TOPIC 2 : NUTRITIONAL ASSESSMENT IN CHILDREN

I. GENERAL OBJECTIVE
After finishing skill practice, the students will be able to perform
1. Assessment of nutritional status by clinical measurements
2. Measurement of growth by anthropometry
3. Conclude the result of the assessment and measurement
4. Decide the further management of malnourished patient

II. SPECIFIC OBJECTIVES

At the end of skill practice, the students will be able to :
1. Assess the clinical manifestation of malnourished patient
2. Measure the weight, height, length, and head circumference of infants and children
3. Calculate mid parental height
4. Plotting in the correct growth chart
5. Measure body proportion

III. SYLLABUS DESCRIPTION

Sub Model Objective:
After finishing skill practice of nutritional assessment and measurement of growth anthropometry the
student will recognize the characteristics of malnourished patient with several tools.
Expected Competencies:
a. Students will be able to assess the clinical manifestation of malnourished patient
b. Students are capable to demonstrate procedure of height, weight and head circumference
measurements
c. Students will be able to calculate prediction of adult height and parental target height
d. Students will be able to record growth measurement on a growth chart
e. Students are capable to determine body proportion
Methods:
a. Presentation
b. Demonstration
c. Coaching
d. Self practices
Laboratory facilities:
a. Skill Laboratory
b. Trainers
c. Models
d. Student Learning Guide
e. Standardized patients
f. Trainer’s Guide
g. References
Venue: Skills Laboratory
Evaluation:
a. Point nodal evaluation
b. OSCE

IV. EQUIPMENT
1. Presentation: Audiovisual
2. Demonstration and coaching
2.1. Measurement of height/length
a. Stadiometer / microtois
b. Infantometer
2.2. Measurements of arm span and upper-lower segment: a ruler in centimeters / measuring tape
3. Growth recording: Growth chart (WHO)
4. Models: Mannequin, SP

1
1. INTRODUCTION
The nutritional status of an individual is often the result of many interrelated factors. It is influenced by food
intake, quantity and quality, and physical health. The spectrum of nutritional status spread from obesity to
severe malnutrition.

Direct Methods of Nutritional Assessment are summarized as ABCD:

‒ Anthropometric methods
‒ Biochemical, laboratory methods
‒ Clinical methods
‒ Dietary evaluation methods

A. CLINICAL ASSESSMENT
It is an essential features of all nutritional surveys. It is the simplest & most practical method of
ascertaining the nutritional status of a group of individuals. It utilizes a number of physical signs, (specific &
non specific), that are known to be associated with malnutrition and deficiency of vitamins & micronutrients.
Good nutritional history should be obtained. General clinical examination, with special attention to organs like
hair, angles of the mouth, gums, nails, skin, eyes, tongue, muscles, bones, & thyroid gland. Detection of
relevant signs helps in establishing the nutritional diagnosis.

Advantages of clinical asessment are: (a) fast & easy to perform, (b) inexpensive, (c) non-invasive.
Limitations: did not detect early cases.

The examination has to be done thoroughly from head to toe, the objective could be slight different in
undernourished patient and in overnourished patients. In undernourished patient we seek the signs of
nutrition deficiencies.

1. HEAD

Figure 1. Severe Protein Energy Malnutrition patient

a. Hair: Spare and thin: zinc deficiency
Easy to pull out: protein deficiency
Corkscrew coil hair: vitamin A and vitamin C deficiency
b. Mouth and tongue:
Glossitis : Deficiency Riboflavin, niacin, folic acid, B12, protein

Figure 2. Glossitis, an inflammation of the tongue

2
 Bleeding and spongy gum: deficiency vitamin C, A, K, folic acid, and niacin

Figure 3. Gingivitis

Cheilosis, fissure tongue : deff B2, B6, niacin

Figure 4. Cheilosis

Angular stomatitis: deff B2,B6, niacin

Figure 5. Angular stomatitis

Leukoplakia : deficiency vitamin A, B12, Bcomplex, folic acid, niacin

Figure 6. Leukoplakia on the tongue Figure 7. Leukoplakia on the lip

c. Eyes
Night blindness: vitamin A deficiency
Photophobia, blurring, conjunctival inflammation: deficiency vitamin A, vitamin B2

