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Nutritional Assessment


Normal Growth and Body Composition in Children

Age-appropriate growth is the hallmark of adequate nutrition; children with abnormal growth patterns should be evaluated for diet adequacy, organic disease, and access to food. Universally, growth can be measured objectively, but growth characterization must be interpreted in the context of a clinical assessment. , Length in infants increases about 2.5 cm per month for the first 6 months and by 1.3 cm per month from 7 months to 1 year of age. Growth subsequently slows to 7.6 cm per year until age 10 and stays constant until puberty, with no difference for boys or girls. Growth spurts for boys occur between the ages of 12 and 17 years, with an expected gain of more than 10 cm in the year of peak velocity; for girls they occur between the ages of 9½ and 14½, with an expected gain of 9 cm in the year of peak velocity.

Adequate weight gain in full-term infants from birth to 3 months is 25 to 35 g per day, then 15 to 21 g per day at 3 to 6 months, and 10 to 13 g per day until 12 months of age. Infants will triple their birth weight by their first birthday and quadruple it by 2 years of age. , From 2 years through adolescence, weight increases by approximately 2 kg per year; peak weight velocity in adolescents can average 3 kg in 6 months.

Head circumference is routinely measured until 2 years of age and is reflective of brain growth; it will average 35 cm at birth, which is 25% of adult size. During the first year of life, increases of 1 cm per month occur and the brain grows to approximately 75% of its adult size.

Tracking body composition in addition to standard growth velocities can provide further insight into the nutritional status of the patient. Fat-free mass and body fat increase with age throughout childhood, as does skeletal mineralization and organ maturation. The intricacies of body composition can be assessed using indirect criteria or direct techniques related to theoretical models that divide the body into two compartments: fat mass and fat-free or lean body mass; three compartments: fat mass, fat-free mass, and bone density; or multiple compartments: atomic, molecular, cellular, and tissue components. Deciding which model to employ should be dictated by the level of precision required for clinical or research purposes, as the techniques vary in cost, accuracy, and utility.

Useful indirect estimates of adiposity that can be applied effectively in the clinical setting are anthropometry, such as triceps skinfold (TSF) or mid-upper-arm circumference, and bioelectrical impedance. Both are examples of the two-compartment model and derive clinical and research value in that they provide a quick, noninvasive, and inexpensive approach to the assessment of body composition.

Prevalence and Classification of Malnutrition in Pediatric Patients

Although at present there is no uniform definition, malnutrition is generally described as a state of nutrition in which deficiency or excess of energy, protein, and other nutrients leads to measurable adverse effects on body mass and function. Although the exact prevalence of malnutrition in the pediatric population is unknown, it is estimated that 50% of hospitalized children in the United States are undernourished; globally, 45% of all childhood deaths can be attributed to malnutrition. Children with GI disorders are among those most susceptible to chronic malnutrition ( Table 86.1 ). In assessing the nutritional status of children, it is important to recognize malnourished individuals in whom nutrition-associated morbidities are likely to occur and for whom applied nutrition therapy can improve outcomes. Evidence urges the clinician to include the patient’s current inflammatory state when his or her nutritional status is being assessed; it has been reported that 22% to 31% of children with inflammatory bowel disease (IBD), specifically Crohn disease, encounter linear growth impairment preceding disease diagnosis. Clinicians should also be aware of the risk for malnutrition in children with functional GI disorders, as emerging research suggests an association with growth disturbances and body composition in affected children secondary to disordered eating patterns and self-restricted diets.

TABLE 86.2
Classification of Protein-Energy Malnutrition
Adapted from: Grover Z, Ee L. Protein energy malnutrition. Pediatr Clin N Am . 2009;56:1055–1068 and UNICEF.
Marasmus Kwashiorkor Marasmic-Kwashiorkor
Extremely emaciated (without edema) Bilateral pitting edema, which can become more generalized Concurrent gross wasting and edema
Distended abdomen
Depletion of subcutaneous fat stores and muscle wasting Reduced fat and muscle tissue (may be masked by edema) Frequently stunted
Almost normal weight for age
Hepatosplenomegaly Enlarged palpable fatty liver
Normal hair Hypopigmented hair
Xerotic, wrinkled, loose skin Dermatosis Mild hair and skin changes
Frequent infections with minimal external signs (not often showing fever) Frequent infections due to skin lesions
Usually active and alert Apathetic and lethargic; irritable when handled

