© 2023 Canadian Malnutrition Task Force
Pediatric patients identified to be at nutrition risk require a diagnosis to confirm malnutrition. Hospitalization is a risk factor for the development of malnutrition and/or worsening of nutritional status. This nutritional impairment can significantly affect morbidity and mortality rates, as well as length of hospital stay and hospitalization costs.
Recommended standard measurements to be performed in pediatric patients within 24 hours of admission to hospital include:
Standard Anthropometric Measurements
P-INPAC recommends these standard measurements be performed and plotted on the WHO growth chart in all children (including those that screened negative in the first step with validated screening tool). These measures allow Z scores to be calculated for the following nutritional indicators:
- Weight-for-age (WFA)
- Weight-for-length (WFL, age < 2 years)
- BMI-for-age (2 years and older)
- Length-for-age (LFA)
- Height for age (HFA, 2 years and older)
- Head circumference for age (age < 2 years)
if any of these indicators has a z-score < -2, further assessment in the form of SGNA should be undertaken.
Frequency of standard measurements in hospital:
Weight should be measured < 24 hours of admission and thereafter:
- Age 0-2 years: minimum 3 times/week
- Age ≥2 years: minimum 2 times/week
Height should be measured < 24 hours of admission, and thereafter:
- Age 0-2 years: every 2 weeks
- Age ≥2 years: monthly
Head circumference (age 0-2 years) should be measured < 24 hours of admission and twice per month.
Growth Curves: The use of the WHO growth curves for Canada for monitoring the growth of infants and children in the public health, primary care and clinical settings are recommended. These charts were redeveloped through a collaboration led by Dietitians of Canada and included the Canadian Paediatric Society, the College of Family Physicians of Canada, Community Health Nurses of Canada and the Canadian Pediatric Endocrine Group. A self-instructional training package is available.
Two sets of growth charts are available, both including the new weight-for-age curves and differing only in the percentiles plotted. The Set 2 curves are generally used in clinical settings.
Set 2 uses centiles 3/10/25/50/75/90/97 on all charts, substituting the 85th for the 90th centile and retaining the 99.9th centile on the weight-for-length (0–24 months) and BMI-for-age (2–19 years) charts. The 85th centile was used on the weight-for-length and BMI charts to correspond to the cut-off for obesity in adults.
Growth charts collect anthropometric measures over time which can facilitate identification of faltering growth. Percentiles for age and sex can express the position of the child’s measurements compared to the population. However, the WHO suggests percentiles do not indicate precisely the degree of deviation from the population and suggest Z scores are better for expressing growth measures. Z scores are more sensitive than percentiles because they are expressed as a standard deviation(SD) how far from the mean (or population average) that the child is. Z scores are available in many electronic medical record formats or can be calculated using online tools such as : BC Children’s: See Anthropometric Calculators for determining percentiles and Z-scores for the WHO Growth Charts for Canada or https://peditools.org
Serial measurements: When using growth curves for malnutrition detection it should be noted that they do not allow for detection of milder degrees of malnutrition and/or the risk of developing it. Thus, in the individual assessment, anthropometric data are more significant for follow-up since they allow verifying whether the growth rate considered normal is maintained. It is therefore highly recommended to try to obtain previous datapoints of weight and height in children admitted to hospital.
Growth curves for special populations: Children with developmental, genetic or other disorders often have growth patterns that are different from healthy children. Their growth can also be monitored on the WHO Growth Charts alone, or in conjunction with specific growth curves that exist for some of these disorders. It is important to note is that these specific growth references do not necessarily reflect the optimal growth pattern of children with specific conditions.
- Cerebral palsy: https://www.lifeexpectancy.org/articles/GrowthCharts.shtml
- Down’s Syndrome: https://www.cdc.gov/ncbddd/birthdefects/downsyndrome/growth-charts.html
- Achondroplasia: Weight for age charts for children with achondroplasia, American Journal of Medical Genetics Part A 143A(19):2227 35 DOI: 10.1002/ajmg.a.31873,
- Williams Syndrome: https://www.orpha.net/data/patho/Pro/en/WilliamsGuidelines_2010.pdf
- Fenton Charts for prematurity: https://ucalgary.ca/resource/preterm-growth-chart/preterm-growth-chart#:~:text=Fenton%20Preterm%20Growth%20Charts&text=The%20Fenton%20growth%20chart%20for,improve%20preterm%20infant%20growth%20monitoring.
Organizations should have procedures developed for staff to complete growth measurements in a standardized, reproducible way. Some examples of reliable growth measurement procedures are:
- Alberta Health Services (Alberta) https://www.albertahealthservices.ca/assets/info/hp/cgm/if-hp-cgm-measurement-protocol.pdf
- Dietitians of Canada video: https://vimeo.com/24744662/72a8322bbc. This video provides instructions on how to weigh and measure infants and children
- Intergrowth: https://www.youtube.com/watch?v=HjOxS0hkPBU