CHAPTER OBJECTIVES
- 1.1 Case Recording Format
- 1.2 Approach to a Sick Child
- 1.3 Bedside Calculations and Nomograms
- 1.4 Assessment of Growth (Anthropometric/Auxologic Measurements and Assessment)
- 1.5 Socioeconomic Status Scale
Many of us doubt whether medicine is either an "art" or a "science". The truth is that it is a perfect blend of art and science. In clinical medicine, especially pediatrics, art should prevail over science. It is the art and science of handling children to achieve the finest information and thus enable to express the sky-high potential in them. The aim is to cause least injury to them and to allow them to bloom in all possible dimensions; physical, mental, emotional and social.
1.1 CASE RECORDING FORMAT
HISTORY
- Sociodemographic/Personal Data
- Name
- Age in years and months (date of birth when relevant)
- Gender
- Address, geographic location
- Informant and reliability of the history.
- Presenting ComplaintsList chief complaints in chronological order
- History Of Present Illness
- Mode of onset, duration, progression
- Associated symptoms, aggravating and relieving factors
- Points relevant to etiology and complications, negative points
- Treatment, history, course of the illness, etc.
- History of Past Illness
- Similar illness in the past
- Episodes of common childhood illnesses like wheeze, acute respiratory illness (ARI), attention deficit hyperactivity disorder (ADHD), vaccine preventable diseases (VPDs), febrile fit, previous hospitalizations, etc.
- Antenatal History
- Antenatal care, antenatal visits, medications, injections, e.g. tetanus, toxoid, IFA tablets, USS reports, anomaly scan, etc.
- Exposure to exanthematous fevers, drugs, radiation
- Addictions, systemic diseases, pregnancy-related illnesses, etc.
- Natal History
- Gestational age, birth weight
- Mode and place of delivery, birth cry
- Initiation of breastfeeding
- Resuscitation, NICU care, medications/procedures like umbilical cannulation.
- Neonatal History
- Hospital stay, special care
- Jaundice, cyanosis, fits, etc.
- Feeding practices.
- Developmental History
- Gross motor, fine motor adaptive, language, personal social milestones
- Vision, hearing.
- Dietary History Including Infant and Young Child Feeding (IYCF) Practices
- Breastfeeding history
- Complementary feeding
- Family pot feeding, cooking practices
- Diet during illness, any exclusion diet, food fads
- Adequacy of calories, protein and micronutrients, supplementary feeding, etc.
- Immunization History
- Whether fully immunized for age as per UIP, IAP schedule
- Primary and booster doses of DPT, OPV, measles, BCG, HBV, etc.
- BCG scar, the last vaccine the child has received and the next vaccine that is due, other "on demand vaccines".
- Vitamin A prophylaxis. Check immunization/Mother child protection (MCP) card.
- Family History
- Consanguinity, a ‘three generation pedigree’ in genetic disorders
- Age and health of parents
- Family planning measures adopted
- Details of siblings, unexplained deaths in the family
- Contact with TB, history of diabetes, allergic disorders and similar illness in the family.
- Socioeconomic History
- Record socioeconomic status, occupation, education and family income, whether APL/BPL family, any insurance or reimbursement/ESI benefits, etc.
- Also record housing conditions, sanitary facilities, source of drinking water, pets, etc.
- The modified "Kuppuswami socioeconomic status scale" is usually used for assessing socioeconomic status and categorization of social classes. It includes education, occupation and income of parents (see Table 1.24).
PHYSICAL EXAMINATION
General Examination
General Comment
Appearance, wellbeing, attitude, hydration, color, sensorium.
Vital signs:
- Temperature (Fig. 1.1): Keep the thermometer in situ and read only after 1-2 minutes. Mercury or digital reading thermometers are usually used. Oral, axillary, rectal, eardrum or skin temperature can be measured. In newborns, rectal or axillary temperature can be measured. Low reading thermometers that read as low as 30 °C, may be needed to detect hypothermia. In young children, axillary temperature and in older children and adults, oral temperature is measured. Normal core temperature is 37 °C or 98.6 °F. Skin temperature is 1 °F or 0.5 °C lower than core temperature. Hyperpyrexia is > 41 °C (105 °F) and hypothermia < 35 °C (95 °F). For axillary reading, 0.5 °C or 1 °F is added to get the core temperature except in newborn babies, who have lot of metabolically active brown fat in the axilla. Body temperature follows a circadian rhythm. It is lowest in the morning and highest in the evening between 4 and 6 pm (1°C = 1.8°F).Factitious fever may be obtained by dipping thermometer in warm water or after drinking a hot drink or keeping warm fluids in the mouth. True fever is associated by tachycardia, 10 beats/1°F.Extremities may be cold in a febrile child due to vasoconstriction and there may be associated chills and rigor indicating that the patients' hypothalamic thermostat is set high. In environmental hyperthermia and septic shock, extremities are warm.
