Pediatric Nutrition for Dietitians 1st Edition
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Library of Congress Cataloging-in-Publication Data
Names: Goday, Praveen S., editor. | Walia, Cassandra Sova, editor.
Title: Pediatric nutrition for dietitians / Praveen Goday, MBBS, FAAP, and
Cassandra Sova Walia, MS, RD, CD, CNSC.
Description: First edition. | Boca Raton : CRC Press, 2022. |
Includes bibliographical references and index. |
Summary: “This book is a comprehensive review of pediatric nutrition primarily
for a dietitian, dietetics student, or a master’s level student in pediatric nutrition.
It is written and edited by experts in the field who continue to
practice pediatric nutrition and serves as a resource for the practicing
pediatric dietitian. With disease-specific chapters, the content begins
with a brief overview of pathophysiology including incidence or
prevalence data, etiology, clinical signs and symptoms, and alterations
in metabolism. This information is followed by nutritional guidance in
the ADIME (assessment, diagnosis, intervention, monitoring, and
evaluation) format”— Provided by publisher.
Identifiers: LCCN 2021057204 (print) | LCCN 2021057205 (ebook) |
ISBN 9780367707637 (hardback) | ISBN 9780367705046 (paperback) |
ISBN 9781003147855 (ebook)
Subjects: LCSH: Children—Nutrition. | Pediatrics. | Dietitians.
Classification: LCC RJ206 .P3628 2022 (print) | LCC RJ206 (ebook) |
DDC 613.2083—dc23/eng/20211124
LC record available at https://lccn.loc.gov/2021057204
LC ebook record available at https://lccn.loc.gov/2021057205
ISBN: 9780367707637 (hbk)
ISBN: 9780367705046 (pbk)
ISBN: 9781003147855 (ebk)
DOI: 10.1201/9781003147855
Typeset in Times
by codeMantra
To Thangam, Arvind, and Tara
For always being at the dinner table and nourishing my soul
Praveen S. Goday
To my parents, who always encouraged me to chase my dreams and provided
unwavering support along the way. And to my husband, who helped me
study and continues to support me through my career every day.
Cassandra L. S. Walia
Contents
Preface...............................................................................................................................................xi
Editors ............................................................................................................................................ xiii
Contributors ..................................................................................................................................... xv
Reviewers ........................................................................................................................................xix
Chapter 1 Growth Assessment ......................................................................................................1
Julia Driggers, Kanak Verma, and Vi Goh
Chapter 2 Nutrition-Focused Physical Exam .............................................................................. 15
Hanna Leikin, Merideth Miller, and Sara Bewley
Chapter 3 Nutrition Screening and ADIME ............................................................................... 35
Jennifer L. Smith and Teresa A. Capello
Chapter 4 Fetal Development and Maternal Diet ....................................................................... 51
Ruby Gupta and Alison Hanson
Chapter 5 Infant Nutrition........................................................................................................... 65
Olivia Mayer, Yasemin Cagil, and John Kerner
Chapter 6 Nutrition in the Older Child ....................................................................................... 79
Sarah Lowry, Jenifer Thompson, and Ann O’Shea Scheimann
Chapter 7 Enteral and Parenteral Devices .................................................................................. 89
Ruba A. Abdelhadi, Ammar R. Barakat, and Beth Lyman
Chapter 8 Enteral Nutrition....................................................................................................... 101
Stephanie G. Harshman and Lauren G. Fiechtner
Chapter 9 Parenteral Nutrition .................................................................................................. 111
Ajay Kumar Jain and Jamie Nilson
Chapter 10 Malnutrition.............................................................................................................. 127
Laura Gearman and Catherine Larson-Nath
Chapter 11 Care of the Hospitalized Child................................................................................. 139
Anushree Algotar, Anna Tuttle, and Mark R. Corkins
vii
viii Contents
Chapter 12 Care of the Premature and Ill Neonate..................................................................... 153
Ting Ting Fu, Kera McNelis, Carrie Smith, and Jae H. Kim
Chapter 13 Care of the Critically Ill Pediatric Patient................................................................. 165
Katelyn Ariagno and Nilesh M. Mehta
Chapter 14 Cardiac Disease......................................................................................................... 175
