GROWTH MONITORING AND INDICATORS OF MALNUTRITION.pptx

This is a power point presentation on growth and anthropometry-and how to monitor growth

1. GROWTH MONITORING AND INDICATORS OF MALNUTRITION PRESENTOR DR.ANDREA FIONA CUTINHA MODERATOR- DR.ANKITHA

2. DEFINITION Growth is a dynamic process Defined as an increase in size or mass of a living being as a result of increase in size or number of cells and/or increase in the intracellular matrix .

3. GROWTH AND DEVELOPMENT Growth - ‘ net increase in size or mass of tissues attributed to multiplication of cells and increase in intracellular substance’ Development -‘maturation of function, related to maturation and myelination of nervous system, indicates acquisition of various skills for individual’s optimal functioning.’ Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2023

4. STAGES OF GROWTH Ovum (0-14 days) Embryo (2-9 weeks) Foetus (9 weeks-birth) Newborn (first 28 days of life) Infant (first year of life) Toddler (1-3 years) Pre-school child (3-5 years) School child (5-9 years) Adolescence (10-19 years)- prepubertal , pubertal and postpubertal stages. Elizabeth KE. Nutrition and child development. Paras medical publisher; 2010

5. DETERMINANTS OF GROWTH Genetic inheritance - especially height, weight, mental, social development and personality. Nutrition before and after birth - Retardation in an infant indicates malnutrition. Age - Growth rate is maximum during fetal life, first two years of life and during puberty. Sex – Boys are generally longer & heavier than girls at the time of birth. During puberty girls grow fast and earlier than boys, but boys grow more. Infections and infestations - Infection with TORCH during intrauterine life retards growth of fetus. Elizabeth KE. Nutrition and child development. Paras medical publisher; 2010

6. DETERMINANTS OF GROWTH Recurrent infections like diarrhea and measles especially in a malnourished child will adversely affect the growth. Physical surroundings - Sun shine, good housing, lighting ventilation have their effect on growth and development. Psychological factors - Love, tender care and proper child parent relationship are all found to influence growth in a child. Economic factors - Higher the family income better is the nutritional status of an infant. Other factors - Birth order, Birth spacing, Education of parents (higher the educational level better the growth). Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2023

7. LAWS OF GROWTH Growth and development of children is a continuous and orderly process Growth pattern of every individual is unique Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2023

8. LAWS OF GROWTH Different tissues grow at different rates Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2023

9. ANTHROPOMETRIC PARAMETERS,TOOLS AND PROCEDURES

10. WEIGHT Best measurement of nutrition and growth ,earliest indicator, both acute and chronic malnutrition Easily measured. Types of weighing scales: digital electronic scales, beam balance scales (with moving weights ) and the spring balance scales. Digital portable weighing scales for infants can measure up to 5 g difference in weight. These should have taring facility to deduct the weight of clothing/diaper, etc. Older children who can climb and stand up on the scale are weighed using the platform scales All scales need regular calibration with known/standard weights. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

11. METHOD OF RECORDING WEIGHT Weigh the child in bare minimum cloths and without shoes. Infants should be weighed naked ( without diaper) and older children can be weighed in short cloths (vest and brief) Ensure scale is resting on a firm, stable, and even surface or uncarpeted floor. Check the zero of the scale before weighing. Calibrate the weight scale at the beginning and at the end of each measurement. Infants - Place the infant in a manner so as to distribute the weight evenly about the center of the pan. If a diaper is worn, its weight should be subtracted from the observed weight Children - Ask them to stand in the center of the platform, with body weight evenly distributed on both feet. Ensure that the child is not holding on to anything. A child on follow-up should preferably be weighed on the same scale. Read the weight by standing in front of the scale Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

12. Weight Birth weight  lose 10% body weight  regain BW by 10 days  gain at 25-30 gm/day for 1st 3 months  400 gm /month till end of 1st year Birth weight doubles by 4 months Triples before 12 months Four times by 2 years 6 times at 5 yrs Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

13. WEIGHT TRENDS

14. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

15. HEIGHT/LENGTH Length : For <2 yrs I nfantometer The infantometer is designed to measure lengths between 0 and 100 cm, with a precision of 1 mm Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

16. Height : ≥ 2 years Stadiometer is the instrument used for measuring standing height Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

17. Position the child’s head so that a horizontal line drawn from the external auditory meati to the lower edge of the eye socket runs parallel to the base of board - the Frankfurt plane positioned horizontally. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

18. HEIGHT 50 cm at birth 60 cm at 3 months 75 cm at 1 yr 90 at 2 yrs 100 cm at 4 yrs Gain 6 cm/ yr till 12 yrs 2-12 years (Age in years x 6) + 77 Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

