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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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Presentation Transcript
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

Medications

Improper or inappropriate food/formula choices or preparation

Psychosocial

Laboratory Values

Examples of Screening risk factors
examples of screening risk factors1
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

Examples of Screening risk factors
assessment
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

Process
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
slide11
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?
slide12
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 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

Examples of Nutrition Diagnosis Options
slide14
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 factors2
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

Examples of Screening risk factors
ncp process

NCP Process

Jayden, Barbara, Mark, Emma, Jake

slide17
NCP
  • Intervention
    • Etiology drives the intervention
  • Monitoring and Evaluation
challenges
Challenges

Nutrient needs influenced by:

genetics, activity, body composition, medical conditions and medications

Individuals anthropometric date influenced by:

genetics, body composition, development, history

challenges1
Challenges

Identification of etiology

Weighing risk vs benefit

Supportive of:

Family

Individual

Development/temperament

challenges2
Challenges
  • 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

Excuses

Assumptions

Faulty reasoning

Incorrect or inaccurate information

Not evidence based

Biased

information collected current and historical
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)

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

Nutrition Assessment
slide27
Who is the regulator of growth?

Who regulates Intake?

What do measurements mean?

Weight

Weight gain

Lab values

Intake information

growth1
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

growth2
Growth

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
basis of recommendations
Basis of recommendations
  • Basis
  • Physiology
    • GI
    • Renal
  • Growth and Development
  • Preventing deficiencies
  • Meeting nutrient needs
    • Water
    • Energy
    • Vitamin D
    • Iron
dietary information
Dietary Information

Collect data

Nutrient Analysis

Comparison with recommendations, guidelines, evidence

Link with additional information

Interpret

dietary information1
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
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
slide46

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

Comparison of individual intake data to a reference or estimate of nutrient needs
slide48
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
slide49
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
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
Other Guidelines
  • AAP
  • Bright Futures
  • Educational or Professional teaching
  • Public Policy Guidelines
    • Consider source
    • Consider Purpose
    • ? How apply to individual
examples
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

Factors that alter Energy needs
energy1
Energy

Correlate individual intake with growth

medical information and history
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
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
Drug-Nutrient Interaction

Altered absorbtion

Altered synthesis

Altered appetite

Altered excretion

Nutrient antagonists

Tolerance

feeding and development
Feeding and development

Feeding Interactions

Feeding Relationship

Feeding Skills

Feeding Development

Feeding Behaviors

feeding
Feeding

Delays in feeding skills

Feeding intolerance

Behavioral

Medical/physiological limitations

Other

sociology of food
Sociology of Food
  • Hunger
  • Social Status
  • Social Norms
  • Religion/Tradition
  • Nutrition/Health
psychosocial and environmental information1
Psychosocial and Environmental Information
  • Family
    • Constellation
    • Dynamics
    • Views
    • Resources
    • other
  • Socioeconomic status
    • employment/education/income/other
  • Beliefs
    • Religious/cultural/other
clinical assessment
Clinical Assessment

General appearance

Temperature

Color

Respiratory/WOB

Skin/hair/nails/membranes

Output (urine and stool)

Other

laboratory assessmet
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

assessment process
Assessment Process

Linking information collected with:

Goals/expectations

Reference data/standards

Evidence

individual

Asking questions

interpretation asking 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?

intervention
Intervention

Identify etiology

Identify contributing factors

Support feeding relationship

Consider psychosocial factors, family choice and input

Weigh risk v.s. benefit

slide81
Adequate intake vs feeding relationship
  • Concentrating formula vs fluid status
  • impact on tolerance, compliance, errors, cost
  • solution to problem vs exacerbating problem
summary
Summary:

Screening

Assessment

Diagnosis

Intervention

Monitoring and reevaluation

summary1
Summary

Identify Problem or risk

Identify Etiology

Determine intervention

Monitor and Reevaluate

summary assessment process
Summary: Assessment Process

Collect data

Interpret data

Link information

Compare to references, standards, expectations

Ask questions

the end
The End

Questions?

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