NUTRITIONAL SUPPORT IN PEDIATRIC SURGERY Nutrition Vol. 14, No.

1, 1998

Nutritional Assessment in Pediatrics

MARIA R. MASCARENHAS, MBBS, BABETTE ZEMEL, PHD, AND VIRGINIA A. STALLINGS, MD

From the Division of Gastroenterology and Nutrition, Children’s Hospital of Philadelphia, University of
Pennsylvania School of Medicine, Philadelphia, Pennsylvania, USA

ABSTRACT
Nutritional status affects every pediatric patient’s response to illness. Good nutrition is important for achieving normal growth
and development. Nutritional assessment therefore should be an integral part of the care for every pediatric patient. Routine
screening measures for abnormalities of growth should be performed on all pediatric patients. Those patients with chronic illness
and those at risk for malnutrition should have detailed nutritional assessments done. Components of a complete nutritional
assessment include a medical history, nutritional history including dietary intake, physical examination, anthropometrics (weight,
length or stature, head circumference, midarm circumference, and triceps skinfold thickness), pubertal staging, skeletal maturity
staging, and biochemical tests of nutritional status. Alternative measures for linear growth assessment (e.g., lower leg and upper
arm measures) can be performed on patients unable to stand or who have musculoskeletal deformities. Bone densitometry can
be used to assess bone mineralization and the risk of fracture. Nutritionally at risk patients may benefit from determination of
resting energy expenditure by indirect calorimetry. The use of age, gender, and disease-specific growth charts is essential in
assessing nutritional status and monitoring nutrition interventions. The importance of accurate measurements using trained
personnel and appropriate equipment cannot be overemphasized. Nutrition 1998;14:105–115. ©Elsevier Science Inc. 1998

Key words: pediatrics, nutrition assessment, anthropometrics, body composition, growth charts

INTRODUCTION The physical examination includes current weight, height, or

Growth in children from birth through adolescence is an ex-
tremely complex process. It is influenced not only by the genetic
make-up of the individual but also by environmental factors,
medical illnesses, and nutritional status. Nutrient intake and nu-
tritional status have a major impact on an individual’s ability to
handle illness, so every pediatric patient’s care should include
nutritional assessment. Initially this consists of a medical history,
physical examination, and growth measurements including plot-
ting of growth charts and pubertal status assessment when appli-
cable. Guidelines have been developed by the American Academy
of Pediatrics1 for the frequency of obtaining these measurements.
Tables I and II outline suggestions for the frequency of obtaining
these measurements for routine pediatric ‘‘well child’’ visits and
in hospitalized patients. Pediatric patients who are identified to be
at nutritional risk require more detailed assessments.
A medical history includes assessment of the acute and chronic
medical problems and medications. In addition, a nutritional his-
tory, including review of a ‘‘typical’’ day’s food intake; past
feeding history; use of caloric, vitamin, or mineral supplements;
and unusual food practices by the child and family should be
obtained. Past growth patterns including pubertal onset and
growth charts are reviewed. The review of systems should em-
phasize oral motor function and the gastrointestinal tract (emesis,
gastroesophageal reflux, diarrhea, and constipation).
length or alternative linear growth measures, and head circumfer-
ence. A careful examination also must be made of the entire
patient, looking for signs of general malnutrition, vitamin defi-
ciency, anemia, rickets, etc. Table III provides an overview of the
physical examination findings of nutritional deficiencies. Midarm
circumference and skinfold measurements add more detailed in-
formation to the nutritional status evaluation and need to be
performed by trained personnel so that the measurements obtained
are reliable and accurate. Details of the recommended methods,
equipment and reference standards for the anthropometric mea-
surements are in the following section.
METHODS OF NUTRITION ASSESSMENT
Dietary Intake
The best way to assess dietary intake is to perform a 3-d
weighed record of food intake and have it analyzed by registered
dietitian using a computerized analysis for calories and nutrients.
Twenty-four– hour dietary recalls can be helpful in obtaining a
rapid estimate of caloric intake but are not as reliable as a 3-d
weighed intake record. Children’s intake can vary considerably
from day to day, so a 3-d record is more representative of their
dietary intake than a single recall. If children are in school or
daycare, $1–2 d during the recording period should be weekdays.

Correspondence to: Maria R. Mascarenhas, MBBS, Division of Pediatric Gastroenterology and Nutrition, Children’s Hospital of Philadelphia, 324 S. 34th
St., Philadelphia, PA 19104, USA.

Nutrition 14:105–115, 1998

©Elsevier Science Inc. 1998 0899-9007/98/$19.00
Printed in the USA. All rights reserved. PII S0899-9007(97)00226-8
106 NUTRITIONAL ASSESSMENT IN PEDIATRICS

TABLE I.

FREQUENCY OF GROWTH MEASUREMENTS FOR NONHOSPITALIZED WELL PATIENTS

Birth–2 mo 2–6 mo 6–24 mo 2–6 y 6–18 y

Weight Every 1 mo Every 2 mo Every 3 mo Every 1 y Every 2 y

Length Every 1 mo Every 2 mo Every 3 mo Every 1 y Every 2 y
HC Every 1 mo Every 2 mo Every 3 mo Every 1 y —

HC, head circumference.

