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Nutritional Assessment. Penny Blacker Dietitian Frimley Park Hospital. Nutritional Assessment. Methods Calculations and what they mean Interpreting Dietary Reference Values Enteral feeding Parenteral feeding Refeeding syndrome. Nutritional Assessment. Growth

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nutritional assessment

Nutritional Assessment

Penny Blacker

Dietitian

Frimley Park Hospital

nutritional assessment1
Nutritional Assessment
  • Methods
  • Calculations and what they mean
  • Interpreting Dietary Reference Values
  • Enteral feeding
  • Parenteral feeding
    • Refeeding syndrome
nutritional assessment2
Nutritional Assessment

Growth

  • Accurate and recent weight, height/length
    • Plot on appropriate growth chart/red book
    • Look at the trend
      • Sudden changes or gradual weight loss or gain
        • Coeliac disease often (but not always) a noticeable drop in weight when gluten introduced
        • CMPI when breast feeds replaced with formula
    • Calculate weight for height for babies and young children and BMI for older children (growth chart suitable for 2yrs and over)
assessing intake
Assessing Intake
  • Talk to parents/carer
    • Concerns
    • Compare with history from medical notes
      • Vomiting, diarrhoea, appetite, abdo pain etc
        • ‘effortless vomiting’ in babies indicative of CMPA
    • What has been tried already
      • Changes in formula, times of feed etc
      • What has helped/not helped
      • What is happening now
  • Fluid/food record charts
  • Calculate average daily intake for energy, protein and fluid taking into account losses due to vomiting
assessing requirements
Assessing Requirements
  • Always use actual weight
  • GOS booklet
  • Increased requirements
    • Cystic fibrosis,cardiac babies, malabsorption
    • Hypertonia (cerebral palsy) severe epilepsy
  • Decreased requirements
    • Hypotonia (cerebral palsy) immobility (muscular dystophy)
requirements gos males
Requirements GOS (males)

Note 1

  • 11-20kg 100ml/kg for first 10kg + 50ml for next 10kg
  • 20kg & above 100ml/kg for first 10kg + 50ml for next 10kg + 25ml/kg thereafter
    • Up to max 2500ml/day
      • Overweight child requires less than calculated as body weight is abnormally high
pre term babies
Pre Term Babies

Differ in requirements from term babies

  • Energy
      • 110-135 cals/kg/day (Klein 2002)
        • In practice >120cals/kg is rarely needed
      • Optimum weight gain is 13-15g/kg/day. Overfeeding can lead to metabolic syndrome in later life
  • Protein
      • Useful to check that intake is optimum (3-3.6g/kg/day)
      • High protein intakes (>4.3g/kg/day) can lead to metabolic stress
  • Fluid
      • May be restricted but aim for 150-200mls/kg/day
breast fed babies
Breast Fed Babies
  • Quantitative assessment more difficult
    • May need to get Mum to express milk and bottle feed but can be difficult if baby not used to bottle
    • If growth is faltering ensure
      • hind milk is used
      • baby is latching on
      • Mum’s diet is OK
older children
Older Children
  • Diet history from parent or carer
    • Meals & snacks. How much how often?
    • Who feeds the child & where?
    • Type of milk. How much how often? Other drinks
    • Do you have family mealtimes?
    • How would you describe child’s appetite?
    • Consistency of food
    • Main concerns. Behavioural issues
    • Any vitamin supplements?
    • Does the child vomit? If so frequency and amount
    • Stools frequency & consistency
  • Toddlers and children with food allergy/intolerance can be very wary about trying new foods so diet can become extremely limited.
    • Behavioural problems/fussy eating is common
  • 3 day food diary for quantitative assessment
    • Be aware of limitations!
    • Assess on computer programme (Microdiet). Compares average of 3 days intake to EAR, LRNI and RNI for age group
dietary reference values
Dietary Reference Values

Set by DOH 1991. Other countries set their own which may differ from UK

  • Estimated Average Requirement (EAR)
    • Represent the level of nutrients that are estimated to meet the nutrient requirement of 50% of the healthy individuals
      • Some children will require more, some less
      • Energy requirements often based on this
  • Reference Nutrient Intake (RNI)
    • Represent the amount of nutrient that is enough for at least 97% of the population
      • This is what we use most frequently when assessing a child’s intake for vitamins & minerals
  • Lower Reference Nutrient Intake (LRNI)
    • The amount of a nutrient that is enough for only a small number of people (about 3%). If intake is habitually below this the child will almost certainly be deficient in any given nutrient.
dietary reference values1
Dietary Reference Values

