Sheri

Sotto
March 3, 2016
NDFS 424
Dr. Richards

I.

II.

III.

Well-Child Project: Emary

Identifying Data
A. Emary
B. Description of the Child: Race: white. Blonde with brown eyes, good
teeth, and lots of energy (good skin and muscles).
C. Economic Environment: She has a good interaction with her parents
and with her siblings. She likes to play with siblings and she does well.
She is with a babysitter 1/week during which she is awake for about 3
hours and asleep for about 4 hours.
Health History
A. Female
B. 4 years 7 months
C. Birth Anthroprometrics:
(1) 7lbs 10 oz (between 50th and 75th percentile)
(2) 20 inches (between 75th and 90th percentile)
(3) See Growth Charts at end of document
D. Current Anthropometrics:
(1) 32 lbs (between 10th and 25th percentile)
(2) 41.5 inches (between 50th and 75th percentile)
(4) BMI = 13.2 (less than 5th percentile)
(3) See Growth Charts at end of document
E. 3 siblings (10 8, 1, and one on the way)
F. Mothers obstetrical history
30-35 lbs gain. Term. 3rd baby.
G. Childs history of illnesses labial adhesion treated with an estrogen
cream
H. No medications or fluoride treatments
I. Childs dental history first saw the dentist at 3 years old. She has one
fused baby tooth, no cavities, good teeth, hasnt lost any.
J. Childs allergies, other food intolerances - milk sensitivity/allergy
(growing out of it)
Emarys Developmental Screening Test: 4 year 7 months
A. See attached DDST form below
B. (1) No Opportunity none identified
(2) Caution

1. Pick Longer Line
(3) Delayed none identified
(4) Interpretation: Normal. Emary had only one caution item, and no
delays or refusals, therefore the plan would be to follow-up at her next
visit.

IV.

V.

Nutritional Assessment
A. See attached Reports (IV. A. 1-3)
B. (1) Macronutrient Distributions:

Carbohydrate: 61% - GOOD (within 45-65% recommendation)

Fat: 32% - GOOD (within 25-35% recommendation)

Protein: 11% - GOOD (within the 10-30%recommendations)
(2) MyPlate Food Group Intake: (rec = recommendation)

Grains: Overall: 6 oz (rec: 5oz)= OVER


Refined Grains: 5 oz (rec: 2.5oz) = OVER


Whole Grains: 1 oz (rec: 2.5 oz) = UNDER

Vegetables: cup (rec: 1.5 cups) = UNDER

Fruits: 1.5 cups (rec: 1.5 cups) = GOOD

Dairy: 1 cup (rec: 2.5 cups) = UNDER

Protein Foods: Overall: 1 oz (rec: 4 oz) = UNDER


Seafood: 0 oz (rec: 6 oz/week) = UNDER
(3) Vitamin/Mineral Intake:

Dietary Fiber: 10g (rec: 25g) = LOW

Linoleic Acid: 8g (rec: 10g) = LOW
Minerals:

Calcium: 612mg (rec: 1000mg) = LOW

Potassium: 1336g (rec: 3800mg) = LOW

Sodium: 2007mg (rec: <1900mg) = HIGH
Vitamins:

Vitamin A: 1034 g RAE (rec: 400 g RAE) = HIGH

Vitamin D: 3 g (rec: 15 g) = LOW

Folate: 585 g DFE (rec: 200 g DFE) = HIGH

Choline: 161mg (rec: 250mg) = LOW
C.. She doesnt like onions or milk (slight milk intolerance). She loves
grilled cheese (asks for it everyday). She doesnt eat dinner very well
though.
D. Family meal times are at the table as well as snack time. Sometimes she
will have chocolate milk in front of the TV in the morning (10am)
E. She takes Flintstone vitamins daily and fiber supplement when she
asks for them (about 2x a week she has had a history of problems with
constipation)
F. WIC they provide for milk, cereal, yogurt, cheese, fruit, eggs, peanut
butter

