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Paediatric Clinic: Anthropometry and Clinical Examination

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PART 1 - ANTHROPOMETRY

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1.1 Core Anthropometric Parameters

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1.2 How to Measure - Techniques

Weight

• Infants (<2 years): Use a pan/beam scale. Remove all clothing and nappies. Weigh to the nearest 10 g.
• Children (>2 years): Stand on upright digital scale. Minimal clothing, no shoes. Weigh to nearest 100 g.
• Trick: Weigh mother holding baby, subtract mother's weight if infant is uncooperative.

Length (0-2 years)

• Use an infantometer (length board with fixed headplate and movable footplate).
• Child lies supine. One observer holds the head with the Frankfurt plane vertical (eyes looking straight up). Second observer extends the knees, keeps feet flat at 90°, and reads the footplate.
• Measure to the nearest 0.1 cm.
• Children measured lying are approximately 0.7 cm longer than standing - remember this at the 2-year handover.

Height (>2 years)

• Use a stadiometer fixed to a flat wall (no skirting board).
• Child stands barefoot, feet together, heels/buttocks/shoulder blades/back of head touching the wall (not all four are always possible - heels and head are priorities).
• Frankfurt plane horizontal (bottom of eye socket level with the top of the ear canal, eyes looking straight ahead).
• Deep breath in, read at maximum inspiration with the headpiece pressed firmly.
• Measure to nearest 0.1 cm, best in the morning (diurnal variation: children are ~1 cm shorter in the afternoon due to spinal compression).

Head Circumference (OFC - Occipito-Frontal Circumference)

• Use a non-stretch tape (paper or fibreglass, never cloth).
• Measure the maximum circumference: tape passes over the most prominent part of the occiput posteriorly and the glabella (supraorbital ridges) anteriorly.
• Take the largest of 3 readings.
• Key values (approximate):
  • Birth: ~34 cm
  • 3 months: ~40 cm
  • 6 months: ~43 cm
  • 1 year: ~46-47 cm
  • 2 years: ~49 cm
  • Adult: ~54-57 cm
• Growth rate: ~2 cm/month in months 1-3; ~1 cm/month months 4-6; ~0.5 cm/month months 7-12.

MUAC (Mid-Upper Arm Circumference)

• Locate the midpoint between the acromion and the tip of the olecranon with the arm bent at 90°. Mark with a pen.
• Let the arm hang relaxed at the side. Place the tape around the mid-arm, ensuring it is horizontal and snug but not compressing tissue.
• Interpretation (WHO, 6 months - 5 years):
  • ≥12.5 cm: Normal
  • 11.5 - <12.5 cm: Moderate acute malnutrition (MAM)
  • <11.5 cm: Severe acute malnutrition (SAM)
• MUAC is preferred over weight-for-height in field settings because it does not require age verification.

Chest Circumference

• Measured at the level of the nipples during mid-respiration.
• At birth: CC ≈ HC (both ~32-34 cm). After 6 months, CC exceeds HC = normal. If HC > CC persists beyond 6 months = consider macrocephaly or undernutrition.

Skinfold Thickness

• Triceps skinfold: Posterior midline of the upper arm at the marked midpoint. Grasp a vertical fold of skin and subcutaneous fat, apply Harpenden callipers, read after 2 seconds.
• Subscapular skinfold: Just below the inferior angle of the scapula at 45°.
• Together these estimate percentage body fat.

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1.3 Indices and Derived Measurements

BMI (Body Mass Index)

• Formula: Weight (kg) / Height² (m²)
• In children, BMI is age- and sex-specific; use z-scores or percentiles (not adult cut-offs).
• WHO thresholds for children 5-19 years:
  • <-2 SD: Thinness
  • <-3 SD: Severe thinness

  • +1 SD: Overweight

  • +2 SD: Obese

Weight-for-Age (WFA)

• Reflects overall growth, but cannot distinguish between stunting and wasting.
• <-2 SD = Underweight; <-3 SD = Severe underweight.

Height/Length-for-Age (HFA/LFA)

• Reflects chronic malnutrition / stunting.
• <-2 SD = Stunted; <-3 SD = Severely stunted.

Weight-for-Height (WFH) / Weight-for-Length (WFL)

• Reflects acute malnutrition / wasting. Independent of age.
• <-2 SD = Wasted (acute malnutrition); <-3 SD = Severely wasted.

