Pediatrics I: Assessment Flashcards
Factors influencing growth in childhood
- Genetics
- Nutritional Status (also mom during pregnancy)
- Sex
- Seasonal Variations (height and weight slowing during winter vs. summer)
- Disease Pathology
Serieal measurements for growth?
height and weight
* Need to follow pattern of growth to determine if changes in body composition are within expected ranges for weight & height
* Changes in % ile curves typical within first 2 years of life
What is included in the clinical assessment for children?
- Review of Growth (includes review of prenatal and neonatal events) & Nutrition History
- Review of Medical History: history of organic causes of growth failure/FTT
- Review of current status: appetite, stooling patterns, urine output, nausea/vomiting, dysphagia, activity level etc.
- Physical /dental examination: edema (palpitating), loss of muscle mass, clubbing, dental decay etc
- Use of Medications
- Skin, hair, nails: iron status etc.
- Developmental history: fine motor & gross motor function, speech,
Indications for weight assessment
Good index of acute changes in nutritional status
* Need to consider non-nutritional reasons for changes in weight (fluid status, presence of disease pathology)
Patterns of weight gain in infancy and childhood?
Infancy: Rapid Growth (must gain weight!)
* 0-6 months: 15-30 g/d
* 6-12 months:10-15 g/d
* 12-24 months: 8-10 g/d
Childhood (>2 years): Slower, constant rates of growth
* 1.8-2.7 kg/year
Indications for height assessment
Relatively insensitive to short-term deficits in nutritional status-good marker of nutritional status over long-term (6-12 month period)
* Infant height related to genetics (maternal height when newborn then fathers genetics kick in post birth)
* Preschool Age: Genetics, gender, nutritional status
Measuring height
- supine length should be done up to 2 years of age
Patterns of height gain in infancy and childhood
- Infancy : Rapid increases in growth (up to 12 cm from age 1-2)
- Childhood: 2-5 cm/yr (depending on age) until pubertal growth spurt
- Seasonal variations in growth occur (more in summer vs. winter; keep annual doctors appointment similar month)
indications for head circumference in assessment
Sensitive indicator of neural growth & maturity related to brain development
* Less sensitive indicator of nutritional status-last to be affected by chronic protein-malnutrition
* After 3 years of age-little or no relationship between nutrition and HC
What things are assessed with growth?
Serial tracking of growth over time
* Height and weight are ideally on the same % ile curve
* Change in movement of height/weight between % ile curves with time
* If weight more than 2 channels: signal for growth alterations
* Assessment of Ideal Body Weight- weight for height
What is used to assess growth?
WHO growth curves (based on EB babiesand reflects diversity)
* Sequential monitoring of growth over time
* Should track on same percentile over time
* Important to consider whether the weight and height fall within the 3-97% iles or z scores between -2-+2
Goal of growth curve
Ideal Body weight on the same percentile curve as the height curve
* 50% ile (0 z-score) is not the goal for everyone
What are the different growth curves?
Birth to 2 years for each gender
* Length for age, weight for age
* Height for age, weight for age
* Weight for length, weight for height
* BMI for age
* HC and weight for stature
2-10 yrs for each gender
* height for age, weight for age
* BMI for age
11-19 yrs for each gender
* height for age
* BMI for age (Note; weight was an issue in the data and so after 10 yrs of age they recommended use of BMI curves only)
Waterlow’s criteria for classification of malnutrition
nutrition status based on weight for height
* normal >90%
* mild 80-90%
* moderate 70-80%
* severe <70%
What is FTT?
Failure to Thrive: lack of weight/height gain or weight loss
* Determine Ideal Body Weight (IBW) (weight %-ile curve where height percentile is)
* <3%-ile is concerning
What is wasting?
Too skinny for height: one or both of following:
* Weight % is much lower than height %-ile: weight is more than two percentile curves away from height (weight for height
* Weight is less than 3%-ile (weight for age) or is on the 3%-ile (z score<-2).
What is stunting?
Lack of height growth (separated from wasting) where height % is much lower than 3 %-ile (or z-scores <- 2)
* Weight for age and weight for height may be fine or they can be low!!
* However, typically height is outside the normal ranges of age appropriate growth (ie less than 3%ile or z-score <-2)
How to calculate height age?
Age at 50%-ile
How to determine if patient is stunted/wasted
* Age=8.5 yrs
* Wt=18 kg
* Ht=112 Ht<3%-ile
- Calculate height age (age at 50%-ile): ~ 5.5 years.
- Then see weight at 50%-ile at height age (5.5 yrs) =19.5-20 kg (this is ideal body weight).
- Calculate the %IBW
- Is he malnourished by the Waterlow Criteria? NO
Patient is stunted but not wasted
Assessment Case
4 year old boy: Wt=13kg; Ht=103cm
1. Plot on the growth curves → what percentiles is he on?
2. What is his ideal body weight?
3. Percentage of ideal body weight?
4. What is his nutritional risk?
- wt=3%-ile; ht=50%-ile
- IBW=16 kg (should be on same percentile curve as height curve (50%))
- %IBW=13kg/18kg=81% (mild risk of malnutrition)
- Wasting; FTT
Use of actual weight vs. IBW to assess nutrition requirements
- When actual body weight is between 90- 120% ideal body weight use actual weight.
- If actual body weight is < 90% ideal body weight or >120% ideal body weight use ideal body weight.
Further assessments with FTT
- Perinatal history
- Maternal history
- Anthropometric trends (weight, head circumference, length)
- Nutrition related labs (Hgb, prelab, lytes, BUN, Creat)
- Social/economic factors n Availability of resources
- Lactation consultants, public health, physicians, formula/feeding supplies
- Nutrition assessment
What to look for in the nutrition assessment with FTT
- Nutrition intake/feeding practices
- voiding/stooling pattern (enough wet diapers, regular stooling?)
- vomiting.diarrhea (spits up or projectile vomit; stool - loose/watery, hard, mucousy)
- allergies (family hx, skin rashes, hives)
Nutrition intake/feeding practices to consider with nutrition assessment for FTT
- Method of feeding – breast, bottle, both
- Breastfeeding – number of feeds/day, any bottle feeds
- Formula feeding – amount and type of formula (powder/concentrate)
- Formula preparation – how are they making the formula
- Special formula
- Duration of feeding – how long does it take for feeding/eating a meal
- 24 hour recall of “typical day” for older children
Goal of intervention for FTT
Goal of treatment is to establish optimal growth velocity while supporting family in the plan of care!
- Age appropriate feeding guidelines.
- Vitamin/Mineral supplementation may be indicated
- Guidelines discussed with parents/caregivers
Infant intervention for FTT
For Infants:
* Breastfeeding: may need to provide supplemental feed
* Increased caloric density breastmilk or formula
* Instructions on mixing breastmilk and formula
* Limit duration of feed
Children intervention for FTT
For children:
* High Protein/High Calorie diet with snacks/supplements
* Diet teaching
* Avoid distractions during meal times (feeding environment important)
* Structure meals/snacks
* Serve age appropriate foods
* Avoid juice, sugar beverages
* Tolerate age appropriate mess
FTT case study
Peds I notes at the end
