Nutritional Assessment

1. Nutritional Assessment Penny Blacker Dietitian Frimley Park Hospital

2. Nutritional Assessment • Methods • Calculations and what they mean • Interpreting Dietary Reference Values • Enteral feeding • Parenteral feeding • Refeeding syndrome

3. Nutritional Assessment Growth • Accurate and recent weight, height/length • Plot on appropriate growth chart/red book • Look at the trend • Sudden changes or gradual weight loss or gain • Coeliac disease often (but not always) a noticeable drop in weight when gluten introduced • CMPI when breast feeds replaced with formula • Calculate weight for height for babies and young children and BMI for older children (growth chart suitable for 2yrs and over)

4. Weight for Height

5. Assessing Intake • Talk to parents/carer • Concerns • Compare with history from medical notes • Vomiting, diarrhoea, appetite, abdo pain etc • ‘effortless vomiting’ in babies indicative of CMPA • What has been tried already • Changes in formula, times of feed etc • What has helped/not helped • What is happening now • Fluid/food record charts • Calculate average daily intake for energy, protein and fluid taking into account losses due to vomiting

6. Assessing Requirements • Always use actual weight • GOS booklet • Increased requirements • Cystic fibrosis,cardiac babies, malabsorption • Hypertonia (cerebral palsy) severe epilepsy • Decreased requirements • Hypotonia (cerebral palsy) immobility (muscular dystophy)

7. Requirements GOS (males) Note 1 • 11-20kg 100ml/kg for first 10kg + 50ml for next 10kg • 20kg & above 100ml/kg for first 10kg + 50ml for next 10kg + 25ml/kg thereafter • Up to max 2500ml/day • Overweight child requires less than calculated as body weight is abnormally high

8. Pre Term Babies Differ in requirements from term babies • Energy • 110-135 cals/kg/day (Klein 2002) • In practice >120cals/kg is rarely needed • Optimum weight gain is 13-15g/kg/day. Overfeeding can lead to metabolic syndrome in later life • Protein • Useful to check that intake is optimum (3-3.6g/kg/day) • High protein intakes (>4.3g/kg/day) can lead to metabolic stress • Fluid • May be restricted but aim for 150-200mls/kg/day

9. Breast Fed Babies • Quantitative assessment more difficult • May need to get Mum to express milk and bottle feed but can be difficult if baby not used to bottle • If growth is faltering ensure • hind milk is used • baby is latching on • Mum’s diet is OK

10. Older Children • Diet history from parent or carer • Meals & snacks. How much how often? • Who feeds the child & where? • Type of milk. How much how often? Other drinks • Do you have family mealtimes? • How would you describe child’s appetite? • Consistency of food • Main concerns. Behavioural issues • Any vitamin supplements? • Does the child vomit? If so frequency and amount • Stools frequency & consistency • Toddlers and children with food allergy/intolerance can be very wary about trying new foods so diet can become extremely limited. • Behavioural problems/fussy eating is common • 3 day food diary for quantitative assessment • Be aware of limitations! • Assess on computer programme (Microdiet). Compares average of 3 days intake to EAR, LRNI and RNI for age group

11. Dietary Reference Values Set by DOH 1991. Other countries set their own which may differ from UK • Estimated Average Requirement (EAR) • Represent the level of nutrients that are estimated to meet the nutrient requirement of 50% of the healthy individuals • Some children will require more, some less • Energy requirements often based on this • Reference Nutrient Intake (RNI) • Represent the amount of nutrient that is enough for at least 97% of the population • This is what we use most frequently when assessing a child’s intake for vitamins & minerals • Lower Reference Nutrient Intake (LRNI) • The amount of a nutrient that is enough for only a small number of people (about 3%). If intake is habitually below this the child will almost certainly be deficient in any given nutrient.

12. Dietary Reference Values Examples • Calcium requirement/day (for babies/children on milk free diets) 0-12m LRNI= 240mg RNI=525mg EAR=400mg • Iron requirement/day (iron deficiency anaemia ?cause) 1-3yrs LRNI=3.7mg RNI=6.9mg EAR=5.3mg • Enables us to suggest foods/supplements to improve diet • If intake meets requirements then other causes need to be investigated. Anaemia often present in undiagnosed coeliac disease despite sufficient intake

13. Dietary Reference Values EAR • Crohns patients who need Modulen liquid diet for 8 weeks • Start with 75% EAR and gradually increase up to 120% EAR • 12 yr old boy. EAR = 2220 cals/day • Start with 1665cals. Aim max 2665cals depending on weight gain • Cystic fibrosis patients can need 120-150% EAR to maintain growth rate

14. Enteral Feeding • Problems assessing • Often difficult to measure height/weight accurately • Appropriate growth charts not always available • Energy expenditure varies • Hypertonia, hypotonia, epilepsy • Reflux, constipation, vomiting can limit tolerance to feeds • Growth can be severely affected • 5yr 3m old boy. Height 76cm (average ht for 1 yr old) Weight 11kg (average wt for 1-1.5 year old) • Plot on centiles both ht and wt well below 0.4th centile • ?malnourished. Wt for ht=108%

15. Enteral Feeding • Best practice • Use height age to calculate requirements • Vitamins and minerals: aim to meet RNI • Protein: essential to provide RNI to lay down lean tissue • Energy: use EAR and adjust for • Malabsorption,recurrent infections,cardiac problems (increased req) • Inactivity,bed rest,immobile,obesity • Start with 75% EAR. • Monitor weight gain. Increase or decrease as necessary • Fibre: aim for age +5-10g/day if over 2yrs old • Fluid: base on actual weight. Beware overweight children need less as body wt is falsely high • Look for adequate hydration-pale urine, stool frequency • These children can also have food allergies/intolerances

16. Parenteral Feeding • ‘If the gut works use it’ • Indications for PN in children • NEC,acute pancreatitis, post op abdo surgery, intestinal failure, short bowel syndrome • Should not be used unless anticipated for a minimum of 5 days • Assessment • Should be calculated on an exact weight • Energy kcal/kg/day • Protein as nitrogen g/kg/day • Sodium/potassium mmol/kg/day • Fluid mls/day • TPN Should be given over 24hrs • PPN Should be given over 20hrs to reduce risk on thrombophlebitis

17. Parenteral Feeding

18. Refeeding Syndrome • Metabolic and clinical changes that occur on nutritional rehabilitation of malnourished patients • Little evidence in paediatric patients. Those at risk could include • Anorexia nervosa, Crohns disease • Patients underfed or not fed for at least 10-14 days (including those on prolonged IV fluids) • Starvation (catabolism) • Fat and protein used as energy source once carbohydrate stores depleted • Plasma insulin levels fall • Results in loss of lean body mass affecting major organs including heart. Diminished cardiac output/myocardial atrophy • Intracellular loss of electrolytes especially K Mg PO4 • Refeeding (anabolism) • Carbohydrate used as energy source • Plasma insulin levels rise • Increased glucose. K Mg PO4 uptake back into cells causes fall in blood levels • Fluid retention leading to increased extracellular volume leading to cardiac failure • Electrolyte abnormalities can lead to cardiac arrest • Hypophosphataemia is central feature of RS • Increased uptake of thiamine (vit B1) required as co enzyme in CHO metabolism. Malnourished patients may already be depleted

19. Refeeding Syndrome • Measure Na K Mg P04 prior to feeding • Correct any deficiencies • Give thiamine 30mins prior to feeding • Deliver feeds and fluid slowly • Max 10 cals/kg/day initially • Increase daily by 10-25% • Monitor biochemistry daily • Enteral feeding for min 1 week • Parenteral feeding always