Growth ASSESSMENT

Growth assessment in children

1. GROWTH ASSESSMENT Dr. DODDABASAVA K. JUNIOR RESIDENT KSHEMA

2. Definition of Growth Growth is increase in size of organs and body. It is quantitative change and refers to physical maturation of the body.

3. Importance of growth assessment Growth is fundamental characteristic of childhood. Normal growth is indicator of optimum health. Deviation from the normal pattern is indicative of pathological process. Periodic assessment facilitates early detection of growth faltering, which may be first manifestation of undernutrition /infection/ disease.

4. Periods of growth Terminology Period Prenatal Period Ovum Ovulation to 14 days Embryo 15 days to 8 weeks Foetus 9 weeks to birth Perinatal Period 22 weeks of gestation to 7 days after birth Postnatal Period Newborn/Neonate First 28 days after birth Infant First year Toddler 1-3 years Preschool child 3-6 years School aged child 6-10 years(girls) 6-12 years(boys)

5. Adolescent Prepubescent or late childhood 10-12 years (girls) 12-14 years(boys) Pubescent 12-14 years(girls) 14-16 years(boys) Postpubescent 14-19 years(girls) 16-20 years(boys)

6. Factors Affecting Growth Genetic factors a.Race b.Sex c.Chromosomal 2.Nutritional Factors 3.Hormonal-Thyroxine GH 4.Environmental Factors a.Infections b.Trauma to growing bones c.Chronic systemic illness

7. 5.Seasonal variation 6.Emotional factors 7.Social Factors a) Socioeconomic class b) Education of parents c) Education of child

8. Laws Of Growth Continuous and orderly process. Growth pattern of every individual is unique. Different tissues grow at different rates. General body growth – first two years of life. Brain growth – 3 rd trimester and 1 st year of life. Lymphoid growth – Mid childhood

9. Rate of growth of different tissues

10. Growth can be measured in terms of : Physical anthropometry Assessment of tissue growth Bone age Dental age

11. Physical anthropometry Age dependent anthropometry- Weight Length or Height Head circumference Chest circumference

12. Age independent anthropometry Midarm circumference(1-5 yrs) Weight for height Mid upper arm/height ratio Midarm /Head circumference ratio Quetlet’s index Ponderal index Dugdale’s index Body mass index

13. WEIGHT Measurement: Child should be naked or in minimal clothing. Ideal is to use sliding beam balance scale or electronic scale. Weighing scale is checked for zero, center the infant on scale tray and older children is weighed standing.

14. beam type weighing scale detecto scale electronic scale bath room type scale Salter spring machine

15. Electronic Weighing Scale

16. Calculation of expected weight Weech’s formula: 3-12 months Expected weight (kg)=Age(months)+9 2 1-6 yrs Expected weight (kg)=2y+8 7-12 yrs Expected weight (kg)=7y – 5 2

17. Age weight At birth 1x 5 months 2x 1 yr 3x 2 yr 4x 3 yr 5x 5 yr 6x 7 yr 7x 10 yr 10x

18. Age Weight gain 10 days- 3 months 30 g / day 3-6 months 20 g / day 6-9 months 15 g / day 9-12 months 12 g / day 1-3 yrs 3 kg / yr 4-12 yrs 2 kg / yr >12 yrs 5-6 kg/yr

19. Interpretation of WHO Charts Z score (percentile) Length/height for age Weight for age BMI for age >3(99) May be abnormal Use BMI Obese >2(97) Normal Use BMI Overweight >1(85) Normal Use BMI Risk of overweight 0(50) Normal Use BMI Normal <-1(15) Normal Normal Normal <-2(3) Stunted Underweight Wasted

20. Growth Chart- Weight for Age

21. IAP Classification Nutritional Status Weight for age(%) for 50 th pecentile of Harvard Standard Normal >80 Grade I 71-80 Grade II 61-70 Grade III 51-60 Grade IV <50

22. Gomez Classifaction Nutritional Status Weight for age(%) for 50 th pecentile of Harvard Standard Normal >90 Grade I 76-90 Grade II 60-75 Grade III <60

23. Wellcome Trust Weight for age Edema Present Edema Absent 60-80% Kwashirkor Undernutrition <60% Marasmic Kwashiorkor Marasmus

24. Length/Height Lenght - < 2yrs - Infantometer Height - > 2yrs - Stadiometer

25. Height/length <2 yrs infantometer Two people required Head against fixed vertical head board Firmly press knee together Nearest 0.5 cms 0-85 cms

26. >2yrs-stadiometer Bare footed with feet parallel Heels , buttocks , shoulders & occiput touching the wall Head erect with eyes aligned horizontally Nearest 0.5cms

27. Infantometer

28. Stadiometer

29. Approximate gain in stature between 0 and 12 years of age Age Rate of increase in stature Birth to 3 months 3.5 cm/month 3-6 months 2.0 cm/month 6-9 months 1.5 cm/month 9-12 months 1.3 cm/month 2-5 yrs 6-8 cm/yr 5-12 yrs 5cm/yr

30. Growth Chart-Height for Age

31. Head circumference Birth – 18 yrs Non stretchable fiber glass tape Should encircle most prominent part of occiput & supra orbital frontal area Accuracy of 0.1 cms Infant : length (cm ) + 9.5 +/- 2.5 2