- Respiration: Record rate rhythm, type, work of breathing (WOB) retractions, and usage of accessory muscles (rate to be counted for 1 minute when the child is settled and quiet, by observing breathing and not by palpation).
- Pulse: Record rate, rhythm, volume, character (start feeling radial pulse and count for 1 minute, except in emergency, when it may be counted for 6 seconds and multiplied by 10), subsequently feel for all peripheral pulses. Carotid, femoral, brachial and axillary pulses are also to be palpated if peripheral pulses are not well felt. Compare between radial and dorsalis pedis; if dorsalis pedis is weak, feel for femorals and look for radiofemoral delay in suspected coarctation of aorta. Heart rate (HR) and pulse rate (PR) may vary in arrhythmias and in ectopic beats. In atrial fibrillation, the difference between PR and HR will be >10. HR in newborn is 140/min, double that in adult.
- Blood pressure (BP): Use appropriate BP cuff size, in order to cover middle 3rd of the upper arm. Smaller cuff will give higher BP. Cuff sizes are:
- 3.5 cm, 7 cm or, 12.5 cm (standard)Both palpatory and auscultatory methods are used. The first Korotkoff's sound indicates the systolic BP and the diastolic BP is between the muffling and disappearance of the sounds. Diastolic BP is two-third of the systolic BP. Considering the age and gender of the individual, BP values > 5th centile is hypotension and > 95th centile is hypertension. 50th centile of BP is roughly 90 + (2X) and 5th centile is 70 + (2X), where "X" is age in years. The average BP of newborn is 60/40, which is half of the adult BP and at 1 year, it is 90/60 mm of Hg. Lower limb BP is recorded in the popliteal fossa with the BP cuff around the thigh in the prone position. Normally, lower limb BP is 10 mm of Hg more due to the larger size of the arteries in the lower limbs and being direct continuation of aorta. It is > 20 mm of Hg in aortic regurgitation (AR). Hill sign is positive when the difference is > 40 mm of Hg, seen in free AR.Other methods of recording BP are oscillometric, Doppler and intra-arterial techniques. Noninvasive BP (NIBP) recording is done in ICUs.
- Capillary filling time (CFT): Raise the limb above the heart level and press the pulp of the finger or sole of the foot, observe the time taken for capillary filling by the disappearance of the blanch. Usually, it is 2 seconds. Three or more seconds is abnormal. Exposure to cold may lead to prolonged filling time especially in the newborn.
Hand to Head-to-Foot Examination
Start with examination of the hands in order not to forget looking at hands. Record "PICCLE"
P: Pallor
I: Icterus
C: Cyanosis
C: Clubbing
L: Lymphadenopathy
E: Edema.
Pallor
- Best detected in the palms in comparison to the examiner's palm and may be graded as no pallor, some pallor or severe pallor
- Also examine palpebral conjunctiva and oral mucosa for pallor, but if the child cries/rubs the eyes or if glossitis/thrush is present in the mouth, it may become difficult to detect pallor.
Icterus
- Look at sclera, under surface of tongue and skin especially in newborns
- More than 2 mg/dl of serum bilirubin is clinically detectable
- 1-2 mg is difficult to detect and is called 'latent jaundice'.
Cyanosis
- Bluish discoloration of skin, nailbeds and mucosa due to presence of reduced Hb < 5 g/dl
- Peripheral cyanosis is seen in hypothermia and disappears on warming the extremities
- Central cyanosis is seen in cyanotic congenital heart disease, respiratory distress, methemoglobinemia and sulfhemoglobinemia
- Hyperoxia test by giving 100% oxygen may help to differentiate cardiac and respiratory causes. In respiratory, it may disappear and PaO2 shall increase > 150 mmHg, unlike in cyanotic heart disease due to mixing of impure blood and pure blood.
