3.

3 ASSESSMENT OF DIETARY INTAKE IN

A. Evaluation
CHILDREN MORE THAN 6 MONTHS
Nutritional intake between 6 months and
24 Hours Dietary Recall
2 years is most critical as inappropriate This is the most common tool used in clinical
feeding practices at this age are the root cause practice for an individual patient. The parents
or patient is asked to recall the actual food and
of malnutrition or obesity. Assessment of diet
and its constituents is essential to know drink consumed in the last 24 hrs. When there
nutrients gaps and excess. Assessment aims is a history of poor appetite, you should take
to find out both quantitative (amount of both pre-morbid intake (before the onset of

mebooksfree.com

Assessment of Diet and Feeding Practices 41

Case Scenario-2
Dietary Assessment of Meena, 14-week-old admitted with Diarrhea for 5 days
Recording Form (Part-A)
Name of Mother Seema Name of Baby Meena
Age (weeks) 14 weeks Weight (in grams) 3400 grams SD score <-28D
When was the first feed given? 1 hour
Whether baby received any prelacteal feeds? Yes
How many times breastfeed was given in last 24 hrs? 4 tímes
How many night feeds were given? Once only
Does the child receive any other food or drink in addition to breastfeeds? Yes/No
If yes which food and drink Cow's milk
If animal milk/formula milk-how many times in last 24 hrs? 4 tímes Dilution 2:1
What is being used to feed the child? Cup/'spoon/bottle
How feeding bottle/cup is prepared washing Yes/No, boiling Yes/No
How many times baby is passing urine in 24 hrs? 8 tímes
What is the color of urine? Colorless
Ask mother, if she has any pain during breastfeeding? No
Decision
After completing (Part-A), it was concluded that there is feeding problem in this baby in view of the
following: () baby was not exclusively breastfed; (ii) low weight; (in) diluted cow milk (2: 1); (v) bottle
feeding; (v) prelacteal feeds.
And, hence, it was decided that observation of breastfeeding is required in this baby.
Recording Form (Part-B): Observe breastfeeding for 4 minutes
To check attachment, look for:
" Chin touching breast: No
" Mouth wide open: No Well attached/Poorly attached
" Lower lip turned outward: No
" More areola visible above than below the mouth: No
Check position
Whether infant's head and body is straight or not? No
Whether the baby is facing breast with infant's nose opposite her nipple or not? Yes
Whether infant's body close to mother's body or not? No
Whether mother supporting infant's whole body or not? No
Is the infant suckling effectively? Not suckling effectively
If baby not suckling effectively; check for ulcer in mouth, and check mother's breast for flat, sore or
inverted nipple/engorged breasts/breast abscess No
Decision
This child has poor attachment and is not suckling effectively.
Action
Mother was praised for continuing breastfeeding and was counseled for:
" Immediately stopping bottle feeding.
" Stop diluting cow's milk.
" Correcting attachment and positioning.
" Frequent breastfeeds and increased number of night feed.
She was advised to come for follow-up after 2 days. It was planned to counsel her to increas
to 8-10 times and gradually stopping cow's milk during follow-up.
 62/669
Table 3.1 Proforma for 24 hours dietary recall
Time Food items Amount Calorie Protein
Consumed (grams) (Cal) (g)
Morning (breakfast)
Mid-morning (snacks, if any)
Afternoon (lunch)
Evening (snacks, if any)
3 Dinner
Pre-sleep (milk/snack, if any)
Midnight (snack, if any)