Megan Horsley and Jeffrey Anderson
Chapter 15 Food Allergy............................................................................................................. 185
Alison Cassin, Ashley Devonshire, Stephanie Ward, and Meghan McNeill
Chapter 16 Gastrointestinal Disease............................................................................................203
Justine Turner and Sally Schwartz
Chapter 17 Intestinal Failure....................................................................................................... 231
Rashmi Patil, Elizabeth King, and Jeffrey Rudolph
Chapter 18 Chronic Liver Disease............................................................................................... 245
Julia M. Boster, Kelly A. Klaczkiewicz, and Shikha S. Sundaram
Chapter 19 Cystic Fibrosis and Pancreatic Disease..................................................................... 263
Elissa M. Downs, Jillian K. Mai, and Sarah Jane Schwarzenberg
Chapter 20 Renal Disease............................................................................................................ 279
Molly Wong Vega and Poyyapakkam Srivaths
Chapter 21 Care of Children and Youth with Special Health Care Needs.................................. 301
Sarah Vermilyea and Elisabeth Pordes
Chapter 22 Adolescent Medicine................................................................................................. 323
Perry B. Dinardo, Jennifer Hyland, and Ellen S. Rome
Chapter 23 Inborn Errors of Metabolism.................................................................................... 337
Surekha Pendyal and Areeg Hassan El-Gharbawy
Chapter 24 Endocrine Disorders.................................................................................................. 363
Lisa Spence, Nana Adwoa Gletsu Miller, and Tamara S. Hannon
Contents ix
Chapter 25 Obesity and Lipid Disorders .................................................................................... 373
Christine San Giovanni, Janet Carter, and Elise Rodriguez
Chapter 26 Oncology and Bone Marrow Transplantation .......................................................... 391
Deena Altschwager and McGreggor Crowley
Chapter 27 Restricted Diets ........................................................................................................405
Margaret O. Murphy, Teresa M. Lee, Therese A. Ryzowicz, and George J. Fuchs
Appendix A: Standard Growth Charts ..................................................................................... 415
Appendix B: Tanner Staging ...................................................................................................... 425
Appendix C: Reference Data for Mid-Upper Arm Circumference (MUAC) ......................... 427
Appendix D: Common Nutrition Diagnoses Utilized for Pediatric Patients .......................... 431
Appendix E: Dietary Reference Intakes (DRIs) for Infants, Children, Pregnancy, and
Lactation ................................................................................................................ 435
Appendix F: Example ADIME Notes ........................................................................................ 441
Index ............................................................................................................................................. 447
Preface
Many physicians, especially pediatricians, learn both the fundamentals and the nuances of practi-
cal nutrition from dietitians. Clinical dietitians, in turn, learn and sharpen their skills with the help
of physicians. This book exemplifies this symbiosis not just because its editors are an MD-RD
combo who have practiced together for more than a decade, but because practically all the chapters
in this book have dietitian and physician authors who have contributed to this “multidisciplinary”
approach. We hope that this approach will serve both the student dietitian and the dietitian who may
not have the support of a physician at her side.
The book begins with the fundamentals of pediatric nutrition assessment, including growth
assessment, nutrition-focused physical exam, and ADIME. Key aspects of nutrition from infancy
through adolescence are discussed before moving on to the specifics of nutrition care in subspecialty
areas of pediatric nutrition. Each disease-specific chapter ends with an ADIME table that summa-
rizes nutrition care for the specific population and serves as a quick guide for providing patient care.
All chapters were written by experts in the field, and then reviewed by expert dietitians actively prac-
ticing in these areas. While no book can cover the spectrum of patients seen by pediatric dietitians,
the Growth Assessment, Nutrition-Focused Physical Exam, Nutrition Screening and ADIME, Care
of Children and Youth with Special Health Care Needs, and Restricted Diets chapters provide the
dietitian with the nutrition assessment and intervention tools needed to adapt to the ever-changing
landscape of pediatric nutrition and provide expert nutrition care regardless of the situation.