Interpretation Summary (WHO Classification)

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1.4 Growth Charts

• WHO Growth Standards (0-5 years): Based on healthy, breastfed children from 6 countries. Prescriptive (how children should grow).
• WHO Growth Reference (5-19 years): Descriptive (how children do grow in population sample).
• CDC Charts (2000): Alternative reference; used primarily in the USA.
• UK-WHO 0-4 Charts (RCPCH): Hybrid charts used in the UK.

1. Identify child's age (correct for prematurity until 2 years for <32 weeks, until 1 year for 32-36 weeks).
2. Find the intersection of age (x-axis) and measurement (y-axis).
3. Identify which centile/SD line the point falls on.
4. Concern if crossing 2+ centile lines downward, or consistently below -2 SD.

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PART 2 - CLINICAL EXAMINATION IN PAEDIATRICS

2.1 The Paediatric Consultation: General Principles

• History first - children cannot fully articulate; parents are key informants.
• Observe before touching. A child playing happily in the waiting room is not critically ill.
• Build rapport - talk to the child at eye level, use their name, offer a toy, let them see and touch equipment.
• Opportunistic examination - examine what you can when the child cooperates; don't follow rigid head-to-toe order in toddlers.
• Respect modesty in older children.
• Parental presence is usually reassuring for younger children; for adolescents, offer time alone for sensitive questions.

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2.2 The Approach by Age

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2.3 General Inspection (The Global Assessment)

• Colour: Pink (normal), pale (anaemia), cyanosis (central vs peripheral), jaundice, mottled (poor perfusion), plethoric.
• Breathing: Tachypnoea, recession (subcostal, intercostal, sternal), head-bobbing in infants, nasal flaring, stridor, grunting, wheeze.
• Conscious state: Alert, irritable, lethargic, AVPU scale.
• Tone: Hypotonic ("floppy") vs hypertonic.
• Dysmorphic features: Syndromes (Down's, Turner's, Marfan's, etc.)
• Nutritional state: Wasting, oedema (kwashiorkor), pot belly.
• Skin: Rashes, bruising, marks, pallor, eczema.

• Green = Low risk; Amber = Intermediate risk; Red = High risk.

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2.4 Vital Signs - Paediatric Normal Values

• Tachycardia is the most sensitive early indicator of shock in children.
• Hypotension is a late sign of decompensated shock - paediatric patients maintain BP until 25-30% blood loss.

• Normal: 36.5 - 37.5°C (axillary or tympanic).
• Fever: ≥38.0°C rectal; ≥37.5°C axillary.
• In infants <3 months: any fever ≥38°C = serious until proven otherwise.

• SpO₂ >95% is normal in most children.
• 92-94%: supplemental oxygen needed; <92%: urgent management.

• Use the correct cuff size: cuff width = 40% of upper arm circumference.
• Normal lower limit of SBP = 70 + (2 × age in years) for 1-10 years.

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2.5 Systematic Examination

A. Cardiovascular

• Central cyanosis (tongue, mucous membranes)
• Peripheral oedema
• Visible precordial pulsation
• Clubbing (chronic hypoxia, SBE, cyanotic CHD)
• Scars (previous cardiac surgery - midline sternotomy, lateral thoracotomy)

• Apex beat: 4th intercostal space, midclavicular line in <7 years; 5th space in >7 years.
• Heaves (right or left ventricular), thrills.
• Femoral pulses: always palpate both simultaneously to exclude coarctation of the aorta (radio-femoral delay or absence).
• Liver: right heart failure causes hepatomegaly in children (not peripheral oedema as in adults).

• Innocent murmurs are common in children (present in up to 50%):
  • Still's murmur: musical, vibratory, 2/6, lower left sternal edge, disappears when supine.
  • Venous hum: continuous, infraclavicular, disappears with head turning/Valsalva.
  • Pulmonary flow murmur: systolic, upper left sternal edge.
• Pathological murmur features: harsh, pansystolic, diastolic, grade ≥3, associated thrill, radiates, no change with position, associated symptoms.