Anthropometric Measurements extends from the lower margin of the orbit to the upper margin of
Anthropometric assessment refers to the measures of body the auditory meatus. The knees should be flattened firmly by the
dimensions and composition obtained on a patient. It is a rapid and anthropometrist to fully extend the legs. The feet should be to-
inexpensive means of determining short- and long-term nutritional gether and flexed to a 90° angle with the infant fully stretched. For
status. Although these measures are noninvasive and can be ac- stature, the child should stand erect with the heels, buttocks, and
complished with simple instruments, training is required to ensure back of the head against the stadiometer. As positioning may not
accurate, reproducible measurements. Numerous anthropometric be possible in the obese patient, the obese patient should be
measures are used in the assessment of nutritional status, because positioned so that they are standing as upright as possible with
no single measure is sufficient for full characterization of nutri- their spine in alignment. For all patients, heels should be placed
tional status. Proper equipment should be used and should be together and the arms should be down and relaxed. The head is
checked regularly for accuracy. When anthropometric measure- positioned so that the Frankfurt plane is parallel to the floor. For
ments are obtained under these conditions and compared with both length and stature, three readings should be taken and the
appropriate reference standards, the clinician is able to evaluate mean recorded.
nutritional status and perform periodic checks for tracking Whenever possible, the stature of both biological parents
progress in individual patients. should be obtained by history or measurement to compute mid-
parental height (the average height of the mother and father).
Weight Adjustment of height or length measurements using midparental
Weight measurements are the easiest measures to obtain and height charts is a technique that recognizes and corrects for
should be performed at every office visit. Weight increments are differences in the genetic potential for growth in height. For a
important for assessing changes in nutritional status between child whose midparenteral height is above or below average, the
office visits and should be measured on a beam balance scale or a child’s height is adjusted by adding or subtracting centimeters and
digital electronic scale. The scale should be set to zero before the the adjusted height is then plotted on the National Center for
patient is placed on the scale and should be checked weekly with Health Statistics (NCHS) growth curve.3 However, if parent-
known calibration weights. In older children, weight should be specific adjustments are used for children from lower socioeco-
measured to the nearest 0.1 kg and in infants, to the nearest 0.01 nomic groups where nutritional stunting of the parents is sus-
kg. Weight measures should be taken with the child wearing little pected, this information is unreliable.
or no outer clothing and no shoes. Infants should be measured
without diapers. Upper Arm Length and Lower Leg Length
Length and stature measures are inappropriate for children
Length or Stature with spinal curvature, contractures, or any musculoskeletal defor-
Linear growth reflects the nutritional history of the patient and mities, because these conditions may interfere with appropriate
heredity and helps to distinguish between short- and long-term positioning of the patient for measurement. Upper arm length and
nutritional problems. Supine length measures are taken for chil-
dren under the age of 2–3 y, and standing height is measured at
age $2 y. For children .3 y of age who are not able to stand erect
TABLE II.
unsupported, a length measurement can be taken. However, when
comparing this measurement to a growth chart for stature, the
FREQUENCY OF GROWTH MEASUREMENTS FOR
length should be decreased by ;2 cm to adjust for the known
HOSPITALIZED PATIENTS
difference between supine length and standing height values due
to gravity.2
Preterm Term–12 mo 12–24 mo 2–18 y
For length measurements, children should be measured on an
infantometer or an inflexible length board with a fixed head board
and a moveable foot board. Stature should be measured by a Weight Every d Every d Every other d Every wk
stadiometer with a head paddle that glides smoothly but is firmly Length Every 2 wk Every 2 mo Every 3 mo Every 1 y
perpendicular to the back of the stadiometer. Alternatively, a tape HC Every 2 wk Every mo Every mo —
measure permanently fixed to a wall or door frame can be used MAC Every mo Every mo Every mo Every mo
provided a head paddle is available that will fit at a 90° angle the TSF — — Every mo Every mo
wall. Both length and stature measurements should be accurate to AMA — — Every mo Every mo
0.1 cm. Length measurements require two people to position and AFA — — Every mo Every mo
hold the child and complete the measurement. The head should be
held firmly at the top of the board by an assistant, with the HC, head circumference; MAC, midarm circumference; TSF, triceps
Frankfurt plane perpendicular to the floor. The Frankfurt plane skinfold; AMA, arm muscle area; AFA, arm fat area.
NUTRITIONAL ASSESSMENT IN PEDIATRICS 107

TABLE III.

CLINICAL SYMPTOMS AND SIGNS OF NUTRITIONAL DEFICIENCY

Nutrient Signs

Protein Changes in percentiles for weight, height, head circumference

Fat Weight loss, essential fatty acid deficiency
Vitamins
Thiamine Anorexia, irritability, vomiting, constipation, edema, cardiac symptoms, peripheral paralysis, neuropathy, coma
Riboflavin Cheilosis, angular stomatitis, glossitis, dermatitis, photophobia
Pyridoxine Failure to thrive, irritability, seizures, anemia, cheilosis, glossitis, GI disturbances
Niacin Weakness, dermatitis, GI disturbances, dementia
Biotin Dermatitis, alopecia, irritability, lethargy
Folic acid Megaloblastic anemia, neutropenia, thrombocytopenia, growth failure, diarrhea, glossitis
B12 Megaloblastic anemia, memory loss, parasthesias, confusion
C Anorexia, memory loss, parasthesias, confusion, irritability, apathy, pallor, failure to thrive, hemorrhages, bone pain, costochondral
beading
A Night blindness, xerophthalmia, xerosis, blindness, follicular hyperkeratosis, pruritis, growth retardation, anemia
D Rickets, osteomalacia, craniotabes, rachitic rosary, pigeon breast, bowed legs, delayed eruption of teeth, bone pain, fractures,
anorexia, weakness
E Hemolytic anemia, progressive neurologic disorder
K Hemorrhage
Minerals
Sodium Poor growth, fatigue, seizures
Potassium Weakness, arrythmias, muscle spasms
Calcium Tetany, fractures, seizures
Phosphorus Anorexia, weakness, bone pain
Magnesium Seizures, arrythmias, tetany (secondary to hypocalcemia), personality changes, GI disturbances, coma
Trace elements
Iron Lethargy, pallor, dyspnea on exertion, cognitive deficits
Zinc Anorexia, growth failure, lethargy, hypogonadism, impaired wound healing, skin lesions, altered taste, alopecia, impaired immune
function, tremors, diarrhea
Copper Microcytic anemia, neutropenia, skeletal abnormalities, depigmentation of hair and skin, neurologic dysfunction
Selenium Muscle pain, weakness, cardiomyopathy, whitened nail beds
Chromium Glucose intolerance, peripheral neuropathy, encephalopathy, hyperlipidemia
Manganese 6Changes in skin, hair, nails
Molybdenum 6Tachypnea, tachycardia, GI disturbances