We have made a few choices in this book. To make it more readable, we refer to dietitians as
such instead of using Registered Dietitian or Registered Dietitian Nutritionist. Again, to enhance
readability, we have elected to use female pronouns for dietitians and patients in this book, with the
exception of the rare case where we have to specifically refer to a male patient.
While we, the editors, are experts in pediatric nutrition, we are not experts in every aspect of this
field. To ensure that the chapters in the book are accurate and evidenced based, authors and review-
ers who are experts in the field have contributed to this work. This book has benefited greatly from
their suggestions and corrections. To them we are immensely grateful.
Praveen S. Goday
Cassandra L. S. Walia
xi
Editors
Praveen Goday is a pediatric gastroenterologist at the Children’s Hospital of Wisconsin and a pro-
fessor of Pediatrics at the Medical College of Wisconsin in Milwaukee, Wisconsin. He is a recog-
nized expert in nutrition and has authored > 50 research publications and ~40 book chapters. He has
already served as editor of a book on Pediatric Critical Nutrition. He has served on the Board of the
American Society for Parenteral Nutrition (ASPEN) and as the chair of the Nutrition Committee of the
North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN).
He is currently on the Committee of Nutrition of the American Academy of Pediatrics. He is also the
recipient of several national honors and awards including: ASPEN Excellence in Nutrition Support
Education Award and the ASPEN Distinguished Nutrition Support Physician Service Award. He has
been on the Best Doctors in America list continuously since 2007 and led the Children’s Hospital of
Wisconsin Team to an ASPEN Clinical Nutrition Team of Distinction Award.
Cassandra L. S. Walia completed the coordinated program in dietetics at Mount Mary University
in 2009, and earned her Master’s of Science in dietetics in 2012. Prior to working at Children’s
Hospital of Wisconsin, she was a dietitian at the City of Milwaukee Health Department WIC clin-
ics. She has worked in the outpatient GI and Allergy clinics at Children’s Wisconsin (CW) since
2009. She is recognized as an expert within her field, has several publications and is a Certified
Nutrition Support Clinician. Cassandra has participated in a variety of quality improvement proj-
ects including creation of a nutrition lab protocol for patients with inflammatory bowel disease and
improving the safety of our electronic medical record build for home parenteral nutrition. During
her time at CW, Cassandra has represented Clinical Nutrition in a variety of multidisciplinary com-
mittees including the Patient Family Education Committee, Joint Clinical Practice Council, and the
Food Allergy Huddle. She worked to create innovative electronic education for food allergy patients
and is currently working to create additional video education on nutrition topics for patient care. In
addition to her role at CW, Cassandra has been an adjunct instructor at Mount Mary University since
2015, where she teaches graduate students and dietetic interns about pediatric nutrition.
xiii
Contributors
Ruba A. Abdelhadi, MD, CNSC, Alison Cassin, MS, RD, CSP, LD
NASPGHAN-F Cincinnati Children’s Hospital Medical Center
Children’s Mercy Hospital Cincinnati, Ohio, USA
Kansas City, Missouri, USA
Mark R. Corkins, MD, CNSC
Anushree Algotar, MD, MPH The University of Tennessee Health Science
The University of Tennessee Health Science Center
Center Memphis, Tennessee, USA
Memphis, Tennessee, USA
McGreggor Crowley, MD
Deena Altschwager MS, RD, LDN, CNSC Boston Children’s Hospital
Boston Children’s Hospital Boston, Massachusetts, USA
Boston, Massachusetts, USA
Ashley Devonshire, MD, MPH
Jeffrey Anderson, MD Cincinnati Children’s Hospital Medical Center
Cincinnati Children’s Hospital Medical Center Cincinnati, Ohio, USA
Cincinnati, Ohio, USA
Perry B. Dinardo, MD, MA
Katelyn Ariagno, RD, LDN, CNSC, CSPCC Cleveland Clinic Children’s Hospital
Boston Children’s Hospital Cleveland, Ohio, USA
