ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN.pptx

An essential and integral part of clinical care in paediatrics
No single method is complete in itself, and each has its own advantages and disadvantages. A combination of the different methods is essential.
Height, weight and OFC measures indicate growth status while MUAC and SFT indicate body composition

1. ASSESSMENT OF NUTRITIONAL STATUS IN CHILDREN

2. Assessment of nutritional status in children - An essential and integral part of clinical care in paediatrics A malnourished child

3. Methods used to assess Nutritional Status in children include: Anthropometric A ssessment Biochemical A ssessment Clinical A ssessment Dietary A ssessment

4. N.B . Rapid growth and development in children is dependent on genetic makeup and nutritional status Nutritional assessment helps to: Identify nutrient deficiency and excess early Designing appropriate interventions No single method is complete in itself, and each has its own advantages and disadvantages. A combination of the different methods is essential.

5. Ø Anthropometric Assessment. Anthropometric parameters include Height, Weight, OFC, MUAC and Skin Fold Thickness Height: - Indicates long term nutritional status
- Serial measurement more beneficial than single measurement Limitations include: - Influenced by non nutritional factors (genetics and hormones)
- Requires accurate standiometer

6. Weight: - Basic measure of nutritional status
- Trends overtime are better than a single measurement Limitations include: - It requires accurate scales. OFC: -Simple to measure Limitations include: -It is influenced by non nutritional factors -It is not beneficial for assessing nutritional status N.B. Height, weight and OFC measures indicate growth status while MUAC and SFT indicate body composition

7. N.B. 1. Measurement of length is 0.5 – 1.5cm greater than measurement of height.
2. In children greater than 2 years or taller than 85cm , subtract 1cm from the length measurement before comparing to reference values.
3. Height and length should be recorded to the nearest 0.1 cm. 4. Weight should be recorded to the nearest 0.1kg. 5. OFC should be recorded to the nearest 0.1cm

8. Anthropometric measures of body composition; MUAC - Indicates the amount of subcutaneous fats and muscle mass
- Changes in its measure are positively and strongly correlated with changes in weight
- It is recorded in the nearest 0.1cm
- It is a portable measure and no need to check height or weight
- Can be used in emergency situations or rapid surveys Limitations include: - Under nutrition may be possibly overestimated in younger children and underestimated in older children
- May be age dependent

9. SFT - Indicates the amount of total body fat and subcutaneous fat
- It is commonly measured around biceps, triceps, subscapularis, mid axillary and superciliary areas
- Measurement from a minimum of two site are recommended. Preferably the limb (e.g triceps) and the body (subscapularis) as they serve a measure of body fat
- Should be recorded to the nearest 0.2mm using the loltane calipers
- Can be used in community nutrition surveys Limitations include: - Single site may not represent whole body fat
- Limited value for assessing under nutrition in children
- Inter-observer variability
- Absence of reference data
- Requires well trained staff to measure

10. Ø Clinical Assessment Children who present to a facility of health should be assessed based on the IMCI strategy. Initially, child should be evaluated for signs of danger such as
- Irritability
- Convulsion
- Persistent vomiting
- Lethargy
- Loss of consciousness
Following the initial assessment, clinical assessment of nutrition should be done examining by the Skin, Eye, Hair, Nails, Mouth, Muscle Bulk, Subcutaneous Tissue, Thyroid, Bones, And Abdomen.

11. Ø Dietary Assessment < 2 years - Exclusive breast feeding or formula feeding (AFASS)
- Complementary feeding (FADUS)
Type; amount; frequency of feeding; method of preparation; brand ≥ 2 years - Quantity, type and frequency of food consumed daily
- Feeding environment, habits and patterns In all children -Appetite -Dietary restrictions -Food aversions -Drug use (vitamins, supplements and minerals)

12. Methods of dietary assessment A. 24 – in recall - Relatively easy to perform
- Provides detailed information on food consumed
- Can be used to quantify nutrient intake Limitations include: - Single recall may not represent usual intake
- Under or over reporting possible
- Omission can lead to low energy intake estimate

13. Methods of dietary assessment B. Food frequency questionnaire (may be daily, weekly, monthly or yearly) - Inexpensive
- Can be used to assess association between diet and dz Limitations include: - Not appropriate for the dietary assessment of single patient
- Portion size are not determined
- Cannot be used to determine nutrient intake
- May not represent seasonal foods

14. Methods of dietary assessment C. Food records - Not memory dependent
- Provide information on early habits
- More representation of actual intake
- Reasonably valid up to five days Limitations include: - Time consuming
- Diet may vary with need to record
- Analysis is expensive

15. Methods of dietary assessment D. Diet history (over a month or year) - Can detect seasonal changes Limitations include: - Time consuming
- Can overestimate intake
- Provide qualitative rather than quantitative data

16.  Plasma proteins and acute illness Note: protein produced by the liver is reduced when Supply of amino acids is lower Liver mass is reduced Clinicians have used these plasma proteins for nutritional assessment but they are also affected by metabolic stress:

17. Positive acute phase reactants Negative acute phase reactants C- reactive protein Albumin Fibrinogem Pre albumin Hepatoglobulin Retinol-binding protein Ferritin Transferrin Ceruloplasmin Alpha-l- antitrypsin Alpha-l- glycoprotein N.B. The magnitude of the effect of the protein acute phase reaction is attenuated during PEM.

