Part II Examination of the Newborn and Older Child
4 Examination of the Older Child
4.4 Assessment of Nutritional Status
• Evaluation of the nutritional status of a child depends on the following parameters:
– Detailed feeding history (see Chap. 1).
– Clinical examination and anthropometry (growth measures) (see below).
– Measurement of basic biochemical and hematological indices, if possible, to identify micronutrient deficiencies (outside the scope of this chapter).
• Strictly speaking, malnutrition refers to undernutrition or being overweight.
However, in this chapter, the term is employed to refer specifically to undernutrition.
Table 4.2 The WHO classification of the severity of dehydration in children with diarrheaa Parameters No dehydration Some dehydrationb Severe dehydrationb Condition Well, alert Restlessness,
irritability
Lethargy or unconsciousness
Eyes Normal Sunken Sunken
Thirst Drinks normally, not thirsty
Drinks eagerly, thirsty Unable to drink or drinks poorly
Skin pinch Goes back quickly Goes back slowly Goes back very slowly (≥2 s)
Treatment Plan A Plan B Plan C
aReproduced with the permission of WHO. [10]
bThe patient should have two or more signs.
Parameters Mild
dehydration Moderate dehydration Severe dehydration
Pulse rate Normal to
increased
Tachycardiaa Tachycardia or bradycardia or absent Pulse quality Normal Normal to decreased Weak, thread,
impalpable Systolic blood pressure Normal Normal but orthostatic Decreased
Urine output Normal or
mildly decreased
Little or absent No urine output for more than 8 h
% Body weight loss
In infants <5% 5–10% >10%
In older
children <3% 3–6% >6%
Notes:
Skin turgor and capillary refill, in addition to rate and pattern of breathing, are the best indicators for hydration status.
Skin turgor and sunken eyes are unreliable signs of dehydration in a severely malnourished child. [9]
aThese signs are helpful in identification of children at risk for progression to shock. [7]
Table 4.1 (continued)
4 Examination of the Older Child
4.4.1 Clinical Examination to Assess Nutritional Status 1. General condition and facial appearance
• A well-nourished child is active and alert, his/her cheeks are full, the buttocks are firm and rounded, the muscle tone is good, the hair is shiny, and the skin is healthy.
• An undernourished child may appear apathic, irritable, or lethargic, and his/
her face may be miserable, puffy, or “moon” shaped (kwashiorkor) or have a
“monkey facies” and an aged appearance (marasmus), or the child’s eyes may be sunken due to loss of periorbital fat, in addition to other signs of undernu-trition (see below).
2. Visible severe muscle wasting
• Undress the child. You can ask for the parent’s help.
• Loose skin folds or severe muscle wasting may be visible at the thighs, but-tocks, shoulders, arms, ribs, and scapulae.
• Look at the child from the side, noting the fat of the buttocks.
• Inspect the child’s chest and note if the outline of the child’s ribs is easily seen.
• Inspect both hips of the child and compare them with his/her chest and abdo-men; they may look small.
• In severe cases, you may see many folds of skin on the buttocks and thighs.
• Although it eventually becomes wasted, the child’s face may still look nor-mal, even when there is severe wasting [9].
3. Edema of both feet
• Inspect both of the child’s feet (dorsum, in particular) to determine the pres-ence of edema.
• Press gently but firmly on the dorsum of each foot for 10 seconds and release, using your thumb. A residual dent in the child’s foot points to the presence of pitting edema.
4. Look for other signs that may suggest specific micronutrient deficiency, such as:
• Pallor
– Pallor is a sign of anemia.
– Iron deficiency is the most common micronutrient deficiency.
– Look for pallor on the palm:
Grasp the child’s palm gently from the side to hold it open.
Avoid stretching fingers backward because it may cause pallor by blocking the blood supply.
Always compare the child’s palm color with your palm and, if possible, with the palms of other children.
– Paleness of the skin of the child’s palm means the child has some palmar pal-lor. If it is very pale or so pale that it looks white, the child has severe palmar pallor [9].
• Signs of vitamin deficiency, e.g., signs of rickets (suggest vitamin D deficiency), signs of scurvy (suggest vitamin C deficiency) (see below).
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• Signs of infection, such as fever or hypothermia; hypothermia may also indi-cate hypoglycemia.
• Look for other signs that may suggest malnutrition (see Table 4.3).
4.4.2 Anthropometric Assessments of Nutritional Status
• Measure the child’s weight and length (<2 years of age) or height (>2 years of age). In addition to these two key measurements, assess mid-upper arm circum-ference (MUAC), which is useful as a screening tool for malnutrition in the com-munity. Head circumference measurement may be useful in children under 3 years of age.
• Determine weight-for-length or weight-for-height and weight-for-age, using the standard growth charts according to the child’s age and sex (see Sect. 4.5).
4.4.3 Classification of Childhood Malnutrition
There are many classifications for malnutrition, for example:
• The World Health Organization (WHO) classification of malnutrition – According to the WHO, malnutrition can be graded as moderate and severe
malnutrition, depending on weight-for-height (measure of wasting),
Table 4.3 Selected physical signs of nutritional deficiency [11, 12]
Organ/body
part Signs
Skin Shiny and edematous skin (as in kwashiorkor) or lose and wrinkled skin (as in marasmus); dry, peeling skin with raw exposed areas; sandpaper feel of the skin; patchy excessive lightness or darkness of the skin (dyspigmentation);
ecchymosis/intradermal petechia (vitamin K or C deficiencies); and jaundice Nail Rigid and spoon-shaped nail (koilonychia) with thin, soft nail plates Hair Alopecia; easily pluckable; light, brown, or reddish color; thin, sparse, and
brittle hair; occasionally flag sign (characteristic of kwashiorkor, it refers to bands of light color alternating with normal darker hair color, representing poor nutrition and reasonable nutrition periods, respectively)
Eyes Angular palpebritis (redness and fissuring of eyelid corners), pale conjunctiva, dryness of conjunctiva and cornea (vitamin A deficiency), corneal
revascularization, keratomalacia, Bitot’s spots, periorbital edema
Mouth Cheilosis, glossitis, angular stomatitis (vitamin B2, B6, and B12 deficiencies), papillary atrophy, purplish-color tongue, and spongy bleeding gums (vitamin C deficiency)
Extremities Widening of wrists and ankles (double malleolus), deformities (result from vitamin D, calcium, or vitamin C deficiencies), loss of deep tendon reflexes of the lower limbs (vitamin B1 and B12 deficiencies), hands and feet may be cold Abdomen Abdominal distention (due to poor abdominal musculature), ascites, tender
hepatomegaly (due to fatty infiltration)
4 Examination of the Older Child
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