Boston, Massachusetts, USA
Elissa M. Downs, MD, MPH
Ammar R. Barakat University of Minnesota Masonic Children’s
Jordan University of Science and Technology Hospital
Irbid, Jordan Minneapolis, Minnesota, USA
Sara Bewley, MS, RD, CSP, LD Julia Driggers, RD, LDN, CSP
Cleveland Clinic Children’s Hospital of Philadelphia
Cleveland, Ohio, USA Philadelphia, Pennsylvania, USA
Julia M. Boster, MD, MSCS Areeg Hassan El-Gharbawy, MD, DSc
University of Colorado School of Medicine Duke University Medical Center
Aurora, Colorado, USA Durham, North Carolina, USA
Yasemin Cagil, MD Lauren Fiechtner, MD, MPH
Stanford University Medical Center MassGeneral Hospital for Children
Palo Alto, California, USA Harvard Medical School
Greater Boston Food Bank and Hunger to
Teresa A. Capello, MS, RD, LD Health Collaboratory
Nationwide Children’s Hospital Boston, Massachusetts, USA
Columbus, Ohio, USA
Ting Ting Fu, MD
Janet Carter, MS, RDN, LDN, CLS, FNLA Cincinnati Children’s Hospital Medical Center
Medical University of South Carolina University of Cincinnati College of Medicine
Charleston, South Carolina, USA Cincinnati, Ohio, USA
xv
xvi Contributors
George J. Fuchs, MD John Kerner, MD
Kentucky Children’s Hospital Stanford University Medical Center
University of Kentucky College of Medicine Palo Alto, California, USA
Lexington, Kentucky, USA
Jae H. Kim, MD, PhD
Laura Gearman, MS, RD, LD, CNSC Cincinnati Children’s Hospital Medical Center
University of Minnesota Masonic Children’s University of Cincinnati College of Medicine
Hospital Cincinnati, Ohio, USA
Minneapolis, Minnesota, USA
Elizabeth King, MS, RD, CNSC
Nana Adwoa Gletsu Miller, PhD UPMC Children’s Hospital of
Indiana University School of Public Health Pittsburgh
Bloomington, Indiana, USA Pittsburgh, Pennsylvania, USA
Vi Goh, MD, MS
Children’s Hospital of Philadelphia Kelly A. Klaczkiewicz, RD, CSP
University of Pennsylvania Children’s Hospital Colorado
Philadelphia, Pennsylvania, USA Aurora, Colorado, USA
Ruby Gupta, MBBS, MS Catherine Larson-Nath, MD, CNSC
Children’s Wisconsin University of Minnesota Masonic Children’s
Medical College of Wisconsin Hospital
Milwaukee, Wisconsin, USA Minneapolis, Minnesota, USA
Tamara S. Hannon, MD, MS
Teresa M. Lee, MS, RD, LD
Indiana University School of Medicine
Kentucky Children’s Hospital
Indianapolis, Indiana, USA
Lexington, Kentucky, USA
Alison Hanson, RD, CD, CNSC
Hanna Leikin, MS, RD, CSP, LD
Froedtert Hospital
Cleveland Clinic
Milwaukee, Wisconsin, USA
Cleveland, Ohio, USA
Stephanie G. Harshman, RD, PhD
Sarah Lowry, MD
MassGeneral Hospital for Children
Johns Hopkins Children’s Center
Boston, Massachusetts, USA
Baltimore, Maryland, USA
Megan Horsley, RD, LD, CSP, CNSC
Beth Lyman, MSN, RN, CNSC, FASPEN,
Cincinnati Children’s Hospital Medical Center
FAAN
Cincinnati, Ohio, USA
Children’s Mercy Hospital
Kansas City, Missouri, USA
Jennifer Hyland, RD, CSP, LD
Cleveland Clinic Children’s Hospital Jillian K. Mai, RD, LD, CNSC
Cleveland, Ohio, USA University of Minnesota Masonic Children’s
Hospital
Ajay Kumar Jain, MD, DNB, MHA Minneapolis, Minnesota, USA
SSM Cardinal Glennon Children’s Medical
Center Olivia Mayer, RD, CSP, IBCLC
Saint Louis University Lucile Packard Children’s Hospital at Stanford
Saint Louis, Missouri, USA Palo Alto, California, USA
Contributors xvii
Meghan McNeill, MS, RD, LD Jeffrey Rudolph, MD
Cincinnati Children’s Hospital Medical Center UPMC Children’s Hospital of Pittsburgh
Cincinnati, Ohio, USA Pittsburgh, Pennsylvania, USA
Kera McNelis, MD, MS Therese A. Ryzowicz, MS, RD, LD
Cincinnati Children’s Hospital Medical Center Kentucky Children’s Hospital
University of Cincinnati College of Medicine Lexington, Kentucky, USA
Cincinnati, Ohio, USA
Christine San Giovanni, MD, MSCR
Nilesh M. Mehta, MD Medical University of South Carolina
Boston Children’s Hospital Charleston, South Carolina, USA
Boston, Massachusetts, USA
Ann O’Shea Scheimann, MD, MBA
Johns Hopkins Children’s Center
Merideth Miller, RD, CSP, LD
Baltimore, Maryland, USA
Cleveland Clinic
Cleveland, Ohio, USA
Sally Schwartz, RD, LDN
Ann and Robert H. Lurie Children’s Hospital
