Anthropometrics

Dr/GihanFouad
MDpediatrics,IBCLC,TQM,
fellowship board Hospital Management
Head of infection control unit ,Quality
unit
Nutritional requirements and growth
department
National Nutrition Institute
Nutritional Assessment

The assessment of nutritional status is

commonly summarized by the mnemonic "ABCD)

Anthropometric Biochemical

Clinical Dietary
§ Growth is an important index of a child’s nutritional
status and should be monitored on a regular basis.
Accurate measurements of growth parameters plotted on
an appropriate growth curve is one of the simplest but
most powerful tools in our care of infants.
§ Anthropometry refers to comparative measurements of
the human body.
-  The primary measures used as indices of growth and
development include stature (length or height), weight,
and head circumference (for young children).
-  The secondary measures used to estimate body
composition include triceps skinfold thickness,
subscapular skinfold thickness, and mid-upper arm
circumference
 I am a person not a dot
§  Factors that alter Energy needs
§  Body composition
§  Body size
§  Gender
§  Growth
§  Genetics
§  Ethnicity
§  Environment
§  Adaptation and accommodation
§  Activity/work
§  Illness/Medical conditions
Variability of Normal Infant growth
 Growth channels

§  children follow a predictable channel ofgrowth (which appears

as a curve that mimics the percentile channels) for height and
weight throughout childhood. If child’s growth changes 2
growth channels in either direction, this may be a sign that
abnormalities in growth are occurring

§  Patient falls off

his or her weight curve during the 12-24 month
period when children are picky eaters but regains their original
channel of growth some months later

§  Some times after 6 or 9 months will have fallen to a lower one,
sometimes crossing more than two percentile lines. He or she
then stays on that particular growth percentile. This is perfectly
normal because early growth may represent intrauterine
growth factors. These can persist in early infancy, but the child
then finds his genetically determined channel of growth and
remains there
Growth spurt of infancy

§  A baby doubles its birth weight in first 6 months of

life.
During this phase infants feed more often than usual
and are often fussy; difficult to controlled.

§  Temporary increase in milk intake during active growing

phase is a normal phenomenon, which gets stabilized
over few following weeks. They often occur at these ages2
to3 week,6 weeks,3 months

§  The great growth spurt ofearly infancy begins to slow

down after 6 months of age. The deceleration of growth
continues until 3 years of age. This is why a toddler
seems to eat less
Catch up growth

§  . Many infants born at or below the tenth percentile for length
may not reach their genetically appropriate growth channel until
1 year of age.

§  This is so termed, because it is perceived as low birth

weight baby's efforts to catch up with the normal expected
weight for the chronological age.

§  The rapid growth helps infants recover from the

compromised fetal growth It usually takes 6 months for the
prematurely born and IUGR (intra uterine growth
retardation) infants to catch up with their normal expected
weight and height. Sometimes it may even take longer.

§  Catch up growth is also seen during early childhood, after a

prolonged illness or nutrition deprivation: Sickness, poverty,
§  Slow growth phase occurs between 3-6 years of age, but
it is a major period of skills development –

§  During preadolescence, child growth seems to be at a

uniform pace, but it is not. It has 3-6 small and short
spurts of growth per year. These spurts do not have any
definite time of occurrence.

§  Children in their preadolescence gain 6-7 cm per year in

height and 3-3.5 kg per year in weight.

§  Lag-down growth ;

Large infants at birth who are genetically determined to be

smaller grow at their fetal rate for several months but do not
reach their growth channel until 13 months of age
Failure to thrive(growth faltering)
§  Length or height for age less than
5th percentile

§  BMI less than 5th percentile

§  Deviation of
more than 2 channels
from established

§  pattern of
growth
• Triceps skinfold less than
5thpercentile.

§  • Subscapular skinfold less than

5thpercentile.

-Mid-arm circumference (MAC),

Upper-arm muscle area(AMA), and
Upper-arm fat area (AFA) less than
5th percentile
growth spurt of adolescence

§  markedly higher than the preadolescent velocity of 6-7cm/

year.

§  Children in their early teenage look very thin, because the
corresponding weight and muscle mass gain of
adolescence is delayed by several months.

§  The accelerated growth increases the demand on the daily

requirement of nutrients and calories. With good amount of
nutritious food intake, the teenagers’ body fill out over 2—3
year.

§  Development ofvision defect, Congenita scoliosis, Iron-

deficiency anemia.