Historically, the classification of malnutrition has been based on the assessment of anthropometric variables. , In 1956, Gomez et al. introduced a classification of malnutrition based on weight below a specified percentage of median weight for age. This method also introduced the calculation of height for age to distinguish stunting (chronic malnutrition) from wasting (acute malnutrition). In 1977, Waterlow et al. recommended the use of percentiles and standard deviations (SDs) below the median to define underweight, wasting, and stunting. , More recently, the World Health Organization (WHO) recommended the use of Z-score cut-off points for weight for age (WFA) or height for age (HFA) to classify degree of wasting or stunting, respectively. Last, an interdisciplinary work group from the American Society of Parenteral and Enteral Nutrition (ASPEN) proposed a new definition and classification scheme for pediatric malnutrition. This definition, which was based on available evidence and multidisciplinary consensus, incorporates chronicity, etiology, mechanisms of nutrient imbalance, severity of malnutrition, and their impact on outcomes. According to the authors, current terminologies such as marasmus and kwashiorkor describe the effects of malnutrition but do not account for the “variety of etiologies and dynamic interactions” that also play a significant role in nutritional depletion.

Although much of the focus in clinical practice is on undernutrition, it should be recognized that obesity is also a form of abnormal nutrition, with global rates reported as high as 41 million children below 5 years of age in 2016. In the United States, 1.7% of children under age 5 are now considered overweight or obese. Table 86.2 summarizes the most commonly used classification schemes for pediatric malnutrition.

TABLE 86.3
Gastrointestinal Diseases Associated With Malnutrition
Adapted from Gibbons T, Fuchs G. Malnutrition: A hidden problem in hospitalized children. Clin Pediatr . 2009;48:356–361. ESLD, End stage liver disease; LCT, long chain triglycerides; MCT, medium chain trigylcerides.
Disease Etiology of Malnutrition Special Considerations
Inflammatory bowel disease Increased energy expenditure from chronic inflammation Medical control of underlying pathology essential to improving nutritional status
Nutrient loss from malabsorption Undernutrition more significant in Crohn disease compared with ulcerative colitis
Decreased oral intake due to abdominal pain, diarrhea, and cachexia Long-term growth may be significantly affected
Chronic liver disease Nutrient loss from malabsorption Specific vitamin/mineral supplementation often required (i.e., vitamins A, D, E, and K)
Inappropriate substrate use May need to modify fat content in formula/diet (increase MCT/decrease LCT)
Increased metabolic needs Calorie intake is often as high as 130%–150% estimated requirement
Decreased oral intake as a result of abdominal pain, altered taste, cachexia (if prominent inflammatory component) Monitor arm anthropometrics in addition to standard growth parameters (especially in ESLD) to account for fluid shifts
Short bowel syndrome Nutrient loss from malabsorption Micronutrient deficiencies will vary depending on which region of the intestine is affected

The two main clinical syndromes of the extreme forms of undernutrition are marasmus and kwashiorkor. These are differentiated on the basis of clinical findings, with the primary distinction being the presence of edema in kwashiorkor. A mix of the two syndromes, known as marasmic kwashiorkor, can also be seen. A more detailed comparison of the etiologies and clinical distinctions between these three syndromes can be found in Table 86.3 .

