Manual of Pediatric Nutrition, THIRD EDITION

598 Pages·2007·16.56 MB·English

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Contents
Part 1 Nutrition and the Well Child
1 Nutritional Assessment: Dietary Evaluation .........1
Kristy M.H endricks, RD, MS, ScD
2 Nutritional Assessment: Anthropometrics and Growth . 8
Krise M. Hendricks, RD, MS,S cD
3 Nutritional Assessment: Clinical Evaluation ........5 2
Kristy M.H endricks, RD, MS, ScD
4 Laboratory Assessment of Nutritional Status ....... 66
Clodagh M. Loughrey, MD, MRCP: MRCPath
Christopher Duggan, MD, MPH
5 Nutritional Requirements:
Dietary Reference Intakes ...................... 77
Linda Gallagher Olsen, MEd, RD
6 Breastfeeding. ................................ 86
Jill Kostka Fulhan, MPH, RD
7 Introduction of Solids ......................... 106
Luurrn R. Furura, MOE, RD
8 Feeding Guidelines for Children and Adolescents ...1 I6
Isahel M. Vazquez, MS, RD
Jun t? Hangen, MS, RD
9 The US Department of Agriculture’s Food
Guide Pyramid .............................. I3 I
Lrurir A. Higgins, RD
10 Vegetarian Diets ............................. 135
Heidi Schuuster; MS, RD
11 Sports Nutrition ............................. 14 1
Sirsari E. Frates, MS, RD
ix
NUTRITIONAL
ASSESSMENT
DIETARY EVALUATION
Kristy M. Hendricks, RD, MS, ScD
Nutritional assessment is the tool by which the nutrition-
ist evaluates the patient far maintenance of normal growth
and health, risk factors contributing to disease, and early
detection and treatment of nutritional deficiencies and
excesses. Comparison of an individual with an established
norm provides a basis for objective recommendations and
evaluation of nutrition therapy.IT2 Although much infor-
mation has been published on the use on increasingly
sophisticated techniques, clinical judgment and perceptive
history taking remain important overall components of
nutritional assessment.' In children, this includes family
history, developmental assessment, medical history
including growth history, and physical examination
including anthropometry. Nutritional assessment in chil-
dren has special significance because undernutrition is the
single most important cause of growth retardati~nA.~c ute
and chronic malnutrition remain common in hospitalized
pediatric patients in the United States, underscoring the
need for early detection and treatment of nutritional defi-
~iencyI.n~ a ddition, in the United States, overnutrition in
the pediatric population has risen significantly,6 and the
association of obesity with chronic diseases in adulthood
such as heart disease and diabetes is strong; thus, nutrition
assessment is equally important for the early referral and
treatment of nutrition excess.
1
2 Part 7 Nutrition and the Well Child
A combination of anthropometric. biochemical. clinical,
and dietary infor~~iatiofno rms the basis of evaluation. As no
one parameter is completely satisfactory with regard to sen-
sitivity and specificity. various tests monitor diff'erent aspects
of nutritional status in each category. Standards that are rele-
\wit to a specific population are important, ;is are appropri-
ate techniques and equipment for measurement. Throughout
this manual, guidelines ;ire provided to help determine where
to begin the assessment of an individual (Table 1-1 1. what
t]r'peo f ;is~essmenti s likel~t.o yield valuable screening infor-
mation, and how and when to proceed with more extensive
and costly evaluation. An example of a worksheet for data
collection and assessment on general pediatrics is included
(Table 1- 2).' Dietary insufticiency or excess generally pre-
cedes signs of bioche~nical,a nthropometric, or clinical defi-
ciency, and guidelines for dietary assessment are included in
this chapter. The various indices of anthropometry, reference
stundards, techniques. interpretation, and classification of
malnutrition are detailed in Chapter 2. Clinical evaluation is
covered in Chapter 3. Biochemical parameters useful in
nutritional assessment, are included in Chapter 3. This infor-
mation provides guidelines related to basic nutritional assess-
ment: reconiinendations for specific disease states and nutri-
tion therapies are discussed throughout the manual. The fol-
lowing are excellent general reference sources for pediatric
nutritional assessment: The Centers for Disease Control
(Nutrition I>i\~ision, Atlanta. Georgia) Anthropometric
Software Package. which can be used to calculate height and
weight percentile, Z score. and rnalnutrition category relative
to the National Center for Health Statistics (NCHS) reference
growth standards: the American Academy of Pediatrics
Potlirrtric. Nictritioti Hmdhook;' and @4trlitj~ Assicrtrric*e
Critork ,fOr Ptditrtrii. iVirtritioii Coriciitioris, prepared by
Dietitians in Pediatric Practice Group and published by the
American Dietetic Association. Chicago, Illinois."
