Covers obesity,

neurological
impairments, and
The Practitioner’s Guide to critical illness

Nutrition-Focused Physical Exam of

Infants, Children, and Adolescents

AN ILLUSTRATED HANDBOOK
NOTE: This publication is designed to provide accurate, All rights reserved. No part of this may be used
authoritative information with regard to the subject or reproduced in any manner whatsoever without
matter covered. It is sold with the understanding that written permission from ASPEN. For information,
the publisher is not engaged in rendering medical or write: ASPEN, 8401 Colesville Road, Suite 510,
other professional advice. Trademarked commercial Silver Spring, MD 20910; call: (301) 587-6315; visit:
product names are used only for education purposes www.nutritioncare.org; or email: aspen@nutr.org.
and do not constitute endorsement by the American
Society for Parenteral and Enteral Nutrition (ASPEN) or
Cleveland Clinic Children’s. ABOUT THE ARTWORK: Unless specifically credited
to another source, the illustrations and photographs
contained in this book are created and owned
This publication does not constitute medical or exclusively by Cleveland Clinic’s Center for Medical Art
professional advice, and should not be taken as such. and Photography, and may not be reproduced without
To the extent the information published herein may be exclusive permission of the Publisher or the Cleveland
used to assist in the care of patients, this is the result Clinic Foundation.
of the sole professional judgment of the attending
health professional whose judgment is the primary
component of quality medical care. The information
presented herein is not a substitute for the exercise of
such judgment by the health professional.

1 2 3 4 5 6 7 8 9 10

Copyright © 2019. American Society for Parenteral and Enteral Nutrition.

Print ISBN: 978-1-889622-34-7

eBook ISBN: 978-1-889622-38-5

Suggested citation: DeTallo C, ed. The Practitioner’s Guide to Nutrition-Focused Physical Exam of Infants, Children, and
Adolescents: An Illustrated Handbook. Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2019.

Printed in the United States.

The Practitioner’s Guide to
Nutrition-Focused Physical Exam of
Infants, Children, and Adolescents
AN ILLUSTRATED HANDBOOK
 Authors Editor
Hanna Freeman, MS, RD, CSP, LD Christina DeTallo, MS, MBA, RD, CSP, LD
Pediatric Nutrition Support Team Director, Pediatric Nutrition Support Team
Pediatric Institute, Cleveland Clinic Children’s Pediatric Institute, Cleveland Clinic Children’s

Bette Klein, MS, RD, CSP, LD

Advanced Practice II Dietitian, Pediatric Nutrition Support Team
Pediatric Institute, Cleveland Clinic Children’s Reviewers

Sara Bewley, MS, RD, CSP, LD Lacey Baker, MS, RD, CSP, LD, CNSC
Advanced Practice I Dietitian, Pediatric Nutrition Support Team Clinical Dietitian
Pediatric Institute, Cleveland Clinic Children’s Johns Hopkins All Children’s Hospital, St. Petersburg, FL

Merideth Miller, RD, CSP, LD Linda Heller, MS, RD, CSP, CLC, FAND
Pediatric Nutrition Support Team Manager of Clinical Nutrition and Lactation
Pediatric Institute, Cleveland Clinic Children’s Children’s Hospital Los Angeles

Kristin Petrullo, DrPH(c),MPH, RD

Pediatric Medical Science Liaison
Abbott Nutrition, Columbus, OH
Contributors
Jeffrey Loerch
Center for Medical Art and Photography, Cleveland Clinic