TABLE 86.1
Classification Schemes for Malnutrition
Adapted from: Mehta NM, Corkins MR, Lyman B, et al. Defining pediatric malnutrition: a paradigm shift toward etiology-related definitions. JPEN J Parenter Enteral Nutr . 2013;37(4):460–481. Gomez F, Galvan RR, Cravioto J, Frenk S. Malnutrition in infancy and childhood, with special reference to kwashiorkor. Adv Pediatr. 1955;7:131–169. Waterlow JC. Classification and definition of protein-calorie malnutrition. Br Med J. 1972;3(5826):566–569.
Classification Variable Grade Definition
Gomez et al. Weight below % median weigth for age (WFA) (%) Mild (grade 1) 75%–90% WFA
Moderate (grade 2) 60%–74% WFA
Severe (grade 3) <60% WFA
Waterlow (wasting) Weight below % median weight for age (WFA) (%) Mild 80%–89% WFA
Moderate 70%–79% WFA
Severe <70% WFA
Waterlow (stunting) Height below % median height for age (%) Mild 90%–94% HFA
Moderate 85%–90% HFA
Severe <85% HFA
WHO (wasting) Z-scores (SD) below median WFH Moderate Z-score between −2 and −3
Severe Z-score ≤3
WHO (stunting) Z-scores (SD) below median HFA Moderate Z-score between −2 and −3
Severe Z-score ≤3
HFA, Height for age; SD, standard deviation; WFA, weight for age; WFH, weight for height; WHO , World Health Organization.

Indications for Nutrition Assessment

Nutrition assessment in the pediatric patient is warranted if a child meets recognized screening standards for increased risk of developing growth failure, protein-energy malnutrition, or obesity. Criteria may include children with restrictive diets, multiple food allergies, anemia, feeding difficulties, nutrition support, developmental disabilities, and patients taking long-term medications that alter metabolism/nutrient utilization.

Clinical determinants for initiating nutrition assessment:

  • Height less than 10th percentile for age

  • WFA plotting less than the third or fifth percentile on Centers for Disease Control and Prevention (CDC)/WHO growth curves

  • Weight-for-height/length plotting less than third or fifth percentile on the CDC/WHO growth curves

  • Change in more than two SDs on the growth curve over a 3- to 6-month period

  • Decreased growth velocity where weight falls more than two major percentile curves over 3 to 6 months

  • ≥5% weight loss 5% or greater weight loss from usual body weight

  • Body mass index (BMI) greater than the 85th percentile with at least one parent who is overweight or obese

Components of a Nutritional Assessment

A comprehensive nutritional assessment should include multiple components: clinical history combined with physical assessment, detailed diet history, anthropometric measurements of growth, biochemic analyses, and a nutritionally focused physical exam. The individual components of a nutritional assessment considered alone have weaknesses. Ideally a combination of the measures listed earlier will provide the most thorough approach to a complete nutritional assessment.

Clinical History and Physical Assessment

A clinical history incorporates the patient’s diagnosis, birth history, medical, and surgical history, medications and/or treatments, as well as neurologic function with attention paid to the ability to safely chew and swallow. This information, considered in conjunction with a physical assessment, directs his or her care. A nutrition-focused physical examination must evaluate the patient from head to toe. An overall review of height and weight; assessment of muscle and fat mass; the appearance of skin, hair, eyes, and fingernails; as well as the presence or absence of edema should be included. The patient’s oral health—including teeth, lips, tongue, and gums—is a key piece of the physical assessment. Signs of bone disease, such as rachitic rosary and bowed legs, may be observed during the examination. Although many physical findings of the clinical assessment are most likely multifactorial, some are diagnostic of nutrient deficiencies ( Table 86.4 ).

