NTRN Exam 1: Growth and Development

What is the difference between growth and development?

Growth refers to more physiological aspects whereas development is more on the cognitive side

What is growth?

Growth: increase in size of the human body through cell multiplication (hyperplasia) and enlargement of cell size (hypertrophy)

Result of metabolic processes in which proteins are broken down and used to make new cells

What is growth velocity? What kinds of things can change this?

• Growth velocity: rate of growth over time 

  • At certain times can be very rapid 

  • Can be modified by environmental insults 

    • Food insecurity (causing failure to thrive), adverse childhood experience, exposure to substances and smoke, parents are on drugs and may not mix formula correctly or they introduce foods at the wrong time, mothers with ppd

What are critical periods?

• Critical Periods: preprogrammed time periods during embryonic and fetal development when specific cells, organs, and tissues are formed and generated, or functional levels are established 

  • Typically, times of rapid cell division

  • Times of greatest vulnerability to an insult 

  • An insufficient supply of nutrients in utero can produce severe and irreversible deficits in growth 

  • Examples

    • During fetal development → the first thing to develop is the NS → first few weeks are a critical period → the problem is that women often do not know they are pregnant that early and they may continue to drink, smoke, or use drugs → an insult during this critical period would cause major abnormalities 

    • Sometimes insults happen even if the mom is doing everything right 

      • Morning sickness → may cause women to lose weight and that embryo is not getting the nutrients they need

What is catch up growth?

• Catch-up Growth: phase of rapid growth occurring after a period of growth development 

  • Often times when an insult happens we will see this rapid growth sometime after the insult in the critical period 

    • Faster than it would have been if the insult had not occurred 

  • Growth impairment due to maternal voluntary or involuntary behaviors, abnormalities with the growing embryo/fetus 

  • Late temporary adverse influence 

    • Rate of growth and development plateaus a bit but catch of growth helps catch up to the healthy rate of development after the environmental insult had resolved itself 

    • This is if the insult occurred later in the critical period 

  • Early adverse influence 

    • Even with catch up growth the embryo will never reach its full potential that it would have if the insult had never occurred

What is protein critical for in regards to growth?

• Protein is critical for: 

  • Making new tissue 

  • Making up the major structural framework of cells 

  • Helping to mend torn tissues 

  • Helping to replace worn-out cells with new cells 

  • Aiding in building enzymes, hormones and antibodies

How does nitrogen play a role in growth?

• Amino acids are the building blocks of protein

  • Nitrogen is a fundamental component of amino acids 

  • Nitrogen balance = nitrogen intake (protein intake) - nitrogen output (urine, feces, sweat, hair, nails, saliva)

  • Can be used to measure protein metabolism and the amount of protein utilized to support growth

What occurs during positive nitrogen balance?

• positive nitrogen balance

  • Anabolism: metabolic process  by which tissue is synthesized (built)

    • Normal for periods of rapid growth

What occurs during negative nitrogen balance?

• Negative nitrogen balance

  • Catabolism: metabolic princess by which tissue is broken down

    • Seen with malnutrition

What is development?

• Development: progression of physical and mental capabilities through growth and differentiation of organs and tissues, and integration of functions 

  • An orderly, sequential step by step process → simple to complex (milestones)

    • Behaviors achieved form the foundation for more advanced behaviors 

  • Rates of development vary between children and among developmental areas within children 

    • Some kids will develop very quickly in their physical areas and slower in cognitive areas (vise versa) 

What is community level assessment?

• Community level assessment 

  • Assessing a community’s state of nutritional health 

  • Use vital statistics data, surveys , observations 

  • Used to develop community wide nutrition programs, policies, initiatives, etc..

what is Individual assessment?

• Individual Assessment 

  • Outcomes and Factors  → we can get a more in depth review of a single person 

  • • Dietary intake
    • Biochemical
    • Clinical outcomes
    • Anthropometric factors
    – Height
    – Weight
    – Body mass index (BMI)
    – Head circumference
    – Growth velocity; growth trajectory

    • Dietary intake 

      • 24 hr dietary recalls 

What are the 5 steps of the USDA’s multiple pass method for 24 hr dietary recalls?