§  Anemia is also seen in early infancy growth spurt and with
catch up growth in premature low birth weight babies. Here
also it is due to rapid growth and is described as “bleeding
within circulation” -
Growth spurt of adolescence(Tanner staging of the adolescent)

Growth spurt of puberty in boys

•  Starts between 10 - 15
years of age.
•  Peaks usually at 14.25
years of age.
•  Growth velocity is about
9.5 cm/year

Growth spurt of puberty in girls

•  Starts between 8 - 13
years of age.
•  Peaks usually at 12.5
years of age.
•  Growth velocity is 8.3 cm/
year.
•  Lasts over 4 to 5 years.
-
Growth rate Vs Growth velocity
Background and history
§  The pioneer data developed in 1940 by Meredith in Iowa USA.
§  1960-1970 two set ofcurves developed Harvard In UN,
tanner growth curves In UK .

§  In 1966 a simplified combined-sexes version of

the Harvard
growth curves was widely disseminated by WHO as the
international growth references.

§  During the next decade, dissatisfaction and limitation of

the
Harvard and other available reference data and the desire for
a more contemporary references led to development of new
national growth reference.

§  In 1974 A combined National of health statistics(NCHS) and

Centers for Diseases control(CDC) using data from the US
Health examination Surveys (HES) of NCHS and from the Fels
Research Institute, constructed a set of smoothed percentile
distributions for attained weight, height, and head
circumferences from birth -18 year.
§  In 1977 a WHO working group on nutritional surveillance
recommended specific criteria for the selection of the new
database for a new international growth curves.

§  In May 2000 the U.S. CDC released growth charts, which
are based on 5 nationally representative surveys
conducted between 1963 and 1994.

§  In April 2006 the WHO released new standards for

assessing the growth and development of children from
birth to 5 y of age The new standards adopt a
fundamentally prescriptive approach designed to describe
how all children should grow rather than the more limited
goal of describing how children grew at a specified time
and place.

§  The WHO standards are based on primary data collected

through the WHO Multicenter Growth Reference Study
(MGRS). The MGRS was a population-based study
conducted between 1997 and 2003 in Brazil, Ghana,
India, Norway, Oman, and the United States
 Egyptian growth curve

§  This was a cross-sectional study, 2002 including 27

826healthy subjects 14( 048boys and 13 778girls) grouped
by age every month during the first 24months of life, then
every year until the age of 18years for each sex separate

§  The great majority of

Egyptians live in the Nile river valley and
a geo- graphical gradient supposedly exists in the genetic
constitution of Egyptians. However, the population of Cairo
amounts to about one-fifth of the Egyptian population and
most Cairo settlers have originated from all parts of Egypt.
For this reason the Greater Cairo area represents much of the
Egyptian population in a single site.
§  The sample selection was confined to children from the
higher socioeconomic groups who were assumed to provide
optimum anthropometric data due to the low likelihood of
their suffering malnutrition or overcrowding at home.

§  Infants and preschool children attending 2maternal and

child welfare centers and 72private kindergartens; and older
children and adolescents attending 13 fee-paying primary,
preparatory and secondary grade schools and 4private
sports clubs.
 Take care……………………

§  For anthropometric parameters to be valid indices of

growth status, they must be growth charts requires that
measurements be made in the same manner in which
the reference data were secured . In order to measure a
child accurately,

§  The individual performing the measurement must be

properly trained, and reliable equipment must be
available. For some children with special health care
needs,
it can be challenging to make accurate measurements
because of factors such as contractures and low muscle
tone.
Z Score

§  z-score or “standard deviation

score” is defined as “the deviation
of an individual’s value from the
median value of a reference
population, divided by the standard
deviation of the reference
population (or transformed to
normal distribution).” Basically this
is the number of standard
deviations a data point is away from
the average.
 Comparison of the WHO and CDC length/height-for-age Z-score curves for boys.

de Onis M et al. J. Nutr. 2007;137:144-148

©2007 by American Society for Nutrition
 Comparison of the WHO and CDC weight-for-age Z-score curves for boys.

de Onis M et al. J. Nutr. 2007;137:144-148

©2007 by American Society for Nutrition
 Comparison of the WHO and CDC weight-for-length Z-score curves for boys.

de Onis M et al. J. Nutr. 2007;137:144-148

©2007 by American Society for Nutrition
 WHO growth Charts

1-Length/height for age (recumbent/lying-down

length or standing height).
2-Weight for age.
3-Weight for length.
4-Weight for height.
5-Body Mass Index for age (BMI for age).
6-Motor development milestones for the six
gross motor. milestones: sitting without
support, standing with assistance, hands and
knees crawling, walking with assistance,
standing alone and walking alone.
Windows of achievement for six gross motor milestones

Walking alone

Standing alone
Motor milestone

Walking with assistance

Hands-&-knees crawling

Standing with assistance

Sitting without support

3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21

Age in months
Primary Measures
Head Circumference
Head Circumference

§  Head circumference is an important screening tool in infants

and young children because it is closely related to brain
growth.