TABLE 86.4
Vitamins and Minerals
Traub S. Basic Skills in Interpreting Laboratory Data . 2nd ed. Bethesda, MD: American Society of Health-Systems Pharmacists; 1996. Bakerman S, Bakerman P, Strausbauch P. ABC’s of Interpreting Lab Data . 4th ed. Phoenix, AZ: Century Graphics; 2002. Institute of Medicine, Food and Nutrition Board. Otten J, Hellwig J, Meyers L (eds.). Dietary Reference Intakes . 10th ed. Washington, DC: The National Academies Press; 2006.
Vitamin/Mineral Mechanisms Symptoms of Defidency Excess Diagnosis Food Sources
B vitamins (water soluble) B1Thiamine Inadequate intake Fatigue, peripheral neuropathy, cardiomyopathy beriberi (severe deficiency) None Response to thiamine supplement; serum B 1 if symptoms severe Liver, pork, milk, grains, beans, seeds, nuts
B 2 Riboflavin Inadequate intake Blurring vision, cheilosis, nasolabial seborrhea, red painful tongue None Urinary riboflavin <30 μg/d Milk, cheese, liver
B 6 Pyridoxine Inadequate intake Seizure, irritability, sensory ataxia Neuropathy, photosensitivity Whole blood concentration plasma pyridoxal phosphate Meat, poultry, liver, kidney, some nuts and seeds, whole grains, beans
Folate Inadequate intake, malabsorption, medications (methotrexate, sulfasalazine) Megaloblastic anemia, hyperhomocysteinemia, glossitis, angular stomatitis, depression Can obscure anemia due to B 12 deficiency Low serum folate (normal ≥3.0 ng/mL), low red blood cell folate levels, elevated homocysteine levels with normal methylmalonic acids levels Liver, fortified cereals, dried beans, orange juice, leafy green vegetables, yeast, kidney
B 12 cyanocobalamin Inadequate intake (vegetarian diet), malabsorption, active ileitis, defective/deficient intrinsic factor, history of ileal or ileocolonic resection Megaloblastic anemia, pancytopenia, peripheral neuropathy (abnormalities of taste and smell), dementia, loss of appetite, smooth and/or sore tongue, failure to thrive, developmental delays None Low serum B 12 , if <400 pg/mL, consider checking methylmalonic acid and homocysteine levels Liver, meats, fish, shellfish, poultry, eggs, cheese
Niacin Inadequate intake of niacin and/or tryptophan-containing foods Vomiting, constipation, rash, glossitis, depression, headache, fatigue, memory loss, dementia, pellagra (severe deficiency) Flushing, nausea, vomiting, liver toxicity, impaired glucose tolerance Low urinary excretion levels of niacin and metabolites (in 24-hour urine) Meat, liver, beans, fortified or enriched foods
Biotin Inadequate intake Pallor, muscle pain, loss of appetite, scaly dermatitis None Decreased urinary biotin (in 24 hours) Liver, lentils, peanuts, mushrooms, chicken, whole wheat, eggs
Pantothenic acid Inadequate intake (usually with other B vitamins) Fatigue, abdominal pain, vomiting, numbness in feet and hands Possible diarrhea, water retention Whole blood pantothenic acid, 24-hour urinary excretion Liver, whole grains, nuts, dried beans, brewer’s yeast
Choline Restricted diet, inadequate provision in formula/total parenteral nutrition (TPN) Fatty liver infiltrate, liver damage Hypotension, fishy body odor, sweating Fasting plasma concentration Milk, liver, eggs, peanuts
C Inadequate intake, increased need with infection, catabolism, obesity, alcohol use Poor wound healing, gingivitis, scaly skin, arthralgia, perifolliculitis, corkscrew hairs, scurvy (severe deficiency) Oxaluria Mainly based on clinical symptoms; plasma vitamin C Broccoli, cantaloupe, peppers, collards, citrus fruit, tomato, strawberries, liver
Fat Soluble Vitamins A Inadequate intake, fat malabsorption/steatorrhea, inadequate bile salts, medications (e.g., cholestyramine) Poor wound healing, night blindness, xerophthalmia, Bitot spots, follicular hyperkeratosis Nausea, vomiting, headache, vertigo, blurred vision, loss of muscle coordination, bulging fontanel (infants) Serum retinol, retinol-binding protein, beta carotene Liver, sweet potato, cantaloupe, carrots, spinach, peas, broccoli, fortified milk
D Inadequate intake, fat malabsorption/steatorrhea, lack of sunlight exposure/latitude Abnormal bone metabolism, rickets, epiphyseal enlargement, bow legs, poor growth, tetany; possible role in increased inflammation Diarrhea, weight loss, calcification of soft tissues 25, OH vitamin D Fatty fish, fortified dairy products