Nutritional Care Plan and Implementation
(1) Her BMI for age is less than the 5th percentile, and her weight for
stature is less than the 3rd percentile. At 14.5 kg, she is at 85% of the
median weight for her height which according to the Waterlow Criteria
classifies her as having mild acute malnutrition. According to
ChooseMyPlates caloric intake recommendation of 1400 calories a day,
Emarys intake is low at around 1200 calories. Her mom reports that she
eats poorly at dinner time which could explain some of this caloric

deficiency. To increase her weight, I would suggest increasing her overall

caloric intake, especially focusing on introducing foods from food groups
she is currently low in such as dairy, protein, and vegetables. Dairy and
protein in particular will be more calorically dense and will help increase
caloric load. Dairy intake (and therefore Vitamin D and calcium intake) is
currently low due to her milk sensitivity/allergy, however mom did
report that it is going away which will help increase her dairy intake. In
the mean time perhaps she can try eating cultured dairy products like
yogurt that are easier to digest than straight milk products, and using soy
milk fortified with Vit D as a milk replacement instead of rice milk which
tends to have lower protein and vitamin content.

(2) The recommendation to increase caloric intake will help Emary to
gain weight and increase her BMI and decrease her risk of acute
malnutrition. Although she is growing at a slower rate now then when
she was an infant, there is still a lot of important cognitive and physical
development happening at this age, so it is important that she get
adequate calories to support that growth. Calcium and Vitamin D play an
important role in bone growth and development, which will be especially
important for Emary as she grows new teeth and her bones continue to
expand as well. I would plan on giving her mom educational materials
about dairy alternatives that will still provide sufficient Vitamin D and
calcium while Emary overcomes her milk sensitivity to avoid deficiencies
in these nutrients. I would also include a list of vegetable preparation
ideas that are appealing to kids to aid in increasing her vegetable intake.
Increasing her vegetable intake will be important not only for the
vitamins and minerals contained therein, but also to increase her intake
of dietary fiber which has also been low. Fiber is important in promoting
healthy intestinal activity and motility, and helps decrease constipation.

Well-Child Project Part 2:

I. Education: Here is a copy of the email I sent to Emarys mom, Collette.

For Emary:
It looks like Emary is getting a little bit less than her calorie needs, and is a
little underweight for her height and age. Here are a few suggestions to help her to
eat more calories and grow at a healthy rate!
There are a couple of ways to increase calories, the first is to eat more, and
the second is to eat foods that are more calorically dense. You mentioned that
she doesn't like to eat a lot at dinner time -some things that might help is to make
sure that snack time is far enough ahead of dinner that she is hungry at dinner time,
and removing as many distractions at dinner as possible (this can be hard when the
distractions are siblings though :) )

 First, because of her milk allergy, Emarys dairy intake is currently low. Dairy
is important because it is rich in Calcium, Vitamin D and Protein, and usually higher
in calories (all things that Emary is currently a little low in). You mentioned that she
may be starting to grow out of her allergy, but in the mean time here are some ideas
of milk replacements that will still be just as nutritious. I would recommend that you
try giving her cultured dairy products like yogurt these are calorie dense,
and easier to digest than straight milk products for those with milk insensitivities.
Also, instead of using rice milk as a milk replacement, I would recommend using soy
milk fortified with Vit D which tends to be higher in protein and vitamins than rice
milk. Calcium and Vitamin D play an important role in bone growth and
development, which will be especially important for Emary as she grows new teeth
and her bones continue to expand as well
Second, Emary is a little low on her vegetable and fiber intake, so I would
recommend that she increase her veggie intake as well. This will help increase her
vitamins and minerals, and also fiber which can help with constipation, as you
know. I know it can be really tricky to get kids to eat vegetables, but I found this
great list of suggestions online hopefully you can find some good ideas in here! I
would suggest focusing on options that add some extra calories as well, such as
offering veggies with peanut butter, butter, ranch, or cooking them in oil, etc.

