Shannon K.

Goff, MPH, RD, RD-AP, CNSC, CSPCC, CLC

Manager, Clinical Nutrition and Lactation Services

NOT JUST LITTLE ADULTS:

ESSENTIALS OF PEDIATRIC NUTRITION
 Objectives
• Improve confidence and comfort assessing pediatric
patients
• Identify at least 3 variances between adult and
pediatric nutrition assessment
• Implement at least 2 strategies for pediatric nutrition
focused physical exam
• Introduce utilization of probiotics during childhood
illness
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Goals of In-Patient Pediatric Nutrition

Normal growth and development

Promote healing and immunity

Decrease time on a ventilator

Decrease length of stay

 Value of Maternal/Pediatric Nutrition

Value Of Maternal/Pediatric Nutrition

PREVENTION OF DISABILITIES

TREATMENT OF CHRONIC ILLNESSES/DX

SUPPORTIVE or ADJUNTIVE CARE

MAXIMIZE POTENTIAL FOR BOTH PHYSICAL AND

COGNITIVE DEVELOPMENT
Basic Components Of The Nutritional Assessment

Feeding
Bio- and
chemical Behavioral

Personal
Physical and
Exam Medical
History
Food
Anthro- and
pometrics Nutrition
History
 Personal and Medical History

BIRTH HISTORY HEALTH HISTORY

DEVELOPMENTAL
MILESTONES
 Food And Nutrition Related History

How? What? Environment?

•Oral • 24-hour • Family meal patterns
•G-tube • Purchasing/preparation
• 3 –day diet record
•J-tube • Eating out
•NG/NJ • Food frequency
• Food/texture refusals
•Parenteral nutrition

Vitamins/Minerals/
Physical Activities? Medications?
Herbs?

Stool?
• Color
• Frequency
 Breast Milk!!!!
• Ideal nutrition for babies
– Immunologic benefits- allergies, viral illnesses, diarrhea
– Cognitive advantages
• Breastmilk is hypoallergenic
• Breastfeeding initiation 83.2% in 2015 births (2020 Goal- 81.9%)
• Breastfeeding at 6 months 57.6% (2020 Goal 60.6%)
• Breastfeeding at 12 months 35.9% (2020 Goal 34.1%)
CDC BF Report Card 2016: http://www.cdc.gov/breastfeeding/data/reportcard.htm
 Starting Solids

• Go to Video

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 Starting Solids
• Never earlier than 4 months of age
• Developmental readiness
– Head control?
– Open mouth?
– Big enough?
– Reaching for foods?
• Beginning foods
– Rice cereal? Oatmeal? Veggies? Fruits? Meats?
– Iron
• Allergens
– No evidence waiting to introduce foods prevents allergy
AAP, Amount and Schedule for Formula Feedings: http://www.healthychildren.org/English/ages-
stages/baby/feeding-nutrition/pages/Amount-and-Schedule-of-Formula-Feedings.aspx
 A Case Example

Baby JT’s mom reports that she is planning

to start giving him solids next week. He is
now 4 months old and has some head
control. She reports that she doesn’t think
that he could sit in his high chair safely.

• Is Baby JT ready for solids?

 Another Case Example

Baby DH is now 6 months old and her mom

reports that she has heard that she should give
her baby only breastmilk until 7 months. She
also reports that Baby DH has been very
interested in what other people are eating.

• What might you think about for Baby DH? Do you have any
follow-up questions for mom?

• Is Baby DH ready for solids?

 Anthropometric Assessment (primary)

HEAD
WEIGHT FOR HEIGHT/LENGTH WEIGHT FOR
CIRCUMFERENCE BMI FOR AGE
AGE: FOR AGE: HEIGHT
FOR AGE

Infant Recumbent
Scale Length
• up to 30 lbs • 0-2 Years
• 0-2 Years • WHO growth
0-3 Years 0-2 Years > 2 Years
• WHO growth chart
chart

Standing Standing
Scale Height
• > 2 years • > 2 years
WHO WHO CDC
• CDC growth CDC growth growth growth growth
chart chart chart chart chart
 Anthropometric Assessment (secondary)

Mid-Upper Arm Circumference (0.1 cm)

Triceps Skinfold (0.02 mm)

Subscapular Skinfold (0.02 mm)