Margaret O. Murphy, PhD, RD, LD, FAND
of Chicago
Kentucky Children’s Hospital
Chicago, Illinois, USA
University of Kentucky College of Medicine
Lexington, Kentucky, USA
Sarah Jane Schwarzenberg, MD
University of Minnesota Masonic Children’s
Jamie Nilson, RD, LD Hospital
SSM Cardinal Glennon Children’s Medical Minneapolis, Minnesota, USA
Center
Saint Louis, Missouri, USA Carrie Smith, MS, RD, CSP, LD
Cincinnati Children’s Hospital Medical Center
Rashmi Patil, MD, MPH University of Cincinnati College of Medicine
UPMC Children’s Hospital of Pittsburgh Cincinnati, Ohio, USA
Pittsburgh, Pennsylvania, USA
Jennifer L. Smith, MS, RD, CSP, LD, LMT
Nationwide Children’s Hospital
Surekha Pendyal, MSc, MEd, RD, FAND Columbus, Ohio, USA
Duke University Medical Center
Durham, North Carolina, USA Lisa A. Spence, PhD, RD
Indiana University School of Public
Elisabeth Pordes, MD, MPH Health-Bloomington
Elisabeth Pordes Consulting LLC Bloomington, Indiana, USA
Charlotte, North Carolina, USA
Poyyapakkam Srivaths, MD, MS
Elise Rodriguez, MS, RDN, LD Texas Children’s Hospital
Medical University of South Carolina Houston, Texas, USA
Charleston, South Carolina, USA
Shikha S. Sundaram, MD, MSCI
Ellen S. Rome, MD, MPH Children’s Hospital Colorado
Cleveland Clinic Children’s Hospital University of Colorado School of Medicine
Cleveland, Ohio, USA Aurora, Colorado, USA
xviii Contributors
Jenifer Thompson, MS, RD, CSP, LDN Kanak Verma, MD
Johns Hopkins Children’s Center Children’s Hospital of Philadelphia
Baltimore, Maryland, USA Philadelphia, Pennsylvania, USA
Justine Turner, MBBS, FRACP, PhD Sarah Vermilyea, MS, RDN, CSP, LD,
University of Alberta CNSC
Edmonton, Alberta, Canada St. Joseph Home of Cincinnati
Cincinnati, Ohio, USA
Anna Tuttle, MS, RD, LDN, CNSC
Le Bonheur Children’s Hospital Stephanie Ward, MD
Memphis, Tennessee, USA Cincinnati Children’s Hospital
Medical Center
Molly Wong Vega, MS, RDN, CSP, CSSD Cincinnati, Ohio, USA
Texas Children’s Hospital
Houston, Texas, USA
Reviewers
Geetanjali Bora, MD Allie LaTray, MS, RD, CSP
Medical College of Wisconsin UCSF Health
Milwaukee, Wisconsin, USA San Francisco, California, USA
Shannon Burke, RD, CSP Julie Lavoie, PhD, AC-PNP,
UCSF Benioff Children’s Hospital MSN, MS, RN, RD, CPN
San Francisco, California, USA Children’s Wisconsin
Milwaukee, Wisconsin, USA
Nicole Fabus, RD, CD, CNSC
Children’s Wisconsin
Milwaukee, Wisconsin, USA Sarianne Madsen, RD, CSP
UCSF Benioff Children’s Hospital
Mary Beth Feuling, MS, RD, CSP, CD San Francisco, California, USA
Children’s Wisconsin
Milwaukee, Wisconsin, USA Catherine Marks, RD, CSP
UCSF Benioff Children’s Hospital
Andrea Gosalvez-Tejada, MD San Francisco, California, USA
Medical College of Wisconsin
Milwaukee, Wisconsin, USA
Nicole Martin, RD, CSP, CD
Shaina Greenspan, RD Children’s Wisconsin
UCSF Benioff Children’s Hospital Milwaukee, Wisconsin, USA
San Francisco, California, USA
Lauren Matschull, MBA, RD,
Caitlin Hessenthaler, MS, RD, CD CD, CNSC
Children’s Wisconsin Children’s Wisconsin
Milwaukee, Wisconsin, USA Milwaukee, Wisconsin, USA
Maria Hetherton, RD, CSP, CSPCC Regina McCarthy, MS, RD, CD
UCSF Benioff Children’s Hospitals Children’s Wisconsin
San Francisco, California, USA Milwaukee, Wisconsin, USA
Julia Hilbrands, MS, MPH, RD, CD Sarah Mencia, MAS, RD, CSP, IBCLC
Children’s Wisconsin UCSF Benioff Children’s Hospital
Milwaukee, Wisconsin, USA San Francisco, California, USA
Catherine Karls, MS, RD, CD, CNSC Tami Miller, RD, CSP, CD
Children’s Wisconsin Children’s Wisconsin
Milwaukee, Wisconsin, USA Milwaukee, Wisconsin, USA
Lisa Keung, MS, RD Rebecca Pipkorn, RD, CD, CNSC
UCSF Benioff Children’s Hospital Children’s Wisconsin
San Francisco, California, USA Milwaukee, Wisconsin, USA
Talya Kurzion MS, RD, CSP, CDE Elizabeth Saunders, RD, CSP
UCSF Health UCSF Health
San Francisco, California, USA San Francisco, California, USA
xix
xx Reviewers
Danielle Schneider, MS, RD, CD Megan Van Hoorn, MS, RD, CSP, CD
Children’s Wisconsin Children’s Wisconsin
Milwaukee, Wisconsin, USA Milwaukee, Wisconsin, USA
Gina Schwebke, RD, CSP, CD Sarah Vermilyea, MS, RDN, CSP, LD,
Children’s Wisconsin CNSC