GI, gastrointestinal.

lower leg length are alternatives under these conditions. Proper
positioning is the only way to assure accurate, reproducible length
measures so that linear growth increments can be incorporated
into the nutritional component of clinical care. For young infants,
sliding calipers (0 –200 mm) can be used. For older infants and
children, an anthropometer is used.
For young children (0 –24 mo), upper arm length is measured
as shoulder-elbow length, from the superior lateral surface of the
acromion to the inferior surface of the elbow with the arm flexed
at a 90° angle. In children 2–18 y, upper arm length is measured
from the superior lateral surface of the acromion to the radial with
the arm relaxed. In children ,24 mo, lower leg length is measured
as knee-heel length from the heel to the superior surface of the
knee. The infant should be lying on his/her back with the leg
flexed to 90° at the hip, the knee, and the ankle. For children ages
2–18 y, the lower leg length measure is taken from the lower
border of the medial malleolus (sphyrion) to the medial tip of the
tibia while the patient is sitting in a relaxed position. Reference
percentiles for upper arm length and lower leg length are avail-
able4 and are shown in Figs. 1– 6. The right side should be
measured unless a physical deformity exists with unilateral in-
volvement affecting the right side. The least affected side should
be measured, and the side that is measured should be noted so that
all future measurements can be done on the same side for accurate
comparison.
Weight-for-Height
Weight-for-height provides a nutritional assessment of weight
in relation to current stature. If only a single set of measurements
is available, weight-for-height is more meaningful than weight for
chronological age. It is used to differentiate whether wasting,
stunting, or both have occurred. The weight-for-height chart on
the reverse side of the NCHS chart is a useful screen for health in
children ,5 y of age. Values ,5th percentile may reflect under-
nutrition, between 5th and 95th percentile normal nutrition, and
.95th percentile overnutrition. Percent ideal body weight (IBW)
is used in older children and can be calculated by the method
outlined below. In addition to classifying the degree of malnutri-
tion (90 –110, normal; 80 –90, mild wasting; 70 – 80, moderate
wasting; ,70, severe wasting; 110 –120, overweight; .120,
obese), percent IBW also provides a weight goal for an individual
patient. Method:
1. Using a NCHS growth chart, plot the patient’s height for
age.
2. Extend the line horizontally until it reaches the 50th per-
centile curve for height.
108 NUTRITIONAL ASSESSMENT IN PEDIATRICS

Head Circumference
Because brain growth is most rapid in the first 3 y of life, head
circumference should be included in the assessment of growth and
nutritional status for all children in this age category.7 This mea-
sure is not helpful in children with medical conditions that result
in primary macrocephaly or microcephaly. A flexible metal or
nonstretchable plastic-coated tape is used. Measuring tapes should
be scaled to 0.1 cm. The tape should be placed superior to the
supraorbital ridge and adjusted around the occiput until maximum
circumference is obtained. The plane of the tape should be the
same on both sides of the head and care should be taken that the
tape is placed evenly flat against the skull. The tape should be
loosened and two more measurements obtained, and the mean
recorded. Hair pins and braids should be removed before measur-
ing.
Growth Velocity
Determination of growth velocity rates can be useful in detect-
ing changes in nutritional status and effectiveness of nutritional
therapies. Gender and age specific charts are available for weight
and length or stature.8 –10
Body Composition
Body composition is an essential component of nutrition as-
sessment. Body composition measurements provide information
about lean body mass and fat tissues, thus indicating body stores
of fat and protein and distinguishing between excess water and fat.
Because fat-free mass is an important indicator of short-term

FIG. 1. Shoulder-elbow length: boys and girls (0 –24 mo). Reprinted with
permission from Stallings and Zemel.4

3. Find the corresponding 50th percentile weight for the 50th

percentile height point. This weight is the IBW.
4. %IBW 5 (actual weight/IBW) 3 100

Body Mass Index

The body mass index (BMI) is another weight-for-height mea-
sure used to assess nutritional status. Weight in kilograms is
divided by the square of height in meters. Values at the 85th
percentile and 95th percentile for age and sex generally indicate
overweight and obesity, respectively.5,6 It should be noted that the
distributions of weight-for-height ratios, such as BMI and %IBW
are influenced by pubertal status. For early or late maturing
peripubertal children, these indices of nutritional status should be
interpreted with caution.

Stature for Age

Stature-for-age comparisons provide information about how
much the patient’s stature has deviated from the reference popu-
lation of normal children. It is an indicator of the patient’s long-
term or previous nutritional status because stature usually re-
sponds more slowly than weight to changes in negative nutritional
influences and because as nutrition and health improve, full re-
covery in statural growth does not always occur. Percent stature
for age standard is expressed as a percentage of the 50th percentile
for age. Values between 95 and 105 are normal, 90 –94 are
indicative of mild stunting, 85– 89 moderate stunting, and ,85 FIG. 2. Knee-heel length: boys and girls (0 –24 mo). Reprinted with
severe stunting. permission from Stallings and Zemel.4
NUTRITIONAL ASSESSMENT IN PEDIATRICS 109

where upper arm area 5 Arm circumference2/(4 3 p). Because

these measures correlate highly with fat and muscle composition
of the body, they are clinically useful. Low AFA and AMA values
suggest protein energy malnutrition.
Midarm Circumference
Midupper arm circumference is a composite measure of mus-
cle and fat stores at a site that is sensitive to current nutritional
status.14 A nonstretchable flexible tape is used. All measurements
should be taken in triplicate to the nearest 0.1 cm. Upper arm
circumference is taken at the midpoint of the upper arm. The
midpoint is located by measuring the length of the upper arm
(from the acromion to the olecranon with the arm flexed at 90°
angle) and marking the midpoint. The midarm circumference is
measured with the patient upright and the arm down in a fully
relaxed position. The measurement is taken at the midpoint with
the tape measure perpendicular to the long axis of the arm. Care
should be taken so that there is no pinching or gaping of the tape
as it encircles the arm. This guarantees that an accurate and
reproducible measure is obtained.
Skinfold Thickness
Skinfold thickness measures at the triceps and subscapular
sites are indicators of whole body fat stores and are sensitive to
changes in nutritional status. Depletion of fat stores at the triceps
site is common in chronically undernourished children. Holtain
skinfold calipers are preferred because they are scaled to 0.2 mm.
Lange calipers also can be used but with some loss of accuracy
because they measure to the nearest 0.5 mm. The patient should be