E Inadequate intake, bile salt deficiency, malabsorption/steatorrhea Peripheral neuropathy, ataxia, retinopathy, anemia With excessive supplementation: potential for hemorrhagic toxicity and diminished blood coagulation with vitamin K deficiency Serum (alpha) tocopherol Vegetable oils, dried beans, sunflower seeds, wheat germ, dark leafy greens
K Inadequate intake, fat malabsorption/steatorrhea, bile salt deficiency, medication (e.g., cholestyramine) Rare, but can occur from antibiotic use (suppressing menaquinone-synthesizing organisms); symptoms include bleeding and abnormal bone metabolism No reported effects Serum phylloquinone, prothrombin time, international normalized ratio, PIVKA II, uncarboxylated osteocalcin (bone levels) Collards, spinach, salad greens
Minerals Calcium Inadequate intake, decreased absorption/losses, vitamin D deficiency or insufficiency, hypomagnesemia (e.g., due to excessive diarrhea) Low bone density, fatigue, depression, memory loss, seizures, tetany Kidney stones, decreased absorption of other minerals, vascular and soft tissue calcification Bone density, serum or ionized calcium Dairy products, calcium-set tofu, calcium-fortified beverages, kale
Phosphorus Inadequate intake, decreased absorption, increased losses, large intake of calcium (e.g., antacids) Anorexia, muscle weakness, bone pain, rickets (children), osteomalacia (adults), anemia Reduced calcium absorption, calcification of nonskeletal tissues (kidneys) Serum phosphorus Dairy products, soda containing phosphoric acid
Magnesium Inadequate intake, losses due to diarrhea, malabsorptive syndromes, excessive laxative use, pancreatitis Symptomatic hypocalcemia, muscle cramps, interference with vitamin D metabolism, neuromuscular hyperexcitability, latent tetany, spontaneous carpal-pedal spasm, seizures Diarrhea, nausea, abdominal cramps, hypokalemia, paralytic ileus, metabolic alkalosis (with very large dose) Serum magnesium, 24-hour urine magnesium (most accurate) Leafy green vegetables, whole grains, nuts
Iron Inadequate intake, poor bioavailability, blood loss, achlorhydria Fatigue, pallor, tachypnea, tachycardia, koilonychia (spoon nails) Vomiting; diarrhea; CNS, kidney, liver, blood effects Ferritin, TIBC transferrin saturation, Hemoglobin/Hematocrit, zinc protoporphyrin Meats, fish, poultry
Zinc Inadequate intake, zinc-deficient TPN, diarrheal losses, high phytic acids in diet, calcium supplements Growth retardation, alopecia, diarrhea, delayed sexual maturation, impaired appetite, delayed wound healing Acute epigastric pain, diarrhea, headache, nausea, vomiting, decreased appetite Serum/plasma zinc; response to zinc supplement Red meat, seafood, whole grains, fortified cereal
Selenium Inadequate intake, selenium-deficient TPN Keshan disease, cardiomyopathy, hypothyroidism, cartilage degeneration Hair and nail brittleness/loss, skin rash, garlic breath Plasma or serum selenium Meat, seafood, cereals, grains, dairy
Copper Copper-deficient TPN or formula, chronic diarrhea, losses w/hemodialysis Normocytic, hypochromic microcytic anemia, leukopenia, neutropenia, osteoporosis (in growing children) Observed in Wilson disease, idiopathic copper toxicosis, liver damage Serum copper, ceruloplasmin Organ meats, seafood, nuts, seeds and cocoa products, whole grains
Chromium Chromium-deficient TPN Unexplained weight loss, peripheral neuropathy, impaired glucose utilization Rhabdomyolysis, liver dysfunction, renal failure Serum, erythrocyte and urine chromium levels All bran and whole grain cereals
Carnitine Carnitine-deficient TPN Defective fatty acid oxidation, cardiomyopathy, depressed liver function, hypoglycemia, neurologic dysfunction Nausea, vomiting, abdominal cramps, fishy body odor Total and free carnitine levels Red meats, dairy, nuts, seed, legumes
Fat Inadequate intake, malabsorption, diarrhea Impaired growth, impaired absorption of fat-soluble vitamins A, D, E, and K Obesity Triene-to-tetraene ratio Nuts, seeds, vegetable oils (corn, soybean, flax, canola) fatty fish, animal products
PIVKA II, protein induced by vitamin K absence or antagonist-II (PIVKA_II) in human serum and plasma; TIBC, Total iron-binding capacity.