1. Quick List

2. Forgotten Foods

3. Time and Occasion

4. Detailed Cycles

5. Final Review

What is step 1 of the USDA’s multiple pass method for 24 hr dietary recalls?

• Interviewer asks respondent to report an
  uninterrupted listing of all foods &
  beverages consumed in a 24-hour period
  the day before the interview

• ”Please think about yesterday, from the
  time you woke up until the time you went
  to bed, and share everything you ate and
  drank during this time period.”

What is step 2 of the USDA’s multiple pass method for 24 hr dietary recalls?

Interviewer asks questions probing for any
forgotten foods from specific categories:
• Snacks eaten between meals?
• Condiments added to foods at meals?
• Beverages consumed with meals and snacks?
• Toppings on foods? (e.g., cold or hot cereal;
butter; dressings; nuts or seeds)
• Side dishes? (e.g., vegetables; rice; rolls;
chips; fruit; yogurt)

What is step 3 of the USDA’s multiple pass method for 24 hr dietary recalls?

Interviewer asks the time & occasion specific
foods were consumed
• Often triggers memory of other foods
consumed or details about already
reported foods

What is step 4 of the USDA’s multiple pass method for 24 hr dietary recalls?

Interviewer goes through entire list of
reported foods and asks very specific
questions about each item listed
• Prepared at home or purchased?
• Preparation methods
• Specifics about ingredients (e.g., bread -
whole wheat, wheat, rye, white?)
• Quantities/portions consumed

What is step 5 of the USDA’s multiple pass method for 24 hr dietary recalls?

Interviewer reads the list of reported foods,
including details gathered throughout the
interview (i.e., time & occasion, specific food
descriptions, portions consumed)
• Interviewer asks interviewee if there are
any additional foods or details forgotten

What is the gold standard for dietary logs?

• Gold Standard: 3 days (2 weekdays and 1 weekend day)

  • Diet may be different on the weekend so it's good to get a look at that as well 

• Diet Record 

  • Record diet for three days 

  • Can be a problem bc people may be embarrassed and underreport 

What are food frequency questionnaires (FFQ)? What are the pros and cons associated with them?

• Food Frequency Questionnaire (FFQ)

  • Surveys → good when trying to gauge dietary intake on large groups of people 

  • Pros: really convenient, easy, cost efficient

  • Cons: includes serving size that most do not follow, long survey is tedious (first half is very accurate and the second half is less so), do not adapt to seasonality and changes in diet

Should we trust internet dietary assessment resources?

• Internet dietary assessment resources 

  • Very few that are accurate and use poor databases 

  • Be careful about using these 

• NO!!

When conducting an individual nutrition assessment, what biochemical things are we looking at?

• Biochemical 

  • Nutrient and enzyme levels 

    • Serum albumin ( helps measure iron status), zinc, cholesterol, 25-hydroxy vitamin D

  • Gene characteristics

    • sickle-cell anemia (hemoglobin S vs A)

  • Other biological markers 

    • Collagen

When conducting an individual nutrition assessment, what clinical outcomes are we looking at?

• Clinical outcomes 

  • Visual inspection for features that may be related to malnutrition 

    • Hair

    • Eyes

    • Gums

    • General vitality 

    • Skin health

What are anthropometric factors?

• Anthropometric factors: process of measuring various dimensions of the human body to help determine basic body composition and needs 

  • Anthropos (person/human) + Metric (measure)

  • Body composition

  • height/length

  • Weight

  • Head and waist circumference

  • blood pressure

  • pulse rate

  • respiration

  • temperature

What 4 things make up our body composition?

1. lean body mass

2. fat mass

3. water

4. mineral mass

What is lean body mass?

• Lean body mass 

  • Makes up 30-65% of total body weight 

  • Consumes energy; metabolically active 

  • Lean muscle mass is using energy constantly → burning calories 

  • More muscle mass need to eat more to maintain metabolic tissue 

  • Muscle tissue

What is fat mass?