FIG. 3. Lower leg length: girls (3–16 y). Reprinted with permission from
Stallings and Zemel.4

nutritional adequacy, assessment of body composition is impor-

tant. Anthropometric measures, namely circumferences and skin-
fold thicknesses, can be obtained at sites known to be sensitive to
changes in nutrient intake and health. Upper arm anthropometry is
particularly useful because excellent reference data are available
for interpretation of the measurements.11 Guidelines for anthro-
pometric measurement techniques have been published and are
described below.12 Circumferences are measures of growth and
also are used to describe nutritional status and fat patterning.
Skinfolds are a simple noninvasive method of assessing general
fatness and characterizing the distribution of subcutaneous fat.
Skinfolds are useful in long-term management of obese and mal-
nourished children as well as those diseases that are associated
with body composition changes. The triceps skin fold (TSF) is the
most commonly measured skinfold because it is accessible and is
correlated closely with total body fat. Equations to predict body
composition from skinfold measures have been developed.13
When midarm circumferences are used with skinfold measure-
ments, arm fat area (AFA) and arm muscle area (AMA) can be
calculated.14 Reference values are shown in Tables IV–VI and
computed as follows:
upper arm muscle area ~mm2!
5 @armcirc 2 ~triceps 3 p !# 2/~4 3 p !,
where p 5 3.14.;
upper arm fat area
FIG. 4. Lower leg length: boys (3–18 y). Reprinted with permission from
5 upper arm area 2 upper arm muscle area, Stallings and Zemel.4
110 NUTRITIONAL ASSESSMENT IN PEDIATRICS

grams per square centimeter (BMD) in different regions of the

skeleton or the whole body. The precision of the measurement is
excellent. The radiation dose is small, ,3 mrem or about 1/20th of
a chest x-ray and equivalent to that received during a standard 3-h
commercial flight in the United States. Usually an anterior-poste-
rior view of the lumbar vertebrae (L1-4 or L2-4) is used for
clinical interpretation because reference data on healthy infants,
children, and adolescents of the same gender and chronological
age are available. These results are expressed as z scores and as
percent predicted. Children with a z score of 21.0 or less are
considered at risk, and children with a z score of 22.0 or less are
considered highly at risk for osteoporosis and bone fracture.
Whole body scans are useful for ongoing assessments of bone
density and also provide body composition measures of bone
mass, fat free mass, fat mass, and percent body fat.15
Sexual and Skeletal Maturation
Nutrition affects pubertal status, which in turn affects growth,
body composition, and bone growth. Therefore, assessment of
nutritional and growth status cannot be complete without a deter-
mination of sexual maturity. The adolescent growth spurt is cor-
related with testicular volume in boys and age of menarche in
girls. Delayed puberty should not be attributed to malnutrition
alone but should be assessed in conjunction with the underlying
medical condition. Sexual maturity in both sexes (growth of pubic
hair and breast development in females and genital development
and growth of pubic hair in males) is staged according to the
Tanner system. Stage 1 is the prepubertal stage, and stage 5
reflects adult maturity.16

FIG. 5. Upper arm length: girls (3–16 y). Reprinted with permission from
Stallings and Zemel.4

positioned upright for measurement. If this is not possible, the

patient can be positioned on his/her side or back, but positioning
should be noted for follow-up measurements. The triceps skinfold
thickness is measured along the back of the arm, over the triceps
muscle, at the same level where the midarm circumference is
measured. The arm is down and fully relaxed for this measure-
ment. The fold of fat and skin is lifted away from the underlying
muscle at that site. The fold is held in position while the thickness
is measured with calipers. The calipers are placed on the skin just
below the fingers lifting up the fatfold, and the reading should be
taken 4 s after releasing the pressure of the caliper’s handles.
Three measurements should be taken and the mean recorded.
An additional skinfold measurement can be taken at the sub-
scapular site.11 This indicates truncal fat stores and, although less
sensitive to changes in short-term nutritional status, better reflects
long-term nutritional status. As with the TSF, positioning should
be upright or noted if otherwise. The measurement is taken with
the arm and shoulder down and fully relaxed. The fat fold is lifted
1 cm below the tip of the scapula at a 45° angle following the
natural contour of the body. The fold is held in place and the
calipers are placed next to the fingers holding the fold, and the
reading should be taken 4 s after releasing the pressure of the
caliper handles. Three measurements should be taken and the
mean recorded.
Dual-Energy X-ray Absorptiometry
Dual-energy x-ray absorptiometry (DEXA) is an indirect, low
radiation exposure, noninvasive measurement of bone mineral FIG. 6. Upper arm length: boys (3–18 y). Reprinted with permission from
content in grams per centimeter (BMC) or bone mineral density in Stallings and Zemel.4
NUTRITIONAL ASSESSMENT IN PEDIATRICS 111

TABLE IV.