3
 Figure 8. The vision of normal people compared to person with night blindness

d. Nail:
Spoon nail : iron deficiency
Transverse line : protein deficiency

Figure 9.Spoon nail Figure 10. Transverse line on the nail

e. Skin:
Follikular hyperkeratosis : vitamin B and vitamin C deficiency

Figure 11. Follicular hyperkeratosis

Bruising, purpura : vitamin K, C, folic acid deficiency

Figure 12. Bruising on upper arm and lower leg

4
 Pigmentation and desquamation: niacin deficiency and PEM

Figure 13. Left: pigmentation, right: desquamation

Flaking dermatitis and desquamation: PEM, def vit B2, vit A, zinc and niacin

Figure 14. Flaking dermatitis Figure 15. Desquamation on a baby’s head

2. NECK
Goiter : iodine deficiency

Figure 16. An endemic goiter patient

3. JOIN AND BONE

Rachitis ; vitamin D (Rickets) and vitamin C deficiency (scurvy)

Figure 17. Figure of “O” formed by curved legs of rachitis patient

5
B. ANTHROPOMETRIC MEASUREMENT

This module reviews for measuring and recording height, length, weight, and head circumference for
infants, children and adolescents. The information in this module is intended for the measurement of typically
developing children.

In this module ‘length’ refers to the measurement technique for infants. Length is measured in
the recumbent position. ‘Stature’ refers to the child and adolescent ‘height’ measure. Stature is
measured standing.

The purpose of these measurements are :

‒ To present accurate techniques for measuring weight, length and head circumference for infants
‒ To present accurate techniques for measuring weight and stature for children and adolescents

The measurement process has two steps:

1. measure
2. record
If measures are in error, then the foundation of the growth assessment is also in error. It is important to have
the date, age, and actual measurements recorded so the data may be used by others or at a later point in time.

Many clinical decisions and clinical interventions are based on physical measurements. Accurate and reliable
physical measures are used to:
‒ monitor the growth of an individual
‒ detect growth abnormalities
‒ monitor nutritional status
‒ track the effects of medical or nutritional intervention

Accurate weighing and measuring have three critical components. These are: technique, equipment, and
trained measurers.
‒ Technique: Standardized
‒ Equipment: Calibrated, accurate
‒ Trained measurers: Reliable, accurate

Figure 18. Balanced scale

6
Position of the Child

Figure 19. Frankfort Plane Figure 20. Examiner’s eye position

Figure 21. The arrow represent the sitting height

7
The chart used in plotting the measurement, to assess the nutritional status of children, as seen below:

8
Interpretation

9
Below is the chart used to assess the body proportion:

Height potential prediction

Mid Parental height formula:
Boys = (Mother’s height + 12.5 cm)+ father’s height/2
Girls = (Father’s height – 12.5) + mother’s height/2

The range will be within 10 cm above and below this target

Appropriate technique for each measure must be utilized. The techniques should be very similar to those used
to obtain data to develop the growth charts. These measures should be performed by a trained measurer so
they are both accurate and reliable.

REFERENCES:
1. Identification and Quantification of Sources of Error in Weighing and Measuring Children, CDC, PHS,
DHEW, 1976.
2. Lohman, TG, Roche, AF, and Martorell, R. Anthropometric Standardization Reference Manual, Human
Kinetics Books, Champaign, IL, 1988.
3. NHANES III Anthropometric Procedures, a video from the National Center for Health Statistics, Centers for
Disease Control and Prevention.
4. Pediatric Anthropometry, from Ross Laboratories, 2000.
5. Weighing and Measuring Children: A Training Manual for Supervisory Personnel, Nutrition Division, CDC,
PHS, DHHS, and Bureau of Community Health Services, HHS,1980.
6. Styne D. Growth.In Greenspan FS and Gardner DG.eds. Lange Medical Books/McGrow Hill 2004; 176 - 214