§  Head circumference should be measured routinely until at

least 36 months of age.

§  Parental head circumferences of infants whose head

circumferences are atypical should also be measured, as
head circumferences of parents and their offspring are
typically closely associated.

§  it is important to consistently plot measurements on the

same chart and to look for consistent patterns in head
growth.
Technique for measurement of head
circumference
§  Non stretchable tap.
§  Position the child standing or
sitting position.

§  Place the lower edge of

the
measuring tape just above the
child’s eyebrows, above the
ears, and around the occipital
prominence at the back of the
child’s head.

§  Read the measurement to the

nearest 0.1 cm .

§  Repeat twice or until two

reading within .2cm present.
Head Circumference
quiz
Stature (Length and Height)

§  Stature is measured in two ways:

§  Recumbent length for the child
younger than 36 months of age.

§  Standing height for children more

than 24 month.

§  Alternatives measurements (e.g.,

crown-rump length, sitting
height, and arm span) can also
provide information about a
child’s stature.
crown-rump length

§  Contractures about the hips,

knees, and ankles can
interfere with an accurate
stature measurement

§  useful estimates of

stature for
children with contractures of
the lower body.

§  Although measurements will

be below the 5th percentile for
age, they will show whether or
not the child is following a
consistent growth curve.
sitting height
The box should be high enough so that the
child’s legs hang freely.
Recumbent length
Standing height (Stadiometer)
Technique for Height Measurement

§  Use a measuring board with an

attached, movable headboard
(stadiometer).

§  non-bulky clothing and no shoes.

§  Read the measurement to the
nearest 0.1 cm .

§  Repeat the measurement until two

measurements agree within 1 cm .

§ 
Stunting VS Wasting
§  Stunting:
§  low height for age, is caused by
long-term insufficient nutrient
intake and frequent infections.
§  Stunting generally occurs before
age two, and effects are largely
irreversible.
§  These include delayed motor
development, impaired cognitive
function and poor school
performance
§  Wasting:
§  low weight for height, is a strong
predictor of mortality among
children under five.
§  It is usually the result of
acute
significant food shortage and/or
disease
§  Wasting is present when the
child’s weight-for-height is less
than -2 standard deviations
from the mean If a child’s
weight-for-height score is less
than -3 standard deviations, the
child is considered to be
severely wasted
Midparent Height

§  Midparent height adjustments should be applied when the

child is below the 5th percentile or above the 95th
percentile in length or height for age .

§  Adjustments remove influence of

genetics on the child’s
measurement and make it easier to recognize potential
growth problems.

§  Rapid decrease or increase in child`s percentiles for length

or stature not indication for this adjustment.

§  Tables of
adjustment have been developed based on the
research of Himes, Roche
Calculation of Mid-Parental Height

--This calculation corrects for the opposite gender parents

height so that a mid-parental height can be calculated and
evaluated on the appropriate gender growth chart
For boys: [paternal height + (maternal height + 5 inches or 13
centimeters)] / 2
For girls: [maternal height + (paternal height - 5 inches or 13
centimeters)] / 2.

--Predicted adult heights are usually within 10 cm of

midparental height. For boys, add 6.5 cm to midparental
height and for girls subtract 6.5 cm to obtain a ‘target’ height
Application Of Anthropometry
Arm span

--- Person A

§  1. Have the child sit in an erect

position with arms outstretched.

§  Hold The Fixed End Of

anthropometer at the tip of middle
finger Of the child’s hands.

-----Person B

§  the anthropometer going across the

child’s back.

§  Have the child stretch her arms

while the movable sleeve is adjusted
to the maximum arm span.

§  Repeat the measurements until two

measurements agree within 0.1 cm .
Arm span

§  The greater distance between

the tips of the extended
middle fingers of left and right
hand when arms are fully
extended to the sides at right
angles to the body and the
back is straight.

§  For the typically developing

child over age six, the ratio of
arm span to height has been
found to be 1:1

§  Can not be applied in

contractures of the upper
extremities (e.g., in spastic
quadriplegia)
 3

Weight Measurements
 ‘Ideal” Body Weight

§  Ideal” Body Weight

§  Because children grow at different
rates, it is impossible to quantify
an absolute “ideal” weight based
solely on age.