19. MPH and Target height Mid parental height : represents the genetic potential Father's height Mother's height MPH = FH + MH  + 6.5 (boy)                       2 MPH =  FH + MH  - 6.5 (girl)                       2 Target height : MPH +/- 8cm Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

20. Height/length for age is a measure of length/height compared to the length/height of children of the same age and gender from a reference population. Indicator of chronic malnutrition/ short stature. A child whose length/height for age is below –2 Z-score is stunted and below –3 Z-score is severely stunted. A height of less than –2 SD is also the conventionally accepted definition of short stature Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

21. WEIGHT FOR LENGTH Weight for length/height - measure of weight compared to the weight of children of the same gender and length/height from a reference population. Indicator of acute malnutrition independent of age. A child whose weight for length/height is below –2 Z-score is wasted and below –3 Z-score is severely wasted Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

22. VELOCITY OF GROWTH Measurement of the velocity of growth or increment in a unit of time Better tool for early identification of factors affecting growth . Velocity of growth can also help in predicting the ultimate adult height. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

23. VELOCITY OF GROWTH Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

24. VELOCITY OF GROWTH A verage height velocity – 1 ST year - 25 cm/year P repubertal children ( 4 and 9 year of age)- 4-8 cm/year P uberty - peak height velocity 7-9 cm / year for girls and of 9-11 cm/year for boys. G rowth acceleration: Girls - Tanner Stage 3 for breast development Boys -Tanner Stage 4 for pubic hair development Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

25. Head Circumference : Maximum circumference from occipital protuberance to forehead Crossed tape method Microcephaly < -3 SD Macrocephaly > 2 SD Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

26. Diene’s formula : Length (cm) +9.5 +/−2.5 2 Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31. Causes -hydrocephalus, achondroplasia , tumours , hematoma CMV, Rubella , toxoplasmosis syndromes like downs, edwards

27. HEAD CIRCUMFERENCE 2 cm /month- up to 3 months 1 cm/ month -3-6 months 0.5 cm/month – 6 months -1 yr 33-35 cm at birth 43 cm at 6 months 46-47 cm at 1 yr 48 cm at 2 yrs 52 cm at 12 yrs Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

28. Chest Circumference : Measured at level of nipples midway between inspiration & expiration in recumbent position. 3 cm less than head circumference at birth, equal at 1 yr After that, chest circumference exceeds HC Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

29. BODY PROPORTIONS US:LS ratio (LS-pubic symphysis to ground) 1.7 at birth 1.1 at 6 yrs 1 by 10 yrs , 0.9 in adults

30. SHORT STATURE PROPORTIONATE SHORT STATURE DISPROPORTIONATE SHORT STATURE Result of abnormal skeletal growth. Either the limbs or the trunk is short. In short limb dysplasia (e.g. achondroplasia), arm span is less than height and US/LS ratio is high. In short trunk anomalies (e.g. mucopolysaccharidosis ), US/ LS ratio is decreased and arm span exceeds the height. More common May occur secondary to constitutional delay in growth, chronic infections, malabsorption, congenital heart disease, renal failure, or endocrine malfunctioning. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

31. AGE INDEPENDENT CRITERIAS Mid upper arm circumference (MUAC) Weight for height Quackstick Midarm /head circumference ratio Quetlet's index Mid-upper arm/height ratio Body mass index (BMI) Ponderal index Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

32. Mid Arm Circumference: To asses the nutritional status of children between 6m- 5yrs of age Measured in the left arm after locating the midpoint ( midway between tip of acromion process of scapula & olecranon of ulna) Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31. MUAC 11.5 – 12.5 Moderate malnutrition <11.5 cm severe malnutrition More than 12.5cm Normal

33. STEPS IN MEASURING MUAC Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

34. BMI U sed to assess the nutritional status of children more than 5 years of age instead of weight for length. For children, there is no absolute BMI cut-off as BMI values change with age. BMI = Weight(kg)/ Height(meter) 2 Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

35. QUACKSTICK Quaker's midarm circumference measuring stick - a height measuring rod, calibrated in MAC rather than height V alues of percent MAC for height marked on the stick at corresponding height levels. If a child is found taller than his/her arm circumference level on the stick, he/she is considered malnourished. T he quackstick was devised in M exico and has since been adapted in A frica and I ndia. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

36. MIDARM/HEAD CIRCUMFERENCE RATIO S imple and useful criterion for detection of malnutrition ratio 0.280 to 0.314 - early malnutrition 0.250 t ο 0.279 –moderate malnutrition L ess than 0.249 -severe malnutrition Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

37. MID-UPPER ARM/HEIGHT RATIO A very good indicator of nutritional status. A ratio of less than 0.29 indicates gross malnutrition N ormal value ranges from 0.32 to 0.33. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