PERCENTILES FOR TRICEPS SKINFOLD FOR CAUCASIANS OF THE U.S. HEALTH AND NUTRITION EXAMINATION SURVEY I
OF 1971–1974

Percentiles for males Percentiles for females

Age (y) n 5 10 25 50 75 90 95 n 5 10 25 50 75 90 95

1–1.9 228 6 7 8 10 12 14 16 204 6 7 8 10 12 14 16

2–2.9 223 6 7 8 10 12 14 15 208 6 8 9 10 12 15 16
3–3.9 220 6 7 8 10 11 14 15 208 7 8 9 11 12 14 15
4–4.9 230 6 6 8 9 11 12 14 208 7 8 8 10 12 14 16
5–5.9 214 6 6 8 9 11 14 15 219 6 7 8 10 12 15 18
6–6.9 117 5 6 7 8 10 13 16 118 6 6 8 10 12 14 16
7–7.9 122 5 6 7 9 12 15 17 126 6 7 9 11 13 16 18
8–8.9 117 5 6 7 8 10 13 16 118 6 8 9 12 15 18 24
9–9.9 121 6 6 7 10 13 17 18 125 8 8 10 13 16 20 22
10–10.9 146 6 6 8 10 14 18 21 152 7 8 10 12 17 23 27
11–11.9 122 6 6 8 11 16 20 24 117 7 8 10 13 18 24 28
12–12.9 153 6 6 8 11 14 22 28 129 8 9 11 14 18 23 27
13–13.9 134 5 5 7 10 14 22 26 151 8 8 12 15 21 26 30
14–14.9 131 4 5 7 9 14 21 24 141 9 10 13 16 21 26 28
15–15.9 128 4 5 6 8 11 18 24 117 8 10 12 17 21 25 32
16–16.9 131 4 5 6 8 12 16 22 142 10 12 15 18 22 26 31
17–17.9 133 5 5 6 8 12 16 19 114 10 12 13 19 24 30 37
18–18.9 91 4 5 6 9 13 20 24 109 10 12 15 18 22 26 30
19–24.9 531 4 5 7 10 15 20 22 106 10 11 14 18 24 30 34
25–34.9 971 5 6 8 12 16 20 24 198 10 12 16 21 27 34 37
35–44.9 806 5 6 8 12 16 20 23 161 12 14 18 23 29 35 38
45–54.9 898 6 6 8 12 15 20 25 104 12 16 20 25 30 36 40
55–64.9 734 5 6 8 11 14 19 22 809 12 16 20 25 31 36 38
65–74.9 1503 4 6 8 11 15 19 22 167 12 14 18 24 29 34 36

Values are expressed in mm2.

Reprinted with permission from Frisancho.14

Delayed bone age can occur with chronic undernutrition so it
should be included in the nutritional assessment. Determination of
skeletal maturity or bone age is also important in children with
endocrine disorders and other chronic conditions and should be
done in any child with short stature or delayed or advanced
puberty. Bone age can be assessed using criteria developed by
Greulich and Pyle17 or Tanner et al. (TW2).18
Biochemical Parameters
The determination of biochemical parameters can comple-
ment the medical history, physical exam, and anthropometric
measurements in the assessment of nutritional status. Usual
tests include serum protein and hematologic status. The labo-
ratory evaluation is focused by recognizing the risk factors
identified from the history and physical examinations for each
individual patient. In general, if the primary nutritional prob-
lem is inadequate caloric intake, the laboratory assessment of
this pattern of malnutrition is limited. Both serum albumin or
prealbumin reflect the adequacy of both calorie and protein
intake. Albumin indicates nutrient intake during the past 3 wk
(half-life, 14 –20 d) and prealbumin that during the past 3 d
(half-life, 2–3 d). Anemia is usually due to iron deficiency and
occasionally vitamin B12 or folate deficiencies. In premature
infants, additional causes of anemia include deficiencies of
folate, vitamin E, and copper. Iron-deficiency anemia is seen in
groups of patients who have limited caloric intake or who have
monotonous food intake with little meat or other sources of
dietary iron. The initial evaluation of iron status includes a
complete blood count (hemoglobin, hematocrit, and red cell
indices). If microcytic anemia is present, then serum iron, total
iron-binding capacity, transferrin, and ferritin should be ob-
tained. Response to iron therapy is monitored by changes in the
components of the complete blood count and a reticulocyte
count. Because malnutrition affects T-cell production, determi-
nation of a total lymphocyte count may be useful. Other labo-
ratory tests done may include serum values for vitamin D,
calcium, phosphorous, and alkaline phosphatase and radiologic
examination of long bones to diagnose rickets. Osteopenia can
occur without rachitic changes and may be diagnosed by de-
termining bone mineral content or bone density (dual energy
x-ray absorptiometry). If indicated, specific vitamin and min-
eral levels should be checked.
Determination of Resting Energy Expenditure
In nutritionally at-risk patients, measurement of resting energy
expenditure (REE) by indirect calorimetry may be performed to
assess caloric needs. Eligible patients include those with failure to
thrive, those that are obese, and those not exhibiting adequate
weight gain or loss with appropriate nutritional intervention. The
World Health Organization prediction equations are useful in
comparing the measured REE to the predicted value based on age,
gender, and weight.19
112 NUTRITIONAL ASSESSMENT IN PEDIATRICS

TABLE V.

PERCENTILES OF UPPER ARM CIRCUMFERENCE AND ESTIMATED UPPER ARM MUSCLE CIRCUMFERENCE FOR CAUCASIANS
IN THE U.S. HEALTH AND NUTRITION EXAMINITION SURVEY I OF 1971–1974