10
2. LEARNING GUIDE

NUTRITIONAL ASESSMENTS
SCORE
No STEPS
0 1 2
OPENING
1. Say Basmalah
2. Greet the mother & introduce yourself
3. Informed consent:
 Procedure
 Purpose
 Agreement
4. Identify infant’s data : Name, sex, date of birth, address
PREPARATION
5. Hand washing
6. Equipments:
 Penlight
 Measuring tape
 Stadiometer
 Weight scale for infant and children
 Tool
 Measuring board for infant
7. Private, comfortable and well illuminated room
CLINICAL ASSESSMENT : Find the clinical sign of nutritional deficiencies
8. Hair:
 Spare and thin : zinc deficiency
 Easy to pull out: protein deficiency
 Corkscrew coiled hair: vit C and vit A deficiency
9. Mouth :
 Glossitis :Riboflavin, niacin, folic acid, B12 , protein
 Bleeding and spongy gums: Vit C Vit. C,A, K, folic acid & niacin
 Angular stomatitis, cheilosis and fissured tongue: B2, 6, niacin
 Leukoplakia: Vit.A,B12, B-complex, folic acid & niacin
 Sore mouth and tongue: Vit B12,6,c, niacin ,folic acid & iron
10. Eyes
 Night blindness: vit A deficiency
 Photophobia, blurring, conjunctival inflammation: vit A and B2 deficiency
11. Nails
 Spooning : iron deficiency
 Transverse line: protein deficiency
12. Skin
 Pallor: folic acid, iron, vit B12 deficiencies
 Follicular hyperkeratosis: vit B and vit C deficiencies
 Flaking dermatitis: PEM, Vit B2, Vitamin A, Zinc & Niacin
 Pigmentation, desquamation: Niacin and PEM
 Bruising, purpura: vit K, vit C and folic acid deficiencies
13. Thyroid gland
 in mountainous areas and far from sea places, Goiter is a reliable sign of
iodine deficiency
14. Joint and bone
 Help detect signs of vitamin D deficiency (Rickets) & vitamin C deficiency
(Scurvy)

11
 ANTHROPOMETRIC MEASUREMENT (PEDIATRIC ANTHROPOMETRIC)
SCORE
No STEPS
0 1 2
ANTHROPOMETRIC MEASUREMENT: WEIGHING CHILDREN
1. A child older than 36 months is weighed standing on a scale
2. Use a calibrated beam balance or electronic scale
3. Child must be able to stand without assistance
4. Child or adolescent wears lightweight undergarments, gown, or lightweight outer clothing
5. Use a calibrated beam balance or electronic scale
6. Child must be able to stand without assistance
7. Child or adolescent wears lightweight undergarments, gown, or lightweight outer clothing
8. Child or adolescent stands on center of scale platform
9. Reposition and repeat measure
10. Measures should agree within 0.1 kg or 1/4 lb
MEASUREMENT OF HEIGHT
11. Use a calibrated vertical stadiometer or microtois with a right-angle headpiece
12. Ask the child to take off the shoes
The child is measured standing with heels, buttocks, shoulders and head touching a flat
13.
upright surface
Child or adolescent stands against stadiometer, with heels together, legs straight, arms at
14.
sides, shoulders relaxed
15. The head should be positioned in the Frankfurt plane
16. Ask the child to take a deep breath, then let it out and relax his shoulders
17. Bring the perpendicular headpiece down to touch the crown of the head
18. Measurer’s eyes are parallel with the headpiece
19. Read to the nearest 0.1 cm or 1/8 inch and recorded on the chart.
20. Repositioned and remeasured.
21. Agree within 1 cm or 1/4 inch.
22. Record on the growth chart appropriate for age and gender.
SITTING HEIGHT
23. Use a calibrated vertical stadiometer or microtois with a right-angle headpiece
24. Ask the child to sit on a stool
25. The back of the head, thoracic spine and buttock should rest against the wall
26. The head should be positioned in the Frankfurt plane
27. Ask the child to take a deep breath, then let it out and relax his shoulders
28. Bring the perpendicular headpiece down to touch the crown of the head
29. Read to the nearest 0.1 cm
30. The sitting height (upper body segment) = Height measured on the scale – height of the
stool
31. Lower body segment = Standing height – sitting height
32. Calculate the upper to lower segment ratio
33. Record the ratio on the appropriate curve
CALCULATION OF MIDPARENTAL HEIGHT
34. Display father’s height and mother’s height on the growth chart
35. Midparental height:
‒ Boys: (Mother’s height + 12.5 cm) + father’s height, divide the result by 2
‒ Girls: (Father’s height – 12.5) + mother’s height, divide the result by 2
The range will be within 10 cm above and below this target
36. Draw the range in the growth chart
PLOTTING THE RESULT
37. Select the appropriate chart for the age, sex, and measurements of the person measured
38. Calculate the child's age carefully
39. Plot the weight measurement on the growth chart appropriate for age and sex
40. For accurate plotting of measurements use a plotting aid such as a straightedge
41. Use the information in the clinical assessment process

12
CLOSING
42. Share the information with the family (i.e., translate into a form that is useful to them)
43. Say Hamdalah

13