38. SKIN FOLD THICKNESS Measured at triceps and subscapular area using Harpenden calipers. Skinfold with subcutaneous fat is picked up with thumb and index finger, and caliper is applied beyond the pinch. >10mm – Healthy children 1-6 years <6mm- is indicative of malnutrition Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

39. PONDERAL INDEX F or the newborn infant is calculated as: birth weight (g)/ birth length (cm)3 x 100

40. RATIOS Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

41. INTERPRETATION OF GROWTH PARAMETERS

42. INTERPRETATION OF ANTHROPOMETRIC INDICES Percentiles : dividing ordered set of data into 100 equal sized groups. An observed measurement at the 50 th percentile indicates the median value and half the population has above and half below the median. Standard Deviation Score: ( Z score): Number of standard deviations an individual measurement is away from the median. A positive SDS score denotes a value above the median and a negative SDS score denotes a value below the median. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

43. Normal vs Abnormal—Percentile, SD, and Z-Score PERCENTILE - position that a measurement would hold in a typical series of 100 arranged in ascending order. The median lies at the 50th percentile, on either side of which lie half the observations. The allowable normal range of variation in observations is between 3rd and 97th percentiles, which roughly correspond to :2 SD (standard deviation). Z SCORE - Usually —1, —2 and —3 Z-score correspond to 15.8, 2.28 and 0.13th percentiles; while 1st, 3rd and 10thpercentiles correspond to —2.33, —1.88 and —1.29 Z-score SD - 15th percentile and 3rd percentile roughly correspond to —1SD and —2SD, respectively. Conventionally , abnormal values are statistically defined as those below —2 SD (Z) score (2.3rd percentile) or above +2 SD (Z) score (97.7th percentile), relative to the reference median (50th percentile). Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

44. GAUSSIAN CURVE

45. GROWTH REFERENCES VS GROWTH STANDARDS GROWTH STANDARDS - Under the given optimal nutritional and health condition how a population of children should grow. Eg - The WHO growth charts published in 2006 for children under the age of 5 years - example of growth standards. GROWTH REFERENCES - are descriptive data that define how children in the population are growing under the best possible state of nutrition and health in a given community. They represent how children are actually growing rather than how they should be growing. Eg - The 2015 IAP growth charts describe how children in India were actually growing at that point of time. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

46. WHO GROWTH STANDARDS Provide a single international standard that is representing the best description of physiological growth for all children from birth to 5 years of age. B ased on the growth of exclusively breastfed infants. I ncludes children from many of the world’s major regions: Brazil, Ghana, India, Norway, Oman and the USA. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

47. WHO GROWTH STANDARDS B ased on longitudinally collected data as opposed to cross-sectional data in previous charts WHO standards describe ”how children should grow” M ake breastfeeding the biological ”norm” and establish the breastfed infant as the normative growth model. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

48. GROWTH REFERENCE FOR INDIAN CHILDREN 5-18 YEARS R egional variations amongst the pattern of growth due to socioeconomic, geographical and racial differences. F or a particular population , the ideal reference standards would derived from that population itself IAP recommend these charts as reference values for Indian children between 5 - 18 years of age. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

49. GROWTH CHARTS It is a visible display of the child's physical growth and development and useful for longitudinal follow-up of a child. WHO growth charts for children below five years which compares weight for age of the child IAP charts for children in 5-18 years which compares their BMI for age. There are separate charts for boys and girls. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

50. INTERPRETATION Assess whether measurement is less than 3rd or more than 97th percentile on the corresponding growth chart If yes, the child may not be growing normally and needs evaluation. A normal Child remains between 15th and 85th percentile curves and does not change his percentile group (e.g. between 15th and 25th or 25th and 50th percentile curves) at succeeding ages or change only gradually. A sudden shift in the percentile group (i.e. from a higher to lower or lower to higher) on serial monitoring needs evaluation. Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

51. In a normal child, height and weight usually follow the same percentile position. However, before being labeled as normal, should be reviewed for growth abnormalities. A normal child stays on or near one percentile curve or between the same curves on subsequent monitoring. Children with weight/height measurements that lie between 3rd and 15th percentile or between 85th and 97th percentile need to be followed up and reviewed periodically (infant: monthly for 3—6 months; children: 3 monthly for 1—2 years). Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

52. INTERPRETATION OF GROWTH PARAMETERS IN CHILDREN 0 TO 5 YEARS OF AGE Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2024

53. GROWTH CHARTS WE USE

54. GROWTH CHARTS WHO growth charts (0 to 60 months/5 years) Weight for age Length for age Weight for length Head circumference IAP growth charts (5 – 18 years) Weight for age Height for age BMI