Milwaukee, Wisconsin, USA St. Joseph Home of Cincinnati
Cincinnati, Ohio, USA
Amber Smith, MBA, RD, CD
UCSF Health
San Francisco, California, USA Kris Walleser, RN, BSN, IBCLC, RLC
Children’s Wisconsin
Nicole Sperl, RD, CD Milwaukee, Wisconsin, USA
Children’s Wisconsin
Milwaukee, Wisconsin, USA Michele Yenter, BSN, RN
Children’s Wisconsin
Linda Strain, BSN, RN Milwaukee, Wisconsin, USA
Children’s Wisconsin
Milwaukee, Wisconsin, USA
1 Growth Assessment
Julia Driggers, RD, LDN, CSP; Kanak Verma, MD;
and Vi Goh, MD
CONTENTS
Infant Growth......................................................................................................................................2
Childhood Growth..............................................................................................................................2
Adolescent Growth.............................................................................................................................2
Measurement of Growth.....................................................................................................................3
Weight............................................................................................................................................3
Length and Height..........................................................................................................................3
Head Circumference......................................................................................................................6
Body Mass Index (BMI)................................................................................................................7
Mid-Upper Arm Circumference (MUAC).....................................................................................7
Additional Growth Measurements......................................................................................................8
Skinfold Thickness.........................................................................................................................8
Handgrip Strength..........................................................................................................................8
Interpreting Growth Measurements.................................................................................................. 10
Standard Growth Charts............................................................................................................... 10
WHO vs. CDC Growth Charts..................................................................................................... 10
Specialty Growth Charts.............................................................................................................. 10
Z-Scores....................................................................................................................................... 11
Additional Growth Assessment Tools............................................................................................... 12
Mid-Parental Height..................................................................................................................... 12
Ideal Body Weight........................................................................................................................ 13
Weight Age and Height Age......................................................................................................... 13
Diagnosis of Underweight and Overweight...................................................................................... 13
Bibliography...................................................................................................................................... 14
Nutrition plays a major role in both the physical and intellectual development of children. Monitoring
growth and development is a cornerstone of pediatric care. Healthy infants and children typically
follow a predictable pattern of development, which allows growth to serve as a sensitive marker
for health and nutritional status. Growth can be affected by a variety of conditions, and alterations