- In methemoglobinemia, filter paper test is useful. Apply a drop of patient's blood on filter paper. In comparison to control blood, it will appear dark in color. If cyanosis is due to reduced Hb, color will improve on exposure to room air with oxygen.
Clubbing
Mechanism of clubbing: Increase in fibrous tissue due to hypoxia. Arteriovenous shunting and altered prostaglandin metabolism are postulated as the causes. There is increase in soft tissue of the nailbed of fingers and toes leading to selective enlargement of distal segment of digit, and later on, nails leading to “parrot beak appearance”.
- Grade 1: Increased fluctuation of nailbed
- Grade 2: Obliteration of angle of nailbed
- Grade 3: Increased convexity of nail from above downward and from side to side
- Grade 4: Bulbous/drumstick appearance of distal segment of digit. It may also then involve the distal bones of the limb.
Causes: The causes of clubbing are:
- Hereditary
- Cardiac (CCHD, infective endocarditis)
- Respiratory (chronic lung diseases like lung abscess, bronchiectasis, empyema, pleural mesothelioma, TB)
- GIT (celiac disese, Crohn's disease, malabsorptions, ulcerative colitis, polyposis intestine)
- Hepatic (chronic active hepatitis, biliary cirrhosis).
- Others (cystic fibrosis, malignancies, Hodgkin's disease, thyrotoxicosis, congenital methemoglobinemia)
- Idiopathic
Detection of early clubbing:
- DPD/IPD ratio: Observe the horizontally held nails at the level of eyes and compare distal phalangeal depth (DPD) to distal interphalangeal joint depth (IPD). Normally DPD is less than IPD. If DPD exceeds IPD, grade 2 clubbing is present.
- Schamroth sign: Approximate terminal segments of both index fingers and look for the diamond space in-between the nailbeds. If it is obliterated, there is grade 2 clubbing. On the other side, koilonychia is depression, thinning and brittleness of nails leading to spoon-shaped nails seen in iron deficiency anemia.
Lymphadenopathy
- Palpate cervical, axillary, epitrochlear, inguinal and popliteal groups
- Use examine's right hand to palpate nodes on the left side and vice versa.
- Look for size, shape, number, discrete, or nut, consistency, mobility and mating. Mating is seen in TB due to periadenitis and infiltration in malignancy. Failure to regress in two weeks may warrant FNAC.
Lymph nodes are usually significant if size >1 cm in cervical and >1.5 cm in inguinal regions. More than two noncontiguous areas denote generalized lymphadenopathy. It may even be pea-sized, but generalized in leukemia.
Edema
- It is due to increase in fluid and leads to shiny appearance and loss of normal wrinkles of skin.
- Edema of face presents as puffiness of eyelids (e.g. renal edema, more in the mornings). Dependent edema is seen in the legs (e.g. cardiac edema more in the evening). Dependent edema is seen in parasacral region in infants and in the bed- ridden, who are not ambulatory. Apply thumb pressure on dorsum of foot for 3 seconds and look for pitting edema, especially in edematous malnutrition.
- Abdominal wall edema presents as transverse umbilicus (smiling umbilicus)
- In ascites, it becomes everted umbilicus
- Anasarca is massive edema
- Edema may be generalized or localized (e.g. IV fluid extravasation), Nonpitting as in angioedema, myxedema, filiarial leg, etc. Pitting edema is elicited by firm pressure in relation to bony prominence like malleolus, sacrum, shin, etc. Press for at least 30 seconds, before deciding there is no edema.
Hand
Look for poly/syndactyly, radial ray anomalies, absent radius, clinodactyly, Simian crease, dermatoglyphics. Polydactyly on the side of the thumb is preaxial/radial polydactyly, on the side of little finger is postaxial/ulnar polydactyly and in between is called mesoaxial polydactyly (Fig. 1.2).
Head
- Look for frontal, parietal and occipital prominence
- Plagiocephaly is localized flattening of bones
- Shape of scalp, forehead bulging, prominent veins
- Sutures: Metopic suture is noted in the midline of forehead. Palpable sutures: ridging of sutures like "keel of the ship" is seen in craniostenosis and overriding sutures with step formation is seen in microcephaly due to reduced brain growth.
- – Coronal suture: Horizontal suture between frontal and parietal bones on either side.
- – Sagittal suture: Longitudinal sutures between the two parietal bones.
