Assessment of nutrition in children. Pptx

Assessment of nutrition in children

1. By-Dr. Ishitri Das, Moderator-Dr. Sanjay Haldar Approach to Nutritional Assessment in Children

2. Need for nutritional assessment To identify early, at risk individuals for malnourishment. To identify malnourished individuals. To develop health care plans for malnourished individuals.

3. Malnutrition (WHO): “ the cellular imbalance between the supply of nutrients and the body’s demand for them to ensure growth,maintenance, and specific functions.” Causes of malnutrition : illiteracy, poor eating habits,low family income,poor hygiene,recurrent infections and poor lifestyle choices. It includes both under nutrition and obesity. Under nutrition can be classified as underweight,stunted or wasted. Under weight- Low weight for age Stunted- Low height for age Wasted- Low weight for height

4. Methods for nutritional assessment Nutritional assessment can be done with ABCD method Anthropomorphic measurements Biochemical parameters Clinical examination Dietary survey Vital statistics Radiology

5. 1. Anthropomorphic Measurements Age depended factors Weight Height or length Head circumference Chest circumference US/LS ratio Arm span

6. Age independent factors Mid upper arm circumference Weight for height Mid upper arm/height ratio Skin fold thickness Chest/head circumference ratio Enderberg index

7. Kanawati index (mid arm/ head circumference ratio) Rao and Singh’s criteria Dugdale’s index Ponderal index Quetelet’s index Body mass index

8. Height/Length Lenghth is measured by infantometer for infants and Stadio meter for child above 2 years. Low height for age indicates stunting and chronic malnutrition. We can use Weech’s formula for expected height upto 12 years. Length or height (in cm)= age in years x 6+ 77

9. Measuring height with stadiometer Use a stadiometer with a vertical back board, a fixed base board, and a movable head board. The stadiometer should be placed on a level floor . Remove the child’s socks and shoes for accurate measurement. Also remove hair ornaments and undo braids if they interfere with measurement. Caption

10. Work with a partner. One person should kneel or crouch near feet and: Help the child stand with back of the head, shoulder blades, buttocks, calves and heel should be touching the vertical board. Hold the child’s knees and ankle to keep the legs straight and feet flat. Prevent the child from standing on their toes. Young children may have difficulty standing to full height. If necessary, gently push on the tummy to help the child stand to full height.

11. The other person should bend to the level of child’s face and Position the head so that the child is looking straight ahead(line of sight is parallel to the base of the board.) Place thumb and forefinger over the child’s chin to help keep the head in an upright position. With the other hand, pull down the head board to rest firmly on top of the head and compress hair. Measure the height to the last completed 0.1 cm and record it immediately on the case record sheet.

12. Measuring length with infantometer Use a measuring board like infantometer with a headboard and sliding foot piece.Lay the measuring board flat, preferably on a stable, level table. Cover the board with a thin cloth or soft paper to avoid causing discomfort and the baby sticking to the board. The difference between height and length could be 2 cm . The height is usually 0.7 cm less than the length as the ligaments are compressed in standing posture. Caption

13. Work with a partner. One person should stand or kneel behind the headboard, and: Position the child lying on his back on the measuring board, supporting the head and placing it against the headboard. Position the crown of the head against the head board, compressing the hair. Hold the head with two hands and tilt upwards until the eyes look straight up, and the line of sight is perpendicular to the measuring board. Check that lies straight along the centre line of the measuring board and does not change position.

14. The other person should stand alongside the measuring board, and: Support the child’s trunk as the child is positioned on the board. Place one hand on the shins or knees and press gently but firmly. Straighten the knees as much as possible without hurting the child. With the other hand, place the foot piece firmly against the feet. The soles of the feet should be flat on the foot piece, toes pointing up. If the child bends the toes and prevents the foot piece touching the soles, scratch the toes slightly and slide in that foot piece when the child straightens that toes. Measure length to that last completed 0.1 cm and record immediately on the case record sheet.

15. The length of the term newborn at birth is approximately 50 cm. At 1 year of age, the length is 75 cm. At 2 years, the height will be 86-87 cm. From 2 year to 12 years, the height increase at the rate of 6cm per year.

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17. Weight Weigh the child as soon as possible after he arrives. If the child is admitted, weigh the child once daily, preferably at about the same time each day. The weighing time should be about one hour before or after a feed It is recommended to weigh children using a scale with the following features: Solidly built and durable Electronic (digital reading) Measures to precision of 0.01 kg (10gm) Allows tared weighing.