illness) and current intake. It is important to After calculating calorie and protein of these
remember that size of utensils and thickness consumed food items, you will need to decide
of food prepared varies a lot. Also try to ascer whether it is appropriate for age. For this,
tain the size of utensils to know the amount. compare the intake of your child with the
You can use the format given in Table 3.1 for recommended requirement according to age
this record. (Table 3.6). Decide whether it is according to the
recommendation for the particular age or not.
How to Calculate Calorie
and Proteins in Diet A
child up to 1 year of age needs 100 kcal/kg/d.
The energy values of food items are tradi Thus, approximately, a 1-year-old healthy
tionally expressed in terms of the kilocalorie child (expected to weigh around 10 kilos)
needs 1000 kcal per day.
(kcal) also called "Calorie". Recently Joule'
has been adopted as the unit of energy Add 100 kcal for every additional year, till
internationally. puberty. For example, a 5-year-old child will
need at least 1000 + 400 = 1400 kcal per day.
1kcal =4.184 kJ (kilo joules) " The above calculations are only a crude esti
However, stillCalorie use is more common, mate and reflect the minimum requirements
and we will be using it for further discussion. at these ages. See Table 3.6 for exact ICMR
recommendations.
The energy in dietary sources is derived from
three sources--protein, fat, and carbohydrate.
Fat 9 Cal (kcal) per gram
History of Feeding Practices and
Protein 4 Cal (kcal) per gram
Food-frequency Questionnaire
Carbohydrate 4 Cal (kcal) per gram Although, dietary recall method gives idea
about calorie and protein it is unable to tellus
Calorie and protein contents of milk of whether diet intake is balanced or not. For this,
different types are given in Table 3.2. Nutritive you need to obtain a proper dietary history
values of cereals, pulses and millets (raw/ and ask questions related to the frequency of
uncooked) are provided in Table 3.3. Calorie consumption of certain food items.
and protein contents of other common food The child or parents are givena list of foods
items are depicted in Table 3.4. For certain and asked to tell how often each item is
common cooked foods prepared in Indian consumed per day per week. Ask parents
kitchen, calories and protein values are about the frequency of five-food groups
provided for cooked items (Table 3.5). Use (cereals, pulses, milk and meat products, fruits
Tables 3.1-3.5 to calculate calorie and protein and vegetables, and fats and sugars) which the
of the food item being consumed. child is taking in the diet. Also ask whether
 Assessment of Diet and Feeding Practices 43

Table 3.2 Nutritive value of milk (per 100 grams)

Milk Calorie Fats Proteins 63/669 C
(kcal) (g) (g)
Buffalo 107 6.6 3.7 0.16 12,
Cow 72 4.5 3.3 0.15 118
Goat 72 4.1 3.3 0.10 170
Human 67 4.2 1.1 0.35 35
Skimmed milk powder (cow) 357 0.1 38.0 1370
Paneer 258 14.8 18.9 0.9 476
Curd (Cow milk) 60 4.0 3.1 0.1 149
Updated from: Indian Food Composition Tables, National Institute of Nutrition, ICMR, 2017.
Table 3.3 Nutritive values of cereals, pulses, millets (per 100 grams)
Food item Calorie Fats Proteins Iron Calcium
(kcal) (g) (g) (mg) (mg)
Bajra 346 5.4 11.0 6.4 27.3
Bengal gram dal 328 5.3 21.6 6.1 46.3
Black gram dal 323 1.7 23.1 4.7 55.7
Green gram dal 325 1.3 23.9 3.9 43.1
Jowar 332 1.7 10.0 3.9 27.6
Maize (dry) 332 3.8 8.8 2.5 8.9
Peas (dry) 302 1.9 20.4 5.1 75.1
Ragi 320 1.9 7.2 4.6 364.0
Rajma (kidney beans) 296 1.7 19.5 6.1 126.0
Red gram dal 330 1.6 21.7 3.9 71.7
Rice raw milled 355 0.5 7.9 0.7 7.5
Soyabean (white) 376 19.4 37.8 8.2 195.0
Wheat (whole) 322 1.5 10.6 4.0 39.4
Wheat, flour (refined) 350 0.8 10.4 1.8 20.4
Wheat, flour (whole) 320 1.5 10.6 4.1 31.0
Updated from: Indian Food Composition Tables, National Institute of Nutrition, ICMR, 2017.
the child is vegetarian or non-vegetarian. In scurvy, and both iron and calcium in adoles
later case, enquire about the frequency of cents.
consumption of such item and the usual Calcium
portion size. Diet history and food frequency
questionnaire usually supplement 24 hrs Calcium is required for formation and main
dietary recall method to know the qualitative tenance of the skeleton and plays an important
aspects of the diet. role in neuromuscular excitation, blood
Recording form for assessment of diet and coagulation, and membrane permeability.
feeding practices for a child more than Calcium is present in both animal and plant
6 months is provided in Key Box 4. foods. The richest source of calcium among
animal foods is milk. Ask for the history of
Assessment of Micronutrient Intake intake of milk, milk products, and egg. Plant
In certain situations, you will also have to foods rich in calcium include amaranth,
assess about micronutrients, e,g. iron in achild tapioca, and ragi. Remember that most cereals
with anemia,calcium in presence of signs of and millets contain some amount of calcium,
rickets, vitamin C in a child with suspected but rice is a poor source.
 46 Clinical Methods in Pediatrics