- – Lambdoid suture: Horizontal suture between parietal and occipital on either side.
- Bregma: It is the meeting point of coronal and sagittal sutures corresponding to the membrane filled anterior fontanel of the fetus
- Lambda: It is the meeting point of lambdoid and sagittal sutures corresponding to the membrane filled posterior fontanel of the fetus
- Fontanels: It is depressed/bulging, open/closed, pulsatile, feel for borders and measure the size also. Fontanel is the meeting point of three bones. At birth there are six fontanels, anterior (AF) at the meeting point of frontal and two parietal bones, posterior (PF) at the meeting point of occipital and two parietal bones, anterior lateral (ALF) at the meeting point of frontal, parietal and temporal on either side and posterior lateral (PLF) at the meeting point of occipital, parietal and temporal bones on 10either side. AF closes by 9 months to 1.5 years, PF by 3 to 6 months. Usually, PF is not palpable at birth and if posterior is open and palpable at birth, check for hypothyroidism, hydrocephalus/skeletal dysplasia bones may be brittle and ping pong sensation or egg shell crack may occur in pre-terms and in rickets.
Hair
Color, growth, texture, hair lines, hypopigmentation, sparse, easy pluckability, seborrheic dermatitis (cradle cap).
Face
- Dysmorphism, mooning of face, coarse facies, mid facial hypoplasia,
- Micrognathia/retrognathia, thick/thin lip, long philtrum, maxilla.
Eyes
- Position and slant: >10% upward or downward slant is significant upward is seen in Down syndrome and downward is William syndrome.
- Pallor, icterus, blue sclera and vitamin deficiency
- Hypertelorism, conjunctival congestion, microphthalmia, corneal clouding, coloboma, cataract, nystagmus, strabismus and muddy cornea. Synophrys is meeting of eyebrows in the midline. Seen in Cornelia-Delange syndrome.
Ears
- Deformities, preauricular tag/sinuses, discharge
- Ear position: Normally one-third of the pinna is above the inner canthus of the eye, if it is < 10% of the pinna, low set ear is diagnosed.
Nose
Flat nasal bridge, upturned position, deviation of nasal septum (DNS)
Tongue
- Glossitis, red/magenta
- Thrush
- Protruded tongue is seen in hypothyroidism, in hypothyroidism Down's syndrome. It is due to small mouth as in DS or due to macroglossia.
Mouth
- Oral hygiene, dental caries, throat/tonsil
- Cleft lip/palate, vitamin deficiency
- Color and number of teeth
- Inverted V-shaped upper lip seen in myopathy.
Neck
- Neck length [distance between external occipital protuberance (inion) and C7]
- Neck length is roughly 13% of height or Neck length = 10 + (0.035 × height) cm, normally 13.5 cm.
- Also look for webbing, low hair line
- Thyroid and lymph node enlargement, pulsations in the neck.
Chest
- Sternum: Pectus excavatum (depression) seen in upper airway obstruction, Marfan's syndrome and in some cases of rickets. Pectus carinatum (bulging) seen in rickets, skeletal dysplasia, long standing heart diseases, etc.
- Absent pectoralis major (Poland's syndrome)
- Athelia/polythelia (accessory nipples)
- Wide spaced nipple normally the distance between nipples is less than one-third of the chest circumference
- Look for shield chest, precordial bulge, barrel-shaped chest
- Harrison's sulcus/groove is depression along the attachment of the diaphragm from sternum to mid axillary line in the lower chest wall. It is seen in rickets or due to pull of the diaphragm on unossified ribs. It may also be due to chronic heart failure, chronic wheeze from infancy, congenital laryngeal stridor, cystic fibrosis, myopathy, spinal muscular atrophy or a congenital anomaly.
Abdomen
- Umbilical hernia
- Dilated veins
- Divarication of recti
- Distention
- Ascites.
Genitals
- Hernial orifices
- Ambiguous genitalia/Indeterminate sex
- Undescended testis
- Precocious puberty
- Hydrocele, scrotal edema
- Micropenis/macropenis, macro-orchidism in fragile X syndrome is noted only during and after puberty.
