GROWTH ASSESSMENT

Dr. DODDABASAVA K.JUNIOR RESIDENT

KSHEMA

Definition of Growth

•Growth is increase in size of organs and body.

•It is quantitative change and refers to physical maturation of the body.

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.

Periods of growthTerminology 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)

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)

Factors Affecting Growth1. Genetic factors a.Race b.Sex c.Chromosomal2.Nutritional Factors3.Hormonal-Thyroxine GH4.Environmental Factors a.Infections b.Trauma to growing bones c.Chronic systemic illness

5.Seasonal variation6.Emotional factors7.Social Factors a) Socioeconomic class b) Education of parents c) Education of child

Laws Of Growth

1. Continuous and orderly process.2. Growth pattern of every individual is unique.3. Different tissues grow at different rates.• General body growth – first two years of life.• Brain growth – 3rd trimester and 1st year of

life.• Lymphoid growth – Mid childhood

Rate of growth of different tissues

Growth can be measured in terms of:

1. Physical anthropometry2. Assessment of tissue growth3. Bone age4. Dental age

Physical anthropometry

Age dependent anthropometry-1. Weight2. Length or Height3. Head circumference4. Chest circumference

Age independent anthropometry

1. Midarm circumference(1-5 yrs)2. Weight for height3. Mid upper arm/height ratio4. Midarm/Head circumference ratio5. Quetlet’s index6. Ponderal index7. Dugdale’s index8. Body mass index

WEIGHTMeasurement:

• 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.

• beam type weighing scale• detecto scale• electronic scale• bath room type scale• Salter spring machine

Electronic Weighing Scale

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

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

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

Interpretation of WHO ChartsZ 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

Growth Chart- Weight for Age

IAP ClassificationNutritional Status Weight for age(%) for 50th pecentile of

Harvard StandardNormal >80

Grade I 71-80

Grade II 61-70

Grade III 51-60

Grade IV <50

Gomez ClassifactionNutritional Status Weight for age(%) for 50th pecentile of

Harvard Standard

Normal >90

Grade I 76-90

Grade II 60-75

Grade III <60

Wellcome TrustWeight for age Edema Present Edema Absent

60-80% Kwashirkor Undernutrition

<60% Marasmic Kwashiorkor Marasmus

Length/Height

• Lenght - < 2yrs - Infantometer• Height - > 2yrs - Stadiometer

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

• >2yrs-stadiometer• Bare footed with feet parallel• Heels , buttocks , shoulders & occiput touching

the wall• Head erect with eyes aligned horizontally• Nearest 0.5cms

Infantometer

Stadiometer

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

Growth Chart-Height for Age

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

Head Circumference

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

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

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

Chest Circumference

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.

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

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)

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

Mid Arm Circumference

Shakir TapeMUAC (cm) Inference

>13.5 Normal

12.5-13.5 Borderline

<12.5 Under nutrition

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.

QUAC STICK

• Quakers arm circumference stick• Consists of rod with 2 sets of markings

heightMAC corresponding to ht

• If ht > ht for expected MAC – child is malnourished

• Modified quack stick – colored rod

Quack Stick

Weight for height

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

Waterlow’s classificationClassification Height for Age

(% of expected)

Normal >95

First degree stunting 90-95

Second degree stunting 85-89

Third degree stunting <85

Classification Weight for height(% expected of expected)

Normal >90

Mild wasting 80-90

Moderate wasting 70-79

Severe wasting <70

WHO ClassificationWeight 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 +/-

Quetlet Index

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

Rao and Singh’s Index

• Calculated as: weight(kg) X 100 { Height(cm)}2 • Normal:0.15-0.16• <0.14 indicate malnutrition

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

Body Mass Index

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

Growth Chart - BMI

Dugdale’s Index

• Calculated as Weight(kg) x 100 Height(cm)1.6

Normal Value-0.88- 0.97Malnutrition - <0.79

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

Assessment of Tissue Growth

1. Triceps skin fold thickness2. Biceps skin fold thickness• Skin fold thickness gives estimation of fat.• Can be measured by Lange’s of Harpenden’s

Skin fold calipers.

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-rayNew born Knee, Ankle

3-9 months Shoulder

3 yrs Wrist

12-16 yrs Elbow, Hip

Dental Age Age Eruption

At birth Nil

6-8 months Central incisors

10 months Lateral incisors

12-15 months 1st molar

15-21 months Canine

21-24 months 2nd molar

The teeth in the upper jaw erupt earlier than the lower jaw except lower central incisors

Permanent TeethAge Eruption

6 1st molar

7-8 Central and lateral incisors

9 First premolar

10-11 2nd Premolar

11-12 Canines

12-13 2nd molars

17-22 3rd molars

THANK YOU