Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.5 Anthropometric Measures (Growth Parameters)
height- for- age (measure of stunting), mid-upper arm circumference, and the presence or absence of edema [12, 13].
– In children between 6 and 59 months of age, moderate acute malnutrition (MAM) is defined as a weight-for-length or weight-for-height between −2 standard deviations (SD) and –3SD (based on the WHO Child Growth Standards) or a mid-arm circumference (MUAC) between 115 mm and 125 mm, while severe acute malnutrition (SAM) is defined as the presence of severe wasting (weight-for-length or weight-for-height < –3SD, or mid-upper arm circumference (MUAC) <115 mm), or the presence of edema of both feet [12, 14].
• Wellcome classification of malnutrition
– The Wellcome classification of malnutrition depends on the standard weight-for- age and the presence or absence of edema to classify malnourished chil-dren into those with kwashiorkor, marasmic kwashiorkor, underweight, and marasmus (see Table 4.4 and Box 4.1) [15].
Table 4.4 Wellcome classification of malnutrition [13, 15]
60–80% expected weight-for-age <60% expected weight-for-age
With edema Kwashiorkor Marasmic kwashiorkor
Without edema Underweight (undernutrition) Marasmus
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– Mid-upper arm circumference (MUAC) – Body mass index (BMI)
• Except in emergencies, you should routinely measure the child’s weight and height or length and plot them on an appropriate growth chart in every physical examination of a child.
• Serial measurements of growth parameters are more important than a single one.
• If possible, use the same equipment at each visit.
• Compare the new measurements with the previous growth trends.
• Plot the results longitudinally on an appropriate growth chart.
4.5.1 Weight
• Use an accurate scale and calibrate it accurately to measure the child’s weight.
• Infants and young children should be naked (no diaper) at the time of weight measurement.
• Older children should be weighed wearing only underwear or light clothes, with-out shoes or socks.
• Plot the measured weight on an appropriate growth chart.
• You can determine a child’s expected weight in kilograms, based on his/her age, using the following formulas:
– Child’s weight at 3–12 months = (age in months + 9)/2 – Child’s weight at 1–6 years = 2(age in years) + 8 – Child’s weight at 7–12 years = (7 × age in years – 5)/2
• If the child’s age and birth weight are known, you can simply estimate his/her current weight in kilograms by using the following formulas:
– Weight at 4–5 months = birth weight × 2 – Weight at 1 year = birth weight × 3 – Weight at 2 years = birth weight × 4 – Weight at 7 years = birth weight × 7 – Weight at 10 years = birth weight × 10
Notes 4.1
4.5.2 Length or Height
• Measurement of infant’s length
– Use an infantometer to measure the supine length of children aged less than 2 years or of those with a handicap.
– Ask an assistant (the child’s parent, if possible) to hold the child’s head against the headboard.
– Move the footboard firmly up against the child’s heels, and, before taking the reading of length, make sure that his/her feet are at 90° and the legs are straight (see Fig. 4.1).
4 Examination of the Older Child
• Measurement of the child’s height
– Use a stadiometer to measure the standing height of children older than 2 years of age.
– The child should stand erect with the feet bare and the scapulae, buttocks, and heels all touching the backboard; the knees should be straight.
– A gentle, upward traction should be applied to the mastoid process to extend the neck, and make sure the child’s eyes are in the same plane with the exter-nal auditory meatus (see Fig. 4.2).
– Plot the measured length or height on an appropriate growth chart.
3233343536373839404142434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899 100 101 102 103 104 105 106 107 108 109 110
Fig. 4.1 Method of measurement of an infant’s length by infantometer
• There is a diurnal variation in the height of children (up to 2 cm). Therefore, to get an accurate determination of the height velocity, it is preferable to take the measure of the child’s height at the same time of the day at each visit—if possible, in the afternoon [17].
Notes 4.2
• The length or height of children can be roughly estimated according to their age:
Age Expected length or height
At birth 50 cm
6 months 66 cm
1 year 75 cm
2 years 89 cm
3 years 95 cm
4½ years 105 cm
5–10 years 105 cm, plus 5–6 cm for each year
• In children aged 2–12 years, height can also be estimated by using the follow-ing formula: child’s height in centimeters = 6(age in years) + 77
Notes 4.3
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4.5.3 Head Circumference
• Head circumference represents the growth of the child’s brain.