Upper Limbs
- Simian crease – Horizontal single palmar crease
- Poly/syndactyly, arachnodactyly (long finger - Marfan's), clinodactyly, (incurring of little finger), camptodactyly
- Short limbs, broad thumbs, cyanosis, clubbing, palmar erythema, flap, pallor, dermatoglyphics
- Koilonychia (spoon like nails), dystrophic nails, leukonychia (white nails)
- Capillary filling time
Lower Limbs
- Hypermobility
- Joint swelling—knee, ankle
- Deformities, weakness
- CTEV
- Chappal sign (Sandal gap) = Increased space between big toe and second toe in trisomy-21
- Kennedy sulcus longitudinal crease on foot
- Rocker bottom feet (Trisomy-18)
- Pedal edema
- Arches of foot
Spine
- Dimples, hairy patches, cleft, open/occult meningomyelocele
- Gibbus, swelling
- Kyphosis, scoliosis and lordosis
Skin
- Neurocutaneous markers, nevus achromians, melanosis and hypomelanosis of ITO,
- Pyoderma scars, scabies
- Subcutaneous emphysema skin turgor
- Phrynoderma, rashes, CFT, etc.
Congenital Anomalies
Search carefully for congenital anomalies.
Assessment of Growth
(Refer Chapters 2 and 4 for details)
- Anthropometry, comparison with reference standards or normal range
- Interpretation of anthropometry, whether normal/grade of malnutrition
- Stunting, wasting, microcephaly, etc.
Assessment of Development
(Refer Chapter 2 for details)
- Gross motor, fine motor-adaptive, language, personal-social development, developmental age, and DQ
- School performance, intelligence, etc.
SYSTEMIC EXAMINATION
Gastrointestinal System
(See Chapter 9 for details)
- Examination of upper GIT: It includes examining lips, teeth, gums, tongue, palate, etc
- Examination of abdomen:
- – Inspection of abdomen
- – Palpation of abdominal organs/mass, liver, spleen, liver span, shifting dullness
- – Percussion: Shifting dullness, fluid thrill
- – Auscultation: Bowel sounds, bruit
- – Hernial orifices, Per Rectal (PR) examination when indicated.
Respiratory System
(See Chapter 10 for details)
- Respiratory rate, rhythm, work of breathing
- Upper airways, nose, throat, paranasal sinuses
- Trachea
- Inspection of chest, lower chest indrawing, subcostal, suprasternal retractions
- Palpation: Vocal fremitus
- Percussion: Normal, hyper-resonance, impaired note, stony dullness
- Auscultation: Vocal resonance, breath sounds, intensity, vesicular/bronchial/vesicobronchial, adventitious sounds, wheeze, stridor, etc.
Cardiovascular System
(See Chapter 12 for details)
- Pulse-rate, rhythm, volume, character, vessel wall, peripheral and central
- BP, capillary filling time (CFT)
- Jugular venous pressure (JVP)
- Inspection: Precordium, pulsations, apex beat
- Palpation: Apex beat, parasternal heave/pulsations, other pulsations/palpable sounds, thrill
- Percussion: Heart borders, dullness beyond heart boarders, dullness beyond 2 cm in pulmonary area called "ribbon sign" in pulmonary hypertension
- Auscultation: Heart sounds, murmur.
Nervous System
(See Chapter 14 for details)
- Higher mental functions
- Cranial nerves
- Motor system
- Sensory system
- Superficial and deep reflexes
- Primitive and neonatal reflexes in relevant cases
- Motor coordination
- Gait
- Skull and spine
- Involuntary movements
- Signs of meningeal irritation
- Peripheral nerves
- Autonomic dysfunction.
Musculoskeletal System
Examination of Joints
- Swelling, tenderness, fullness, warmth, redness, limitation of movements, deformity, Migratory or additive arthritis
- History: Duration of pain, swelling, limitation of movement
- Patellar tap, range of movements
- Measurement of limb length.
SUMMARY
- History and examination: Salient points
- Diagnosis and differential diagnosis: Points in favor and against the diagnosis
- Investigations
- Treatment
- General/supportive care
- Specific management
- Writing of a prescription as per the weight/age of the child.
- Prevention
- Primary: General measures to prevent airborne, waterborne, vector borne diseases, health promotion, early screening, pollution control, safe drinking water, public health engineering and biosafety
- Secondary: Specific protection, immunization, universal precaution for nosocomial and opportunistic infections and personal protection
- Tertiary: Disability limitation and rehabilitation.