§  the desirable weight for a 108 cm,

6 year old girl is not the same as
for a 120 cm, 6 year old girl,
although both children’s growth
rates can be described as typical.

§  So using the weight that would

place the child at the 50th
percentile for weight for stature as
an “estimated desirable weight” or
“ideal” body weight
Digital scale with a “strain-gauge” mechanism.

Used: Infant and toddler less than 12 kg 

Pan-type or bucket seat-type pediatric scale
To weigh infants and young children who cannot stand
calibrated beam balance scale with non-detachable weights
Technique for Weight Measurement

§  Do not use a spring type bathroom scale which,

with repeated use, will not maintain the
necessary degree of accuracy

§  Frequently check and adjust the zero weight on

the beam scale by placing the main and
fractional sliding weights at their respective
zeros and moving the zeroing weight until the
beam balances at zero.

§  Calibration 2-3 times/ year

§  2 times/ year is enough.
Weight/age for girl
Body Mass Index (BMI)

§  Body mass index (BMI) is a calculation that is used

to assess obesity in children over 2 years

§  BMI =(weight in kilograms) ÷ (height in meters) ÷

(height in meters) .

§  no single BMI is ideal during childhood and

adolescence.
Simple formulas to calculate expected growth in children
Average Weight for Age
Age
3 to 12 months [ Age(mo) + 9 ] divide by 2

1 to 6 years [ Age(yr) x 2 ] + 8

7 to 12 years { [ Age(yr) x 7 ] - 5 } divide by 2

Average height (cm) for age (2 to 12 years) : [ Age(yr) x 6 ] + 77

 Nutritional intervention depending anthropometric
assessment
Secondary Measures
•  Triceps Skinfold Measurements
•  Mid-Upper Arm Circumference
•  Subscapular Skinfold
Skin fold Locations
Mid-Upper Arm Circumference

§  Use flexible Non stretchable

tap measure.

§  Measure the circumference of

the right arm at the midpoint
mark (midway between the
acromial and olecranon
processes as shown in Figure)

§  Measure to the nearest 0.1

cm.

§  Repeat until 2measurment

agree within 0.2cm
Triceps Skinfold Measurements
Skin fold Calibers
Technique for Triceps Skinfold Measurements
•  Accurate calibrated Skin fold caliper.
•  Pick up the skinfold overlying the triceps muscle, 1 cm
above the midpoint mark
•  At the mid point mark apply the jaws ofthe caliper
continuing to hold the skinfold above the mark
•  Re-position the child and re-measure the skinfold. Make sure
there is not tissue compression with the repeated
measurement.
Guidelines for Interpretation of Upper Arm
Indices of Fat and Muscle Stores

§  Frisancho RA. New norms of upper limb fat and muscle
areas for assessment of nutritional status. Am J Clin
Nutr, 1981; 34:2540-2545.

§  Percentiles for triceps skinfold, mid-upper arm

circumference, arm muscle circumference, arm muscle
area, and arm fat area for Caucasians male and female
from 1/75 year.

§  The best use of these measurements for children with

special health care needs is for assessing changes over
time (e.g., increases in fat and muscle stores in the
undernourished child and decreases in fat stores in the
overweight child)
 Subscapular Skinfold

§  the best use of

the subscapular
skinfold measurement in managing
children who are overweight or
underweight is to evaluate individual
change over time.

§  Pick up the subscapular skinfold just

under the shoulder blade, following
the natural fold of the skin. The arm
and shoulder should be relaxed

§  With a pen, mark the midpoint of the

fold.

§  Holding the skinfold approximately 1

cm from the midpoint mark, apply
the jaws of the caliper to the skinfold
so that the mark is midway between
the jaws
Growth Chart Percentiles are Only a Guide
-It is important to remember that growth charts are not
an examination to be passed by a baby, and a “higher score”
does not mean a healthier baby.
-These charts are simply one diagnostic tool.
Another tool is a parentʼ’s intimate knowledge of her baby.
If a baby feeds well at the breast, seems content and is
gaining regularly, chances are she is healthy and growing the
way she is meant to regardless of where she falls on the
chart .
Be carful sometimes Interventions, by mothers and health
visitors, were targeted towards increasing weight gain
rather than improving breastfeeding effectiveness.
Nutrition Risk Indicators