Veggie-Prep Ideas:
Have a challenge getting your family to eat vegetables? Then maybe you need to get
sneaky so they can reap the benefits. If veggies meet with family resistance, try
these suggestions to fit them in.
Serve salsa. Salsa (with tomatoes, beans or other veggies) served with pita,
bagel or tortilla chips doesn't seem like a vegetable.
Blend them in. Put shredded carrots in mashed potatoes, or mix them with
potatoes for a twice-baked version, chopped broccoli in macaroni and cheese,
layered zucchini in lasagna, or shredded spinach in slaw.
Wrap it up. Hide veggies in a tortilla wrap, under pizza cheese or at the
bottom of a pita.
Serve one-dish meals. That way, they can't push away the veggie side dish.
http://www.eatright.org/resource/food/nutrition/healthy-eating/sneak-em-in


II. Reflection:


When I initially met with Collette, Emarys mom to collect information for
this assignment she seems very receptive to the idea of improving Emarys diet and
finding ideas for how to help her eat more. At the same time, I dont think that she
felt a great need to change anything drastically because Emary is an active healthy
little girl as is, and will likely grow out of this phase of not eating too much. I dont
think that she has the impression that Emary is underweight, but I think that if she
understands that she is a little too small for her age she would make an effort to help
her eat more and grow faster.


When I sent Collette the feedback from the assignment, her and her kids
were sick with the stomach flu, and her husband was about to be deployed in a few
weeks to the middle east for a 6-month duty there. She told me that she was pretty
overwhelmed with everything, and that she probably wouldn't get the chance to
look over the suggestions for a while. Even though I think Collette would be open to
making the suggested changes, I think the biggest barrier for her will be finding the
time and energy to even think about it. Life as a mom, pregnant lady, and military
wife is stressful and hectic, and making nutrition changes when there doesnt seem
to be any pressing health issues is probably very low on her priority list.
Considering this, I probably could have improved my education by summarizing the
main points in bullet point format rather than in paragraph form so that she is more
likely to read and at least be aware of the suggestions that I had for her.

II. C. Growth Charts: Birth Anthropometrics:

Birth to 24 months: Girls
Length-for-age and Weight-for-age percentiles

Emary

98
95
90
75
50
25
10
5
2

98
95
90

75

50
25
10
5
2

7#10 oz

20 in

Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

Birth to 24 months: Girls

Head circumference-for-age and
Weight-for-length percentiles
in

20
H
E
A
D
C
I
R
C
U
M
F
E
R
E
N
C
E

19

NAME
RECORD #

Birth
cm

cm

52

52

50

50

98
95
90
75

48

20

48

19

46

18

50

18

46

25
10
5
2

44

44

17

17
42

16
15
14

24

40
38

98
95
90

36

14
14
12
10
8
6
4
2
lb

22

48

21

46

20

44
42

19

50

17

32

25

16

30

10
5
2

15
14
13

28
26
24
22
20
18
16

52
50

18

34

12

23

75

13

W
E
I
G
H
T

in

34
32
30

12

12

11

11

24

10

10

22

20
18
16

5
kg

LENGTH

3
2
1
kg
cm 46 48 50 52 54 56 58 60 62

64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98100102104106108 110
26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43
Date

Age
Birth

Weight
Length
7 lbs 10 oz 20 in

Head Circ.

C
I
R
C
U
M
F
E
R
E
N
C
E

40
38
36

28
26

H
E
A
D

W
E
I
G
H
T

14
12

lb

cm
in

Comment

in 18 19 20 21 22 23 24
Published by the Centers for Disease Control and Prevention, November 1, 2009
SOURCE: WHO Child Growth Standards (http://www.who.int/childgrowth/en)

II. D. Growth Charts: Current Anthropometrics:

2 to 20 years: Girls
Stature-for-age and Weight-for-age percentiles

NAME Emary
RECORD #

14 15 16 17 18 19 20
cm
AGE (YEARS)

