1. Infant Nutrition Assessment: GROWTH Beth Ogata, MS, RD, CSP Joan Zerzan, MS, RD UW – CHDD bogata@uw.edu NUTR 526 – Fall 2012

2. Nutrition Screening and Assessment

3. Growth Data Used Throughout the Nutrition Care Process Screening Assessment Diagnosis Monitoring and Evaluation

4. NCP: Nutrition Screening Definitions ▫Process of identifying characteristics known to be associated with nutrition problems (ASPEN, 1996) ▫Simplest level of nutritional care (level 1) (Baer et al, 1997) Purpose ▫Identify individuals who appear to have or be at risk for nutrition problems ▫Identify individuals who require further assessment or intervention

5. Examples of Screening Risk Factors Anthropometrics: weight, length/height, BMI measures < 5 th %ile measures > 95 th %ile alterations in growth patterns ▫change in Z-scores ▫change 1-2 SD ▫change percentile channels Medical Conditions Medications Improper or inappropriate food/formula choices or preparation Psychosocial Laboratory Values

6. NCP: Nutrition Assessment Obtain, verify, interpret information Data used might vary according to setting, individual case, etc… Questions to ask ▫Is there a problem? ▫Define the problem? ▫Is more information needed?

7. Tools Used in Nutrition Assessment Growth ▫Measurements ▫Growth charts ▫Absolute size (percentile) ▫Pattern ▫Body composition (water, bone, muscle, fat) Intake ▫Food record/recall analysis Additional information ▫Medical ▫Development ▫Social ▫Laboratory ▫Etc.

8. NCP: Nutrition Diagnosis Identification or labeling of problem that is within RD scope of practice to treat ▫Examples:  Inadequate intake  Inadequate growth

9. NCP: Intervention, Monitoring and Evaluation Intervention ▫Etiology drives the intervention Monitoring and Evaluation

10. PART 2 – Definition of Growth

11. Growth Dynamic process Increase in the physical size of the body as a whole or any of its parts associated with increase in cell number and/or cell size Reflects changes in absolute size, mass, body composition A normal, healthy child grows at a genetically predetermined rate that can be compromised by imbalanced nutrient intake

12. Growth in the first 12 months From birth to 1 year of age, normal human infants triple their weight and increase their length by 50%. Growth in the first 4 months of life is the fastest of the whole lifespan - birthweight usually doubles by 4 months 4-8 months is a time of transition to slower growth By 8 months growth patterns more like those of 2 year old than those of newborn.

13. Changes in Body Conformation

15. Weight Gain (g/d) in one-month increments – Girls and Boys

16. Evaluating Growth: Adam

17. Evaluating Growth: Adam, cont’d

18. Rates of weight gain: Breastfed vs. Formula-fed Rates of gain for breastfed and formula fed infants during early months of life generally have been found to be similar although some reports have demonstrated greater gains by breastfed infants and others have shown greater gains by formula fed infants ▫Dewey, Pediatrics, 1992;89:1035 ▫Nelson, Early Human Development, 1989;19:223. ▫Cole, Acta Paediatr, 2002;91:1296.

19. PART 3: How growth is evaluated

20. Do parents understand growth charts? Ben-Joseph E, et al. Do parents understand growth charts? A national, internet-based study. Pediatrics. 2009; 124(4):1100-09. n=1000 parents (US) Completed internet survey about awareness of, knowledge of, and attitudes toward growth monitoring and ability to interpret growth data Survey at: http://kidshealth.org/misc/surveys/GrowthChartSurvey.pdf http://kidshealth.org/misc/surveys/GrowthChartSurvey.pdf

21. Chart 1 Based on this point, how old is the child? How much does he weigh? What “percentile” is this child’s weight at?