32. Head Circumference

33. Expected head circumference in children Age Head Circumference (cm) At birth 35 2 months 38 3 months 40 4 months 41 6 months 42-43 1 yr 45-46 2 yr 47-48 5 yr 50-51

34. Approximate gain in head circumference between 0 and 5 yrs Age Growth velocity of head circumference 0-3 months 2 cm/month 3-6 months 1 cm/month 7-12 months 0.5 cm/month 1-3 yrs 1 cm/6 months 3-5 yrs 1 cm/yr

35. Chest Circumference Measured at the level of nipples on mid inspiration. < 5 yrs – Lying down position > 5 yrs – Standing position At birth – HC is 3cm more than CC At 1 year – HC = CC After 1 year – CC > HC

36. Chest Circumference

37. US:LS Length between vertex and pubic symphysis is upper segment. Length between pubic symohisis and the heel is lower segment. Ratio is decreased in rickets.

38. Normal upper segment/ lower segment ratio in children Age Upper segment/lower segment ratio At birth 1.7:1 6 months 1.6:1 1 yr 1.5:1 2 yr 1.4:1 3 yr 1.3:1 4 yr 1.2:1 7 yr 1.1:1 10 yr 1:1 18 yr 0.9:1

39. Arm span Distance between tips of middle fingers of both the arms when out stretched at right angles. In < 5yrs of age arm span is 1-2cm less than height. By 10-12 yrs both become equal. After 12 yrs arm span exceeds height (but difference is <3cm)

40. Midarm Circumference Measured on left upper arm midway b/w acromion and olecranon process with arm hanging by side of body. Shakir tape Bangle test At birth: 9-11 cm 1-5years: 16-17 cm

41. Mid Arm Circumference

42. Shakir Tape MUAC (cm) Inference >13.5 Normal 12.5-13.5 Borderline <12.5 Under nutrition

43. Bangle Test Used for quick assessment. Fibre glass ring of internal diameter of 4cm is slipped up arm. If it passes above elbow , suggests MAC <12.5 cm and child malnourished.

44. QUAC STICK Quakers arm circumference stick Consists of rod with 2 sets of markings height MAC corresponding to ht If ht > ht for expected MAC – child is malnourished Modified quack stick – colored rod

45. Quack Stick

46. Weight for height Calculated as: weight of child(kg) X100 Expected weight for a healthy child of same height

47. Waterlow’s classification Classification Height for Age (% of expected) Normal >95 First degree stunting 90-95 Second degree stunting 85-89 Third degree stunting <85

48. Classification Weight for height (% expected of expected) Normal >90 Mild wasting 80-90 Moderate wasting 70-79 Severe wasting <70

49. WHO Classification Weight for Height Inference Z- score < -2 (70-79% of expected) Moderate wastimg Z- score < -3 (<70% of expected) Severe wasting Height for age Inference Z- score < -2 (85-89% of expected) Moderate stunting Z - score < -3 (<85% of expected) Severe stunting Edema +/-

50. Quetlet Index Calculated as: weight(kg) X 100 { Height(cm)}2 Normal:0.14-0.16 <0.14 indicate malnutrition

51. Rao and Singh’s Index Calculated as: weight(kg) X 100 { Height(cm)}2 Normal:0.15-0.16 <0.14 indicate malnutrition

52. Ponderal Index Calculated as: weight(g) X 100 height(cm)3 Ponderal Index Significance in newborn >2.5 Term,AGA baby <2 Asymmetrical IUGR (Severe PEM) >2 Symmetrical IUGR

53. Body Mass Index Calculated as: weight(kg) X 100 [Height(m)]2 Nutritional intervention is required if BMI <15 or less then 5 th percentile in children.

54. Growth Chart - BMI

55. Dugdale’s Index Calculated as Weight(kg) x 100 Height(cm) 1.6 Normal Value-0.88- 0.97 Malnutrition - <0.79

56. Kanawati Index Calculated as MAC(cm) HC(cm) Grades of Malnutrition Kanawathi Index Mild 0.28-0.32 Moerate 0.25-0.28 Severe <0.25

57. Assessment of Tissue Growth Triceps skin fold thickness Biceps skin fold thickness Skin fold thickness gives estimation of fat. Can be measured by Lange’s of Harpenden’s Skin fold calipers .

58. Bone Age For 1-8 yrs, bone age is determined by examining carpal bones in X-ray of left wrist. No. of osification centres in wrist = Age(yrs)+1 Age X-ray New born Knee, Ankle 3-9 months Shoulder 3 yrs Wrist 12-16 yrs Elbow, Hip

59. Dental Age Age Eruption At birth Nil 6-8 months Central incisors 10 months Lateral incisors 12-15 months 1 st molar 15-21 months Canine 21-24 months 2 nd molar The teeth in the upper jaw erupt earlier than the lower jaw except lower central incisors

60. Permanent Teeth Age Eruption 6 1 st molar 7-8 Central and lateral incisors 9 First premolar 10-11 2 nd Premolar 11-12 Canines 12-13 2 nd molars 17-22 3 rd molars

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