18. Tared weighing has two advantages: There is no need to substract weights to determine the child’s weight alone (reducing risk of error). The child is likely to remain calm when held in mother’s arms for weighing. If the SCALE for tared weighing is not available, a beam scale or a hanging scale (Salter type) may be used to weigh the child. Remove the child’s clothes, but keep the child warm with a blanket or cloth while carrying to the scale. Put a cloth in the scale pan to prevent chilling the child. Adjust the scale to zero with the cloth in the pan. (If using a scale with a sling or pants , adjust the scale to zero with that in place)

19. Place the naked child gently in the pan (or in the sling or pants). Wait for the child to settle and the weight to stabilise. Measure weight to the nearest 0.01 kg(10gm) or as precisely as possible and record immediately. Wrap the child immediately to rewarm.

20. Standardize scale In case of other type of weighing scale standardize scale daily or whenever they are moved: Set the scale to zero. Weigh three objects of known weight (e.g. 50 gms, 100 gms, 500 gms) and record the measured weight. Repeat the weighing of these objects and record the weights again. If there is a difference of 0.01 kg or more between duplicate weighing, or if a measured weight differs by 0.01 kg or more from the standard, check the scales and adjust or replace them if necessary.

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22. Head circumference The head circumference increases due to the growth of the brain inside the skull. The rate of brain growth is rapid during the first year of life.Hence the rate of increase in the head circumference is more in the first year of life. The head circumference is measured by placing the tape over the occipital protruberance at the back and just over the supra orbital ridge and the glabella in front. The growth velocity of the head circumference is the increase in the head circumference in relation to unit time or period.

23. Approximate gain in Head Circumference between 0 and 5 years AGE Growth Velocity of the Head Circumference 0-3 months 2cm/month 3-4 months 1cm/month 7-12 months 0.5 cm/months 1-3 years 0.25 cm/ months (3cm/years) 3-5 years 1cm/year Measuring head circumference in a child

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25. MUAC For 1 to 5 years. Mid upper arm circumference is constant between 1 and 5 years. The circumference is around 16-17 cm. MUAC is measured with a measuring tape. Arnold’s classification: 1. Normal - Muac 16cm 2. Mild PEM: Between 13.5 and 16 3. Moderate PEM: Between 12.5 and 13.5 cm 4. Severe PEM: <12.4 cm

26. Shakir’s tape: This tape has three zones with the colour red, yellow, and green. This tape is placed over the mid arm to see in which zone the MUAC falls. This is simple and easy way to assess the presence of malnutrition. MUAC Colour Inference >12.5cm Green Normal 111.5-12.5 Yellow Borderline <11.5cm Red Wasted

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28. Triceps skin fold thickness Measured by a standard calliper (Lange or Harpenden) Used for children 1-6 years of age. Normal child- >10mm Mild malnutrition- 6-10 mm Moderate to gross malnutrition : <6 mm Caption

29. BMI It is defined as weight in kg per height in meters square (kg/m^2) Classification Asia (BMI) WHO(BMI) Under weight <18.5 <18.5 Normal 18.5-22.9 18.5-24.9 Over weight 23-24.9 25.0-29.9 Obese >=25 >=30

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31. Chest circumference At birth the circumference of chest is about 3 cm less than head circumference. Head circumference and chest circumference equals by end of first year . Thereafter , the chest circumference exceeds the head circumference. It is usually measured at the level of nipples. It can also be measured at the level of xiphisternum as the position of nipple varies. It should be done in a lying down position in children below 5 years of age .

32. Upper segment/Lower segment ratio The length between the vertex and pubic symphysis is the upper segment . The length between pubic symphysis and the heel is lower segment. The upper segment is not measured directly, but by subtracting the lower segment from the height or length of the child. This ratio is decreased in rickets due to vitamin D deficiency.

33. Normal upper segment/lower segment ratio in children Age Upper segment/lower segment ratio At birth 1.7:1 6 month 1.6:1 1 year 1.5:1 3 year 1.3:1 7 year 1.1:1 10 years 1:1 18 years 0.9:1

34. Growth Charts These are charts which are used to assess growth by plotting changes in weight , height, etc. We can also assess nutritional status of a child by plotting on these charts, as there are markers with z scores or percentile on these charts. Percentile curves illustrate frequency distribution of children based on selected body measurements. Z scores or SD score are the measures of dispersion from the median value A standard chart contains weight for age, height for age and weight for height. Head circumference can be marked till 3 years. The values of measurements (weight, head circumference, etc) are given in y axis,while age of the child is given on the x axis.