Examples

  • Calcium requirement/day (for babies/children on milk free diets)

0-12m LRNI= 240mg RNI=525mg EAR=400mg

  • Iron requirement/day (iron deficiency anaemia ?cause)

1-3yrs LRNI=3.7mg RNI=6.9mg EAR=5.3mg

  • Enables us to suggest foods/supplements to improve diet
  • If intake meets requirements then other causes need to be investigated. Anaemia often present in undiagnosed coeliac disease despite sufficient intake
dietary reference values2
Dietary Reference Values

EAR

  • Crohns patients who need Modulen liquid diet for 8 weeks
    • Start with 75% EAR and gradually increase up to 120% EAR
      • 12 yr old boy. EAR = 2220 cals/day
        • Start with 1665cals. Aim max 2665cals depending on weight gain
  • Cystic fibrosis patients can need 120-150% EAR to maintain growth rate
enteral feeding
Enteral Feeding
  • Problems assessing
    • Often difficult to measure height/weight accurately
    • Appropriate growth charts not always available
    • Energy expenditure varies
      • Hypertonia, hypotonia, epilepsy
    • Reflux, constipation, vomiting can limit tolerance to feeds
    • Growth can be severely affected
      • 5yr 3m old boy. Height 76cm (average ht for 1 yr old) Weight 11kg (average wt for 1-1.5 year old)
      • Plot on centiles both ht and wt well below 0.4th centile
        • ?malnourished. Wt for ht=108%
enteral feeding1
Enteral Feeding
  • Best practice
    • Use height age to calculate requirements
      • Vitamins and minerals: aim to meet RNI
      • Protein: essential to provide RNI to lay down lean tissue
      • Energy: use EAR and adjust for
        • Malabsorption,recurrent infections,cardiac problems (increased req)
        • Inactivity,bed rest,immobile,obesity
        • Start with 75% EAR.
        • Monitor weight gain. Increase or decrease as necessary
      • Fibre: aim for age +5-10g/day if over 2yrs old
      • Fluid: base on actual weight. Beware overweight children need less as body wt is falsely high
        • Look for adequate hydration-pale urine, stool frequency
  • These children can also have food allergies/intolerances
parenteral feeding
Parenteral Feeding
  • ‘If the gut works use it’
  • Indications for PN in children
    • NEC,acute pancreatitis, post op abdo surgery, intestinal failure, short bowel syndrome
    • Should not be used unless anticipated for a minimum of 5 days
  • Assessment
    • Should be calculated on an exact weight
    • Energy kcal/kg/day
    • Protein as nitrogen g/kg/day
    • Sodium/potassium mmol/kg/day
    • Fluid mls/day
  • TPN Should be given over 24hrs
  • PPN Should be given over 20hrs to reduce risk on thrombophlebitis
refeeding syndrome
Refeeding Syndrome
  • Metabolic and clinical changes that occur on nutritional rehabilitation of malnourished patients
    • Little evidence in paediatric patients. Those at risk could include
      • Anorexia nervosa, Crohns disease
      • Patients underfed or not fed for at least 10-14 days (including those on prolonged IV fluids)
  • Starvation (catabolism)
    • Fat and protein used as energy source once carbohydrate stores depleted
      • Plasma insulin levels fall
      • Results in loss of lean body mass affecting major organs including heart. Diminished cardiac output/myocardial atrophy
      • Intracellular loss of electrolytes especially K Mg PO4
  • Refeeding (anabolism)
    • Carbohydrate used as energy source
      • Plasma insulin levels rise
      • Increased glucose. K Mg PO4 uptake back into cells causes fall in blood levels
      • Fluid retention leading to increased extracellular volume leading to cardiac failure
      • Electrolyte abnormalities can lead to cardiac arrest
  • Hypophosphataemia is central feature of RS
    • Increased uptake of thiamine (vit B1) required as co enzyme in CHO metabolism. Malnourished patients may already be depleted
refeeding syndrome1
Refeeding Syndrome
  • Measure Na K Mg P04 prior to feeding
  • Correct any deficiencies
  • Give thiamine 30mins prior to feeding
  • Deliver feeds and fluid slowly
    • Max 10 cals/kg/day initially
    • Increase daily by 10-25%
  • Monitor biochemistry daily
    • Enteral feeding for min 1 week
    • Parenteral feeding always