8.6 Assessing nutrition, growth and development
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1 8.6 Assessing nutrition, growth and development Measuring nutritional status Calculating the child s weight for length This is the most relevant measurement in nutritional assessment. knees and press down fi rmly, and with the other hand place the foot- piece fi rmly against the heels measure the length (to the nearest 0.1 cm) and record it immediately. Measuring length At 2 years Ideally two people are needed to take this measurement, and the child should be supine on a fl at surface. The fi rst person should: assist in positioning the child face up on the measuring board, supporting the head and placing it against the headboard position the crown of the head against the headboard, compressing the hair check that the child lies straight along the centre line of the board and is not slanted, and does not change position (it is usual for this person to stand or kneel behind the headboard). The second person should: support the trunk as the child is positioned on the board lie the child fl at along the board place one hand on the shins above the ankles or on the The measuring board should be checked for accuracy every month. At 3 years This measurement should be taken without the child wearing shoes. The child should stand with their heels and back in contact with an upright wall. The head is held to look straight forward with the lower eye sockets in line with the ears. The nose must not be tilted upward. A weighted block at right angles to the wall is then lowered on to the head and a scale fi xed to the wall is read. During measurement the child should be asked to stretch their neck to be as tall as possible, but their heels must not leave the ground. The measurer should help to stretch the neck by fi rm pressure upward under the mastoid processes. Measure the height immediately to within 0.1 cm. 871
2 International Maternal & Child Health Care Measuring weight At 2 years Leave a cloth in the weighing pan to prevent chilling of the child. Adjust the scales to zero with the cloth in the pan. Place the naked child gently on the cloth in the weighing pan. Wait for the child to settle and the weight to stabilise. Measure the weight (to the nearest 10 grams) and record it immediately. Standardisation of the scales should be performed weekly or whenever the scales are moved. At 3 years The child should be weighed naked or, if pants are worn, 0.1 kg should be subtracted from the weight measured. The bladder should be emptied before weighing. Determining the child s percentage weight for length or SD weight for length See Figure Locate the row containing the child s length in the central column of the table. Look to the left in that row for boys, and to the right for girls. Note where the child s weight lies with respect to the weights recorded in this row. Select the weight closest to that of the child. Look up this column to read the weight for length of the child. Note: Although the interpretation of a fi xed percent- ofmedian value varies across age and height, and generally the two scales cannot be compared, the approximate percent- of- the median values for 1 SD and 2 SD are 90% and 80% of the median, respectively (Bulletin of the World Health Organization, 1994, 72, ). Length is measured below 85 cm; height is measured at 85 cm or above. Recumbent length is on average 0.5 cm greater than standing height, although the difference is of no importance to the individual child. A correction may be made by deducting 0.5 cm from all lengths above 84.9 cm if the standing height cannot be measured. Example 1. Boy of length 61 cm and weight 5.3 kg: this child is 2 SD weight for length (84% of the median: 5.3 divided by ). Example 2. Girl of length 67 cm and weight 4.3 kg; this child is less than 4 SD weight for length (less than 60% of the median: 57%). Monitoring weight gain Calculating weight gain The example below is for weight gain over 3 days, but the same procedure can be applied to any inter val. Subtract the child s weight (in grams) that was measured 3 days earlier from their current weight. Divide by three to calculate the average daily weight gain (grams/day). Divide by the child s average weight (in kg) to cal culate the daily weight gain per unit body weight (grams/kg/ day). Monitoring charts: explanation of the charts on the following pages Figure shows a weight chart which has been used to monitor the weight gain of a severely malnourished child. The horizontal x axis repre sents the number of days after admission, while the vertical y axis represents the weight of the child in kilograms (kg). FIGURE Weight- for- length reference chart (below 87 cm). SD = standard deviation score or Z- score. Based on World Health Organization data. FIGURE Personalised weight chart for child. 872
