ABCD for nutritional assessment

1. Nutritional Assessment in
Children
Prof. (Dr.) Smriti Arora
Amity College of Nursing, Amity University Haryana
smritiamit@msn.com

2. Need for nutritional assessment
 To identify early, at risk individuals for malnourishment
 To identify malnourished individuals
 To develop health care plans for malnourished individuals.

3. • Malnutrition (WHO) - "the cellular imbalance between the supply of nutrients and energy and
the body's demand for them to ensure growth, maintenance, and specific functions."
• Causes of malnutrition - illiteracy, poor eating habits, low family income, poor hygiene, recurrent
infections and poor lifestyle choices.
• It includes both Undernutrition and Obesity.
• Under nutrition can be classified as underweight, stunted or wasted.
 Underweight - Low Weight for age
 Stunted – Low Height for Age
 Wasted – Low Weight for Height

5. Methods of nutritional assessment
• Nutritional assessment can be done with ABCD
method i.e.
• Anthropometric measurement,
• Biochemical parameters,
• Clinical examination and
• Dietary survey.

6. 1. Anthropometric Measurement
 Height
 Weight
 BMI
 Mid Upper Arm Circumference (MUAC)
 Head circumference
 Chest circumference

7. Height
• Height is measured by infantometer for infants and stadiometer for child above 2 years.
• Low height for age indicates stunting and chronic malnutrition
• Weech’s formula for Expected Height upto 12 yrs
 Length or height (in cms) = age in years x 6 +77

8. Height
• Expected weight of a child till 12 years of age can be calculated using Weech’s
formula.
• Weech’s Formula for Expected Weight
Age Expected weight(kg)
a) 3 – 12 months age (months) + 9 / 2
b) 1- 6 years age (years) x 2 + 8
c) 7 – 12 years age (years) x 7 - 5 / 2

9. Weight
• Weight can be measured by weighing scale.
• Weight for age – low weight for age refers to underweight, indicates
chronic malnutrition.
• Weight for Height– low Weight for Height is called wasting.

10. • BMI- it is defined as weight in kg per height in metres square.

11. MUAC
• Shakir’s tape
Color coding MUAC Interpretation
Red 0-11.5 cms Severe acute malnutrition (SAM)
Yellow 11.5-12.5 cms Moderate malnutrition
Green 12.5-26.5cms Well nourished

12. Head circumference
• Infants have a large head at birth as compared to the rest of the body.
• At birth it is 33-35 cms which is 3 cms greater than chest circumference.
• Head circumference increases 2 cm per month from birth to 3 months, 1cm/month
from 4-6 months and 0.5 cm/month for next 6 months.
• Average HC at 6 months is 43 cm and at 12 months it is 46 cm.
• Closure of cranial sutures takes place with posterior fontanel fusing at 6-8 weeks
of age and anterior fontanelle fusing by 12-18 months of age.
• HC can be measured with an ordinary tape.

13. Chest circumference
• At birth the circumference of chest is
about 3 cm less than head circumference.
• Head circumference and chest
circumference equals by end of first year.

14. Skin fold thickness
• Harpenden and Lange callipers are used
to assess the skinfold thickness, as a
measure for subcutaneous fat.
• Areas commonly measured are biceps,
triceps, subscapular and suprascapular.
• When there is insufficient intake of
calories for over a long period of time,
the skin fold thickness reduces thus
indicating undernutrition.

15. 2. Biochemical Measurement
• In a full nutritional assessment it can be useful to screen the
biochemical parameters like albumin, prealbumin, CRP,
transferrin, hemoglobin, urea and creatine and
lymphocytes.