B. Respiratory

• Respiratory rate (count for full 60 seconds in young infants)
• Chest shape: hyperinflation (barrel chest = chronic air trapping as in asthma), pectus excavatum, pectus carinatum, Harrison's sulcus (chronic subcostal recession leaving a groove = long-standing airways disease)
• Work of breathing: subcostal, intercostal, supraclavicular recession; nasal flaring; tracheal tug; head bobbing (infants)
• Breathing pattern: abdominal breathing is normal in infants

• Crackles: fine (pulmonary oedema, pneumonia), coarse (secretions, bronchiectasis)
• Wheeze: expiratory or biphasic (obstructive)
• Stridor: inspiratory = extrathoracic obstruction (croup, epiglottitis, inhaled foreign body); expiratory stridor = intrathoracic
• Bronchial breathing: consolidation

C. Gastrointestinal / Abdomen

• Abdominal distension: gaseous (obstruction), ascitic (liver disease, nephrotic syndrome), organomegaly.
• Visible peristalsis: pyloric stenosis (waves from left to right in epigastrium)
• Umbilicus: hernias are common and usually resolve by age 4-5 years.
• Scars, skin changes.

• Begin away from the area of pain; use warm hands, distract with conversation.
• Liver: Palpate from the RIF upward. Normal in infants up to 2 cm BCM. Note span by percussion.
• Spleen: Palpate from the RIF toward the left hypochondrium. Enlarged spleen moves with respiration, has a notch, cannot get above it.
• Kidneys: Bimanual palpation ("ballottement"). Right kidney is slightly lower. Kidneys are palpable in neonates and thin infants normally.
• Assess for renal masses (Wilms' tumour - unilateral, smooth, does not cross midline).

• Inguinal hernia: More common in boys, premature infants. Indirect type. Reduces with pressure and lying. Risk of strangulation.
• Umbilical hernia: Extremely common; typically resolve spontaneously.

D. Neurological

• Observe posture and spontaneous movement.
• "Floppy infant" = hypotonia. Central vs peripheral: central hypotonia usually has preserved reflexes and brisk DTRs; peripheral (LMN) has absent/reduced reflexes.

• Deep tendon reflexes: biceps (C5-6), triceps (C7), knee (L3-4), ankle (S1-2).
• Primitive reflexes (neonatal): should disappear by stated ages:

E. Musculoskeletal / Developmental

• Hips: Barlow and Ortolani tests in neonates. Galeazzi sign. From 6+ months, assess gait.
• Spine: Scoliosis screen (Adams forward bend test from ~6 years).
• Gait: Observe walking, running; age 1-3 years have a wide-based toddler gait (normal).
• Feet: Talipes, flat feet (usually physiological to age 7-8), in-toeing.

F. ENT

• Ear: Otoscope; note position (low-set ears = Turner's, Down's, renal anomalies). Look for discharge, perforation, effusion ("glue ear").
• Nose: Obstruction, discharge, septal deviation.
• Throat: Tonsil size (Brodsky grading 1-4+), pharyngeal erythema, exudate, Koplik's spots (measles), strawberry tongue (Kawasaki, scarlet fever).

G. Skin and Lymph Nodes

• Up to 1 cm cervical lymph nodes are normal in children.
• Supraclavicular nodes are always pathological.
• Note: size, consistency, tenderness, mobility, overlying skin changes.

• Mongolian blue spots: benign, common in dark-skinned infants; lumbar/sacral; fade by age 5.
• Erythema toxicum: benign pustules, days 1-3.
• Milia: tiny white sebaceous cysts on nose/face; resolve spontaneously.
• Port wine stain (Sturge-Weber association if V1 distribution).
• Café-au-lait spots: >5, >0.5 cm = consider neurofibromatosis type 1.

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2.6 Developmental Assessment

• No social smile by 8 weeks
• No babble by 12 months
• No pointing/waving by 12 months
• No single words by 16 months
• No 2-word phrases by 24 months
• Any regression at any age

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2.7 Neonatal Examination (NIPE - Newborn Infant Physical Examination)

1. Eyes - Red reflex bilaterally (absent = congenital cataract, retinoblastoma)
2. Heart - Murmurs, femoral pulses (coarctation), four-limb saturations
3. Hips - Ortolani and Barlow (developmental dysplasia of the hip - DDH)
4. Testes - Descended bilaterally; undescended testes must be referred

• Palate intact (finger through mouth - submucosal clefts are missed by inspection alone)
• Moro reflex
• Tone and posture
• Fontanelles: anterior (closes 12-18 months), posterior (closes 6-8 weeks)
• Spine: sacral dimple, hair tuft, lipoma = spinal dysraphism
• Anus: patent
• Genitalia: normal configuration, hypospadias