• Fat mass 

  • Healthy body fat: ~11-20% for men; ~16-25 for women

    • If a womens fat mass drop 14 → stop getting period → could not support fetus → protective measure

Discuss water’s role in body composition

• Water

  • Primarily found in lean mass

  • Lean muscle contains more water than fat 

    • Water is dense here so not a ton

  • Most is found in: Extracellular fluid: blood plasma, interstitial fluid, secretory fluid and dense tissue fluid

What is mineral mass?

• Mineral Mass

  • Body's minerals are found primarily in skeletal mass (calcium)

  • 99+% is found in bones

What are adipocytes? Why is a good way to estimate body fat?

Adipocytes: quantity established during childhood and adolescence and held relatively constant throughout life

What are ways we can estimate body fat?

• Skinforld calipers 

  • Between muscle and skin we have our adipose tissue → take calipers and peel back skin on arm 

• The bod pod – air displacement 

  • Very large piece of equipment that measures density 

  • Wearing tight fitting clothing 

  • Person stands on calibrated scale to measure mass 

  • Measure volume of air inside bod pod 

  • Person goes inside and volume is measured again 

  • Volume without - volume with patient 

  • mass/volume=density which equates your fat mass 

  • Not commonly done because it's very expensive 

How do we measure length in infants?

• Length

  • Infants want to be in fetal position they do not like to be stretched out or flat 

  • Makes getting length really difficult

  • Take infant head and put flat against headboard of measuring board 

  • Lock legs down so the infant doesn't curl them back up and they can measure the length 

How to measure weight in infants?

Nude or dry diaper
• Two measures that
should agree within 0.1
kg or ¼ lb
– If not, take 3rd measure &
use the mean of the two
closest measurements

What does head circumference in infants tell us?

• Head circumference 

  • 80% of a humans head and brain growth occurs during the first 2 years of life 

  • Can identify microcephaly and macrocephaly 

  • Measures compared with past measurements and reference measures of infants of the same sex and age

How do we ensure accuracy of anthropometric measurements?

• Accuracy of measurements 

  • Two measurements should always be taken for all anthropometric assessments 

    • Should be within recommended agreement for consecutively taken measures 

      • If not 3rd measure should be taken 

      • Errors can significantly and inaccurately alter understanding of an infant's growth trajectory

How do we measure height in children and adolescents?

• Height

  • Instrument: stadiometer

  • Before measuring 

    • Remove hair ornaments/headbands and hair buns/braids at the top of the head

    • Patient must remove shoes

  • Lower the stadiometer head piece with enough pressure to compress the patients hair 

  • Ask patient to take a deep breath and hold it while you record their height measurement 

    • Inhalation will assist in straightening the spine 

How do we measure weight in children and adolescents?

• Weight

  • Instrument: digital weight scale 

  • Before measuring

    • Take off any top pieces of clothing if possible (jacket, sweatshirt, etc.)

    • Patient must remove shoes 

  • Patient stand on the center of the scale hands at sides, looking straight ahead 

What are the two most critical components of measuring?

• Two most critical components of measuring 

  • Accuracy: degree to which the result of measurement conforms to the correct value; precision

  • Reliability: overall consistency of a measure 

    • High reliability produced similar results under consistent conditions 

  • Of great importance to accuracy and reliability:

    • Make sure our equipment is accurate 

      • Should be properly calibrated; regularly maintained 

      • Make sure it is actually reading correctly and as it should 

      • 0 at 0 

      • Pre set weights → 5lbs the scale should say 5lbs if not recalibrate the scale 

    • Set protocols and processes to measure heights and weights to make sure all clinicians are doing it the same 

What is the purpose of a growth chart?

• Growth Charts

  • Purpose: compare growth with a nationally representative reference based on children of all ages and racial/ethnic groups 

    • Helps assess physical growth in children and adolescents over time 

    • Identify potential health or nutrition related problems 

  • • Types: length/stature-for-age; weight-for-age; weight-for-
    length; BMI-for-age (children (>2 yrs ) & adolescents
    only); head circumference-for-age (birth-2 yrs only)

How do percentiles work?

• Percentile 

  • Jaylen is in the 45% percentile for weight

    • Compared to other youth he is heavier than 45% of kids his age 

Which growth charts do we use for infants and toddlers (birth-24 months)?

