • Views

      • Resources

      • other

    • Socioeconomic status

      • employment/education/income/other

    • Beliefs

      • Religious/cultural/other

    Clinical assessment
    Clinical Assessment acceptance?

    General appearance





    Output (urine and stool)


    Laboratory assessmet
    Laboratory Assessmet acceptance?

    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

    Linking information
    Linking Information acceptance?

    Assessment process
    Assessment Process acceptance?

    Linking information collected with:


    Reference data/standards



    Asking questions

    Case examples
    Case Examples acceptance?

    Interpretation asking questions
    Interpretation: Asking Questions acceptance?

    Is there a problem?

    Was there a problem?

    Does information make sense?

    What are goals and expectations?

    What is etiology of the problem?

    Intervention acceptance?

    Identify etiology

    Identify contributing factors

    Support feeding relationship

    Consider psychosocial factors, family choice and input

    Weigh risk v.s. benefit

    Adam acceptance?

    Adam acceptance?

    Summary: acceptance?





    Monitoring and reevaluation

    Summary acceptance?

    Identify Problem or risk

    Identify Etiology

    Determine intervention

    Monitor and Reevaluate

    Summary assessment process
    Summary: Assessment Process acceptance?

    Collect data

    Interpret data

    Link information

    Compare to references, standards, expectations

    Ask questions

    The end
    The End acceptance?