3 Section 8.6 Notice that the weight in kilograms is stepped in 0.5- kg increments. In this example, the range has been written in from 5.0 to 7.5 kg to provide a suitable range for this individual child s expected growth. For other children, fi ll in the starting weight at the appropriate level (e.g. 5 kg, 5.5 kg, 6 kg, etc., or 7 kg, 7.5 kg, 8 kg, etc.). Choosing an appropriate starting weight like this is preferable to using a chart with weights marked from 0, because this more fl exible chart gives a larger scale and thus shows the pattern of change much more clearly. Figure shows a blank intake and output chart for recording the food given to an individual patient, the amount con sumed, and any losses through vomiting or diarrhoea. FIGURE Weight chart for girls from birth to 2 years. Based on FIGURE Twenty- four- hour food intake chart. Additional measurements for assessing nutritional status Mid upper arm circumference (MUAC) This is measured with non- stretchable tape placed around the arm midway between the elbow and the shoulder. The tape should be gently tightened, but not so much that it compresses the underlying tissues. This measurement includes fat and muscle. FIGURE Supine length and head circumference chart for girls from birth to 2 years. Based on World Health Organization data. Normal values of MUAC for a child aged 1 5 years are in the range cm. For a child aged 1 5 years, a MUAC of < 12.5 cm indicates that the child is defi nitely malnourished, and a MUAC in the range cm indicates that they are probably malnourished. Triceps skinfold thickness Special skinfold callipers are used to measure the double layer of skin and subcutaneous fat overlying the triceps muscle when the skinfold is lifted. Measuring growth and development Individual measurements of weight and height/length can be plotted sequentially on charts to identify any failure of growth. See the charts below for height and weight for boys and girls. These charts also include data for infants born prematurely, as well as head circumference measurements. FIGURE Weight chart for boys from birth to 2 years. Based on 873
4 International Maternal & Child Health Care FIGURE Supine length and head circumference chart for boys from birth to 2 years. Based on World Health Organization data. FIGURE Weight chart for boys aged 2 18 years. Based on FIGURE Weight chart for girls aged 2 18 years. Based on FIGURE Height chart for boys aged 2 18 years. Based on Measurement of head circumference Use a non- stretchable tape. Measure around the forehead above the eyebrows to the maximum occipital point. Measure twice for accuracy. Assessment of pubertal state Girls The following should be recorded. FIGURE Height chart for girls aged 2 18 years. Based on Breast development Stage 1. Pre- adolescent: elevation of papilla only. Stage 2. Breast bud stage: elevation of breast and papilla as a small mound, and enlargement of areola diameter. Stage 3. Further enlargement and elevation of breast and areola, with no separation of their contours. Stage 4. Projection of areola and papilla to form a secondary mound above the level of the breast. 874
5 Section 8.6 Stage 5. Mature stage: projection of papilla only, due to recession of the areola to the general contour of the breast. Pubic hair Stage 1. Pre- adolescent: the vellus over the pubes is not further developed than that over the abdominal wall (i.e. there is no pubic hair). Stage 2. Sparse growth of long, slightly pigmented downy hair, straight or slightly curled, chiefl y along the labia. Stage 3. Hair is considerably darker, coarser and more curled, and spreads sparsely over the junction of the pubes. Stage 4. Hair is now adult in type, but the area covered is still considerably smaller than in the adult; there is no spread to the medial surface of the thighs. Stage 5. Hair is adult in quantity and type, with distribution of the horizontal (or classically feminine ) pattern; there is spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle (spread up the linea alba occurs late, and is rated as Stage 6). Document whether axillary hair is present. Document age at menarche. Boys The following should be recorded. Genital (penis) development Stage 1. Pre- adolescent: the testes, scrotum and penis are of about the same size and proportion as in early childhood. Stage 2. Enlargement of the scrotum and testes. The skin of the scrotum reddens and changes in texture. There is little or no enlargement of the penis at this stage. Stage 3. Enlar gement of the penis, which initially is mainly an increase in length. Further growth of the testes and scrotum. Stage 4. Further enlargement of the penis, with an increase in breadth and development of the glans. The testes and scrotum are larger, and the scrotal skin is darkened. Stage 5. Genitals are adult in size and shape. Pubic hair Stage 1. Pre- adolescent: the vellus over the pubes is not further developed than that over the abdominal wall (i.e. there is no pubic hair). Stage 2. Sparse growth of long slightly pigmented downy hair, straight or slightly curled, chiefl y at the base of the penis. Stage 3. Hair is considerably darker, coarser and more curled, and spreads sparsely over the junction of the pubes. Stage 4. Hair is now adult in type, but the area covered is still considerably smaller than in the adult; there is no spread to the medial surface of the thighs. Stage 5. Hair is adult in quantity and type, with spread to the medial surface of the thighs but not up the linea alba or elsewhere above the base of the inverse triangle (spread up the linea alba occurs late, and is rated as Stage 6). Document whether axillary hair is present. Testicular volume The approximate volume at each genital stage is shown. Stage 1: ml. Stage 2: 4 6 ml. Stage 3: 6 10 ml. Stage 4: ml. Stage 5: ml. Source: The standard illustrations in Tanner JM (1962) Growth at Adolescence, 2nd edn. Oxford: Blackwell Scientifi c Publications. 875
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