Pediatric Nutrition Assessment (0–5 Years) Format

Infant & Under-5 Child Nutrition

Used by dietitians, nutrition students, hospitals and health workers across India.

Fill online | Download blank PDF (free sign-up)

What the format covers

Child Profile

  • Registration No.
  • Date of Assessment
  • Child's Name
  • Date of Birth
  • Age at assessment (months)
  • Sex
  • Parent/Guardian Name
  • Contact No.
  • Birth Weight (kg)
  • Birth Type
  • Immunization Status
  • Modified Kuppuswamy scale class
  • Medical diagnosis / chief complaint
  • Past medical & surgical history
  • Family history
  • Physical activity level (ICMR-NIN 2020)

Anthropometric Measurements (WHO Z-Scores)

  • Weight (kg)
  • Height / Length (cm)
  • Head Circumference (cm)
  • MUAC (cm)
  • Weight-for-Age Z-score (WAZ)
  • Height-for-Age Z-score (HAZ)
  • Weight-for-Height Z-score (WHZ)
  • Weight-for-Height (WHO 2006)
  • Height-for-Age (WHO 2006)
  • Weight-for-Age (WHO 2006)
  • Overweight (WHZ >+2)
  • SAM Criteria Present

Feeding History

  • Breastfed?
  • Age of Complementary Feeding Initiation
  • Current Diet Type
  • Meal frequency yesterday (breastfed: solid/semi-solid/soft feeds incl. snacks; non-breastfed: include milk feeds)
  • Child's Appetite
  • 24-hour dietary recall — table: Time, Meal, Food / dish, Ingredients, Household measure, Approx. quantity (g/mL)
  • Food frequency — table: Frequency, Usual portion

Clinical Investigations

  • Haemoglobin (Hb) (g/dL)
  • Serum Ferritin (ng/mL)
  • Vitamin D (25-OH) (ng/mL)
  • Vitamin B12 (pg/mL)
  • Serum Zinc (µg/dL)
  • Stool Examination

IYCF, SAM & preventive care

  • Food groups eaten yesterday (WHO IYCF 2021)
  • Minimum dietary diversity (≥5 of 8; 6–23 months)
  • At least one solid / semi-solid / soft feed yesterday? (non-breastfed child)
  • Minimum meal frequency (WHO IYCF 2021)
  • Bilateral pitting nutritional oedema grade
  • Appetite test
  • Medical complications
  • SAM — refer to NRC
  • Vitamin A last given
  • Deworming last given
  • UIP immunisation record (age-appropriate doses verified)

Nutrition Diagnosis & Risk Stratification

  • Nutritional status (age-specific clinical assessment)
  • Overweight/obesity status
  • PES: Problem
  • PES: Etiology (Related to)
  • PES: Signs & Symptoms (Evidenced by)

Nutrition Care Plan & Recommendations

  • Energy Requirement (clinician prescribed) (kcal/day)
  • Protein Requirement (g/day)
  • Special Nutrient Focus
  • Dietary Advice / Modifications
  • Sample Meal Plan Given?
  • Next Follow-Up Date
  • Counselling Notes
  • Monitoring & Evaluation — table: Indicator, Baseline, Target, Review date, Outcome

Diet Prescription (filled by dietitian)

  • Prescribed energy (kcal/day)
  • Prescribed protein (g/day)
  • Prescribed fluid (mL/day)
  • Diet type / consistency
  • Restrictions
  • Meal plan — table: Time, Food / dish, Quantity (household measure)
  • Foods to include
  • Foods to avoid
  • Prescribed by (name, reg. no.)

Signature

  • Dietitian Name & Signature

Automatic scores in this form

  • Age at assessment
  • Minimum dietary diversity (≥5 of 8; 6–23 months)
  • Minimum meal frequency (WHO IYCF 2021)
  • SAM — refer to NRC

All calculated values are indicative — clinical judgement required.

Standards & references

  • WHO Child Growth Standards 2006
  • IAP
  • MoHFW SAM guidelines
  • WHO IYCF indicators 2021
  • MoHFW UIP
  • WHO wasting guideline 2023
  • GLIM 2019
  • Nutrition Care Process (ADIME)

Frequently asked questions

What is included in the Pediatric Nutrition Assessment (0–5 Years) format?

The format has 9 sections: Child Profile; Anthropometric Measurements (WHO Z-Scores); Feeding History; Clinical Investigations; IYCF, SAM & preventive care; Nutrition Diagnosis & Risk Stratification; Nutrition Care Plan & Recommendations; Diet Prescription (filled by dietitian); Signature. It also calculates 4 values automatically, such as Age at assessment, Minimum dietary diversity (≥5 of 8; 6–23 months), Minimum meal frequency (WHO IYCF 2021).

Which guidelines does the Pediatric Nutrition Assessment (0–5 Years) follow?

It follows WHO Child Growth Standards 2006, IAP, MoHFW SAM guidelines, WHO IYCF indicators 2021, MoHFW UIP, WHO wasting guideline 2023, GLIM 2019, Nutrition Care Process (ADIME). All calculated values are indicative — clinical judgement is required.

Can I download the Pediatric Nutrition Assessment (0–5 Years) as a PDF?

Yes. After a free sign-up you can fill the form online and download both blank and filled A4 PDFs, and save private case sheets for your patients.

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