Chapter 152C - Neuroleptic Malignant Syndrome and Serotonin Syndrome

Editors: Perkin, Ronald M.; Swift, James D.; Newton, Dale A.; Anas, Nick G.
Title: Pediatric Hospital Medicine Textbook of Inpatient Management, 2nd Edition
Copyright ©2008 Lippincott Williams & Wilkins
> Table of Contents > Section XVIII - ▪ Nutrition > Chapter 141 - ▪ General Principles of
Nutritional Assessment
Chapter 141
▪ General Principles of Nutritional Assessment
Kristin J. Brown
John M. Olsson
Nutritional assessment of the pediatric patient involves interpretation of data divided into five
major categories: anthropometric, physical, laboratory data, as well as social and dietary history.
There is no single marker for assessment of nutritional status at this time, and health care
professionals must evaluate information from each of these categories to determine nutritional
status and develop a plan of care. This chapter's intent is briefly to review these categories and
discuss ongoing controversies in interpretation. Children with special health care needs often
require intensive nutrition therapy, and therefore some of this population's unique nutritional
needs are discussed in summary.
ANTHROPOMETRIC DATA
Accurate gathering of anthropometric data is essential. The standard data collected on admission
should include weight, length/height, abdominal girth, and head circumference. Children older
than 3 years of age do not require abdominal girth and head circumference measurements unless
clinically indicated. Standard growth charts are available from the National Center for Health
Statistics and the National Center for Chronic Disease Prevention and Health Promotion
(www.cdc.gov/growthcharts). These tools allow the health care professional to compare each
patient measurement with those of the general population of this country and to track growth
patterns over time. Each measurement is best used when it is evaluated in relation to the other
anthropometric measurements. For example, weight for age is useful, but when the weight-to-
length ratio is reviewed concurrently, the two together give a greater understanding of the growth
characteristics of the child. Length (supine) is recorded for children up to age 2 years, whereas
height (standing) is recorded for older children and adolescents. The weight-to-length ratio is
recorded for infants and toddlers, whereas the body mass index (BMI) and weight-to-height ratio
are used for children older than 2 years of age:
BMI = Weight (kg)/Height (m)2
It is of particular importance to assess serial growth measurements whenever possible; growth
history is a key factor in nutritional assessment. Many infants move into different age-specific
growth percentiles over time, changes that may be determined by genetic potential and
nutritional support. Assessing patterns of all anthropometric measurements is useful. For
example, in undernourished children the weight percentiles will slow first, then length, and last
of all the rate of growth of head circumference. Additional nutrition support via enteral or
parenteral routes may enable a child to grow along a given percentile; this growth pattern may be
different from genetic potential, and therefore care must be taken when weaning nutrition
support to set appropriate and individualized nutritional goals. Consideration must also be given
to patients whose anthropometrics indicate obesity. Selecting an adjusted body weight on which
to base pharmacologic and nutritional decisions is of great importance in the acute-care setting.
There are several methods available; however, a widely utilized calculation for adolescents is:
[(ABW - IBW) × 0.25] + IBW = Adjusted Body Weight
where ABW is the actual body weight and IBW is the ideal body weight. Ideal body weight is
the 50th percentile weight for the child's height as noted on the standard pediatric weight-for-
height chart.
Some infants and children have medical conditions with special health care needs that affect their
growth pattern and warrant the use of specific growth charts. Such growth charts include, but are
not limited to, those for children with prematurity, low or very low birthweight, cerebral palsy,
Down syndrome, and Prader-Willi syndrome (http://depts.washington.
edu/growth/cshcn/text/page6a.htm). There also are growth charts specific for race and ethnic
background. An extensive medical evaluation for failure to thrive may be avoided by plotting
anthropometric data on appropriate growth charts and by accounting for prematurity. Additional
measurements, such as midarm circumference, midarm muscle circumference, and triceps
skinfold, may be useful to assess muscle and adipose tissue stores in children with special health
care needs. Because using the triceps skinfold is controversial, caution should be taken in
interpreting results from a single measurement. Although there are standard techniques for
obtaining measurements such as triceps skinfold, application of these techniques may vary
slightly between clinicians, which in turn may lead to a wide range of results. These types of
measurements can only be helpful in monitoring body composition if the same experienced
individual is able to obtain serial measurements for a given child.
PHYSICAL EXAMINATION DATA
The physical assessment should focus on identifying potential anomalies related to energy,
protein, vitamin, and mineral deficiencies. Particular findings on examination may suggest
nutrient deficiencies or toxicities (Table 141.1). Some children may present with abnormal
growth patterns resulting from a change in nutritional intake, energy expenditure, metabolism, or
absorption of nutrients. This may occur because of individual or cultural preferences, or as a
result of acquired physical disabilities. Physical limitations may be as obvious as those
associated with surgical interventions, or they may be as subtle as enzyme deficiencies. During
the physical exam, presence of ascites; enlarged organ size; abnormal hair, nail, or skin quality;
reflexes; tone; dentition and mucosa; and bone age or density can all help in interpretation of
nutritional status.
P.792