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2.8 The 6-8 Week Check

• Full general examination
• Growth: weight, length, OFC - plot on centile chart
• Developmental milestones (smiling, fixing/following, head control)
• Immunisation history
• Feeding history
• Maternal mental health (Edinburgh Postnatal Depression Score)
• Hip check
• Eye: red reflex, fixes and follows
• Hearing: screen was at birth; parental concerns

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PART 3 - INTEGRATED ASSESSMENT IN THE CLINIC

3.1 Nutritional Assessment (ABCDE)

3.2 Common Nutritional Signs to Examine For

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PART 4 - QUICK REFERENCE SUMMARY

Anthropometry Equipment Checklist for Clinic

• Calibrated digital infant scale (0-10 kg, to 10 g)
• Adult scale with paediatric range
• Infantometer (length board) for <2 years
• Wall-mounted stadiometer for ≥2 years
• Non-stretch measuring tape (OFC, MUAC, chest)
• WHO Growth Charts (age/sex appropriate, 0-2 and 2-18 yrs)
• MUAC tape (tri-colour for 6 months - 5 years)
• Harpenden skinfold callipers (optional, specialist use)

Key Formulas

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Key Sources

• Park's Textbook of Preventive and Social Medicine - covers anthropometry in nutritional assessment (Chapter 11)
• The Harriet Lane Handbook, 23rd Edition (Johns Hopkins) - paediatric vital signs, examination norms
• Red Book 2021, Committee on Infectious Diseases (AAP) - newborn screening
• WHO Multicentre Growth Reference Study (MGRS) - growth standards 0-5 years
• RCPCH UK-WHO Growth Charts - centile and z-score references
• NICE Guideline CG160 - Fever in under 5s (traffic light system)

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Holliday-Segar Formula

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The Formula

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How to Calculate - Step by Step

• First 10 kg: 10 × 100 = 1000 mL
• Next 10 kg (10-20 kg): 10 × 50 = 500 mL
• Each kg above 20 kg: × 20 mL

• First 10 kg: 10 × 4 = 40 mL/hr
• Next 10 kg: 10 × 2 = 20 mL/hr
• Each kg above 20 kg: × 1 mL/hr

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Worked Examples

• All weight in first 10 kg bracket
• Daily: 8 × 100 = 800 mL/day
• Hourly: 8 × 4 = 32 mL/hr

• First 10 kg: 1000 mL/day (40 mL/hr)
• Next 5 kg: 5 × 50 = 250 mL/day (5 × 2 = 10 mL/hr)
• Total: 1250 mL/day = 50 mL/hr

• First 10 kg: 1000 mL/day (40 mL/hr)
• Second 10 kg: 500 mL/day (20 mL/hr)
• Remaining 5 kg: 5 × 20 = 100 mL/day (5 × 1 = 5 mL/hr)
• Total: 1600 mL/day = 65 mL/hr

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Quick Mental Formula (Summary)

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Important Notes

1. Not for neonates <14 days old - the formula overestimates fluid needs in newborns. Use dedicated neonatal fluid protocols instead.
2. Maximum rate: Experts recommend a maximum of 120 mL/hr in the absence of cardiac, hepatic, or renal pathology. Lower the rate if there is risk of fluid overload.
3. Fluid type (updated guidance): The original Holliday-Segar paper recommended hypotonic fluids (¼ NS) based on the electrolyte composition of human milk. However, AAP guidelines (2018) now recommend isotonic fluids (0.9% NaCl or Hartmann's/Lactated Ringer's) as the maintenance fluid of choice for most hospitalised children, to prevent hospital-acquired hyponatraemia. The volume calculated by Holliday-Segar remains valid; the composition has changed.
4. Total body water (TBW) = 60% of body weight in kg (75% in infants) - used alongside Holliday-Segar when calculating dehydration deficits.
5. Adjust upward for:
   • Fever (+12% per 1°C above 37.5°C)
   • Increased insensible losses (burns, phototherapy, high ambient temperature)
   • Ongoing losses (diarrhoea, vomiting, drains)
6. Adjust downward for:
   • SIADH / fluid retention states
   • Oliguric renal failure
   • Post-operative states (ADH release increases fluid retention)
   • Cardiac or hepatic disease

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Electrolyte Requirements (Original Holliday-Segar)

• Sodium: ~3 mEq
• Potassium: ~2 mEq

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