12 13
Mothers Stature
Date

Fathers Stature
Age

01/16/2016 4 years 7 mo

Weight
32 lbs

Stature

BMI*

41.5 in

190

13.2

185
180
95
90

175
170

75

in
62
60
58
56
S
T
A
T
U
R
E

54
52
50
48
46
44
42
40
38

cm

10 11

50

160

25

155

10
5

150

165
160
155
150

50
40
30
lb

66

S
T
A
T
U
R
E

64
62
60

100 220

130

95 210
90 200

125
120

85
95

115

80

110

90

75

190
180
170
160

70

105
75

100
95

85

60

68

135

34

70

70

105 230

90

80

72

140

50

150
65 140
60 130
55 120

25
10
5

80

30

W
E
I
G
H
T

74

145

36

32

in
76

50 110
45 100
40 90

35

35

30

30

25

25

20

20

15

15

10
kg

10
kg

AGE (YEARS)
2

10 11

12 13

W
E
I
G
H
T

80
70
60
50
40
30
lb

14 15 16 17 18 19 20

Published May 30, 2000 (modified 11/21/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

2 to 20 years: Girls
Body mass index-for-age percentiles
Date
Age
Weight
01/16/16 4yrs 7mo 32 lbs

Stature
41.5 in

NAME Emary
RECORD #
Comments

BMI*
13.2

BMI
35
34
33
32
31

95

30
29
BMI

28

90

27

27

26

26

85

25

25

24

24

75

23

23

22

22
50

21

21

20

20

25

19

19
10

18

18

17

17

16

16

15

15

14

14

13

13

12

12

kg/m

kg/m2

AGE (YEARS)
2

10

11

12

13

14

15

16

17

18

19

20

Published May 30, 2000 (modified 10/16/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

NAME Emary

Weight-for-stature percentiles: Girls

Date
Age
Weight
01/16/16 4 yrs7mo 32 lbs

RECORD #

Comments

Stature
41.5 in

kg
34
33

lb
76
72

32
31

68

30
29
28

97

lb
56
52
48

kg

27

26

26

25

90

25

24

85

24

23

75

23
22

22
50

21
44
40

60
56
52
48

21

20

25

20

19

10

19

18

64

18

44
40

17

17

16

16

15

15

14

14

13

13

12

12

11

11

10

10

20

20

lb

8
kg

8
kg

lb

36
32
28
24

STATURE

cm
in

80
31

85
32

33

90
34

35

95
36

37

100
38

39

105
40

41

110
42

43

115
44

45

36
32
28
24

120
46

47

Published May 30, 2000 (modified 10/16/00).

SOURCE: Developed by the National Center for Health Statistics in collaboration with
the National Center for Chronic Disease Prevention and Health Promotion (2000).
http://www.cdc.gov/growthcharts

III.A. Developmental Screening Test:

Emary
4yrs 7 months

P
P
P
P
P
P
P
F
P
P
P
P
P
P
P
P
P
P

P
P

P
P

IV. A. (1) Food Group and Calories Report:

Food Groups and Calories Report

01/15/2016
Your plan is based on a 1400 Calorie allowance for a preschooler.

Food Groups

Target

Average Eaten Status

Grains

5 ounce(s)

6 ounce(s)

Over

Whole Grains

2 ounce(s)

1 ounce(s)

Under

Refined Grains

2 ounce(s)

5 ounce(s)

Over

Vegetables

1 cup(s)

cup(s)

Under

Dark Green

1 cup(s)/week

0 cup(s)

Under

Red & Orange

3 cup(s)/week

0 cup(s)

Under

Beans & Peas

cup(s)/week

0 cup(s)

Under

Starchy

3 cup(s)/week

0 cup(s)

Under

Other

2 cup(s)/week

cup(s)

Under

Fruits

1 cup(s)

1 cup(s)

OK

Whole Fruit

No Specific Target

cup(s)

No Specific
Target

Fruit Juice

No Specific Target

cup(s)

No Specific
Target

Dairy

2 cup(s)

1 cup(s)

Under

Milk & Yogurt

No Specific Target

cup(s)

No Specific
Target

Cheese

No Specific Target

cup(s)

No Specific
Target

Protein Foods

4 ounce(s)

1 ounce(s)

Under

Seafood

6 ounce(s)/week

0 ounce(s)

Under

Meat, Poultry & Eggs

No Specific Target

1 ounce(s)

No Specific
Target

Nuts, Seeds & Soy

No Specific Target

0 ounce(s)

No Specific
Target

Oils

4 teaspoon

3 teaspoon

Under

Limits

Limit

Average Eaten Status

Total Calories

1400 Calories

1223 Calories

OK

 Added Sugars

< 140 Calories

91 Calories

OK

Saturated Fat

< 140 Calories

115 Calories

OK

Note: If you ate Beans & Peas and chose "Count as Protein Foods instead," they will be
included in the Nuts, Seeds & Soy subgroup.