TABLE 141.1 PHYSICAL EXAMINATION FINDINGS ASSOCIATED WITH

DEFICIENCY AND TOXICITY OF ESSENTIAL NUTRIENTSa
Nutrient Deficiency (inadequate nutrient) Toxicity (excessive nutrient)
Carbohydrate Ketosis Obesity, diarrhea, dental caries
Protein Edema, easy hair pluckability, skin Acidosis, azotemia,
degradation, poor wound healing, hyperammonemia
lymphopenia, impaired immune function,
fatty liver, growth retardation
Fat Poor growth, poor wound healing, eczema, Obesity, coronary artery disease,
hair loss cancer, abnormal lipid panel
Vitamin A Growth retardation, retinal degeneration, Hair loss, dry itchy skin, jaundice,
hyperkeratosis, Bitot spots, follicular fatigue, bone pain, abdominal
hyperkeratosis, night blindness pain, headache, hepatomegaly,
 vomiting, hypercalcemia
Vitamin D Osteomalacia, rickets Impaired renal function,
hypercalcemia, anorexia,
impaired growth, emesis
Vitamin E Retinopathy, neuropathy, increased Impairs normal physiologic
hemolysis, myopathy, peripheral neuropathy response of iron; may interfere
with vitamin K activity
Vitamin K Hemorrhages, cirrhosis, prolonged clotting, Hemolytic anemia, kernicterus
ecchymoses, petechiae
Ascorbic acid (C)Scurvy, inadequate wound healing, joint Increased uric acid excretion,
tenderness, capillary hemorrhaging, gastrointestinal distress
gingivitis, petechiae
Thiamin (B1) Beriberi, cardiac failure, edema, anorexia, None known
increased intracranial pressure, confusion,
neuropathy, muscle tenderness
Riboflavin (B2) Photophobia, itchy eyes, cheilosis, glossitis, None known
scrotal skin changes, seborrheic dermatitis
Niacin (B3) Pellagra, apathy, cheilosis, angular Dilation of the capillaries
stomatitis, anorexia, peripheral neuropathy, (flushing), tingling, dizziness,
encephalopathy, diarrhea, dermatitis nausea, diarrhea
Pyridoxine (B6) Microcytic hypochromic anemia with high Sensory neuropathy, progressive
serum iron, weakness, convulsions, ataxia
depression, oxalate stone formation,
nervousness, insomnia, glossitis, stomatitis,
cheilosis
Cyanocobalamin Megaloblastic anemia, leukopenia, None known
(B12) thrombocytopenia, neurologic deterioration,
stomatitis, glossitis
Folic acid Megaloblastic anemia, leukopenia, None known
thrombocytopenia, poor growth, glossitis,
stomatitis, diarrhea, malabsorption
Biotin Anorexia, nausea, vomiting, glossitis, None known
depression, hypercholesterolemia, insomnia,
dermatitis, thin hair
Pantothenic acid Infertility, abortion, slow growth, Diarrhea, water retention,
depression, vomiting, fatigue, abdominal hemochromatosis, hemosiderosis
distress, insomnia, muscle cramps,
burning/tingling feet
Iron Hypochromic microcytic anemia, Vomiting, sweating, dizziness,
malabsorption, irritability, tachycardia, copper deficiency
anorexia, pallor, lethargy, koilonychia
Zinc Decreased wound healing, decreased Nausea, vomiting, headache,
growth, diarrhea, hypogonadism, mild diarrhea, cramping, Wilson
anemia, decreased taste acuity, decreased disease, anemia
cellular immunity, rash
Copper Hemolytic microcytic anemia, neutropenia, Neuropsychiatric disorders in
 Menkes syndrome very high doses
Manganese Impaired growth, skeletal anomalies, Hair loss, brittle nails, fatigue,
neonatal ataxia, poor reproductive function, irritability, tooth decay, peripheral
defects in fat and carbohydrate metabolism neuropathy
Selenium Cardiomyopathy, nail changes, myalgia, Thyroid enlargement
muscle tenderness
Iodine Endemic goiter, hypothyroidism, cretinism
Chromium Hyperglycemia, negative nitrogen balance, None known
impaired growth, peripheral neuropathy,
increased low-density lipoprotein cholesterol
Fluoride Dental caries Mottling of teeth
Molybdenum None known Gout-like symptoms, antagonist
to copper
a
Arsenic, boron, nickel, silicon, and vanadium are ultratrace elements. There are inadequate
reports to define deficiencies and toxicities for inclusion in this table.
P.793