Arm circumference percentiles Arm muscle circumference percentiles

Age (y) 5 10 25 50 75 90 95 5 10 25 50 75 90 95

Males
1–1.9 142 146 150 159 170 176 183 138 142 148 156 164 172 177
2–2.9 141 145 153 162 170 178 185 142 145 152 160 167 176 184
3–3.9 150 153 160 167 175 184 190 143 150 158 167 175 183 189
4–4.9 149 154 162 171 180 186 192 149 154 160 169 177 184 191
5–5.9 153 160 167 175 185 195 204 153 157 165 175 185 203 211
6–6.9 155 159 167 179 188 209 228 156 162 170 176 187 204 201
7–7.9 162 167 177 187 201 223 230 164 167 174 183 199 216 231
8–8.9 162 170 177 190 202 220 245 168 172 183 195 214 247 261
9–9.9 175 178 187 200 217 249 257 178 182 194 211 224 251 260
10–10.9 181 184 196 210 231 262 274 174 182 193 210 228 251 265
11–11.9 186 190 202 223 244 261 280 185 194 208 224 248 276 303
12–12.9 193 200 214 232 254 282 303 194 203 216 237 256 282 294
13–13.9 194 211 228 247 263 286 301 202 211 223 243 271 301 338
14–14.9 220 226 237 253 283 303 322 214 223 237 252 272 304 322
15–15.9 222 229 244 264 284 311 320 208 221 239 254 279 300 322
16–16.9 244 248 262 278 303 324 343 218 224 241 258 283 318 334
17–17.9 246 253 267 285 308 336 347 220 227 241 264 295 324 350
18–18.9 245 260 276 297 321 353 379 222 227 241 258 281 312 325
19–24.9 262 272 288 308 331 355 372 221 230 247 265 290 319 345
25–34.9 271 282 300 319 342 362 375 233 240 256 277 304 342 368
35–44.9 278 287 305 326 345 363 374 241 251 267 290 317 356 378
45–54.9 267 281 301 322 342 362 376 242 256 274 299 328 362 384
55–64.9 258 273 296 317 336 355 369 243 257 280 303 335 367 385
65–74.9 248 263 285 307 325 344 355 240 252 274 299 326 356 373
Females
1–1.9 138 142 148 156 164 172 177 105 111 117 124 132 139 143
2–2.9 142 145 152 160 167 176 184 111 114 119 126 133 142 147
3–3.9 143 150 158 167 175 183 189 113 119 124 132 140 146 152
4–4.9 149 154 160 169 177 184 191 115 121 128 136 144 152 157
5–5.9 153 157 165 175 185 203 211 125 128 134 142 151 159 165
6–6.9 156 162 170 176 187 204 211 130 133 138 145 154 166 171
7–7.9 164 167 174 183 199 216 231 129 135 142 151 160 171 176
8–8.9 168 172 183 195 214 247 261 138 140 151 160 171 183 194
9–9.9 178 182 194 211 224 251 260 147 150 158 167 180 194 198
10–10.9 174 182 193 210 228 251 265 148 150 159 170 180 190 197
11–11.9 185 194 208 224 248 276 303 150 158 171 181 196 217 223
12–12.9 194 203 216 236 256 282 294 162 166 180 191 201 214 220
13–13.9 202 211 223 243 271 301 338 169 175 183 198 211 226 240
14–14.9 214 223 237 252 272 304 322 174 179 190 201 216 232 247
15–15.9 208 221 239 254 279 300 322 175 178 189 202 215 228 244
16–16.9 218 224 241 258 283 318 334 170 180 190 202 216 234 249
17–17.9 220 227 241 264 295 324 350 175 183 194 205 221 239 257
18–18.9 222 227 241 258 281 312 325 174 179 191 202 215 237 245
19–24.9 221 230 247 265 290 319 345 179 185 195 207 221 236 249
25–34.9 233 240 256 277 304 342 368 183 188 199 212 228 246 264
35–44.9 241 251 267 290 317 356 378 186 192 205 218 236 257 272
45–54.9 242 256 274 299 328 362 384 187 193 206 220 238 260 274
55–64.9 243 257 280 303 335 367 385 187 196 209 225 242 266 280
65–74.9 240 252 274 299 326 356 373 185 195 208 225 244 264 279

Values are expressed in mm2.

Reprinted with permission from Frisancho.14
NUTRITIONAL ASSESSMENT IN PEDIATRICS 113

TABLE VI.

PERCENTILES FOR ESTIMATES OF UPPER ARM FAT AREA (mm2) AND UPPER ARM MUSCLE (mm2) FOR CAUCASIANS
IN THE U.S. HEALTH EXAMINATION SURVEY I OF 1971–1974