Chapter 1 Nutritional Assessment Dietary Evaluation 3
Table 1-1. An Approach to the Identification of Nutritional Problems
Screening Dietary Clin/ca/ Anthropometric Biochemical
Routine
To be done on all patients Typical dietary pattern Physical and Weight, length, Hemoglobin.
If problems are indicated, (food pyramid/food dental history head hematocrit, MCV,
additional midlevel or frequency), vitamin and and examination, circumference. total cholesterol
in-depth parameters mineral supplement, sexual maturation. weight for height. (LDL dependent
should be evaluated family eating habits use of and BMI on total cholesterol, see
subsidy support medication(s) Table 29-2, page 436)
Midlevel. add
As indicated by routine 24-hour recall and More extensive Height and weight Albumin, total protein,
screening or in 3- to 7-day examination 2 score, triceps total lymphocyte
populations at risk for food records, (eg. skin, hair skinfold, arm count
chronic nutrition problems developmental nails) circumference,
and children with special evaluation of prediction of
health care needs feeding skills mature height
In-depth. add
As indicated in acute Same, observation Bone Height velocity Specific vitamin. mineral,
and chronic PCM and in hospital mineralization and electrolyte levels or
to monitor chronically (eg. epiphyseal enzymes and proteins
ill patients enlargement. that require that nutrient.
cranial bossing), delayed cutaneous
bone age hypersensitivity (see
Table 4-2 pages 71-6)
BMI = body mass index. MCV = mean corpuscular volume, LDL = low-density Iipoprotein, PCM = protein calorie
malnutrition
4 Part 7 Nutrition and the Well Child
Table 1-2. Pediatric Nutritional Assessment Data Sheet
Name - _____
Date _______________
Date of birth
History
Presenting problems
__ ~__~_- -- --__-___
______ - ___--_________
Growth history _____________-_____
_________ _-__ ~___~____--__-___--
__ - ____ ____
Anthropometric Data
Weight kg percentile o/o standard
Height ____ cm ____~ __p-e rcentile o/o standard
WeighVheight percentile
BMI ___
Head circumference cm percentile
Skinfold thickness mm percentile
Arm circumference cm -____ percentile
Biochemical Data
Hemoglobin -
He matoc r it
MCV--____----
Albumin ___ _____
Total protein
Clinical Data
Signs or symptoms of nutrient deficiencies or excess -
Classification of malnutrition _ _ _ _ ~
__ ~ _ _ _ _ _ - ~ -
Dietary Data
Estimated calorie i nt a ke from __________
Chapter 1 Nutritional Assessment: Dietary Evaluation 5
Table 1-2. continued
kcallday kcallkg
g protein proteinlkg o/o kcal
g fat Ol0 calories
g carbohydrate Y0 calories
Vitamin/mineral supplement type and amount
Feeding skills and behavior appropriate for age: L1 yes G delayed
Use of: 0 Food stamps U WIC Other
Recommendations
Ideal weight for height kg
Recommended kcallday
Recommended proteinlday
Dietary inadequacy or excess is frequently the cause of
under- or overnutrition and often precedes biochemical,
anthropometric, or clinical signs; thus, evaluation of an
individual’s diet plays an important role in nutritional
diagnosis and treatment. Quality and quantity of food
intake and the macro and micronutritients provided can be
measured using a variety of techniques. In addition, past
dieting history, development of feeding skills. abnormal
eating habits, difficulty in feeding. and activity le\.el
should be assessed.
A number of methods are available for the collection
of information about food consumption.I0 Some are more
appropriate for the assessment of population data on food
intake. In the clinical setting, where individual informa-
tion is important, more detailed and precise methods are
generally used. The most comnmn dietary assessment
6 Part 1 Nutrition and the Well Child
tools in clinical practice ;ire the ?+hour recall, 3- to 7-day
food records. or "usual p:itterns" described by the patient
or caregit'cr. A complete dietary history combines a num-
ber of methods bvith the gathering of medical and clinical
i ii form at i on re I at i \re to diet iir y ;is se ss me n t .
Each method has certain weaknesses and limitations,
ancl difficulty in quantifying and qualifying actual intake
is w ~ ldlo cumented. I I I' Patients of normal weight give
the most accurate record whereas underweight patients
o \re res t i nia t e ancl ovenve i g h t patients underestimate act u-
:il food consumed. Similarlqr. assessInents of dietary intake
o\w long periods tend to overestimate actual intake. and
those co\wing ;I short period tend to underestimate intake.