TABLE 141.2 GENERAL GASTROINTESTINAL SECRETION AND ABSORPTION

SITES
Site Secretion Absorption
Mouth/esophagu Salivary amylase Carbohydrate
s
Stomach Gastric lipase Alcohol
Pepsin
Hydrochloric acid
Intrinsic factor
Duodenum Pancreatic enzymes Iron
Bicarbonate Chloride
Bile Sulfate
Calcium
Magnesium
Jejunum Intestinal brush border Glucose, galactose, fructose
enzymes Vitamin C
Thiamin
Riboflavin
Pyridoxine
Folic acid
Ileum None Protein
Vitamins A, D, E, K
Vitamin B12
Fat
Cholesterol
Bile salts
Sodium
Potassium
Colon None Vitamin K (formed by bacterial action)
Water
Rectum/anus None
Vitamin deficiencies often are associated with malfunction of specific absorption sites in the
gastrointestinal tract, either as a result of physical manipulation or faulty enzymatic processes.
Table 141.2 outlines the general secretion and absorption sites in each section of the
gastrointestinal tract. The boundaries of secretion and absorption are not discrete, and labeled
areas may overlap.
Children with special health care needs are particularly at risk for nutritional toxicities or
deficiencies; aggressive identification and treatment of these is essential for achievement of full
growth potential. Children with chronic medications including, but not limited to,
anticonvulsants, anticoagulants, steroids, diuretics, or narcotics should be regularly evaluated for
anomalies due to medication interactions. Children with intestinal resections, liver disease,
chronic inflammatory states, allergies, renal diagnoses, or lymphatic involvement are at higher
risk for vitamin and mineral deficiencies and toxicities.
DIAGNOSTIC/BIOCHEMICAL DATA
There is no single laboratory test for malnutrition, and therefore the clinician must rely on
several biochemical indicators to help determine nutritional status. The analysis of serum protein
levels such as albumin, prealbumin, retinol-binding protein, and transferrin, along with bone
minerals, is a reasonable screening process for malnutrition. Each of these laboratory values is
affected by the function of certain organ systems, and normal values may vary by laboratory.
Renal or liver disease, infection, dialysis, altered nutrient intake, and catabolism all affect serum
protein values. Albumin is a serum protein that functions as a transport protein and as a
determinant of oncotic pressure. Its half-life of 14 to 20 days makes it useful as a screening tool
for chronic undernutrition, but not as useful in acute malnutrition. Transthyretin, or prealbumin,
with a half-life of 2 to 3 days, is suited to assess trends in response to acute changes in therapy.
Transferrin (half-life of 8 to 10 days) is a sensitive indicator of iron balance as well as visceral
protein status. Because it is affected by inflammation, infection, catabolism, hepatic or renal
disease, state of hydration, iron deficiency, and pregnancy, it is not a good single indicator of
protein status.
Retinol-binding protein is more sensitive than albumin and transferrin to changes in protein
intake or to metabolic stress, although care should be taken in interpreting its value in patients
with renal failure or possible vitamin A and zinc deficiencies. C-reactive protein is indicative of
inflammatory response and may help in distinguishing acute inflammation from nutritional
deficiency in the evaluation of serum protein values.
Urine studies also are useful in determining the appropriateness of the nutrition care plan.
Creatinine-height index is used to estimate lean body mass and to screen for malnutrition. The
creatinine level from a 24-hour urine collection is compared with those of reference children of
similar age, height, and sex. Difficulties encountered with this diagnostic tool are the accuracy of
urine collection and skewing of normal values by data from patients with compromised renal
status, patients in catabolic states, patients with abnormal thyroid function, unusual activity
levels, or abnormal dietary intake of protein. Assessment of urine electrolytes and osmolarity can
also help identify the source of growth anomalies.
Nitrogen balance studies are a useful diagnostic tool to monitor adequate protein supply in
hypercatabolic patients. In the acute state, it may be difficult to determine the actual amount of
protein needed to maintain a zero or positive nitrogen balance. Zero nitrogen balance occurs
when the amount of nitrogen (e.g., protein) consumed equals the amount that the body is
currently excreting. A positive nitrogen balance indicates that protein provision is ample for
growth and tissue repair. Complicating nitrogen balance studies is the need to account for the
nitrogen excreted in other systems (wounds, ostomy output, feces), and for altered excretion in
patients with renal insufficiency. Most facilities have the ability to run a standard nitrogen
balance and possibly a total urinary nitrogen study.
Indirect calorimetry (sometimes referred to as a metabolic cart study) uses measures of heat and
oxygen consumption in comparison with carbon dioxide output to determine the basal metabolic
rate (BMR) or resting energy expenditure (REE). This may be useful for children with
complicated problems that have not responded to administration of previously calculated caloric
estimates. The BMR is a measure only of the energy expended in a resting state, and does not
include energy used in storage or growth, or lost in excretion. The limitation of this diagnostic
tool is that it is a snapshot of the energy expenditure during the 30-minute study, whereas
P.794