22. Chart 1 - continued What does it mean that the child’s weight is at the 90 th percentile? a.90% of children are heavier b.Child is heavier than 90% of others c.Child is 90% of recommended weight d.I am not sure e.Other

23. Reference vs Standard Reference: a set of data used for normalizing measurements so that they can be manipulated statistically, grouped and compared with other sets of measurements. In principle, implies no value judgment and tells us nothing about optimal or satisfactory growth Standard: Implies a value judgment. In theory, standards are selected based on representing “optimal,” “normal,” or “goal”

24. Fetal/Neonatal Growth Charts Intrauterine charts ▫Classification of newborn  AGA  LGA  SGA Postnatal Charts

25. Intrauterine/Fetal Growth Standards Lubchenco Gairdner Babson/Benda Fenton Olsen

26. Fetal Growth Data

27. Fenton Chart Data Sets: ▫Kramer, et al: 676,605 infants, 22-43 weeks ▫Nicholson, et al: 376,000 Swedish infants 28-40 weeks ▫Breeby, et al: OFC (N=29,090) and Length (N=26,973), 22-40 weeks ▫CDC Data Time period 1963-2001

28. Postnatal Growth Charts Accounts for initial weight loss Dancis: Data 1948, very small sample size in lowest weight group Ehrenkranz: Pediatrics 1999:104:280 ▫N=1660 ▫14-16 g/kg/d weight gain ▫0.9 cm/week increase length ▫0.35 cm/week increase OFC

29. Infant Growth Charts (References): Timeline Stuart/Meredith Growth Charts (1946-76) ▫Caucasian, Boston/Iowa city, small sample size NCHS growth charts (1976-1978) ▫Cross sectional Data from NHES, NHANES, and FELs ▫CDC produced normalized version ▫1978 WHO recommended international use CDC (2000) ▫5 cross sectional nationally representative surveys between 1963-1995 ▫Included more breast fed infants WHO (2006) ▫Data from Brazil, Ghana, India, Norway, Oman and US ▫Multiethnic, affluent ▫Exclusive breastfeeding to 4 months ▫Solids according to recommendations 6 months ▫Continued breastfeeding to 12 months

30. Evolution: NCHS  CDC Charts NCHS infant data: Fels studyCDC infant data: NHANES I, II, III Primarily formula-fed Underrepresented groups: largely Caucasian, middle class Intervals of measurements (q3 months from 3-36 months) may not define dynamic patterns during rapid growth phases Statistical smoothing procedures Standardized data collection methods Expanded sample More breastfed infants Exclusions ▫VLBW infants ▫NHANES III weight data for >6 year olds

31. Evolution: NCHS  WHO Charts Released new growth standards April 2006 ▫Assumed infants and children grow similarly when needs are met. Concerns for CDC charts included: ▫Frequency of growth measures during dynamic periods of infant growth

33. Compare the charts (<24 month olds) CDC growth reference (2000) WHO growth standard (2006) Data sourcesNat’l vital statistics (birthwts), PNSS, NHANES I, II, III (1971- 1994) MGRS longitudinal component (Brazil, Ghana, India, Norway, Oman, United States) Data typeCross-sectional starting at age 2 mo, with mathematical modeling Longitudinal: birth, 1, 2, 4, 6, 8 weeks; 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, 24 months Sample size4697 observations for 4697 children 18,973 observations for 882 children Breastfeeding among infants in sample ~50% ever breastfed ~33% breastfeeding at 3 mo 100% ever breastfed 100% predominantly breastfeeding at 4 mo 100% breastfeeding at 12 mo Complementary foods introduced at mean age 5.4 mo Source: MMWR, 2010; 59(No. RR-9):1-15.