1.2 APPROACH TO A SICK CHILD
Triage: Ask, Look and Feel for Categorization
- Take a quick history. Treatment may have to be started earlier than completing history and examination in a critically ill child
- Assigning "red flag", stratification of patient by paying special attention to 'Danger signs' and "ABC": Appearance (wellbeing, sensorium, color, tone, cry, activity), Breathing and Circulation.
- Check for general danger signs, watch for abnormal smell (Table 1.1)
- Differentiate between hematemesis and hemoptysis (Table 1.2).
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Danger Signs
- Altered sensorium
- Persistent vomiting
- Inability to drink
- Stridor/respiratory distress
- Cyanosis
- Bleeding tendency
- Seizures
- Looks pale
- Decreased urine output.
Vital Signs
See Tables 1.3 and 1.4
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- Respiratory rate and heart rate in newborns are double and BP is half than those in adults (Adult: RR 18-20/min, HR: 70 and BP: 120/80).
- Temperature (Table 1.5): Circadian rhythm of temperature is lowest in the morning and highest in the evening between 4 and 6 pm. This is usually preserved in febrile illness.
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- Continuous/sustained fever does not touch the baseline and the day to day variation is < 1°C.
- Remittent fever has variation > 1°C.
- Intermittent fever/relapsing fever touch the baseline (see Fig. 1.1).
- Daily fever (e.g. paroxysm) is called quotidian, alternate day is called tertian (1st and 3rd day), e.g. Plasmodium vivax and fever once in 3 days is called quartan fever (1st and 4th day), e.g. Plasmodium malariae.
- Hectic/septic fever has wide fluctuation in fever
- Biphasic fever has two phases of fever, also called "camel-back fever"
- Periodic fever shows regular periodicity like cyclical neutropenia.
Sensorium
Alertness
- AVPU scale
- A: Awake/Alert
- V: Verbal response present
- P: Pain response present
- U: Unresponsive/unconscious
- Glasgow coma scale (GCS): See Table 1.6.
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ABC Assessment Triangle
See Figure 1.3.
Clinical Staging of Encephalopathy
See Table 1.7
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1.3 BEDSIDE CALCULATIONS AND NOMOGRAMS
Indian Council of Medical Research (ICMR) Recommendations for dietary allowances for various categories of population are discussed in (Tables 1.8 to 1.10). These are for the ideal/expected weight.
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Bedside Calculation of Energy
See Table 1.11.
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Holliday and Segar's Formula for Energy and Fluid
See Table 1.12.
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Protein Quality and Net Protein Utilization (NPU)
- Digestibility coefficient (DC): It refers to the amount of absorbed nitrogen compared to the total nitrogen present in the food item. Cooking improves digestibility. Trypsin inhibitor present in soyabean and egg white that decreases digestibility, gets destroyed on cooking.
- Biological value (BV): It refers to the amount of retained nitrogen compared to absorbed nitrogen.
- Net protein utilization (NPU): It refers to the amount of retained nitrogen compared to the nitrogen present in the food item.
- Protein efficiency ratio (PER): It refers to the gain in weight of experimental animal per unit weight of protein consumed (Table 1.13).
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Nutritive Value of Foods (Tables 1.14 and 1.15)
See Tables 1.14 and 1.15.
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Items that give 6 g Protein are
- 1 egg
- 200 ml milk
- 3 idlis
- 3 chappatis
- 3 dosas
- 6 puris
- 12 tsp cooked dal
- 18 tsp ragi
- 1 ounce (30 mg) meat/fish
- 50 groundnuts
- 15 cashewnuts
- 3 cup cooked rice
- 6 tsp bengal gram
- Green leafy vegetable (100 g)
- Skimmed milk powder (20 g)
- Cheese (30 g)
- Cereal (60 – 90 g)
- Pulses (25 – 30 g)
- Soybean (15 g)
Bedside RDA of Vitamins and Minerals
See Table 1.16.
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1.4 ASSESSMENT OF GROWTH (ANTHROPOMETRIC/ AUXOLOGIC MEASUREMENTS AND ASSESSMENT)
Auxology
- Auxology is the preferred term for human live measurements
- For measurement of weight, accurate equipments preferably with digital display and minimum resolution of 10 g should be available
- Bedside calculation for weight, height and head circumference are given in Table 1.17
- It is observed that weight doubles by 4 months and triples by 12 months, quadruples by 2 years and height doubles by 4 years and triples by 12 years.