in growth can be the first sign of a pathologic condition. Marked deviations from a normal growth
pattern, particularly during early life, have also been associated with an increased risk of comor-
bidities later in life. Delayed growth in childhood has been associated with decreased adult height
and altered body composition, including increased abdominal fat mass, in adulthood. Further, a
substantial body of research has demonstrated that malnutrition can lead to abnormal brain develop-
ment, including tissue damage, disordered differentiation of neural cells, reduction in synapses and
synaptic neurotransmitters, and delayed myelination. These can lead to lasting cognitive impair-
ment, affecting attention, visual, auditory, memory, and executive function, and interfering with a
child’s school performance and potential for achievement.
DOI: 10.1201/9781003147855-1 1
2 Pediatric Nutrition for Dietitians
Clinical evaluation of a child’s growth should focus on key historical features, as well as accu-
rate measurement of all growth parameters. The history should include a thorough dietary history,
weight, length, and head circumference at birth, prenatal history, past medical and family history,
and a complete review of systems for evidence of systemic disease. Body weight, length or height,
head circumference, and w eight-for-length or body mass index (BMI)-for-age are easily measured
or calculated and can be compared with population standards using growth charts (Appendix A).
Pediatric growth can be divided into three periods: infancy, childhood, and adolescence.
INFANT GROWTH
The intrauterine environment and maternal nutrition are primarily reflected in the growth param-
eters at birth and during the first few months of life, after which genetic and environmental factors
exhibit a stronger influence. Many infants will significantly change growth percentiles (and hence,
their corresponding z -scores) for weight and length during the first 2 years of life, but then usually
follow their established growth trajectory after age 2.
Term neonates can lose up to 10% of their birth weight during the first few days of life and should
get back to their birth weight by days 1 0–14. After return to birth weight, infants typically follow an
established pattern of weight gain during the first year of life. Expected weight gain during infancy
is approximately 30 g/day from age 0 to 3 months, 20 g/day for ages 3 to 6 months, and 10 g/day for
ages 6 to 12 months. Infants should roughly double their birth weight by 4 months of age and triple
their birth weight by 12 months of age. Weight gain slows after the infant’s first birthday. Normal
linear growth in infants is approximately 10 inches (~25 cm) during the first year of life.
Feeding methods can impact the weight gain patterns seen in infants. Breastfed infants typically
gain weight more rapidly during the first 3–4 months of life when compared to formula-fed infants, and
relatively slowly thereafter. By age 1 –2 years, the weights of breastfed and formula-fed infants are simi-
lar. It is important to correct growth parameters for gestational age in preterm infants; however, there is
limited consensus on the duration of “catch-up” growth in premature infants and how long to correct for
gestational age when interpreting growth. The World Health Organization (WHO) suggests correction
of weight, height, and head circumference until age 2 –3 years for children born prematurely (Chapter 12).
CHILDHOOD GROWTH
Children gain approximately 2 kg/year between age 2 years and puberty. They typically gain
4 inches (~10 cm) in length/height during the second year of life, 3 inches (~7.5 cm) during the
third year of life, and 2 inches (~5 cm)/year between age 4 years and puberty. With increasing
height and slowed weight gain, toddlers and preschoolers grow taller and leaner. Of note, growth
during this period is pulsatile, consisting of periods of rapid growth separated by periods of mini-
mal growth. There is also normal deceleration of height velocity before the pubertal growth spurt
during adolescence.