Table 3.6 Average requirement for infants and children*

Age Energy requirement Protein Fat Calcium Iron
(g/d) (mg/d) (mg/d)
0-6 months 92 kcal/kgd 1.16 g/kg/d 500 0.46
6-12 months 80 kcal/kg/d 1.69 g/kg/d 19 500 0.5
1-3 years 1060 kcal/d 16.7 g/d 27 600 9.0
4-6 years 1350 kcal/d 20.1 g/d 25 600 13.0
3 7-9 years
10-12 years
1690 kcal/d
Boys - 2190 kcal/d
29.5 g/d
39.9 g/d
30
35
600
800
16.0
21.0
Girls - 2010 kcal/d 40.4 g/d 35 800 27.0
13-15 years Boys - 2750 kcal/d 54.3 g/d 45 800 32.0
Girls - 2330 kcal/d 51.9 g/d 40 800 27.0
16-17 years Boys - 3020 kcal/d 61.5 g/d 22 800 28.0
Girls - 2440 kcal/d 55.5 g/d 35 800 26.0

* Nutrient requirements and recommended dietary allowances for Indians: ICMR, 2010.

The energy needs from complementary average amount breastmilk. If the breast
foods for infants with "average" breastmilk feeding is not being given in the usual way,
intake in developing countries (WHO/ ie. given only occasionally or only 2-3 feeds,
UNICEF, 1998) are approximately 200 kcal per the energy intake would be lower. In that case,
day at 6-8 months of age, 300 kcal per day atit is better to say that the child is consuming
9-11months of age, and 550 kcal per day at so many calories from complementary foods
12-23 months of age. In industrialized in addition to breastfeeding which is given
countries, these estimates differ somewhat only 2-3 times in a day.
(130, 310 and 580 kcal/d at 6-8, 9-11 and 12
23 months, respectively) because of differences B. Decision
in average breastmilk intake. After taking history, decide:
2. Alternative Method
1. Whether the child is getting adequate
calories or not?
Calculate the calorie intake from complemen- 2. Whether the child is getting adequate
tary foods and add to it the average breastmilk proteins or not?
intake by a healthy baby of that age as follows: 3. Whether the child is getting all food group
Among breastfed children in developing items or not (if child is not getting any
countries, average breastmilkenergy intake is particular food group, you will have to
413, 379, and 346 kcal/d at 6-8,9-11 and 12 counsel to increase that food item)?
23 months, respectively (WHO/UNICEF, 4. Whether the child is getting food items with
1998). The equivalent values for industrialized right consistency?
countries (for breastfed children only) are 486,
375, and 313 kcal/d, respectively. The above 5. (weight
Whether the child's growth parameters
for age, height for age, weight for
guideline is based on children receiving height; and body mass index in children >5
average amounts of breastmilk at each age. If years of age) are normal or abnormal?
an infantis consumingmore or less breastmilk
than the average, the amount needed from How to decide ohether calories and proteins are
complementary foods will differ accordingly. adequate in diet
However, both these estimates are based on Forpoints 1and 2above, compare the present
the assumption that infant is consuming intakeof caloriesand proteins (calculated with
 Assessment of Diet and Feeding Practices
47