Weech's Formula for Weight (kg)
• At birth | : | 3 kg |
• 3-12 months | : | |
• 1-6 years | : | 2X + 8; X = age in years |
• 7-12 years | : | (7X − 5)/2; X = age in years |
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Growth Rate and RDA
See Table 1.18.
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IAP Classification of Protein Energy Malnutrition (PEM) * (Weight for Age)*
• 71-80% | : | Grade-I PEM |
• 61-70% | : | Grade-II PEM |
• 51-60% | : | Grade-III PEM |
• < 50% | : | Grade-IV PEM |
*Add "K" to the grade to indicate "kwashiorkor"
Wellcome Trust Classification (Weight for Age)
See Table 1.19.
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Height Measurement
- For less than 2 years, use infantometer (Fig. 1.4A)
- Recumbent length is 1 cm more than standing height.
Bedside Calculation
• Birth | : | 50 cm |
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• 6 mon | : | 66 cm |
• 1 year | : | 75 cm |
• 2 years | : | 87 cm |
• 4 years | : | 100 cm (double the birth length) |
• 8 years | : | 125 cm |
• 12 years | : | 150 cm (triple the birth length) |
(2 × height at 2 years = adult height)
Weech's formula for height: 2-12 years = (6 × age in year) + 77
Waterlow Classification for Stunting (Height for Age)
See Table 1.20.
|
Waterlow Classification for Wasting (Weight for Height)
See Table 1.21.
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WHO Classifications
I. WHO Grading/Interpretation
- Normal weight, normal height, normal weight for height—Normal nutrition
- Decreased weight, normal height, decreased weight for height— A/C malnutrition
- Decreased weight, decreased height, normal weight for height— C/C malnutrition
- Decreased weight, decreased height, decreased weight for height—A/C on C/C malnutrition.
II. WHO Classification of Undernutrition (Table 1.22)
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III. WHO Criteria for Diagnosis of Severe Acute Malnutrition (SAM)
- Weight for Height < 3 SD/< 70% and/or
- Wasting, MAC > 11.5 cm (6 – 60 mo.) and < 11 (< 6 mo) and or
- Bilateral pitting edema.
Upper Segment: Lower Segment (US: LS) Ratio
- LS: Length from symphysis pubis to toes
- US: Total height - LS
- US:LS ratio for different age (Adult 1 : 1) and Adolescent 0.9:1)– Birth:1.7:1–6 months:1.6:1–1 years:1.5:1–2 years:1.4:1–3 years:1.3:1–4 years:1.2:1
- US shorter implies (short trunk), spondyloepiphyseal dysplasia, kyphoscoliosis and MPS
- US longer implies (short limbs), achondroplasia, rickets (bowlegs), hypothyroidism, etc.
- Mid point of a newborn baby is umbilicus and that of adult is pubic symphysis.
Head Circumference (HC) (Fig. 1.5)
Maximum occipitofrontal circumference (OFC)
- Anteriorly: point above glabella
- Posteriorly: point of occipital protuberance
Bedside Calculation
See Table 1.23.
Dine's Formula (HC in cm)
Infant = Length/2 + 9.5 +/− 2.5
Chest Circumferences
Chest circumferences (CC) (level of substernal notch in mid inspiration)
• Infancy: | HC > CC |
• 1 year: | HC = CC |
|
• Later: | CC > HC |
• In PEM: HC > CC: > 1 year | |
• CC usually measured up to 2-3 years |
Decreased in myopathy, asphyxiating thoracic dystrophy, malnutrition.
Mid-upper arm circumference (1-5 years) (MUAC) (Fig. 1.6)
- Left triceps, midway between acromion and olecranon, hence called mid upper arm circumference (MUAC)
- Position: Arm held by side and hanging loose
- > 13.5 cm: Normal
- 12.5-13.5: Moderate PEM
- < 12.5: Severe PEM
- < 11.5: SAM
- Newborn (NB): 9 cm
- Low birth weight (LBW) <8
- Men: 30–33 cm and women: 27–30 cm
- Adult Wasting: < 18 cm.
MAC: HC ratio: Kanawati Index (M/H Ratio)
- 0.28-0.314: Mild PEM
- 0.25-0.279: Moderate PEM
- < 0.249: Severe PEM.
- SAM: Severe acute malnutrition.