As part of the physical assessment, recognizing the loss of subcutaneous fat is of utmost importance. Closely examining the child’s arms by identifying defined muscle outlines, hollow cheeks on the face, and minimal skin to pinch between two fingers on the chest wall is an important part of a nutrition-focused physical examination. Overall, muscle wasting should be identified in areas that lose bulk and tone due to malnutrition; areas of focus should include the clavicle, shoulder, temple, and calf. It is important to note that the lower body is less sensitive to change in weight than the upper body, and acute weight loss can be reflective of hydration status or a result of a intercurrent illness. Hand dynamometry may also be measured as a surrogate gauge of muscle function. The presence of pitting edema over the sacrum or at the ankles may indicate hypoproteinemia; the presence of certain disease states such as liver disease, kidney disease, or congestive heart failure may underlie fluid retention. In these cases, assessment of weight change and edema together will help the clinician identify loss of lean body mass masked by fluid retention. The visual impressions of body composition can be corroborated by objective anthropometric measurements.

Anthropometric Measurements

Deviations in growth tend to be the earliest predictors of poor nutritional status in children; therefore accurate serial measurements of height, weight, and head circumference are the hallmarks of an age-appropriate nutrition assessment. Heights and weights of both parents should be documented to determine the child’s genetic potential and to help identify decelerations in growth caused by nutritional factors. The midparental height can be calculated, correcting for height of the opposite gender parent, so that the measurement can be evaluated on the appropriate gender growth chart:

  • For boys: (paternal height + [maternal height + 5 in or 13 cm])/2

  • For girls: (maternal height + [paternal height − 5 in or 13 cm])/2

Growth measurements can be plotted on age- and gender-appropriate growth charts from the WHO or CDC and compared with reference standards. Currently, the CDC and the American Academy of Pediatrics (AAP) recommend that health care providers use the WHO growth charts revised in 2006 to monitor growth for infants and children 0 to 2 years of age in the United States. WHO charts reflect growth patterns among children from six countries including the United States who were predominantly breast-fed for at least 4 months and are still breastfeeding at 12 months.

The 2000 CDC growth charts should be used continuously from ages 2 to 20. Clinicians often use the CDC growth charts as standards to determine how young children should grow. However, the CDC growth charts are references; they identify how typical children in the United States did in fact grow during a specific time period. Typical growth patterns may not be ideal growth patterns. The WHO growth charts are standards; they identify how children should grow under optimal conditions.

Weight: Suboptimal weight gain or weight loss is an indicator of acute undernutrition; in the pediatric population, loss of body weight in the face of poor dietary intake can occur in less than a week. In malnourished children, a decline in percentile curves appears first in weight, then in height, and finally in measurements of head circumference. Body weight should be obtained using an infant scale in children weighing less than 30 lb and a beam scale for those weighing more than 30 lb. Weights should be obtained consistently with minimal clothing and without shoes; infants should be weighed in a dry diaper or naked if possible. The following are clinically useful calculations to assess the degree of weight loss:

  • Calculation for percentile weight loss:

    • [Usual body weight − current weight]/usual weight

  • Determining ideal body weight (IBW)/height

    • First estimate the patient’s height/age (defined as the age at which their height would be at the 50th percentile) and then identify the weight at the 50th percentile for that height/age

Height : Poor linear growth is a key indicator of chronic malnutrition. In children younger than 2 years of age, length should be obtained using a length board with the patient lying in the recumbent position. The length board is a flat board with a moveable head piece and secure foot piece that is perpendicular to the surface. The infant’s length should be recorded as the distance between the head piece and the foot piece and recorded to the nearest 0.1 cm. Children older than 2 years of age are measured without shoes using a stadiometer. The child should stand erect with heels, shoulders, and buttocks all touching the measurement on the wall.

Height and weight measurements can be converted to Z-scores, which are values that represent SDs from the median height and weight values for a specific age. A height or weight Z-score equivalent to −1.64 indicates that the patient is plotting below the fifth percentile. Additional information on calculating and applying Z-scores is available at www.who.int .

Weight for Length and Body Mass Index

Weight for length and body mass index (BMI) are calculations based on weight and recumbent length or weight and standing height. Weight for length indicates the proportionality of patients under 24 months of age. The BMI provides a clinical estimate of potential weight-related medical risk factors despite the limitation that it does not differentiate lean muscle from body fat. The BMI for age is calculated by taking the patient’s weight in kilograms and dividing by height in meters squared (kg/m 2 ). It is recognized among experts in the field of pediatric obesity that the BMI should not be used alone as a benchmark for determining the degree of adiposity in a clinical setting.