KEY BOX 4
Feeding Assessment Form
Recording Form for Assessment of Diet and Feeding Practices for a Child
more than 6 months
Child's Name: Age: ...........n months) Sex:
Weight: (kg)
Relationship with caregiver/attendant:
" Was the child exclusively breastfed? If yes, the
artificial feeding? Does your child take breastfeedduration?
And if no, the nature and mode of
now? Yes No
- If yes, how many times in 24 hours? ...
times
Do you breastfeed during the night? Yes No
"Any other milk - Yes/No
If yes then-which milk
- Amount
Dilution
- By- -Katori/Spoon/Bottle
" Semi-solid started Yes/No
" At what age semi-solids were started months
" Child's Growth Card Available Yes No
- Ifavailable, is the line going well? Yes No.
- If not available, what is the child's present weight?
- Is child malnourished? Yes No
In the last week did child eat any
" Pulses Yes/No. If yes, how many days
" Dark green vegetables Yes/No. If yes, how many days
" Eggs/meat/fish/milk products Yes/No. If yes, how many days
" Fruits Yes/No. If yes, how many days.
" Fats and sugars Yes/No. If yes, how many days
Any difficulty with child's feeding Yes/No. If yes, list them.
Dietary Recall: List all the foods and drinks consumed in last 24 hours in addition to breast
feeds. Note amount (approx.) of each by showing a suitable katori/glass
Time Food items Amount Calorie Protein
consumed (grams) (Cal) (g)
Morning (breakfast)
Mid-morning (snacks, if any)
|Afternoon (lunch)
Evening (snacks, if any)
Dinner
Pre-sleep (milk/snack, if any)
Midnight (snack, if any)
Total Calorie Protein
 48 redi

Table 3.7 Micronutrients and food sources

Calcium Milk, cheese, green vegetables, pulses (Bengal gram, horse gram, rajmah), sitaphal,
ragi. Bioavailability from cereals is poor because of the presence of phytic acid.
Iron
Liver, meat, seafood, legumes and pulses, enriched grain products, nuts, dried fruits.
Food rich in vitamin C increases iron absorption while tannins, phytates decrease it
Zinc Seafood, liver, meat, fish
Copper Seafood, meat, legumes, chocolate
Magnesium Nuts, seafood, green vegetables

Table 3.8 Food grouping systems

Food group Main nutrients 68/669
Cereals Grains Products
Rice, wheat, ragi, bajra, maize, jowar, barley, Energy, protein, invisible fat, vitamin B,
riceflakes, wheat flour vitamin B, folic acid, iron, fiber
Pulses and Legumes
Bengal gram, black gram, green gram, redgram, Energy, protein, invisible fat, vitamin B,
lentil (whole as well as dhals), peas, rajmah, vitamin B, folic acid, calcium, iron, fiber
soybeans, beans, etc.
Milk and Meat Products
Milk, curd, skimmed milk, Protein, fat
Cheese Vitamin B,, calcium
Meat, chicken, liver, fish, Protein, fat
Egg, meat Vitamin B,
Fruits and Vegetables
Fruits
Mango, guava, tomato Carotenoids
Ripe papaya, orange, sweet lime, watermelon, Vitamin C, fiber
banana

Green Leafy Vegetables

Amaranth, spinach, gogu, drumstick leaves, Invisible fats, carotenoids, vitamin B, folic
coriander leaves, mustard leaves, fenugreek leaves acid, calcium, iron, fiber
Other Vegetables
Carrots, brinjal, lady fingers, capsicum, beans, Carotenoids, folic acid, calcium, fiber
onion, drumstick, cauliflower, potato
Fats and Sugars
Fats
Butter, ghee, hydrogenated oils, Energy, fat, essential fatty acids
cooking oils like groundnut, mustard, coconut
Sugar, jaggery Energy
 Assessment of Dief and Feeding Pratiés 49

Points to Remember while Assessing Feeding Practices in 6 months-2 years old children
" Since at this age child starts learning eating, they need help by parents. Many a times child push out
food, because they have not learnt the skill of moving food inside or swallow solids. This does not
imply that the child is not interested in food.
" Feeding is more successful when it is given in response to child's cues or signals.
" Feeding is more successful when it is given bya person who has a good relationship with the child.
" Feeding is more successful when it is given in suitable
feeding situation, i.e. all family members taking meal at
same time so child develops interest in feeds, use separate
bowl for the child, feed when child is alert and happy. Just right
" If the child is in the initial stages of being given comple
mentary foods, ask what is the consistency of such food Too thin
(Fig. 3.3).
" Also assess whether foods prepared are safe or not. Talk
to the family to know whether following practices are
fulfilled or not:
- Caregiver washes hands and utensils
- Uses clean and safe water
- Keeps food at safe temperature and covered Fig. 3.3 Show this picture to know what
- Uses freshly prepared foods is the correct consistency of given food
items.

the help of 24 hours dietary recall and Tables Fats.