Arm muscle area percentiles Arm fat area percentiles

Age 5 10 25 50 75 90 95 5 10 25 50 75 90 95

Males
1–1.9 956 1014 1133 1278 1447 1644 1720 452 486 590 741 895 1036 1176
2–2.9 973 1040 1190 1345 1557 1690 1787 434 504 578 737 871 1044 1148
3–3.9 1095 1201 1357 1484 1618 1750 1853 464 519 590 736 868 1071 1151
4–4.9 1207 1264 1408 1579 1747 1926 2008 428 494 598 722 859 989 1085
5–5.9 1298 1411 1550 1720 1884 2089 2285 446 488 582 713 914 1176 1299
6–6.9 1360 1447 1605 1815 2056 2297 2493 371 446 539 678 896 1115 1519
7–7.9 1497 1548 1808 2027 2246 2494 2886 423 473 574 758 1011 1393 1511
8–8.9 1550 1664 1895 2089 2296 2628 2788 410 460 588 725 1003 1248 1558
9–9.9 1811 1884 2067 2288 2657 3053 3257 485 527 635 859 1252 1864 2081
10–10.9 1930 2027 2182 2575 2903 3486 3882 523 543 738 982 1376 1906 2609
11–11.9 2016 2156 2382 2670 3022 3359 4226 536 595 754 1148 1710 2348 2574
12–12.9 2216 2339 2649 3022 3496 3968 4640 554 650 874 1172 1558 2536 3580
13–13.9 2363 2546 3044 3553 4081 4502 4794 475 570 812 1096 1702 2744 3322
14–14.9 2830 3147 3586 3963 4575 5368 5530 453 563 786 1082 1608 2746 3508
15–15.9 3138 3317 3788 4481 5134 5631 5900 521 595 690 931 1423 2434 3100
16–16.9 3625 4044 4352 4951 5753 6576 6980 542 593 844 1078 1746 2280 3041
17–17.9 3998 4252 4777 5286 5950 6886 7726 598 698 827 1096 1636 2407 2888
18–18.9 4070 4481 5066 5552 6374 7067 8355 560 665 860 1264 1947 3302 3928
19–24.9 4508 4777 5274 5913 6660 7606 8200 594 743 963 1406 2231 3098 3652
25–34.9 4694 4963 5541 6214 7067 7847 8436 675 831 1174 1752 2459 3246 3786
35–44.9 4844 5181 5740 6490 7265 8034 8488 703 851 1310 1792 2463 3098 3625
45–54.9 4546 4946 5589 6297 7142 7918 8458 749 922 1254 1741 2359 3245 3928
55–64.9 4422 4783 5381 6144 6919 7670 8149 658 839 1166 1645 2236 3976 3466
65–74.9 3973 4411 5031 5716 6432 7074 7453 573 753 1122 1621 2199 2876 3327
Females
1–1.9 885 973 1084 1221 1378 1543 1621 401 466 578 706 847 1022 1140
2–2.9 973 1029 1119 1269 1405 1595 1727 469 526 642 747 894 1061 1173
3–3.9 1014 1133 1227 1396 1563 1690 1846 473 529 656 822 967 1106 1158
4–4.9 1058 1171 1313 1475 1644 1832 1958 490 541 654 766 907 1109 1236
5–5.9 1238 1301 1423 1598 1825 2012 2159 470 529 647 812 991 1330 1536
6–6.9 1354 1414 1513 1683 1877 2182 2323 464 508 638 827 1009 1263 1436
7–7.9 1330 1441 1602 1815 2045 2332 2469 491 560 706 920 1135 1407 1644
8–8.9 1513 1566 1808 2034 2327 2657 2996 527 634 769 1042 1383 1872 2482
9–9.9 1723 1788 1976 2227 2571 2987 3112 642 690 933 1219 1584 2171 2524
10–10.9 1740 1784 2019 2296 2583 2873 3093 616 702 842 1141 1608 2500 3005
11–11.9 1784 1987 2316 2612 3071 3739 3953 707 802 1015 1301 1942 2730 3690
12–12.9 2092 2182 2579 2904 3225 3655 3847 782 854 1090 1511 2056 2666 3369
13–13.9 2269 2426 2657 3130 3529 4081 4568 726 838 1219 1625 2374 3272 4150
14–14.9 2418 2562 2874 3220 3704 4294 4850 981 1043 1423 1818 2403 3250 3765
15–15.9 2426 2518 2847 3248 3689 4123 4756 839 1126 1396 1886 2544 3093 4195
16–16.9 2442 2567 2865 3248 3718 4353 4946 1126 1351 1663 2006 2598 3374 4236
17–17.9 2442 2674 2996 3336 3883 4552 5251 1042 1267 1463 2104 2977 3864 5159
18–18.9 2398 2538 2917 3243 3694 4461 4767 1003 1230 1616 2104 2617 3508 3733
19–24.9 2538 2728 3026 3406 3877 4439 4940 1046 1198 1596 2166 2959 4050 4896
25–34.9 2661 2826 3148 3573 4138 4806 5541 1173 1399 1841 2548 3512 4690 5560
35–44.9 2750 2948 3359 3783 4428 5240 5877 1336 1619 2158 2898 3932 5093 5847
45–54.9 2784 2956 3378 3858 4520 5375 5964 1459 1803 2447 3244 4229 5416 6140
55–64.9 2784 3063 3477 4045 4750 5632 6247 1345 1879 2520 3369 4360 5276 6152
65–74.9 2737 3018 3444 4019 4739 5566 6214 1363 1681 2266 3063 3943 4914 5530

Values are expressed in mm2.