temperature, activity, stress, neuromuscular blockade, respiratory status, dialysis, and even
feeding routes can alter the child's moment-to-moment energy expenditure. Careful
documentation of the patient's clinical status and treatments at the time of the test can help to
provide the clinician with a better analysis. General estimates of a patient's caloric requirement,
if a measurement of REE is not available, are found in pediatric nutrition references. See Table
141.3 for estimates of caloric requirements for children, birth through young adulthood.
TABLE 141.3 ESTIMATED ENERGY REQUIREMENTS, INFANTS TO YOUNG
ADULTS
Category Age (yr) Reference weight (kg) REEa (kcal/kg) RDAb(kcal/kg) Energy (kcal/day)
Infants 0.0-0.5 655 108 650
0.5-1.0 955 98 850
Children 1-3 1355 102 1,300
4-6 2045 90 1,800
7-10 2840 70 2,000
Males 11-14 4530 55 2,500
15-18 6625 45 3,000
19-24 7225 40 2,900
Females 11-14 4630 47 2,200
15-18 5525 40 2,200
19-24 5825 38 2,200
a
REE, resting energy expenditure computed from WHO equations.
b
From Recommended Dietary Allowances. 10th ed. Washington, DC: National Academy Press;
1989.
DIET AND SOCIAL HISTORY
The dietary history helps identify eating habits, composition of meals, food intolerances,
allergies, cravings, cultural influences, and medication or nutrient supplementation of a child. A
food recall history often is useful for identifying grossly abnormal intakes. This method usually
is a good indicator of quality of food eaten, but the quantity of portions usually is subjective. It is
important to ask not only what the child is eating, but how it is prepared. For example, the cause
of undernutrition may be as simple as the dilution of formula with extra water, or the addition of
large volumes of rice cereal, which displace the nutrient-rich formula. In an older child,
evaluation of the beverages the child drinks may reveal the source of excess weight gain. Food
jags (e.g., eating macaroni and cheese for every meal) or picky eating may trigger an
investigation into possible vitamin and mineral deficiencies. Food may be a comfort for a
depressed or emotionally abused child.
With the wide use of herbal supplements and super-dosing of vitamins and minerals in the adult
population, it seems prudent to inquire about these items when taking a pediatric diet history.
These products may provide a desirable effect, although there is little medical literature on
proper dosing, and product purity often is questionable. Herbal supplements also may interfere
with prescribed medications. Dosing mishaps may occur when a patient is prescribed a larger
dose of a specific vitamin while in the hospital, and the family does not realize that it is intended
for short-term use only, so that the child presents with physical signs of toxicity at a follow-up
visit.
A careful developmental assessment should be part of the dietary history. An infant or child's
developmental level determines both the types of foods she can eat, as well as her feeding skills.
Nutritional supplements may be required if the child is not able to consume an age-appropriate
diet (Table 141.4).
The social history, also a very important part of the nutritional assessment, should identify
potential neglect, evaluate the parenting skills of the primary caregivers, and determine any
financial strains on the family. Medical plans will fail if the family is not able to provide the
recommended nutritional intervention. It should be kept in mind that many children today are
effectively their own caregivers owing to parents' work schedules. Special consideration may
need to be given to identifying high-quality nutritional resources, safe cooking facilities,
governmental assistance (e.g., WIC or AFDC), and community resources for safe food and
exercise opportunities. Social work and discharge planning professionals are essential in
assisting children and their families in meeting these needs.
CHILDREN WITH SPECIAL HEALTH CARE NEEDS
Children with various diagnoses fall under the umbrella of “special health care needs.” These
children may have special needs because of congenital anomalies or acquired disorders, and may
require more than the general pediatric plan of care. A good nutritional assessment can help
identify these patients for intervention. Special health care needs children often present with
atypical growth patterns or delay in mastering developmental milestones. For example,
unexplained weight loss or growth failure and delayed gross motor skills may be seen in children
with cystic fibrosis, celiac disease, bronchopulmonary dysplasia, and seizure disorders.
Conversely,
P.795