35. The revised IAP 2015 growth charts are recommended by IAP for use in children from 5-18 years. For children <5 years, IAP recommends the use of WHO 2006 growth standards. Z score = observed value— median value of the reference population/ SD value of reference population WHO recognises that Z score is an apt descriptor of malnutrition. While percentiles convey similar information, Z-scores are more useful for mathematical analysis and can be used to calculate mean, median and SDs or other summary statistics. It is worth noting how percentiles and Z-scores are interchangeable. For a growth chart, the upper and lower ends of a percentile chart at the 98th and 2nd centiles represent approximate Z-scores of +2.0 and -2.0. SD.

36. WHO -IAP combined growth chart for girls WHO-IAP combined growth chart for boys

37. Biochemical status Serum proteins : The visceral protein stores are assessed by measuring the serum proteins (albumin, prealbumin, retinol binding protein). Albumin is decreased in severe malnutrition. Reversal of albumin/globulin ratio is seen in malnutrition. Serum transferring < 0.45 mg/dL is suggestive of severe malnutrition. Albumin, prealbumin, retinol-binding protein and transferrin are acute phase reactants which decreases in response to infection. The positive acute phase reactants are C-reactive protein, ferritin, alpha 1 antitrypsin etc. Ratio of non-essential to essential amino acid : normal ratio 1.5, sub clinical PEM (ratio 2-4). And PEM > 4.

38. Lipid metabolism: Serum beta lipoprotein, phospholipid and cholesterol are decreased in PEM . Serum lipoproteins are decreased in Kwashiorkor but not in children with marasmus. Serum triglycerides are increased in marasmus and decreased in Kwashiorkor. Carbohydrate metabolism: Blood glucose is decreased in severe malnutrition. Minerals: Low potassium (hypokalemia), normal or increased sodium and decreased serum copper are seen in severe malnutrition. Urine analysis: Amount of creatinine excretion in the urine is constant between 1 and 5 years of age . Any decrease in creatinine excretion in the urine should arise a suspicion of malnutrition. Urinary hydroxyproline excretion index (HOP index) - molecules of hydroxyproline/mL/ molecules of creatinine /mL Normal HOP index is 2-5. Less than 2 indicates retarded growth.

39. Urinary hydroxyproline/creatinine excretion ratio: This ratio usually rises in the first 3 months of life. After 3 months, the ratio starts falling. The rate of fall is more from 3 months to 4 years and then falls gradually. The ratio falls to adult level by puberty. Urinary urea / creatinine ratio falls with decreased intake of proteins. Urinary 3-methyl histidine excretion is decreased in PEM. Urinary creatinine-height index: 24-hour urine creatinine/ 24-hour creatinine for a normal child of same height. Urinary creatinine-height index Inference 1 Normal 0.25-0.75 Kwashiorkor 0.33-0.85 Marasmus

40. Some biochemical tests used in nutritional surveys Nutrients Method used Normal values Vitamin A Serum retinol 20 mcg Thiamine Thiamine pyrophosphate stimulation of RBC transketolase activity 1.00-1.23 (ratio) Riboflavin RBC glutathione reductase activity stimulated by flavin adenin dinucleotide 1.0-1.2(ratio)

41. Nutrients Method used Normal ratio Niacin Urine N-methyl nicotinamide (Not very reliable) Folate Serum folate
Red cell folate 6.0 mcg/ml
160 mcg/ml Vitamin B12 Serum vitamin B12 concentration 160 mg/L Vitamin C Leukocytes ascorbic acid 15 mcg/10^8 cells Vitamin K Prothrombin time 11-16 sec

42. Clinical examination General appearance: Thin built , sickly Hair: Lack of lustre, Dyspigmented, Thin and Sparse. Easily pluckable. Flag sign (seen in Kwashiorkor.) Caption

43. Head: Craniotabes,Frontal bossing , Partietal bossing, Caput quadratum, Delayed closure AF( VIT D deficiency) Face: Diffuse pigmentation, Nasolabial dyssebacea (Vitamin B12 deficiency), Moon face (Kwashiorkor). Eyes: Conjunctiva- Dryness, Bitot’s spot( vitamin A deficiency), pale conjunctiva (Fe deficiency.) Cornea- Dryness, Haziness or Opacity (Vitamin A deficiency), corneal vascularisation (Riboflavin deficiency) Lips: Angular stomatitis, cheilosis (Vitamin B12 and Folate deficiency) Tongue: Pale and flabby , red and raw , fissured , Geographic (Vitamin B12 deficiency) Teeth: Mottled enamel, caries, attrition, Delayed and irregular eruptions (Vitamin D deficiency)