IV. A. (2) Nutrients Report

Nutrients Report 01/15/2016

Your plan is based on a 1400 Calorie allowance for a preschooler.

Nutrients

Target

Average Eaten Status

Total Calories

1400 Calories

1223 Calories

OK

Protein (g)***

19 g

35 g

OK

Protein (% Calories)***

10 - 30% Calories 11% Calories

OK

Carbohydrate (g)***

130 g

OK

Carbohydrate (% Calories)***

45 - 65% Calories 61% Calories

OK

Dietary Fiber

25 g

10 g

Under

Total Sugars

No Daily Target
or Limit

79 g

No Daily Target
or Limit

Added Sugars

< 35 g

23 g

OK

Total Fat

25 - 35% Calories 32% Calories

OK

Saturated Fat

< 10% Calories

9% Calories

OK

Polyunsaturated Fat

No Daily Target
or Limit

7% Calories

No Daily Target
or Limit

Monounsaturated Fat

No Daily Target
or Limit

12% Calories

No Daily Target
or Limit

Linoleic Acid (g)***

10 g

8 g

Under

Linoleic Acid (% Calories)***

5 - 10% Calories

6% Calories

OK

-Linolenic Acid (% Calories)*** 0.6 - 1.2%

Calories
0.9 g
-Linolenic Acid (g)***

0.7% Calories

OK

0.9 g

OK

Omega 3 - EPA

No Daily Target
or Limit

1 mg

No Daily Target
or Limit

Omega 3 - DHA

No Daily Target
or Limit

8 mg

No Daily Target
or Limit

Cholesterol

< 300 mg

135 mg

OK

187 g

 Minerals

Target

Average Eaten Status

Calcium

1000 mg

612 mg

Under

Potassium

3800 mg

1336 mg

Under

Sodium**

< 1900 mg

2007 mg

Over

Copper

440 g

1180 g

OK

Iron

10 mg

16 mg

OK

Magnesium

130 mg

221 mg

OK

Phosphorus

500 mg

810 mg

OK

Selenium

30 g

47 g

OK

Zinc

5 mg

8 mg

OK

Vitamins

Target

Average Eaten Status

Vitamin A

400 g RAE

1034 g RAE

Over

Vitamin B6

0.6 mg

1.5 mg

OK

Vitamin B12

1.2 g

3.6 g

OK

Vitamin C

25 mg

53 mg

OK

Vitamin D

15 g

3 g

Under

Vitamin E

7 mg AT

7 mg AT

OK

Vitamin K

55 g

74 g

OK

Folate

200 g DFE

585 g DFE

Over

Thiamin

0.6 mg

1.5 mg

OK

Riboflavin

0.6 mg

1.4 mg

OK

Niacin

8 mg

17 mg

OK

Choline

250 mg

161 mg

Under

Information about dietary supplements.

*** Nutrients that appear twice (protein, carbohydrate, linoleic acid, and -linolenic acid) have two separate
recommendations:

1) Amount eaten (in grams) compared to your minimum recommended intake.

2) Percent of Calories eaten from that nutrient compared to the recommended range.
You may see different messages in the status column for these 2 different recommendations.

IV. A. (3) Meal Summary Report:

Date
Lunch
Breakfast
01/15/16

1 envelope (1.3

medium (2-

oz) 1/2 serving

3/4" across)

carnation
instant
breakfast

1/4 medium
apple

Dinner

Snacks

1 cup Fried

rice, with
pork

6 fluid ounce(s)

Apple juice

cup Kellogg's

1 baby

Raisin Bran
Cereal

carrot(s)

Carrot, baby

1 fun size bar

Snickers Bar

cup, goldfish

mug (8 fl oz)

Rice Milk (Rice

Dream)

1 sandwich

Grilled cheese
sandwich