• Infants and toddlers (birth - 24 months) 

  • Height/length: measure for length 

    • Growth chartsL CDC control and prevention 2009 birth to 24-month sex-approprire length for age growth charts 

      • Data: WHO, birth-24 months 

  • Weight 

    • CDC 2009 birth to 24-month sex-appropriate weight for age growth charts 

      • Data: WHO, birth-24 months

What growth charts do we use for children 24 months and older?

• Stature:
– Growth charts: CDC 2000 2 to 20-years sex-appropriate
stature-for-age growth charts
• Data: National Center for Health Statistics & CDC
• Weight:
– Growth charts: CDC 2000 2 to 20-years sex-appropriate
weight-for-age growth charts
• Data: National Center for Health Statistics & CDC
• Body Mass Index:
– Growth charts: CDC 2000 2 to 20-years sex-appropriate
weight-for-age growth charts
• Data: National Center for Health Statistics & CDC

What is the growth chart procedure for the initial visit?

• Record information on factors that influence growth 

  • Record mothers and fathers stature as reported 

• Record the child's birth data (skip if ages >2 years old

  • Date of birth 

  • Birth weight, length and head circumference

  • Gestational age 

  • Add notable comments (e.g, breastfeeding, colic)

• Record date of visit

What is the growth chart procedure for successive visits?

• Successive visits 

  • Determine age to the nearest month for infants/children (<2 years) & ¼ year for children 2-20 years old 

    • Enter child's age 

    • Enter weight, stature and head circumference (<2 years old) immediately after taking measurements

    • Add any notable comments

How do we round age for someone less than 2 years old in order to look at a growth chart?

• <2years

  • 0-15 days round down

  • 16-31 days round up

How do we round age for someone more than 2 years old in order to look at a growth chart?

• >2 years old: round to nearest ¼ year 

  • 0-1 months → 0 years 

  • 2-4 months → ¼

  • 5-7 months → ½ 

  • 8-10 months → ¾

  • 11-12 months → 1

How do we calculate age?

• Date of measurement: 2024/09/05

• DOB:                             2021/03/6

  • Take off one month and add 30 days 

  • 2024/08/35

  • Take off a year and add 12 months 

  • 2023/20/35

  • = 2/10/29

  • With rounding → 3 years of age

How do we calculate BMI?

• Calculating BMI 

  • Calculate body mass index (BMI)

    • BMI = weight (kg)/height (m)^2

      • lbs/2.2 kg

      • Inches x 0.0254 = meters 

    • (35.5/2.2)/(38x0.0254)^2=17.321kg/m^2

      • 85th percentile for a 3.5 yr old boy

    • (27.5/2.2)/(35x0.0254)^2=15.816

    • (31.1/2.2)/(37x0.0254)^2=16.005

How do we plot measurements on growth charts?

• Plotting Measurements 

  • Use the appropriate growth chart 

  • Find the child's age on  the horizontal axis 

  • Find the appropriate measurement (weight, length/stature, head circumference or BMI) on the vertical axis

  • Make a small dot where the two lines interact 

  • Use a straight edge or right angle ruler to connect the dots to observe trends of growth

How do we interpret plotted measurements on a growth chart?

• Interpret the plotted measurements 

  • Determine the percentile rank 

  • Determine if the percentile rank suggests that the anthropometric index is indicative of nutritional risk based on the percentile cutoff value 

  • Compare today's percentile rank with the rank from previous visits

What percentile range is considered underweight?

<5th percentile

What percentile range is considered a healthy weight?

5th - <85th percentile

What percentile range is considered overweight?

85th-<95th percentile

What percentile range is considered obese?

> or equal to 95th percentile

What are standards? Examples?

• Standards: indicative of an optimal, normal or goal value 

  • When within these values → prevent chronic disease

  • BMI (adults): 18.5-24.9 kg/m^2 → healthy 

  • Blood pressure (adults): <120/80 mmHg

  • Waist Circumference 

    • Men: <40 inches

    • Women: <35 inches 

    • Larger waist circumference increases risk of chronic disease 

  • Triglycerides (adults): <150 mg/dL

  • Total Cholesterol (adults): <200 mg/DL 

What are references?