44. Gums: Spongy, bleeding (Vitamin C deficiency). Glands: Thyroid enlargement (Iodine deficiency) Neck : casal necklace (Niacin deficiency) Chest: Pigeon chest, beading of ribs ( Vitamin D deficiency), Rachitic rosary, Scorbutic rosary (Vitamin C deficiency), Cardiomegaly, Tachycardia (Thiamine deficiency) Abdomen: Harrison’s sulcus, Pot belly (Vitamin Deficiency), Hepatomegaly (PEM ), scrotal and vulval dermatosis. Spine: Kyphosis, Scoliosis, Rachitic pelvis (Vitamin Deficiency)

45. Limbs: oedema, Epiphyseal enlargement, knock knee or Bow legs ( Vitamin D deficiency) , Muscle wasting, oedema (PEM). Motor weakness, Calf tenderness (Thiamine deficiency).Frog position (Vitamin C deficiency). Skin: Dry and scaly, Follicular hyperkeratosis,Flaky paint dermatosis, (PEM), Petechiae (Vitamin C deficiency), Pellegrous dermatosis (Niacin deficiency). Acrodermatitis (Zn deficiency) Nail: Koilonychias

46. 4. Dietary history 1. Weighing of Raw foods Duration of survey may range from 1-21 days, but commonly employs 7 days. Which is called “one dietary cycle “. Involves weighing of all foods going to be cooked. Widely practiced in India, practical and fairly accurate.

47. 2. Weighing of cooked food: Foods should preferably be analysed in the state in which they are normally consumed, but this method is not easily acceptable among people. 3. Oral questionnaire methods: This is useful in carrying out a diet survey of a large number of people in a short time. Inquiries are made retrospectively about the nature and quantity of foods eaten during the previous 24 or 48 hours. If properly carried out, oral questionnaire methods can give reliable result The data that is collected have to be translated into (a) mean intake of food in terms of cereals, pulses, vegetables, fruits, milk, meat, fish and eggs, and (b) the mean intake of nutrients per adult man value or “consumption unit”.

48. Consumption unit In nutrition, a consumption unit is a standardised measure used to estimate the food and nutrient needs of individuals or households based on age, sex, and activity level. It allows comparison of dietary intake and requirements across different populations groups. A consumption unit (CU) represents the energy needs of a sedentary man aged 18-30 years, whose requirements is set at 1.0 cu (around 2400 kcal/day). All other individuals are then expressed as fractions or multiplies of this reference.

49. Typical Consumption unit table Age/Sex/Group Consumption unit Adult man (sedentary) 1.0 Adult women 0.8 Adolescent boy (14-18yrs) 1.0 Adolescent girls (14-18 years) 0.9 Child(10-12yr) 0.8 Child (5-9 yrs) 0.6 Child (1-4 yrs) 0.5 Infant (<1 yr) 0.3

50. Uses Estimating household food needs. Comparing food availability vs. requirement. Planning food distribution or rationing. Nutrition surveys and dietary intake studies.

51. Vital statistics Mortality data 1. Mortality in 1-4 years age group 2. Infant mortality rate 3. Neonatal mortality rate 5. Under 5 mortality rate Mortality data however, do not provide a statisfactory picture of nutritional status of population. Uses 1. Identify the groups at high risk. 2. Indicate the extent of risk to the community.

52. Radiological Assessment Parameters like bone age should be assessed. Bone age is retarded and is less than chronological age in a child suffering from malnutrition. In chronic malnutrition, height is decreased. The bone age may correspond to height age. The following radiological findings may be seen: Osteoporosis Transverse lines at the long end of bones due to periods of arrested growth. Features of scurvy. Rickets: It is not manifested in severely malnourished child as the growth of bones is delayed. As rickets manifests in the growing bones, features of rickets will manifest during treatment.

53. Classification of PEM Indicators Acute malnutrition Chronic malnutrition W/A ( underweight) Low Low H/A(Stunting) Normal Low W/H Low Normal

54. WHO classification Parameters Moderate under nutrition Severe under nutrition Symmetrical oedema Absent Present (oedematous malnutrition) Weight for height (measure of wasting) Z score or SD score between-2 to -3 (70-90% of expected wasting) Z score or SD score <-3 (70% of expected severe wasting) Height for age Z score or SD score between-2 and -3 (85% -89% of expected) stunting Z score or SD score <-3( <85% of expected) severe stunting

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57. Thank You!