Nutrition screening and assessment nutrition 526 2010
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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

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


Nutrition screening and assessment nutrition 526 2010
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?


Nutrition screening and assessment nutrition 526 2010
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


Nutrition screening and assessment nutrition 526 2010
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


Nutrition screening and assessment nutrition 526 2010
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


Nutrition screening and assessment nutrition 526 2010

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


    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

    Interpret


    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


    Nutrition screening and assessment nutrition 526 2010

    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


    Nutrition screening and assessment nutrition 526 2010
    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


    Nutrition screening and assessment nutrition 526 2010
    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


    Nutrition screening and assessment nutrition 526 2010
    Adam conditionally essential nutrients


    Nutrition screening and assessment nutrition 526 2010
    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
    Examples conditionally essential nutrients

    • Baby cereal at 6 months

    • Juice

    • Introduction of Cows milk to infants

    • Weight gain in pregnancy

    • Family meals


    Energy
    Energy conditionally essential nutrients


    Factors that alter energy needs

    Body composition conditionally essential nutrients

    Body size

    Gender

    Growth

    Genetics

    Ethnicity

    Environment

    Adaptation and accommodation

    Activity/work

    Illness/Medical conditions

    Factors that alter Energy needs


    Energy1
    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

    Tolerance


    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
    Feeding acceptance?

    Delays in feeding skills

    Feeding intolerance

    Behavioral

    Medical/physiological limitations

    Other


    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

    Temperature

    Color

    Respiratory/WOB

    Skin/hair/nails/membranes

    Output (urine and stool)

    Other



    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:

    Goals/expectations

    Reference data/standards

    Evidence

    individual

    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
    Intervention acceptance?

    Identify etiology

    Identify contributing factors

    Support feeding relationship

    Consider psychosocial factors, family choice and input

    Weigh risk v.s. benefit



    Nutrition screening and assessment nutrition 526 2010


    Nutrition screening and assessment nutrition 526 2010
    Adam acceptance?


    Nutrition screening and assessment nutrition 526 2010
    Adam acceptance?


    Summary
    Summary: acceptance?

    Screening

    Assessment

    Diagnosis

    Intervention

    Monitoring and reevaluation


    Summary1
    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?

    Questions?