Reprinted with permission from Frisancho.14
114
Growth Charts
Growth charts are used to separate normal from abnormal patterns of
growth. Serial measurements are more useful than a single measure
because abnormal growth patterns may be easier to identify over time. A
number of specialized growth charts have been developed. These include
charts for prematurity and for specific conditions, e.g., Down’s syndrome
and Turner’s syndrome.
Premature Infants
The following growth charts are frequently used in the nutri-
tion assessment of premature infants.
1. Lubchenco growth charts: These are growth charts used to
assess growth based on gestational age.20,21 Infants who
fall below the 10th percentile are considered small for
gestational age (SGA). Infants who grow above the 90th
percentile are large for gestational age (LGA). The disad-
vantage of this chart is that it was based on infants born in
Denver at a high altitude. These Denver infants may be
smaller than infants born at a lower altitude and so may not
be representative of the general population.
2. Babson growth charts: These growth charts were devel-
oped from a small number of infants born at sea level and
so may be more representative than the Lubchenco growth
charts.22 They consist of weekly measures of weight,
height, and head circumference for premature infants by
gender from 24 wk gestational age through term (40 wk).
3. Infant Health Development Program growth charts: These
sex-specific growth charts were based on a large sample of
low birth weight (LBW) and very low birth weight
(VLBW) premature infants.23,24 These are appropriate
charts to use for LBW and VLBW infants with chronic
medical problems because the growth of these infants
differs from that of normal birth weight infants during
infancy and childhood, i.e., catch-up growth in LBW and
VLBW infants occurs later.
National Center Health Statistics (NCHS) Growth Charts
These charts25 were developed from data derived from longitudinal
studies of a selected population of Caucasian children ,3 y. For the
REFERENCES
1. Guidelines for Health Supervision II, American Academy of Pediat-
rics, 1988
2. Roche AF, Davila GH. Differences between recumbent length and
stature within individuals. Growth 1974;38:313
3. Himes JH, Roche AF, Thaysen D, Moore WM. Parent-specific ad-
justments for evaluation of recumbent length and stature of children.
Pediatrics 1985;75:304.
4. Stallings VA, Zemel BS. Nutrition assessment of the disabled child.
In: Sullivan PB, Rosenbloom R, eds. Clinics in developmental medi-
cine: feeding the disabled child. London: MacKeith Press, 1996:62
5. Must A, Dallal GE, Dietz WH. Reference data for 85th and 95th
percentiles of body mass index (wt/ht2) and triceps skinfold thickness.
Am J Clin Nutr 1991;53:839
6. Must A, Dallal GE, Dietz WH. Reference data for obesity: 85th and
95th percentiles of body mass index (wt/ht2)—a correction Am J Clin
Nutr 1991;54:773
7. Roche AF, Mukherjee D, Guo S, Moore WM. Head circumference
reference data: birth to 18 years. Pediatrics 1987;79:706
8. Guo S, Roche AF, Fomon SF, et al. Reference data on gains in weight
and length during the first two years of life. J Pediatr 1991;119:355
9. Roche AF, Himes JH. Incremental growth charts. Am J Clin Nutr
1980;33:2041
10. Tanner JM, Davis PSW: Clinical longitudinal standards for height and
height velocity for North American children. J Pediatr 1985;107:317
11. Johnson CL, Fulwood R, Abraham S, Bryner JD. Basic data of
anthropometric measurements and angular measurements of the hip
and knee joints for selected age groups 1-74 years of age: United
NUTRITIONAL ASSESSMENT IN PEDIATRICS
growth charts for children ages 2–18 y, data from a cross-sectional
representative sample of children who participated in the national survey
were used. Using computer techniques, the data were smoothed and
presented as percentiles. All full-term and preterm infants whose cor-
rected age is 40 wk can be plotted on the NCHS charts. Corrected age is
used for preterm infants until they reach 3.5 y, especially if they are
extremely premature with ongoing medical or surgical complications.
Because the charts for 2–18 y were derived from cross-sectional and not
longitudinal data, the growth curves of an individual may be different
from these standard curves during periods of rapid growth (late infancy
and early adolescence).
Growth Velocity Charts
These charts are available for height and weight velocities.8 –10
The charts for older children10 allow for differences between
early, normal, and late maturing children. They were developed
from data based on whole-year growth velocity. Therefore the data
plotted should be based on observations taken over the course of
a year.
Disease-Specific Growth Charts
For some patient groups where genetic causes of abnormalities
of growth are described, the NCHS growth charts may not be
representative. Specific growth charts are available for children
with the following conditions: Down’s syndrome,26 Prader-Willi
syndrome,27 Turner’s syndrome,28 and Duchenne’s muscular dys-
trophy.29
SUMMARY
The assessment of nutrition and growth status in the pediatric patient
is a very important and integral part of the patient’s care. Various
techniques and growth charts are available to the clinician. There is no
single method that is best for nutritional assessment but rather a combi-
nation of different methods should be used to define the nutritional status
of the individual patient. Accurate measurements with the proper equip-
ment over time is the best approach. Periodic assessments will help the
medical team identify the children who are at risk for malnutrition and
provide a method to monitor the clinical response to the nutritional
intervention.
States 1971-75. National Center for Health Statistics (DHHS Publi-
cation no. (PHS) 81-1669), Vital and Health Statistics Series 11, no.
219, Hyattsville, MD, 1981
12. Lohman TG, Roche AF, Martorell R. Anthropometric standardization
reference manual. Champaign, IL: Human Kinetics Books, 1988
13. Slaughter MH, Lohman TG, Boileau RA, et al. Skinfold equations for
estimation of body fatness in children and youth. Hum Biol 1988;60:
709
14. Frisancho AR. New norms of upper limb fat and muscle areas for
assessment of nutritional status. Am J Clin Nutr 1981;34:2540
15. Ponder SW. Clinical uses of bone densitometry in children: Are we
ready yet? Clin Pediatr 1995;34:237
16. Tanner JW. Growth at adolescence, with a general consideration of
the effects of heredity and environmental factors upon growth and
maturation from birth to maturity, 2nd ed. Oxford: Blackwell, 1962
17. Greulich WW. Radiographic atlas of skeletal development of the hand
and wrist, 2nd ed. Stanford, CA: Stanford University Press, 1959
18. Tanner JM, Whitehouse RH, Cameron N, Marshall WA, Healy MJR,
Goldstein HG. Assessment of skeletal maturity and prediction of adult
height (TW2 Method), 2nd ed. London: Academic Press, 1983
19. WHO. Energy and protein requirements. Technical Report Series No.
724. Geneva: World Health Organization, 1985
20. Lubchenco LC, Hansman C, Boyd E. Intrauterine growth in length
and head circumference as estimated from live births at gestational
ages from 26 to 42 weeks. Pediatrics 1966;37:403
21. Battaglia FC, Lubchenco LC. A practical classification of newborn
infants by weight and gestational age. J Pediatr 1967;71:159
NUTRITIONAL ASSESSMENT IN PEDIATRICS
22. Babson SG, Benda GI. Growth graphs for the clinical assessment of
infants of varying gestational age. J Pediatr 1976;89:814
23. The Infant Health and Development Program. Enhancing the outcomes of
low-birth-weight, premature infants. JAMA 1990;263:3035
24. Casey PH, Kraemer HC, Bernbaum J, et al. Growth status and growth rates
of a varied sample of low birth weight, preterm infants: a longitudinal cohort
from birth to three years of age. J Pediatr 1991;119:599
25. Hamill PVV, Drizd TA, Johnson CL, et al. Physical growth:
National Center for Health Statistics percentiles. Am J Clin Nutr
1979;32:607
115
26. Cronk C, Crocker AC, Pueschel SM, et al. Growth charts for children
with Down’s syndrome: 1 month to 18 years of age. Pediatrics
1988;81:102
27. Holm VA, Nuggent JK. Growth in Prader-Willi syndrome. Birth
Defects 1992;18:93
28. Lyon AJ, Preece MA, Grant DB. Growth curve for girls with Turner’s
syndrome. Arch Dis Child 1985;60:932
29. Willig TN, Carlier L, Legrand M, Riviere H, Navarro J. Nutritional
assessment in Duchenne’s muscular dystrophy. Dev Med Child Neu-
rol 1993;35:1074