Reference: set of data grouped together and manipulated statistically to serve as a point of comparison for other measures

• in principle, implies no value judgement and tells us nothing about optimal, normal or satisfactory growth

What are the stuart/meredith grow charts?

• Stuart/Meredith Grow Charts (1946-1976)

  • Data collected between 1930-1940

  • Sample: predominantly caucasian; from boston and Iowa city; VERY small sample 

  • Not a good representation of children across the entire US 

  • Not generalizable to all children in the US

Discuss the growth charts from National Center for Health Statistics, NCHS (1977-1999).

• National Center for Health Statistics, NCHS (1977-1999)

  • Pediatric (2-20) data collected between 1960-1970 from cross sectional data from the National Health Examination Survey (NHES) and the national health and nutrition examination survey 

  • Infant (<2 yrs old) data collected between 1929-1975 by the fels research institute

What are the concerns with the infant data from the Fels research institute used for growth charts?

• Concerns with the infant data from fels research institute

  • Although not ideal, FRI infant data considered the best available data at the time 

  • Issue 1: data not representative of the entire country 

    • Derived from caucasian, middle class infants from southwestern ohio between 1929-1975

    • Infant (<2 yrs old) data collected from the FRI 

  • Issue 2: infants were predominantly formula fed 

    • Breast is best so no representation of breast fed infants 

      • during this time formula was used more widely than breast milk 

  • Issue 3: birth weights in Fels sample did not match the national distribution of birth weight

    • Therefore, not a good reference sample

  • Issue 4: very significant difference between length in fels data and stature in the national data used for other children 

• Leading to a disjunction between infant and older child growth curved between 24 and 36 months of age 

• Despite limitations these growth charts were used in US from 1946-1976 AND recommended by the WHO for international use

Discuss the 2000 CDC growth charts

• 2000 CDC (2000-present)

  • Data collected on 2-20 year olds from 5 national cross-sectional surveys (NHANES) surveys between 1963-1994)

  • Sample: nationally representative; racial/ethnic sampling representative of US population; large sample size 

  • Infant (birth-36 months) data: greater inclusion of breastfed infants; weight data unavailable between birth-3 months; small sample size during first six months 

    • Reduced disjunction between infant recumbent length and child stature between 24-36 months 

    • Infants grow rapidly these first months we need to know if there is something interfering with this

  • These 2000 CDC growth charts are currently the recommended growth charts for pediatric growth assessment in the US for 2-20 year olds

Discuss the WHO infant growth charts

• WHO Infant Growth Charts (2006-present)

  • The WHO released new international growth standards for infants and children up to 5 years of age 

  • Describes the growth of infants living in environments believed to support optimal infant growth 

  • Criteria: breastfed exclusively for 4 months and continued breastfeeding to 12 months; good healthcare; mother does not smoke

  • First standard growth chart instead of a reference growth chart

  • ONLY OPTIMAL CONDITIONS

What are CDC growth chart recommendations?

• CDC growth chart recommendations 

  • Infants (birth-23 months): use data from the WHO 2006 growth charts to monitor growth 

    • CDC is publishing it but the data came from WHO

  • Children (2-20 years old): CDC 2000 growth charts to monitor growth

    • Data came from national surverys 

Why use WHO growth standards for infants in the US

• #1: WHO standards establish growth of the breastfed
infant as the norm for growth
– Breastfeeding is the recommended standard for infant
feeding

• #2: WHO standards provide a better description of
physiological growth in infancy
– CDC growth charts are references; they identify how typical
infants in the U.S. grew during a specific time period
• Typical growth patterns may not be ideal growth patterns
– WHO growth charts are standards; they identify how infants
should grow when provided optimal conditions

• #3: WHO standards based on a high-quality study
explicitly designed for creating growth charts
– Longitudinal length and weight measured at frequent
intervals
– Adequate sample size for entire period

Why use CDC growth references for children in the US?

• CDC growth charts can be used continuously from ages
2-19
– WHO growth charts only provide information up to 5 years
of age
• In addition, similar methods were used by the CDC and
WHO to create their growth charts for children 2-5 years
old