Because of considerable differenccs in nutrient intake data
o b t a i ned bq' d i ffe re n t t ech n i q U e s , twia b i I i t y of i n t ake
from day to day, and difficulty in obtaining information on
children by difterent care providers, it is helpful in some
cases to use a combination of methods ( 2-4-hour recall
with 3-day food records) to provide ;i more complete and
accurate dietary e\.aluation. Emphasis should be placed on
careful questioning and detailed recording of intake.
Additional limitations to the accurate assessment of
intake include a wide variety of food composition tables
and computerized datnbases for analysis and difficulty in
' '
c s t ;I b 1i s h i n g act U a 1 n U t rie n t needs. 2*
References
I. Blackburn CL, Bi\trian BK. Maini BS, et al. Nutritional and
mctaholic a\scssiiient of the ho\pitalid patient. J Pcdiatr
Endocrinol Metab 1977; 1 : I I.
2. Lee RD. Nieman DC. Introduction to nutritional assessment.
In: Nutritional :isscssment. 2nd ed. St Louis: Moshy; 1996.
3. 13nher JP. Dctsk~A, S. Mi'chson DE. et al. Nutritional assess-
rncnt: c.ompiiri\on of clinical judgment iind ohjccti\rc ITIU-
\iircnicnls. N Engl J Mccl I982:306:969.
Chapter 1 Nutritional Assessment: Dietary Evaluation 7
3. Duggan C. Failure to thrive: management in the pediatric
outpatient setting. In: Walker WA, M'atkins JB. editors.
Nutrition in pediatrics. Toronto: BC Deckcr; 1996:705- 15.
5. Hendricks KM, Duggan C. Gallaghcr L, et al. Slalnutrition in
h osp i t al i zed ped i at ri c patients : c u rre n t p re \,a Ie n cc' . Arc I1
Pediatr Adolesc Med 1995;1 49: 1 1 18-22.
6. I n t erage nc y Board for Nutrition M on i tor i n g and R c I ii t e d
Research. Third report on nutrition monitoring in thc United
States: executive summary. Washington (DC) : LIS Government
Printing Office: 1995: 159-97.
7. Laramee SH. Hendricks KM. De\.elopment and use of pedi-
atric nutrition and metabolic \vorksheet. Abstracts of the
American Dietetic Association 1979.
8. American Academy of Pediatrics Committee on Nutrition.
Pediatric nutrition handbook. 4th ed. Kleinman RE, editor.
Elk Grove (IL): American Academ). of Pediatrics; 1998.
9. Quality Assurance Committee. Pediatric Nutrition Practice
Group. Quality assurance criteria for pediatric nutrition con-
ditions: a model. Chicago (IL):A merican Dietetic Association:
1993.
10. Lee RD. Nieman DC. Nutritional assessment. 2nd ed. St Louis:
Mosby; 1996:9 I- 145.
1 I. National Research Council, Food and Nutrition Board.
Recommended dietary allowance. Washington (DC):N ational
Academy of Sciences; 1989.
12. Carter RL. Sharbaugh CO, Stapell CA. Rcliabilitj, and \did-
ity of the 24-hour recall. J Am Diet Assoc I98 1 :79:549.
13. Karvetti RL, Knuts LR. Agreement between dietary inter-
views. J Am Diet Assoc 198 I :79:654.
13. Stunkard AJ. Waxman M. Accui-ac>,o f self-reports of food
intake. J Am Diet Assoc I98 I ;79:537.
2
NUTRITIONAL
ASSESSMENT
ANTHROPOMETRICS
AND GROWTH
Kristy M. Hendricks, RD, MS, ScD
Anthropometric Evaluation
Physical growth is, from conception to maturity, a complex
process influenced by environmental, genetic, and nutrition-
al factors. Anthropometry is the measurement of physical
dimensions of the human body at different ages. Comparison
with standard references for age and sex helps determine
abnormalities in growth and development that may have
resul red from nutrient deficiencies or excesses. Reference
standards (included here) are derived from measurements of
a normal population. Revised standards are expected to be
available soon. Repeated measurements of an individual
over time provide objective data on nutrition, health, and
well-being. Errors in the comparison of measurements
taken at different times can be caused by poor technique
and equipment. Detailed descriptions of standardized tech-
niques and equipment can be found in other sources.'.?
Weight
Body weight is a reproducible growth parameter and a good
index of acute and chronic nutritional status. An accurate
age, sex. and reference standard is necessary for evaluation.
Weight is evaluated in three ways: weight for age. weight
for height, and body mass index (BMI). Weight for age
compares the individual to reference data for weight
8