Tricep Skin Fold/Mid-Arm Circumference (TSF-MAC)

Upper limb anthropometric measurements have become routine practice in many clinical settings. The best application of skinfold calipers is to determine whether subcutaneous fat is increasing or decreasing, but not to determine total body fat. The error for skinfold measuring has been reported to be 3% to 5% in age-specific populations.

TSF and MAC measurements provide indirect data on body composition and can be useful for the longitudinal assessment of a patient’s response to nutritional therapy considered over time and in conjunction with clinical assessment and body weight. This is based on evidence that starved or malnourished humans use stored energy in the form of fat and skeletal muscle. TSF assesses stored energy in the form of fat, whereas the MAC is reflective of muscle protein reserves. Although 12 body sites are available to measure skinfold thickness using calipers, the TSF is most commonly used because of its ease of use and high correlation with total body fat. Skinfold measurements cannot be taken in infants less than 3 months of age secondary to fluctuation in fluid compartments. It is imperative that the person obtaining the measurement be well trained and familiar with the process. Calculations of adiposity and obtained anthropometric data points—such as TSF, MAC, and others—can be compared with population-based indices published by the CDC and the National Center for Health Statistics based on information routinely collected by the National Health and Nutrition Examination Surveys to help examine the relationship between estimated body fat and health conditions among typically developed children in the United States.

Detailed Diet History

One of the most critical components of the nutritional assessment is obtaining a diet history that reflects the quality and quantity of foods offered to and consumed by the child. It is just as important to gain an understanding of the household structure surrounding family mealtimes. It is essential for the clinician to understand how frequently the child eats, where the child consumes most of his or her meals and snacks, and with whom he or she is eating. A detailed diet history should not only include an assessment of the table foods consumed but also take into account the quantity and frequency of beverages consumed such as milk, water, soda, sports drinks, and fruit juice. The percentage of energy contributed by milks (formula, breast milk, and cow’s milk) declines consistently as children age, going from 88% of energy at 4 to 5 months to 24% of energy at 12 to 24 months. As children consume less milk, the intake of low-nutrient beverages tends to increase. Recent evidence suggests that the consumption of sugar-sweetened beverages is positively associated with obesity indices in children and adults.

A record of all oral supplements consumed and/or tube feedings and free water prescribed to support the growth of the child must be carefully considered. Information on daily vitamin and mineral supplements as well as possible herbal supplements should be included. Consideration of food allergy, elimination diets, ability to chew and swallow foods, as well as the family’s access to food requires assessment.

In an outpatient setting, a 24-hour diet recall can be useful in gaining a general sense of the types of food(s) consumed by the child; however, this can be misleading, as the information provided reveals the diet for only 1 day. This approach can be modified by asking the family/child “What does a typical day look like for breakfast, lunch, dinner, and snacks?” For specific situations, there are validated Food Frequency Questionnaires (FFQs) available to obtain complete and accurate diet intake information.

A more valid tool that is widely used in clinical practice to assess diet adequacy is the 3-day food record. A registered dietitian (RD) can estimate the content of the diet by using Atwater conversion factors (carbohydrate = 4 calories per gram, protein = 4 calories per gram, fat = 9 calories per gram) or a computer software program that analyzes diet composition based on US Department of Agriculture (USDA) standards (The Food Processor Version 10.11.0, ESHA Research, Salem, OR). With either approach, the energy and nutrient composition of the diet must be compared with gender- and age-specific dietary reference intakes (DRIs). In medically complex patients where estimates of basal energy requirements are necessary to provide medical nutritional therapy, indirect calorimetry can be useful.

Special attention should be paid to the quantity of dietary fat infants and toddlers consume, because fat is a concentrated source of energy and plays a critical role in brain growth and central nervous system function. Parents who may be restricting dietary fat for perceived health reasons should be counseled on the biologic need for fats in the first 2 to 3 years of life. Education should be provided to reassure families that in the 6- to 24-month period, the amount of fat intake does not show associations with adult disease related to excessive intake of dietary fat. In fact, it is becoming well recognized that the type of fat may be more important to human health than the quantity considered alone.

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