ADOLESCENT GROWTH
Puberty refers to the physical changes that occur during adolescence, including growth in stature and
development of secondary sexual characteristics. The latter occurs in a series of events that also fol-
lows a predictable pattern, with some individual variation in sequence and timing of onset (between
8 and 13 years in girls and 9.5 and 14 years in boys). Sexual maturation can happen gradually or with
several changes at once. Tanner staging is a sexual maturity rating system used to define physical
measures of sexual development, including breast changes in females, genital changes in males, and
pubic hair changes in both females and males. Tanner staging is commonly used to define the p re-
or p eri-pubertal stage of a child at a single point in time (Appendix B). In boys, the first change is
Growth Assessment 3
testicular development followed by penile growth and pubic hair development. In girls, the first change
is breast development followed by the appearance of pubic hair which is then followed by menarche.
Approximately 20% of adult height accrual occurs during puberty, though the pattern of
height accrual can be highly variable. It can be steady growth or periods of rapid growth inter-
spersed with periods of slow growth. The typical pubertal growth pattern involves a phase of
acceleration, followed by a phase of deceleration, and ending with the eventual cessation of
growth with the epiphyseal (g rowth plate) closure. The timing of the growth spurt varies by sex,
occurring 2 years earlier on average in females than in males, and is impacted by sexual develop-
ment. Therefore, a child’s Tanner staging can provide clues regarding the timing of an expected
acceleration in growth.
Peak height velocity is reached in boys between Tanner stages 4 and 5 while in girls it is high-
est between stages 3 and 4 and is followed by menarche. Menarche can occur between 10 and
16.5 years. After menarche, the average height gain is about 2.75 inches (~7 cm) and can be even
greater for girls who menstruate on the early side of normal. Growth typically ceases about 2 years
after menarche. Early onset of puberty, and subsequent earlier peak height velocity, can lead to
transient periods of tall stature when compared to same-age peers but is typically associated with
reduced overall adult height accrual. The major sex differences in height are established during
puberty, with a final average height difference of 4.9 inches (~12.5) cm between males and females
in the general population. See Appendix B for more information about Tanner staging.
MEASUREMENT OF GROWTH
Surveillance through regular measurements of growth is an important tool to monitor the health
of children. While a normal growth pattern does not guarantee overall health, atypical growth can
reflect nutritional insults and can be the presenting sign of systemic illness. Accurate measurements
of growth are essential for growth assessment. Growth can be measured in two ways: (1) current,
attained growth relative to same-age peers, and (2) growth velocity, which reflects the change in a
growth parameter over time.
Weight
Weight should be obtained naked for infants less than 2 years of age, and with only light clothing
without shoes for older children. Measurements should be repeated two to three times and used to
calculate an average value (Tables 1.1–1.3). Whenever possible, subsequent weights should be mea-
sured using the same scale to improve accuracy. This measurement can be plotted on a standard-
ized growth chart (Appendix A), as described below, to assess a child’s weight relative to same-age
peers. Wheelchair scales can also be used for patients that are unable to stand unsupported. This can
be done by recording the weight of the empty wheelchair followed by weighing the patient in the
wheelchair. The difference between the weight of the patient in the wheelchair and the wheelchair
alone is the patient’s weight.
For hospitalized patients, weight should be measured daily for preterm and term infants and
at least weekly for older children. Patients with nutrition and growth concerns may require daily
weights, including older children. For patients seen in the outpatient setting, weight should be mea-
sured minimally every 3 months for infants and yearly for children. More frequent weights may be
needed in the outpatient setting as well for patients with nutrition and growth concerns.
Length and Height
Length, as opposed to a standing height, is used for children < 2 years of age, < 85 cm, and/or unable
to stand. Length can be obtained using an infant measuring board or measuring mat (Table 1.4) but
should not be measured using a tape measure or by marking the infant’s length on an exam table.