3.1-3.5) with the recommended intake at that Sugars
Minimal
age (calculated as per Table 3.6). In case, the Antake
present intake is less than the recommended
for that age, you also need to calculate the Milk and Mik Products
nutrient gap as follows: Egg and Meat Products
Calorie gap Recommended calories for that Moderate ntake
age-present intake of calories.
Proteingap Recommended proteins for that Legumes, Pulses, Nuts
age-present intake of proteins. Should be incuded in al main
meals
How to decide whether the child is getting all food Vegetables and Frults
group items
They are nich sources of vitamins and minerals
Table 3.8 lists the various items categorized in Eatin plenty
5 main food groups. Relative importance and Cereals
contribution to diet by the 5 food groups is
These are main sources of energy Eat in plenty
depicted in Fig. 3.4. The dietary habits also
vary according to socioeconomic status, Fig. 3.4 The food pyramid: What should be the
customs and traditions. Assessment of diet optimal food items?
and its constituents is also essential to know
excess or deficiency of different food groups. Finally, you should be able to decide whether the
Ask from the parents regarding relative intake diet and feeding practices of the given child are:
of items from each food group. i. Normal Praise and counsel to continue the
Decide whether complementary food is same diet:
ii. Near normal Need counseling for some
timely, adequate, properly fed and safe. changes and follow-up evaluations; or
Characteristics of ideal complementary foods
are given in Key Box 5. i.Inappropriate Need immediate intervention.
 50 Clinical Methods in Pediatrics

KEY BOX 5 Dietary diversity is a proxy for adequate

Characteristics of ldeal micronutrient density of foods. Consumption
of foods from at least 4 food groups ensures
Complementary Food
good dietary diversity.
1. Timely
Introduced when need for energy and nutrients C.Action
exceed that provided by breast milk (completes
6 months) No intervention is required
3 2. Adequate
When nutritional status is normal and assessed
diet and feeding practices are normal. Praise
Should provide sufficient energy, protein, and parents and advise to continue the same diet.
micronutrients (iron,vitamin A, C, etc.)
3. Properly Fed Needs counseling and follow-up evaluation
Active feeding method and proper frequency You will need to counsel family and the child,
if their nutritional status is not normal
according to age (use feeding guideline table)
(undernutrition or obesity), diet is insufficient
4. Safe
or excess in any particular food group items.
Should be hygienically prepared, stored and fed First praise mother and family for the things
5. Right consistency they are doing right:
Soft, easy to digest, which family can afford, Give a few relevant information regarding
easily available, prepared, culturally acceptable
changes you want.
6. Locally available and culturally acceptable "Suggest changes.
" Check their understanding.

