• Assessment of nutritional status is the primary step

in the evaluation of children's growth and should be

an integral part of the evaluation and management
of children with acute and chronic disease
• There is no easy and satisfactory way to measure
the nutritional status of a child or community at a
single examination. Four methods that are widely
used are described below. However, none of them
is ideal.
 1 Clinical Method

• The clinical method assesses nutritional status by

examining the changes in the skin, hair, buccal mucosa or
thyroid glands which are believed to be due to inadequate
nutrition.
• It is a cheap, noninvasive and quick method.
• The main drawbacks are it is very subjective, less specific
(other diseases may have similar picture e.g. edema can
be due to cardiac disease) and usually the signs cannot be
attributed to be deficiency of a particular nutrient (e.g.
glossitis may be observed in riboflavin, vitamin B12,or iron
deficiency.)
Some clinical signs of malnutrition that are
used for nutritional assessment.
• 2. Anthropometric assessment
• Measures the variations in physical growth at
different ages and the degree of nutrition.
• Evaluates the long term nutritional history.
• It is a widely used, simple, accurate, rapid,
quantitative, inexpensive and non-invasive
measure of the general nutritional status of an
individual or a population group.
• Can help to monitor the growth over a time
• The major pitfalls are:
• Cannot detect impaired nutritional status of
short duration.
• Cannot identify specific nutrient deficiencies.
• Needs appropriate equipment and techniques
for measuring stature/length and weight.
 . Length or Stature
• Is the most useful indicator of growth status.
• In infants and children younger than 2 years,
recumbent length is measured
• Height is measured for children older than 2
years.
Child length measurement
Height measurement
• ii. Weight
• Various apparatus: Infant scales, beam-balance
scales or read-out scales.
• The apparatus needs to be regularly calibrated to
maintain accuracy.
• Weight should always be recorded as nude
weight. If the subject is not weighed nude, then
the estimated weight of the clothing should be
subtracted from the total weight.
• iii. Head Circumference
• HC is a useful measurement until about 3 years of age,
when head growth slows.
• It must be measured with a narrow and non stretchable
measuring tape. To obtain an accurate measurement, the
tape must cross the forehead just above the supraorbital
ridges, passing around the head at the same level on both
sides to the occiput. It is then moved up or down slightly
to obtain the maximum circumference. The tape should
have sufficient tension to press the hair against the skull.
Head circumference measurement
• The commonly used four building blocks or measures used to
undertake anthropometric assessment are age, sex, weight and
height.
• When two of these variables are used together they are called an
index/indices.
• There are many anthropometric measures including mid-upper-
arm-circumference (MUAC), head circumference, and skin fold
thickness but three indices are commonly used in assessing the
nutritional status of children
• Weight-for-age
• Length-for-age or height-for-age;
• Weight-for-length or weight-for-height
• The values of these measurements will be
interpreted using standard charts (Harvard
curve, NCHS) of weight-for-age, height-for-age,
weight-for-height, and HC-for-age.
• The three indices are used to identify three
nutritional conditions: underweight, stunting
and wasting.
 Weight-for-age (WFA or W/A
• For monitoring growth of children over a limited
period, weight-for-age is the simplest method.
• A low weight-for-age index identifies the condition of
being underweight, for a specific age. The advantage
of this index is that it may reflect both past (chronic)
and/or present (acute) under nutrition (although it is
unable to distinguish between the two).
• Underweight, based on weight-for-age, is a
composite measure of stunting and wasting.
 Height-for-age
• This index is an indicator of past under nutrition
or chronic malnutrition.
• It cannot measure short term changes in
malnutrition. For children below 2 years of age,
the term is length-for-age; above 2 years of age,
the index is referred to as height-for-age.
• Deficits in length-for-age or height-for-age is
called stunting. Stunting is an indicator of past
growth failure.
Weight-for-height (length for<2yrs)
• This ratio helps to identify children suffering from
current or acute under nutrition or wasting and is
useful when exact ages are difficult to determine.
• Can be used to differentiate stunted growth from
wasting and is independent of age.
• Wasting results from acute or subacute nutritional
deprivation and by acute medical conditions such as
diarrhea. Body weight is depleted out of proportion
to length, making the weight-for-height ratio low.
Indices
 Mid-upper-arm circumference (MUAC
• The mid upper arm circumference is an indicator
of muscle growth. It is age independent,
relatively easy to measure and a good predictor
of immediate risk of death. It is used for rapid
screening of acute malnutrition in children from
1-5 years of age. MUAC can be used for acute
undernutrition screening in emergency
situations and for estimating prevalence of
undernutrition at the population level.
• Because MUAC is fairly constant in the first 5 years of life,
fixed cut-off point (not based on age specific cutoffs) were
being used
•  Although there were some variations, the following were
one set of the cut-offs used
• MUAC > 12.5cm = normal
• MUAC 11.5-12.5cm=moderate acute malnutrition(MAM)  
• MUAC < 11.5cm=severe acute malnutrition(SAM)
• Note: in our context admitting patients for therapeutic
program is common with MUAC<11cm
• Assessing the levels of stunting
• Child’s height is compared to the median
height attained by reference children of same
age/sex and the extent variation of the child's
height from the median is computed
• The height for age reference distribution/table
is used to calculate the variation
• Assessing the levels of under-weight
• Child’s weight is compared to the median
weight attained by reference children of same
age/sex children and the extent of variations is
computed.
• The weight for age reference
distribution/table is used to calculate the
extent of variation
• Assessing the levels of wasting
• Child’s weight is compared to the median
weight attained by reference children of same
height and same sex and the extent of
variation is calculated.
• Weight for height reference distribution/table
is used to calculate the variation from the
median weight
• The extent of variation in various
anthropometric indices from their respective
medians (height for age, weight for age, BMI
for age and weight for height) are commonly
expressed in one of the following ways
• Z-scores deviations
• Percentiles
• Percent from the median
• Calculations of the deviations from the median
• Percent of the median
• It doesn't require the knowledge of standard deviation(SD)
• Easier to calculate
• Preferable method to admit children in therapeutic centers
• Wt of a child /median wt of reference children of the same sex
and age X 100
• Ht of a child /median Ht of reference children of the same sex
and age X 100
• Wt of a child /median wt of reference children of the same
height and sex X 100
Classification of nutritional status based on percent median
 Welcome's classification
• Uses the weight for age, measured by the Harvard Curve.
• Based on the presence or absence of edema and a deficit on
body weight
• Some children with features of kwashiorkor with wt above 80%
are classified
• This system is preferable for clinical setups to distinguish
different forms of PEM
• Its shortcomings includes that it:
• Relies on age
• Does not consider height
• Does not differentiate acute VS chronic malnutrition
Welcome’s…
 Water-low classification
• In this system terms suggest the following:
• Wasting  acute malnutrition
• Stunting  chronic malnutrition  
• Advantages:
• It is the best method for screening malnourished children in the
community
• It can detect mild forms of PEM, but doesn’t differentiate
severe forms of PEM.
• It can distinguish acute from chronic malnutrition
• It does not rely on age, which is sometimes difficult to ascertain
in rural settings.
Water-low…
• Classification of nutritional status based on Z-score
• For the three indicators
• Below -3sd is considered as severely malnourished and
above +3sd is considered as severely over nourished
• -2sd to -3sd is considered as moderately malnourished
+2sd to +3sd is considered as moderately over-nourished
• -1sd to -2sd is considered as mildly malnourished and
+1sd to +2sd is considered as mildly over-nourished
• -1sd to +1sd is considered as norm
• Percent of median =
• observed value * 100
• median value of reference population
• Eg.sex of child=male, age of child=12months
• weight of child=7kg, median weight=9.6kg
• calculate percent of median for this child?
• Wt of a child /median wt of reference children of the same
sex and age X 100
• =7kg/9.6kgX100%=73% of median
• Interpretation=the child is moderately malnourished
• Calculations of the deviations from the median
• Z-score deviations from the median
• When the underlying distributions are normal such as
height/length for age, standard deviations are uniform
across the distribution and z-scores are calculated by
the following formula