examples of lower energy needs populations, with the risk of becoming overweight, include
children with Down syndrome, Prader-Willi syndrome, or spina bifida, or children confined to
bed or wheelchair. Table 141.5 lists the basal metabolic needs of infants and children. A child's
physical activity, muscle tone, stress, and thermal factors must be taken into account when
determining total energy needs. Bed rest adds 10% to caloric requirements, whereas light,
moderate, and heavy activity call for 30%, 50%, and 75% increases, respectively. Fever requires
a 12% increase in calories per degree centigrade elevation. The thermal effect of the digestion of
food is thought to account for a 10% increase in caloric expenditure. Bone fractures and traumas
can cause a 20% to 40% increase in total caloric expenditure, whereas burns can increase caloric
needs by 50% to 100%. These are general guidelines to initiate care; monitoring weight and
biochemical data allow fine-tuning of each patient's energy needs.
TABLE 141.4 DEVELOPMENTAL STAGES OF FEEDING FROM BIRTH TO 3 YEARS
Gestational Foods
age Skills
Birth to 4 mo Breast milk or infant Appropriate latch-on to breast with good suck and
formula swallow mechanism
Hand to mouth while holding object
4-6 mo Breast milk or formula Head and neck control
Iron-fortified baby cereal Sitting with support
(optional) Can hold bottle independently
6-8 mo Breast milk or formula Finger feeding initiated
Iron-fortified baby cereal: Hold handled cup
4-8 tbspa
Bread: offer
Crackers: 2a
Fruit: 4-6 tbspa
Fruit juice: 3 oz from cupa
Vegetables: 4-6 tbspa
8-12 mo Add: Finger feeding independently
Cheese, yogurt, cottage Early spoon to mouth
cheese Holds cup with some spilling
Chicken, beef, pork Mechanically altered textures
Cooked, dried beans or egg
yolks
12-24 mo Add: Independent scooping of food to mouth with spoon
Whole milk Drinks entirely from cup
Cereal, pasta, rice, muffins Increased textures
Whole fruits and vegetables Food jags
Fish, turkey Preferences
Egg Booster chair
24-36 mo Full diet Feeds independently with utensil, palm up
Pours liquids from small container
Early use of fork to stab food
a
Per-day limit.
There are a number of issues that enter into planning for these children's nutritional care:

 The patient's growth pattern. The clinician should start with the growth history and the
child's individual pattern, comparing it with disease-specific norms if available.
Conditions like Down syndrome, Prader-Willi syndrome, cerebral palsy, and spina bifida
may not present with standard linear growth, so the weight-to-height ratio becomes more
important than weight for age.
 The patient's skeletal muscle activity. High muscle tone, seizures, tics, and hyperactivity
increase energy expenditure dramatically.
 The patient's method of feeding. Patients with a swallowing dysfunction who are fed by
mouth may not necessarily have higher energy needs, but may simply be unable to
 consume enough calories to meet their needs. Feeding tubes or parenteral nutrition may
also be used in conjunction with oral feeding for extended lengths of time. Selection of
product and route of nutritional support may vary based on the family dynamic to ensure
continued compliance.
 Metabolic anomalies and drug/nutrient interactions may be present in the patient. Once
the dysfunctional metabolic process is corrected, children usually regain weight much
more efficiently. For example, children with cystic fibrosis need pancreatic enzymes to
use dietary fat, children with celiac disease need restriction of gluten to prevent
destruction of the intestinal villi, and children on some anticonvulsants need
supplemental vitamin D and B-complex vitamins.
 Environmental factors may affect the patient, as described in the social history section.
Implementation of and compliance

P.796

with the care plan can be confirmed by normalizing growth patterns, increased muscle
and adipose tissue on subsequent triceps skinfold measurements, improved stool quality,
improved biochemical markers, or improved developmental skills.

TABLE 141.5 BASAL METABOLIC RATES FOR INFANTS AND CHILDREN

Age 1-10 mo Age 11-36 mo Age 3-16 yr
Weight M/F Weight Male Female Weight Male Female
(kg) kcal/hr (kg) kcal/hr kcal/hr (kg) kcal/hr kcal/hr
3.5 8.4 9.022.0 21.2 15 35.8 33.3
4.0 9.5 9.522.8 22.0 20 39.7 37.4
4.5 10.5 10.023.6 22.8 25 43.6 41.5
5.0 11.6 10.524.4 23.6 30 47.5 45.5
5.5 12.7 11.025.2 24.4 35 51.3 49.6
6.0 13.8 11.526.0 25.2 40 55.2 53.7
6.5 14.9 12.026.8 26.0 45 59.1 57.8
7.0 16.0 12.527.6 26.9 50 63.0 61.9
7.5 17.1 13.028.4 27.7 55 66.9 66.0
8.0 18.2 13.529.2 28.5 60 70.8 70.0
8.5 19.3 14.030.0 29.3 65 74.7 74.0
9.0 20.4 14.530.8 30.1 70 78.6 78.1
9.5 21.4 15.031.6 30.9 75 82.5 82.2
10.0 22.5 15.532.4 31.7
10.5 23.6 16.033.3 32.6
11.0 24.7 16.534.0 33.4
From Johnson HL. Energy metabolism at various weights: man. In: Altman PL, Dittmer DS, eds.
Metabolism. Bethesda: Federation of the American Societies for Experimental Biology; 1998:
344. With permission.
Suggested Readings
American Academy of Pediatrics. Pediatric nutrition handbook. Elk Grove Village, IL: American
Academy of Pediatrics; 1993.
American Society of Parenteral and Enteral Nutrition. Nutritional considerations in the intensive
care unit: science, rationale, and practice. Dubuque, IA: Kendall Hunt; 2002.
American Society of Parenteral and Enteral Nutrition. The science and practice of nutrition
support: a case-based core curriculum. Dubuque, IA: Kendall Hunt; 2001.
Mahan KL, Escott-Stump S, eds. Krause's food, nutrition, and diet therapy. 9th ed. Philadelphia:
Saunders; 1996.
Wessel J. Standards for specialized nutrition support: hospitalized pediatric patients. Nutr Clin
Pract 2005;20:103-116.
Wilmore D. The metabolic management of the critically ill. New York: Plenum; 1977.
Zitelli BJ, Davis HW. Atlas of pediatric physical diagnosis. 3rd ed. St. Louis: Mosby-Wolfe;
1997.