Gwen Barron, RD, CSP, LD

Pediatric Nutrition Support Team
Pediatric Institute, Cleveland Clinic Children’s

ii
About ASPEN About Cleveland Clinic Children’s
The American Society for Parenteral and Enteral Cleveland Clinic Children’s is dedicated to medical,
Nutrition (ASPEN) is a scientific society whose surgical, and rehabilitative care of infants, children,
members are healthcare professionals—physicians, and adolescents. Our staff uses the latest technology
dietitians, nurses, pharmacists, other allied health and most recent research to achieve the best possible
professionals, and researchers—that envisions an outcomes at over 40 locations across northeast Ohio.
environment in which every patient receives safe, We have more than 350 pediatric specialists, who
efficacious, and high-quality patient care. are leaders in research for cardiac care, neurological
conditions, digestive diseases, and other conditions.
ASPEN’s mission is to improve patient care by Cleveland Clinic Children’s is proud to be named a
advancing the science and practice of clinical national leader in clinical care by consistently ranking
nutrition and metabolism. among the “Best Children’s Hospitals” by U.S. News
and World Report. Our goal is to have the children and
adolescents we care for back on their feet and living
normal lives as quickly as possible.

https://my.clevelandclinic.org/pediatrics

The Practitioner’s Guide to Nutrition-Focused Physical Exam of Infants, Children, and Adolescents iii
 Contents

Preface.............................................................................................. vi 5 Physical Exam of Subcutaneous Fat loss and

Muscle Wasting....................................................................... 19

1 Introduction.................................................................................. 1 • Overview
• The Head-to-Toe Approach to Reviewing Systems

2 Nutrition Assessment............................................................. 3
• Head and Face (Fat and Muscle)
• Upper Body (Fat And Muscle)
• Overview • Upper Back (Muscle)
• Anthropometrics • Ribs/Midaxillary Line (Fat)
• Medical History • Lower Extremities (Muscle)
• Laboratory Data • Lower Extremities (Fat)
• Dietary Data • Mid–Upper Arm Circumference
• Interview Techniques and Tips • Other Tools for Body Composition Assessment

3 Indicators of Malnutrition................................................. 12 6 Physical Exam of Fluid Status........................................ 36

• Overview
4 Overview of Physical Exam Techniques.................... 14
• Dehydration
• Edema

iv
7 Assessing Functional Status........................................... 40 10 Childhood Nutrition (Ages 3 to <11 Years)............. 61

• Overview • Overview
• Measuring Functional Status • Growth

8 Physical Exam of Hair, Eyes, Oral Cavity, 11 Adolescent Nutrition (Ages 11–20 Years)............... 64
Nails, and Skin......................................................................... 45
• Overview
• Overview • Growth
• Hair
• Eyes 12 Nutrition Issues in Specialty Populations................ 67
• Oral Cavity
• Patients with Obesity or Overweight
• Nails
• Patients with Neurological Impairments or
• Skin Developmental Delays
• Patients in Critical Care
9 Infant/Toddler Nutrition
(Birth to 3 Years of Age)..................................................... 56

• Overview
• Growth

The Practitioner’s Guide to Nutrition-Focused Physical Exam of Infants, Children, and Adolescents v
 Preface

The Cleveland Clinic Pediatric Nutrition Support Team Our PNST follows a systematic method during the
(PNST) has created this illustrated nutrition-focused NFPE, and we have found that a visual learning tool
physical exam (NFPE) handbook to assist clinicians in on how to perform the NFPE is beneficial for clinician
performing comprehensive nutrition assessments in training and standardization of methods. The photos
the pediatric population. This handbook is a resource and illustrations demonstrating exam areas and
for the identification and degree of physical depletion techniques in this handbook provide step-by-step
and malnutrition. It is imperative that the clinician guidance for the clinician and will help users build
understands nutrition-related concerns specific to the confidence in their NFPE skills.
pediatric population because nutrition assessment
is individualized to different stages of development. We would like to thank the American Society for
This handbook helps clinicians perform the NFPE on Parenteral and Enteral Nutrition (ASPEN) for giving our
infants, children, and adolescents and addresses PNST the opportunity to collaborate on this handbook.
nutrition concerns for specialty populations, including We are grateful for our professional relationship with
patients with obesity, patients with neurological ASPEN and our shared core values, which include a
impairments, and patients in critical care. The NFPE is commitment to improving patient care.
fundamental for early identification of depletion and
prevention of pediatric malnutrition. For that reason, it
should be a required skill set for clinicians.

vi