• Ẋ-Y/sd
• Ẋ is child's measurements; y is the median value and sd
is standard deviation
• Eg.sex of child=male, height of child=84cm
• weight of child=9.9kg, median weight=11.7kg
• standard deviation =0.908
• Using these values calculate z-score for this child?
• z-score = 9.9-11.7 =-1.98
• 0.908
• Interpretation: this child is mildly malnourished
 3.Biochemical methods of Nutritional
assessment
• Biochemical methods measure the total amount or
concentration of nutrient in body fluids (blood,
serum, urine) and organs (storage sites) of the body.
• The tests reflect recent nutritional status and
identify specific nutrient abnormalities. They also
detect subclinical deficiencies.
• The most commonly used tests are hemoglobin,
serum albumin and others like vitamin A, thiamine
in urine, serum ferritin etc.
 4. Dietary survey for Nn. Ass’t
• Dietary survey is an important component of
nutritional assessment. It assesses through
recording the food intake and translating it
into nutrients consumed
 Severe malnutrition
• A child is labeled as having severe malnutrition if
any one of the following is present:
• Weight for height less than 70 % of what it should
be;
• MUAC <11cm for a child with a length less than or
equal to 65cm;
• Bilateral pitting edema; or
• Based on the Welcome classification, if the child
has Kwashiorkor, Marasmus, or Marasmic-Kwash
• Stunting is due to chronic malnutrition while
wasting and oedema are due to acute Mn.
• Acute Malnutrition is defined as moderate
acute malnutrition if the wasting is less
severe(W/H between 70% and 80% NCHS
median); oedematous cases are always
classified as severe.
 Diagnosis
• History – nutritional history
• Physical findings
• Anthropometric measurements
• most children have similar growth potential regardless of
ethnicity
• Need for international reference standard
• WHO recommends NCHS as a reference
• Wt for ht –index of current nutritional status
• Ht for age –index of past nutritional history
• Harvard status – for under 5th
Investigation