Nutrition‐Focused Physical Examination in Pediatric Patients

Abstract

A complete nutrition assessment includes several components: medical record review, anthropometric measurements, diet/nutrition intake, interview, and physical examination. The nutrition-focused physical examination (NFPE) can identify or confirm muscle wasting, subcutaneous fat loss, and edema and clarify information gathered during the medical record review. The physical examination component of the nutrition assessment is more critical in pediatric patients because pediatric patients can become malnourished more quickly than adults and because prolonged malnutrition can negatively affect growth and development. In addition, case studies of micronutrient deficiencies, essential fatty acid deficiency, and protein-calorie malnutrition with skin manifestations have been reported in developed countries. The etiologies of the deficiencies are chronic disease, long-term tube feedings, or long-term parenteral nutrition. An NFPE involves an in-depth examination of the patient from head to toe by a trained nutrition professional. Nutrition professionals recognize the importance and value of an NFPE, yet it is seldom completed, particularly in pediatrics, most likely due to lack of training and lack of pediatric-specific information or training opportunities. Although there are similarities between NFPE in pediatric and adult patients such as the techniques used (inspection, palpation, percussion, and auscultation), there are important differences related to growth and development. This review provides an overview of nutrition assessment with focus on the NFPE and aspects unique to the pediatric patient.

ASPEN Consensus Recommendations for Refeeding Syndrome

“…Table 5 114‐116 lists criteria recommended, by consensus, for inclusion in assessing risk of RS in the pediatric population. As with adults, this list cannot be considered exhaustive, nor is it known the strength of impact of each or multiple characteristics.…”

“…Abnormal electrolyte values are expressed as percentages below the lower limit of normal, as different medical laboratories may have different values for the normal range. Table 5 [114][115][116] lists criteria recommended, by consensus, for inclusion in assessing risk of RS in the pediatric population. As with adults, this list cannot be considered exhaustive, nor is it known the strength of impact of each or multiple characteristics.…”

Optimizing Nutrition in Pediatric Heart Failure: The Crisis Is Over and Now It’s Time to Feed

“…A child’s growth can be evaluated with standardized growth charts (percentiles) and by calculating the child’s z score . Other anthropometric values, such as triceps skinfold and mid upper arm circumference, may be useful to assess lean muscle mass and fat stores . These are essential measurements when edema is present and weight becomes an unreliable assessment of nutrition status.…”

Diagnosing Pediatric Malnutrition

“…Likewise, a child who has a normal or low BMI may actually have a low muscle mass and high percentage of body fat 49 . Obtaining a thorough nutrition and physical activity history with a nutrition‐focused physical examination may help tease out these differences 50 , 51 . Grip strength may also prove to be a valuable indicator of pediatric malnutrition, especially in overweight or obese children, because it measures muscle function—a valuable outcome measure—and can serve as a proxy for muscle mass 52 – 55 .…”

“…Physical examination to determine muscle/fat wasting was thought to be “too subjective.” 8 However, physically touching a child's muscle, bones, and fat provides empirical evidence that is arguably more “objective” than asking parents to remember what their child has eaten over the past several days, weeks, or months. In practice, dietary intake and nutrition‐focused physical examination are invaluable when diagnosing pediatric malnutrition 6 , 50 , 80 , 81 . Measuring grip strength is feasible in children 64 , 65 , 82 and yields reliable information that could inform the malnutrition diagnosis.…”