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29 and cystic fibrosis; and of sickle cell anemia, and hemophilia. C. Past History of Patient; 1. Feeding practices and problems during woman's infancy childhood, and adolescence. 2. The patient's recollection of her growth and development in relation to other family members and to peers. 3. Past history of illnesses or defects. 4. Weight history. D. Present Pregnancy; 1. Immediate prepregnant weight and patient's concept of her desirable weight. 2. Change in weight during present pregnancy. 3. Pica * 4. Major food likes and dislikes including major categories of foods rarely or never eaten. 5. Use of pharmaceutical preparations including vitamins and/or minerals. 6. Medically prescribed or self-imposed dietary restrictions. This dietary information may be obtained by the physician or by a nutritionist, nurse, or midwife. To further determine general eating patterns, including food preparation and buying habits, a questionnaire such as that outlined in the Appendix (page 56) may be helpful, and may serve as a basis for meaningful dietary instruction.

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30 E. Physical Examination: 1. Height is probably the most important single indicator of lifetime nutritional experience and should be accurately determined. Readings should be made without shoes to the nearest quarter-inch (or one centimeter). 2. Weight should be recorded in the nude, or with an appropriate correction if clothing is worn. This correction should be made at the time of the measure- C ment. Weight should be recorded to the nearest pound (or 0.5 kilogram), then should be compared to a standard to give a general idea of the individual's weight to height status. (See Appendix, page 58 ) 3. Physical signs frequently associated with nutritional deficiencies are: a. General apathy pallor irritability chronic fatigue c. Teeth number decayed, missing or filled e. Thyroid visible enlargement b. Gums swollen bleeding on pressure d. Tongue red fissured swollen papillary atrophy f. Skin unusual dryness of skin and hair petechiae dermatitis brittle nails

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31 g. Abdomen h. Lower Extremities enlarged liver edema enlarged spleen absence of ankle jerks i. Skeletal enlarged joints costochondral beading F. jjaboratory; 1. Hemoglobin. If the level is below the standard for pregnant women, a hematocrit should be done and a thin blood film studied for cell morphology. If these are not sufficient to establish a diagnosis, special investigations such as determination of serum levels of 1 Q o iron , folic acid^, vitamin B^2 or bone marrow biopsy may be indicated. 2. There is not sufficient information on which to base a nutritional profile in pregnancy. Ordinary adult standards must be used for laboratory determinations which may be made. 3. PKU screen on mother's blood. A recommendation that all pregnant women be tested routinely for elevated serum phenylalanine levels to identify progeny presumably at risk of mental retardation may be premature at this time. It is, however, reasonable to perform such tests on blood taken from retarded women who are pregnant. For those who wish to assess nutritional status in

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32 greater detail, the following biochemical tests are suggested: Total protein , albumin , iron-binding capacity1, ascorbic acid^, vitamin A + beta-carotene , and C.; 9 transketolase . Urine determinations include creatininea', total nitrogen or urea"', and thiamine G. References; 1. Woodruff, C.W.: "A Micromethod for Serum Iron Determina- tion." J\ Lab. & Clin. Med. 53:955, 1959. 2. Herbert, V., et. al.; "The Measurement of Folic Acid Activity in Serum, a Diagnostic Aid in the Differentia- ' tion of Megaloblastic Anemias," Blood 15:228, 1960. 3. Spray,- G.EL: "An Improved Method for the Rapid Estima- tion of Vitamin B^2 in Serum." Clin. Sci. 14:661, 1955. 4. Interdepartmental Committee on Nutrition for National Defense: Manual for Nutrition Surveys, 2nd ed., Wash- ington, D.C.: U.S. Government Printing Office, 1963, p. 134. 5. Beckman Methods Manual, Technical Bulletin #6095A. Spinco Division, Beckman Instrument, Inc., Palo Alto, 1961. 6. Bessey, O.A., Lowry, O.H., & Brock, M.J.: "The Quanti- tative Determination of Ascorbic Acid in Small Amounts

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