55. SUGGESTED GROWTH MONITORING AT DIFFERENT AGES AGE HEIGHT/LENGTH WEIGHT HEAD CIRCUMFERENE OTHER Birth ✔ ✔ ✔ 1.5,3.5,6 ,9 and 15 mths ✔ ✔ ✔ 18mths- 3 years ✔ ( 6 monthly) ✔( 6 monthly) ✔ ( 6 monthly) 3.5-5.5 yrs ✔ ( 6 monthly) ✔( 6 monthly) 6 – 8 yrs ✔( 6 monthly) ✔( 6 monthly) BMI (yearly) 9-18 yrs ✔(yearly) ✔(yearly) BMI and SMR (yearly)

56. ASSESSMENT OF NUTRITION BY ANTHROPOMETRY

57. SEVERE ACUTE MALNUTRITION R ecommended by WHO for identifying and managing children with life threatening undernutrition in public health programme settings . Between 6-59mths of age- Weight-for-height below -3 standard deviation ( <-3SD) on the WHO Growth Standard Presence of bipedal edema ; Mid upper arm circumference (MUAC) below 11.5 cm. In a child below 6 months of age, the MUAC is not used as a criterion OP GHAI

58. IAP (Indian Academy of Pediatrics) Classification of PEM (Protein Energy Malnutrition) Based on weight for age S imple and the cut-offs are suitable for Indian population. DISADVANTAGE – D oes not take into account the child’s height. The weight is also dependent on height, besides the built. Moreover does not tell about the duration of energy deprivation. Short children (not necessarily because of nutritional deprivation) are also misclassified as PEM by this classification. GRADE OF MALNUTRITION WEIGHT FOR AGE NORMAL > 80% GRADE 1 71 – 80% GRADE 2 61-70% GRADE 3 51-60% GRADE 4 ≤50% Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

59. WELLCOME TRUST CLASSIFICATION B ased on deficit in body weight-for-age and presence or absence of edema Weight-for-age No edema Edema 60—80% Of expected Undernutrition Kwarshiorkor < 60% of expected Marasmus Marasmic kwarshiorkor Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

60. WHO Classification of Undernutrition This classification is based on two anthropometric indicators (stunting and wasting ), and one clinical indicator (edema ) Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

61. REFERENCES Elizabeth KE. Nutrition and child development. Paras medical publisher; 2010 Ghai OP, Paul VK, Bagga A. Textbook of Paediatrics ; 2023 Gupta P, Menon PS, Ramji S, Lodha R. PG Textbook of Pediatrics: Volume 1: General Pediatrics and Neonatology. JP Medical Ltd; 2015 Aug 31.

62. Case 1 A 3 1/2 month male baby is brought for vaccination. The baby was born at 35 weeks gestational age with birth weight of 2.5 kg. Baby is on exclusive breast feeds. Currently, weight is 4.8 kg, length is 56 cm and head circumference is 36.5 cm. Plot the weight, length, weight for length and head circumference of the baby Mention your interpretation for each of these anthropometric parameters What is your interpretation regarding the baby’s weight gain?

63. Case 2 A 12 years old girl presents with poor height gain compared to her peers. Her weight is 42 kg, height is 132 cm and Tanner’s stage 1. Her mother’s height is 155 cm and father’s height is 160 cm. She is otherwise well, with adequate dietary intake and has no significant medical history. Her mother and elder sister attained menarche at 15 years and father started shaving at 20 years. Upper to lower segment ratio is 1 and systemic examination is within normal limits, with no dysmorphic features. Basic investigations including hemogram , RFT, LFT, TSH are normal. Bone age is 10 years. Plot her height, weight and BMI for age and mention your interpretation Calculate and depict her midparental height What is the likely etiology for short stature? At which stage of puberty is growth spurt expected in girls?

64. Case 3 A 9 month male infant is brought with loose stools since 3 days. On examination, weight is 6 kg, length 70 cm and head circumference is 44 cm. There is history of bottle feeding, with feeds predominantly being diluted cows milky . Child appears emaciated, with loose skin folds and no edema. Oral mucosa is dry. Plot the weight, length and weight for length for this child, mention your interpretation What additional anthropometric parameter would you look for in this child? Would you advise outpatient or inpatient management? What would be the expected weight gain during nutritional recovery?

65. Case 4 You are the medical officer conducting a school health camp. A 6 year old girl has height of 115 cm, weight is 26 kg. Screen time is 3 hours/day with preference for processed foods, and she does not take part in sports activities. Plot her weight, height and BMI for age B What is your interpretation? What are the risks of this condition? What advise would you give?

66. THANK YOU