34. Compare the charts (<24 month olds) CDC growth reference (2000) WHO growth standard (2006) Exclusion criteriaVLBW (<1500 g) Low socioeconomic status Birth at altitude >1500 m Birth at 42 wk Multiple birth Perinatal morbidities Child health conditions known to affect growth Maternal smoking during pregnancy or lactation Breastfeeding for <12 mo Complementary foods before 4 mo or after 6 mo Wt-for-length >3 SD +/- study median

35. Comparison of WHO and CDC Chart (weight-for-age) GirlsBoys Source: MMWR, 2010; 59(No. RR-9):1-15.

36. Comparison of WHO and CDC Chart (stature-for-age) GirlsBoys Source: MMWR, 2010; 59(No. RR-9):1-15.

37. Charts to Evaluate Growth of Infants CDC Clinical Charts http://www.cdc.gov/growthcharts/ WHO Child Growth Standards http://www.who.int/childgrowth/en Sex-specific ▫Weight-for-age ▫Length-for-age ▫Weight-for-length ▫Head circumference-for-age Choice between outer limits at 3 rd and 97 th percentiles, or 5 th and 95 th Sex-specific ▫Weight-for-age ▫Length-for-age ▫Weight-for-length ▫Head circumference-for-age ▫On WHO site: BMI, other measures Outer limits at 2 nd and 98 th percentiles

38. Differences between WHO and CDC infant charts WHO mean > CDC mean birth to 6 months “Healthy breastfed infants track weight-for-age along WHO but falter on CDC” Cross at 6 months and WHO mean < 6 months On the CDC chart, children appear heavier and shorter On the WHO chart, children appear taller WHO charts: ▫Higher estimate of overweight ▫Lower estimates of underweight, undernutrition

39. CDC Recommendations for infant growth charts Expert Panel (NIH, AAP) to review scientific evidence. Recommendations: WHO charts from birth to 24 months CDC charts for >24 months As a screen, 2 rd and 98 th percentile on WHO corresponds to 5 th and 95 th on CDC Clinicians should be aware that fewer individuals will be screened as “underweight” and more as “overweight” using WHO For more, see http://www.cdc.gov/growthchartshttp://www.cdc.gov/growthcharts

40. Controversies/Issues Screen vs. assessment Standard vs. reference Typical vs. ideal growth Environmental influence Variety of diets may result in acceptable growth and nutrition status Normal population diversity  Plot individuals on both CDC and WHO. Does your assessment change? Absolute size vs. pattern

42. Carl

43. Carl – absolute size vs. pattern

44. PART 4: Problems with Growth Underweight Overweight Failure to Grow “Overfat”

45. Screening  Assessment Screening identifies nutritional risk and/or need for further assessment. Assessment: Collect data Interpret data ▫Link information ▫Compare to references, standards, expectations ▫Ask questions

46. Interpretation: Asking Questions Is there a problem? Was there a problem? Does information make sense? What are goals and expectations? What is etiology of the problem?

47. Overweight Weight in infancy associated with weight in childhood ▫Crossing percentiles (upward) in infancy is associated with ↑d OR of childhood obesity (Taveras, 2011) ▫ Children in upper tertile had higher risk of childhood obesity than children in lower tertile (Andersen, 2012) Appropriate screening tool, intervention not clear; Beth’s take-home message: keep feeding babies

48. Undernutrition ↓ weight, no effect on length  low weight-for- length ↓ ↓ weight  ↓ length or height  eventually may appear proportionate

49. Failure to Grow, Failure to Thrive Failure to gain weight or grow at expected rates ▫Weight-for-age <5 th %ile ▫Weight-for-length <5 th %ile ▫Decreased growth velocity (decrease over 2 SD over 3- 6 months) ▫<80% ideal body weight 1-5% tertiary hospital admissions for <1 year olds Prevalence varies ▫5-10% <3 years of age ▫Some populations at higher risk

50. Failure to Grow Inadequate intake ▫Not enough food offered: Food insecurity, lack of knowledge of child’s needs ▫Not enough food consumed: Oral-motor dysfunction, behavioral feeding problems ▫Emesis Malabsorption Increased metabolic demand

51. Figure 5: Proposed algorithm[s] for identification and assessment of possible undernutrition in infancy [and childhood] (White, 2012)

52. Potential Pitfalls in Growth Assessment Excuses Assumptions Faulty reasoning Incorrect or inaccurate information Not evidence-based Biased

53. Process Identify Problem or risk Identify Etiology Determine intervention Monitor and Reevaluate