Case Scenario-3
An 18 months male child is brought for immunization. His dietary assessment is as follows:
Child's Name: Rohit Age: 18 months (in months)
Sex: M Weight 12 (kg)
Relationship with caregiver/attendant: Mother
Does your child take breastfeed? Yes
If yes, how many times in 24 hours? 2 times
- Do you breastfeed during the night? Yes
Any other milk: Yes If yes then - which milk Mother dairy
Amount: 250 ml Dilution: No By: Katorispoon/ Bottle
Semisolid started: Yes If yes, at what age? 6 months
Child's Growth Card Available: No
- If available, is the line going well? Yes
Is the child malnourished? No, because the expected weight (50th percentile of WHO standards) at
18 months is 10.9 kg and this child (12 kg) lies between 75th (11.8 kg) and 90th percentiles (13.1 kg)
which is acceptable.
In the last week, did child eat any
Pulses Yes. If yes, how many days daiy
- Dark green vegetables Yes. If yes, how many days daly
- Eggs/meat /fish Yes. If yes, how many days 3
Fruits Yes. If yes, how many days 4
Any difficulty with child's feeding No.
Dietary Recall
List all the foods and drinks consumed in last 24 hours in addition to breastfeeds. Note amount (approx.)
of each by showing a suitable katorilglass. Convert to calories with the help of Tables 3.1-3.5.
Meal Food items consumed Calorie Protein
Breakfast 1. Milk 1cup (150 mL) 72/100 x 150 = 108 3.3/100 x 150 = 4.9
2. Sugar 1 tsf (5 g) 4 x 5 20 =0
3. Bread1 slice (big) 1x 85 85 2.2 x 1 =2.2
4. Butter 1 tsf (5 g) 9x5 = 45 =0
258 Cal 7.1 g
Snacks Banana big 1 (80 g) 110/100 x80 =88 Cal 1.2/100 x 80 = 1g
Lunch 1. Rice 1 katori = 110 =2g
2. Dal 2 Cup = 100 =5g
3. Ghee 1tsf (5 g) 9x5 = 45 =0
4. Vegetable 1 cup = 150 =1g
360 Cal 8.0 g
Snacks 1. Biscuits (3) (Parle-G) 30 x 3 = 90 0.5 x 3 = 1.5
2. Apple 1(100 g) = 60 =0.3
150 Cal 1.8 g
Dinner 1. Chapati 1 80 x 1 = 80 = 2.4
2. Ghee 1tsf (5 g) 9 x5 = 45 =0
3. Dal Vh cup = 100 = 5.0
4. Vegetable (1 cup) = 150 = 1.0
375 Cal 8.4 g
Bedtime Milk 100 mL 72 Cal 3.3 g
Present intake: 1303 kcal (expected 1060 kcal); and 29.6 g proteins (expected 16.7 g)
Evaluation
1.Whether child is getting adequate calories or not: Taking adequate caloríes
He is receiving 1303 calories in addition to mother's feed. Requirement for his age is 1060 calories.
2. Whether child is getting adequate proteins or not: Taking adequate proteins
He is receiving more than 20 g proteins in addition to mother's feed. Requirement for his age is approx
17g
3. Whether getting all food group items: He is geting all food group items
4. Whether right feeding practices are being followed: Yes
Decision
Diet and feeding practices in this child are Normal.

Action
The child mother duo needs no intervention. Parents and child were praised for breastfeeding, and
good diet. They were advised to continue same diet.
 Assessment of Diet and Feeding Practices 55

How to Counsel Mother for Reasons for substituting the breastmilk are
Complementary Feeding listed in Key Box 6.
The process of giving an infant other foods and KEY BOX 6
liquids along with breastmilk is known as Acceptable Reasons for
complementary feeding. Additional food is Using Breastmilk Substitute
required after 6 months of age as breastmilk Infant conditions
alone is no longer sufficient to meet the " Galactosemia A galactose-free formula is
nutritional requirements of an infant older needed.
than 6 months. The term 'weaning' which was " Maple syrup urine disease A formula free of
earlier used is not used these days because the leucine, isoleucine and valine is needed.
additional foods complement breastfeed. " Phenylketonuria A phenylalanine-free
Breastfeeding should be continued till 2years formula is needed.
or longer and it does not aim to wean from
breastfeed (Table 3.9). Maternal conditions which may justity temporary
cessation:

Disadvantages of adding foods to0 soon Herpes simplex virus type 1infection
" Decrease the intake of breastmilk resulting " Maternal medications: Antipsychotic or
in a low nutrient diet. cytotoxic drugs
"Increase risk of illness especially diarrhea. Infants for whom breastmilk remains the best
feeding option but who may need other food in
Disadvantages of adding foods too late addition to breastmilk for a limited period
" Growth and development slows down. " Risk of hypoglycemia is very high by virtue of
Risk of deficiencies and malnutrition. impaired metabolic adaptation or increased
glucose demand (those who are VLBW,
Substituting breastmilk preterm, smallfor gestational age or who have
A child with severe acute malnutrition or experienced significant intrapartum hypoxic/
other problems will need urgent attention ischemic stress)
" And those who are ill and those whose mothers
and hospitalization. These children are
managed with special therapeutic diets, i.e. are diabetic, if their blood sugar fails to
starter (F-75 formula) and catch-up diet respond to optimal breastfeeding or breast
milk feeding.
(F-100 formula).