Skinfold Thickness
- Severe acute malnutrition (SAM)
- Usually measured over triceps on mid (L) arm (measure from posterior aspect) usually by using Harpenden's calipers (11mm or more). Also measured over the triceps or subscapular region
- Gives an indication of subcutaneous fat and indirectly the caloric reserve in the body.
Arm Span (AS)
- UL stretched out at right angles to body; child facing the wall
- Compare with height
- AS is 2 cm more than height in toddler
- AS = height by 7-10 years
- AS more than height 2-3 cm in adolescents
- AS more than height—Marfan's syndrome, homocystinuria, spondyloepiphyseal dysplasia.
Body Mass Index (BMI) of Adult
- Weight in kg/height in m2: 18.5-25 N
- < 15 moderate underweight (chronic energy deficiency)
- < 13 severe underweight
- > 25 over weight (> 23 in Indians and Asians)
- WHO BMI Charts are available for birth to 18 years (See Appendix).
- The ELIZ Health Paths are three-in-one weight, height BMI charts for screening purpose (Appendix).
Quetelet Index
Weight (kg)/height (cm2) × 100: > 0.15 normal
Ponderal Index in Newborns
Weight (g)/height (cm3) × 100 = > 2.5 is normal
2-2.5 hypoplastic babies (symmetric IUGR)
< 2 asymmetric IUGR (malnourished).
Weight: Hip Ratio
- Central obesity is a risk factor for noncommunicable diseases (NCD). Hence, weight:hip ratio should be measured.
- Male < 0.95
- Female < 0.8.
Crown-rump (Sitting Height) as (Percentage of Total Height/Recumbent Length) (%)
• At birth | : | 70 |
• At 6 months | : | 66 |
• At 1 year | : | 64 |
• At 2 years | : | 61 |
• At 3 years | : | 58 |
• At 5 years | : | 55 |
• At puberty | : | 52 |
Age Independent Anthropometry
It is applicable to all children in certain age groups, irrespective of the age:
- MAC: 6 – 60 mo
- Bangle test: 6 – 60 mo
- Shakir's tape: 6 – 60 mo
- Quack stick
- Body mass index
- Ponderal index.
Shakir's tape for MAC: It is a plastic tape with colored zones—green, yellow and red:
- Red indicates severe malnutrition <12.5 cm
- Yellow indicates moderate malnutrition (12.5-13.5 cm)
- Green indicates normal >13.5 cm
Bangle test: Bangle made of metal with internal diameter of 4 cm (circumference 12 cm). If the bangle crosses the elbow, the child is malnourished. It is a simple but less sensitive test.
QUAC stick: It is the short name for Quacker arm circumference stick (QUAC). It is a rod with two sets of marking one indicating the height and other for MAC for the corresponding height. The MAC is measured, and the QUAC stick is placed behind the standing child. If the height is more than the expected height for the measured arm circumference, the child is considered malnourished.
Modified QUAC stick: This utilizes a rod that is colored green, yellow and red that represents normal, borderline and severe malnutrition status respectively. The upper zone is colored red, mid zone yellow and lower zone green.
Dentition
- Young child: Number of teeth = age in months − 6
- Primary/milk teeth (20 teeth by 2 ½ years)
- 1st Permanent tooth: 1st molar − 6 years.
Eruption Sequence
• Central incisors | 6–7 months |
• Lateral incisors | 8–9 months |
• Canine | 16–18 months |
• First molar | 12–14 months |
• Second molar | 20–24 months |
Completion of Enamel Formation
• Central incisors | 1 ½ months |
• Lateral incisors | 2 ½ months |
• Canine | 9 months |
• First molar | 6 months |
• Second molar | 11 months |
Permanent Teeth
• Central incisors | 7–8 years |
• Lateral incisors | 8–9 years |
• Canine | 11–12 years |
• First premolar | 10–1 years |
• Second premolar | 10–12 years |
• First molar | 6–7 years |
• Second molar | 12–13 years |
• Third molar | More than 17 years |
Permanent Teeth Enamel Formation
• Central incisors | 4–5 years |
• Lateral incisors | |
• Canine | 6–7 years |
• First premolar | 5–6 years |
• Second premolar | 6–7 years |
• First molar | 2½–3½ years |
• Second molar | 7–8 years |
1.5 SOCIOECONOMIC STATUS SCALE
Updated Kuppuswamy's Scale for Socioeconomic Status Scale (SESS) (2007) see Table 1.24.
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