§  Anthropometric Assessment

1.  Height or length for age less than 10th
percentile
Weight for age less than 10th percentile
Weight for length (or height) less than 10th
percentile
Weight for length (or height) greater than
90th percentile
BMI less than 10th or greater than 90th
percentile
Change in weight or length of 2 or more
percentile channels
Inadequate growth or weight gain for more
than one month (under age 2)
Specialty Growth Charts
§ For the child with special health care needs,
previous parameters may not be reliable
indicators of atypical growth.
§  However, they are useful in screening for
children who are at risk for growth problems.
§ These charts should be used as an additional
tool for interpretation of growth after data have
been plotted on the WHO charts. They are
based on the growth of small groups of children
with specific disorders and do not necessarily
reflect ideal rates of growth
Specialty Growth Charts
§  Intrauterine growth charts
§ Down syndrome
§ Turner syndrom
§ Williams syndrome
§ Spastic quadraplegic CP
§ Prader-willi syndrome
§ Achondroplesia
§ charts for measuring crown rump and sitting
height
 Intrauterine growth curves

§  Babson and Benda (Babson) extended an

intrauterine chart past term age by including a
section based on the growth of infants born at term.
They published this chart in 1976 which they referred
to as a "fetal-infant growth graph".

§  this chart has built in correction factor for prematurity

and infant growth can be followed from 22 to 50
weeks of gestation It is best to continue to correct for
prematurity until the child’s growth is plotted on the
charts for 2-20 year olds

§  40week-birthgestational age=Na of

week premature (correction factor).

§  Chronological age-Correction factor=

adjusted age for prematurity
Fenton growth curve
 Ehrenkranz growth Chart

All neonates typically loss some weight after birth. Preterm's have more ECF
than term and thus tend to lose more weight(15%).term infant regained wt by
2nd or 3rd ws ,but small and sick neonate take longer time.
 How to Distinguish ????????????????
§  Natural" slow gainer
§  A baby that is a "natural" slow-gainer
still gains weight steadily, albeit
slowly:
§  maintains a particular growth curve.
§  increases in length and head
circumference increase according to
typical rates of growth.
§  wakes on his/her own and is alert
and cues to breastfeed about eight to
12 times in 24 hours.
§  produces wet and dirty diaper counts
similar to a faster-growing baby.
§  slow-weight-gain
§  does not gain at least one-half an
ounce (15 g) a day by the fourth or
fifth day after birth.
§  does not regain birth weight by two
to three weeks after birth.
§  does not gain at least one pound
(454 g) a month for the first four
months (from lowest weight after
birth versus birth weight).
§  exhibits a dramatic drop in rate of
growth (weight, length, or head
circumference) from her/his
previous curve
Down syndrome
Williams syndrome (WS, also Williams-Beuren syndrome), now recognized
to be caused by a microdeletion of chromosome 7, is a multisystem disorder first identified as
a distinct clinical entity in 1961.1 It is present at birth and affects boys and girls equally
Williams syndrome
HeadCircumferance
Prader-willi syndrome

§  a complex genomic imprinting

disorder characterized in infancy by
central hypotonia, a poor suck and
feeding difficulties with failure to
thrive, growth hormone deficiency,
and hypogonadism.

§  However, hyperphagia occurs in

early childhood, leading to obesity if
left uncontrolled.

§  Mental deficiency is present with an

average IQ of 65 along with
behavioral problems (eg, obsessive-
compulsive disorder, temper
tantrums, skin-picking),
hypopigmentation, small hands and
feet, short stature, hypogonadism,
hypogenitalism, and a characteristic
facial appearance
Prader-willi syndrome
 Standardized curves for weight of male (upper) and female (lower) infants with PWS (solid
lines) and normative 50th percentile (broken line).

Butler M G et al. Pediatrics 2011;127:687-695

©2011 by American Academy of Pediatrics

 Standardized curves for length of male (upper) and female (lower) infants with PWS (solid
lines) and normative 50th percentile (broken line).

Butler M G et al. Pediatrics 2011;127:687-695

©2011 by American Academy of Pediatrics

Standardized curves for head circumference of male (upper) and female (lower) infants with
PWS (solid lines) and normative 50th percentile (broken line).

Butler M G et al. Pediatrics 2011;127:687-695

©2011 by American Academy of Pediatrics

Standardized curves for BMI of male (upper) and female (lower) infants with PWS (solid lines)
and normative 50th percentile (broken line).

Butler M G et al. Pediatrics 2011;127:687-695

©2011 by American Academy of Pediatrics

Standardized curves for weight/length of male (upper) and female (lower) infants with PWS
(solid line) and normative 50th percentile (broken line).

Butler M G et al. Pediatrics 2011;127:687-695

©2011 by American Academy of Pediatrics

Achondroplesia