16. 3. Clinical Method
• It involves looking for clinical sign and symptoms indicative of particular deficiency.
Areas Signs Observation
General activity Lethargic/Active
Hair Shiny/ Loss of Luster/Sparse and thin/Discolored/Easily
plucked/flag sign
Face Moon face /Buccal fat pad
Eyes Nightblindness/photophobia/
Pigmentation of the conjunctiva-Brown/conjunctival
xerosis/bitot’s spots/corneal xerosis /keratomalacia Angular
conjunctivitis/pale conjunctiva/ yellow sclera
Mouth Glossitis/bleeding and spongy gums/ Angular
stomatitis/Cheilosis/sore mouth and tongue/ leukoplakia
Teeth Caries/Mottled enamel
Glands Goiter
Skin Pallor/Follicular hyperkeratosis/flaky
dermatitis/pigmentation/desquamation/bruising/purpura/
Grazy-pavement Dermatosis
Tenting of skin
Edema
Nails Spooning of the nails, brittle nails/transverse lines
Limbs Baggy pants appearance
GI system Diarrhoea, constipation
Joints and bones Cranial Bossing-Frontal/Parietal/Beading of ribs/Knock
knees/Bow legs
Nervous system Numbness and tingling of extremities /Burning feet/tenderness of
calf muscles/loss of knee/ankle jerks

17. 4. Dietary Survey
• It is a systematic survey into the food consumption of population/individual. It includes 24 hours dietary
recall, food frequency questionnaire and dietary history.
• 24 hr. Recall: Interviewer asks the child to recall all food and drinks taken in the previous 24 hours.
Time Food items Amount Remarks
Early morning
Breakfast
Mid-Morning
Afternoon
Post lunch
Tea time
Evening
Dinner
Post dinner

18. • Dietary history - details about usual intake, type, amount
frequency, preferences, allergies, etc.
• Food diary – individual is asked to maintain a food diary for
1-7 days .

19. Classification of PEM
The classification is done based on
• Weight for age,
• Height for age and
• Weight for Height.

20. Formula to calculate weight for age
% for Gomez classification
Weight for age (%)= (weight of the
child/weight of normal child of
same age) x 100

22. Grading of Marasmus and Kwashiorkar

24. Z Score
 Any score greater than -2 indicates no stunting (linear growth
retardation) or wasting (failure to gain weight or weight loss),
 score in between -2 and -3 indicates moderate stunting or wasting
 any score up to -3 indicates severe stunting or wasting;

25. WHO classification for children with protein-energy malnutrition
• Infants younger than 6 months
- No gold standard exists for infants younger than 6 months. It is
recommended that clinicians follow the same criteria used for older
children.

26. Children aged 6-59 months

27. WHO 10 steps to recovery in malnourished children. It is done in 2 phases: Initial stabilization (1-7 days) and
Rehabilitation (2-6 weeks)
1. Hypoglycemia – if blood glucose is less than 54 mg/dl
• For asymptomatic child- give 50 ml of 10 % dextrose or sucrose solution orally or by NG tube.
• Start F 75 every 2 hour.
• For symptomatic child with seizures, lethargy - give 5 ml/kg of 10 % dextrose followed by 50 ml of 10 % dextrose
by NG tube. Start F 75 every 2 hour. Start antibiotics
2. Hypothermia- if rectal temp is less than 35.5 C then cover with warm clothes, STS contact, feed and administer
antibiotics.
3. Dehydration – Give ORS, Start F 75 formula
4. Electrolytes- supplemental potassium at 3-4 meq /kg/day for atleast 2 weeks, on day 1 give 50% Mg So4- 0.3 ml/kg
/ IM
5. Infection- administer antibiotics. Ampicillin IV for 2 days followed by oral amoxycillin. Encourage handwashing.

28. 6. Micronutrients- on day 1, Vitamin A orally - 2 lakhs IU if child is greater than 1 yr and 1 lakh IU if less than 1
year. Folic acid 1 mg/day , Zinc- 2 mg/kg/day , Copper- 0.2-0.3 mg/kg/day and iron- 3 mg/kg/day after the
stabilisation phase
7. Initiate feeding – F 75, F 100
8. Catch up growth – monitor appetite, increase volume and decrease frequency of feeds. Add complimentary
foods.
9. Sensory stimulation – provide structured play, cheerful environment and tender loving care.
10. Prepare for follow up after recovery. A child is said to have recovered when weight for height is 90% of
NCHS median and has no edema.

29. Thank you !