• Use a flexible, but non-stretchable, tape to measure the maximum occipitofrontal circumference in children under 36 months.
• The landmarks for the measurement are the superior orbital ridge (just above the eyes), at the front, and the external occipital protuberance, at the back (see Fig. 4.3).
• Repeat the measurement three times and take the largest diameter.
• Plot the measured head circumference on an appropriate growth chart.
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Head should be straight Child’s eyes should be at the same plane with the external auditory meatus
A gentle upward traction should be applied to the mastoid process to extend the neck
Knees should be straight
Feet should be bare and flat on the floor Scapulae, buttocks, and heels
should touch the backboard Calibration should be checked
Fig. 4.2 Method of measurement of the child’s height
4 Examination of the Older Child
Fig. 4.3 Method of head circumference measurement
• If the measured circumference of the child’s head is significantly greater or lower than normal, take the measurements of each of the parents’ heads, espe-cially the father, and see whether these measurements fit on the chart or not.
Familial large or small head is not uncommon [1].
Clinical Tips 4.3
• Head circumference increases with age as follows:
– 2 cm per month in the first 3 months of age – 1 cm per month from 3 to 6 months of age – 0.5 cm per month from 6 months to 1 year of age
• The average head circumference can be calculated simply according to the child’s age, as follows [1, 13]:
Age Head circumference in centimeters
At birth 35 cm
3 months 41 cm
6 months 44 cm
1 year 46 cm
2 years 48 cm
5 years 50 cm
15 years 55 cm
Notes 4.4
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4.5.4 Mid-Upper Arm Circumference (MUAC)
Use a non-stretchable tape to measure the mid-upper arm circumference (MUAC) at the midpoint between the tip of the shoulder (the acromion) and the tip of the elbow (the olecranon process) (see Fig. 4.4).
23 20
15 1819 242526
cm
a b
cm 18 cm 23 24 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26
Fig. 4.4 (a) Method of measuring the mid-upper arm circumference (MUAC). (b) Mid-upper arm circumference (MUAC) measuring tape. A measurement in the green zone (from 12.5 cm) means the child is well nourished; a measurement in the yellow zone (11.5–12.5 cm) indicates that the child is at risk of acute malnutrition; a measurement in the red zone (0–11.5 cm) signifies that the child is acutely malnourished. If this tape is not available, you can use any flexible, non-stretchable tape instead
• Mid-upper arm circumference (MUAC) is a useful screening tool to detect malnutrition in the community in the situations where resources are limited or when the child’s weight is misleading, as in cases of cancer, edema, or liver diseases [15].
• MUAC at birth is 10 cm, while it is relatively constant in children between 6 months and 5 years, ranging from 16 to 17 cm. Measurements of >13.5 cm are considered normal [13].
Notes 4.5
4.5.5 Body Mass Index (BMI)
• Body mass index is a useful index of thinness, overweight, and obesity in children.
• It can be calculated by dividing the child’s weight (in kilograms) by the square of the height (in meters).
• Normal BMI is 18.5–25 kg/m2.
4 Examination of the Older Child
4.5.6 Growth Charts
• Growth charts are very important tools for assessing the growth of a child.
• Health professionals can monitor the growth and nutritional status of a child by measuring the child’s anthropometric parameters and plotting the measurements on an appropriate growth chart—e.g., the WHO Child Growth Standards, which are recommended in many countries (see Fig. 4.5). This is helpful in comparing the child’s growth measurements with the measurements of normal children of the same age and sex.
• The calculations of weight-for-age, weight-for-height, and height-for-age are very important in the assessment of the child’s growth and nutritional status (see Box 4.2).
• The choice of an appropriate growth chart depends mainly on the child’s age (in months), sex, and the measured parameters.
• The measurement of the child should be marked on the chart with a dot (not a cross or a circle).
• When the evaluated child’s growth does not follow a normal pattern, consider factors that may influence the growth, such as parental stature, birth weight, gestational age, nutrition, type of feeding (breast or formula), environment, or chronic illness.