18.  Ø Biochemical Assessment N.B. This method is not routinely recommended to evaluate nutritional status . Nutrient Test Usefulness Limitations Protein 1. Serum protein Poor ↓ 2. Nitrogen balance Good ↓ 3. Transferring transthyretin Good

19. Nutrient Test Usefulness Limitations Vitamin A 1. Serum retinol Poor ↓ 2. Retinol binding protein Poor ↓ Vitamin D Plasma Ca. P Good May be first sign of deficiency Folate 1. Serum folate Good Reflect recent uptake 2. Red cell folate Good Reflect whole body uptake Iodine 1. Thyroid function test Good

20. Nutrient Test Usefulness Limitations Iron 1. Serum ferritin (released from the liver) Poor ↑ well acute phase response 2. Serum iron and transferritin Poor ↑ well acute phase response Zinc Plasma zinc Poor ↓ during states of inflamation N.B. MCV or MCHC are better indicators of Fe stores in acute inflammatory conditions. Also soluble Fe receptors are markers of cellular Fe index - Vitamin E is studied with Serum vitamin E assays or ratio of Vitamin E to other lipids

21. SUGGESTED SCHEDULE FOR GROWTH ASSESSMENT Age Weight Height OFC HOSPITALISED Preterm Daily weekly weekly Full term to 12 months 3*/wk monthly monthly 1-2 years 3*/wk monthly monthly 2- 20 years 2*/wk monthly As indicated Outpatient well child 0-2 months Monthly monthly monthly 2-6 months 2 monthly 2 monthly 2 monthly 6months-2 years 3 monthly 3 monthly 3 monthly 2yrs-6yrs Annually annually - 6yrs – 10years 2 yearly 2 yearly - 11yrs- 20yrs Annually annually -

22. Growth Indicators and Components of Growth Chart · Indicators for assessing growth
- L/H for age
- WFA
- Weight for length/ height
- BMI for age · Components of growth chart
a. x- axis (age or length or height)
b. y- axis (L/H or weight or BMI)
c. plotted points Determining Age of the Child · Tools for determining child’s age
- Computerised system
- WHO child age calculation · If date of birth is unknown
- Local event calendar · Preterm infants
- Use ‘ corrected age” for the 1 st 3years of life

23. Formula to calculating corrected age Chronological age – ([40wks – age of preterm in weeks] * 1month/4wks)
e.g. corrected age of a 24 months old male born at 28 weeks =
24 – ([40-28] * 1 month/4 weeks)
= 24 months – (12)wks
= 24 months - 3months
= 21 months L/H FA WHO growth chart - Helps to identify children with stunting or excessively tall for age
- Z - Score interpretation · >3 very tall · <-2 stunting of stunted ( depending on age) · < -3 sever stunting or stunted (depending on age)

24. WFA WHO growth chart - Helps to assess whether a child is underweight or severely underweight
N.B. it cannot be used to classify a child as overweight or obese
* It also cannot be used when a child’s age cannot be accurately determined.
- Z- score interpretations
* < -2 underweight
* <-3 severely underweight Points to Remember · In children with edema of both feet, the weight may appear to be ↑ed due to the fluid retention and thus, the presence of very low weight may go unnoticed. · In such instance, Plot the child’s WFA and WFL/H and mention clearly near the plotted point that the child has edema · Such children should be considered severely undernourished and referred for specialized care

25. WFL/H WHO Growth chart - Help to identify children with: · Low WFH (wasting or severe wasting) · High WFH (at risk of becoming overweight or obese) Z - Score interpretations >3 – Obese
>2 – Overweight
>1 – Possible risk of becoming overweight
<-2 – Wasted
<-3 – Severely wasted N.B. L/H measurements are rounded off to the nearest whole cm before plotting

26. BMI for age WHO’s growth chart - Useful to screen for overweight and obesity. Z – Score interpretations > 3 – obese
> 2 – overweight
> 1 – possible risk of becoming overweight
< -2 – wasted (thin for 5 – 19 years)
< -3 – severely wasted ( severely thin for 8 – 19 years) N.B. To plot BMI on a chart, first plot the age ( in completed wk, month, or year) on the vertical line and then BMI on the horizontal line or in between lines. BMI is recorded to the nearest decimal point.

27. WFL/H vs BMI for age for children < 2years N.B . WHO recommends the use of BMI for age charts in children and adolescents ( i.e. birth to 19 years) N.B. CDC recommends use of BMI for age chart only in children aged ≥2 yrs and not in those <2 yrs of age. N.B. according to CDC, a child aged ≥2 years is considered overweight if the BMI – for – age is in the range of 86 th to less than 95 th percentile and obese if the BMI – for – age is > 95 th percentile N.B. WFA cut-off only applicable for children up to 10 years of age. N.B. According to WHO Global Database on child growth and malnutrition: A. A Z-score cut-off point of <-2 for WFA, HFA and WFH chart indicates moderate and severe under-nutrition.
B. A Z-score cut off point of <-3 for WFA, HFA and WFH chart indicates severe under-nutrition N.B. Some countries prefer to use CDC Z–score to classify under-nutrition

28. Composite Assessment of Growth and Nutritional Status - All growth chart should be considered together, especially if only one chart indicate a growth problem
- Trends should be observed over time
- Trends parallel to the median Z- score indicates normal growth Red Flags - Flat growth line
- Growth line crossing the Z-score line
- Sharp incline or decline in growth line N.B. A sharp incline or decline may be good in some cases such as catch up growth (weight gain after illness) or catch down growth (weight loss in an obese or overweight child) respectively. N.B. Food based dietary guidelines (FBDG) are specific to each nation.

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