Transcript weight-for-age

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
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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
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ASPEN, Nutri in Clin Practice 1996
(5):217-228
• Simplest level of nutritional care (level 1)
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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
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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
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Is there a problem?
Define the problem?
Is more information needed?
How best to assess growth
and nutrition?
• Weight
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Reflects mass of lean tissue, fat, intra- and extracellular fluid compartments
• Length
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More accurately reflects lean tissue mass
• Head circumference
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Correlates well with overall growth and
developmental achievement
Tools Used in Nutrition
Assessment
• Growth
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Measurements
Growth charts
Absolute size
(percentile)
Pattern
Body composition
(water, bone, muscle,
fat)
• Intake
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Food record/recall
analysis
• Additional information
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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:
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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:
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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:
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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:
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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
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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
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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
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5-10% <3 years of age
Some populations at higher risk
Failure to Grow
• Inadequate intake
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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
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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
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Classification of newborn
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AGA
LGA
SGA
• Postnatal Charts
Intrauterine/Fetal Growth Standards
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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:
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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
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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)
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Caucasian, Boston/Iowa
city, small sample size
• NCHS growth charts
(1976-1978)
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Cross sectional Data from
NHES, NHANES, and
FELs
CDC produced normalized
version
1978 WHO recommended
international use
• CDC (2000)
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5 cross sectional nationally
representative surveys
between 1963-1995
Included more breast fed
infants
• WHO (2006)
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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
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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)
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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
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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
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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
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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?
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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
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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
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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
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5-10% <3 years of age
Some populations at higher risk
Failure to Thrive
• Inadequate intake
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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:
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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
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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
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Prematures: Evidence for PostDischarge Nutrient Deficits
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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
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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
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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
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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
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Respiration>60-80 NG feeding
Respiration>80 high risk for aspiration (NPO)
Gastrointestinal Development
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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
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Correlates with brain growth and later development
Tools Used for Determination
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Indirect calorimetry
Underlying disease process
Biochemistrys and nitrogen balance
Published papers (reference charts)
Nutritional status
Parenteral
Metabolic Complications:
• Amino acids – toxic
• Carbohydrate
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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
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Childs name, nickname, age, sex,
ethnic origin
Birth date, religion
Important phone number and parent
contact information
• General Appearance
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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
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Onset
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Sudden or gradual, date and time began
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Type of Symptom
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Location
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Pain, itching, cough, vomiting, runny nose,
diarrhea, etc
General or localized
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Severity
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Influencing factors
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Previous and Current
Treatment
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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:
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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
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Family composition
Housing / home environment
School or childcare arrangements
Daily Routines – very important
Potential Indicators of Child Abuse
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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:
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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
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•
•
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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
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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