Calculated Arm Muscle Circumference (mm2)

Hand Grip Strength (function, > 6 years of age)

 Alternative Methods to Measure Height

ARM SPAN:
• should equal height

ARM LENGTH:
• multiply by a factor to estimate height

SITTING HEIGHT:
• reference chart , starts at age 2 years

KNEE HEIGHT: CHART ESTIMATES WITHIN 2 INCHES

• starts at age 6 yrs

SEGMENTAL HEIGHT/LENGTH:
• An estimate

ULNA LENTH
• Linear Regression Analysis Equation
• Starts at 5 years
 Growth History

• WEIGHT & HEIGHT HISTORY:

– collect & plot on a growth chart
– standards for wt and growth expectations
– Visual demonstration of trends

• DIAGNOSIS-SPECIFIC GROWTH CHARTS

– down syndrome
– turner syndrome
– prader-willi syndrome
– preterm growth charts: Fenton and Olsen
 Feeding Assessment

• OBSERVE FEEDING/EATING
• COMPARE TO NORMAL MILESTONES OF FEEDING
– sucking ability
– chewing ability
– method of feeding
– body position during feeding
– gagging, choking, coughing
– drooling
– time required to feed
– consistency of foods tolerated
– food refusal/disruptive mealtime behaviors
 Nutrition-Focused Physical Exams

• Physical signs of deficiencies are more evident in

pediatrics
• Key Areas to Emphasize
– Gluteal Folds
– Extremities
– temporalis
• Passive, gentle approach
• Sing
• Integrate parents

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 Biochemical Assessment

• Lytes, Renal and Liver labs

CHEM 14 • HgbA1C, prn

COMPLETE BLOOD • Hemoglobin, Hematocrit, MCV, MCH

CELL COUNT • Iron studies

PERTINENT • D, A, E
VITAMINS

PERTINENT • Cu, Zn, Se

MINERALS

ACUTE PHASE • C-reactive Protein

• Albumin(very affected by fluid)
REACTANTS • Prealbumin
 Clinical Signs

ABNORMAL RECURRENT
ENDURANCE MUSCULATURE
SKIN OR HAIR INFECTIONS

FOOD
DENTAL
INTOLERANCE IRRITABILITY
STATUS
S/ALLERGIES
 Intake vs. Needs

ENERGY:
• Estimated Energy Requirement
• Age and Gender dependent
• Often overestimates energy needs in ill children
• WHO equation or Schofield for BMR
• Ideal for critically ill children
• Kcal/kg OF PRESENT WEIGHT
• best used for the child whose weight is appropriate
• Kcal/cm
• short stature children (<3rd percentile)
• CONSIDER:
• Physical activity, pubescence, catch-up needs, metabolic
rate, disease state
 Intake vs. Needs
PROTEIN
• Gm/kg:
• Age-dependent
• CONSIDER:
• Infections, Trauma, Burns, Activity, Energy Intake, Disease
State, Catch-Up Growth

FLUID NEEDS: DETERMINED BY WEIGHT

• Holliday-Segar
• 100 ml/kg (1-10 kg) + 50 ml/kg (2-20) + 20 ml/kg thereafter
• Body Surface Area
RDAs/RDIs
 Ask Yourself:

• Are they growing?

• What do they look like?
• How do they measure?
• Are they eating?
• Is it age appropriate?
 Developing a Nutrition Care Plan

 Assess and integrate results of the assessment

 Collaborate with other members of the health care team

 Integrate information from parents/caregivers/teachers

 Identify medical nutrition therapy diagnosis

 use PES statement

 Develop interventions that act on the etiology of your

statement

 Make necessary referrals

 Outcomes of Pediatric Malnutrition

Length of
Stay

Disease Mortality

Malnutrition

Wound Longer
Healing ICU stay

Develop-
mental
Delay
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When in doubt, Growth.

• Pediatric nutrition assessment is an essential process

to determine appropriate interventions and follow-up
required to ensure proper growth and development
• Different requirements exist from infancy to
adolescence
• Infants require the highest number of calories per kg of
weight than any other time in human development
• Adult nutrition management does not translate to the
pediatric nutrition management >> new skill set
• Essential components of a nutrition assessment also
include a pediatric nutrition-focused physical exam
A GRAND THANK YOU
AND
A FOND FAREWELL!

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