UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

BASICS IN PEDIATRIC HISTORY TAKING

IDENTIFYING DATA:
Age, gender, address, race/nationality, religion, number of admissions in the same institution, date of
present admission

SOURCE AND RELIABILITY:

Numerical grade or excellent-good-fair-poor

CHIEF COMPLAINT:
Concise statement of complaint with duration

HISTORY OF PRESENT ILLNESS:

Organized, clear, complete, concise, and accurate chronological narration of the development of the
current illness

REVIEW OF SYSTEMS (only for Pediatric patients who can answer the questions appropriately)

PERTINENT POSITIVES & NEGATIVES (for Pediatric patients whose parent/informant answers the
questions for the patient)

TEMPORAL PROFILE:
Graphical representation of history of present illness

PEDIATRIC HISTORY: (In paragraph format and always start the sentence with “The patient”)

Birth & Maternal History:

• Course of pregnancy (maternal history)
• Age of the mother
• Age of gestation
• Gravidity, Parity (Term, preterm, abortion, living)
• Manner of delivery
• Place of delivery
• Condition at birth
• Congenital anomalies
• Neonatal course
• Others

Feeding History:
• Breastfeeding Interval, duration, volume
• Formula
• Appetite
• Vitamin supplement
• Addition of solids
• Adverse food reactions
• Vomiting
• Stool
• Present diet

Immunization History:
• Date, place and number of doses of immunizations:
Primary: BCG, Hepatitis B, Diphtheria, Pertussis, Tetanus, Polio, Hib, Measles, MMR
Other vaccines: Rotavirus, Pneumococcal conjugate, Flu, Meningococcal, Japanese encephalitis,
Varicella, Hepatitis A, Pneumococcal polysaccharide, Typhoid, Dengue
• Adverse vaccine reactions
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS
Developmental History:
• Gross motor skills
• Fine motor skills
• Language (Expressive and Receptive)
• Social-Emotional
• Present milestones

Adolescent Psychosocial History:

• H – home
• E – education/employment
• E – eating
• A – activities (including media and internet exposure)
• D – drugs (alcohol, tobacco, and other drugs)
• S – sexuality
• S – suicidality/ depression
• S – safety (strength/spirituality)

Past Medical History:

• Previous hospitalizations not related to patient’s present admission and illnesses including
viral exanthem such as Measles, Varicella, Mumps, Rubella and other communicable
diseases such as Upper Respiratory Tract Infections, Tonsillitis, pyoderma
o Frequency, severity of illnesses and place of admission
• Previous injuries or surgery
• Other chronic illnesses

Family History:
• Health status of living relatives
• Cause of death of deceased relatives
• Heredofamilial diseases: cancer, diabetes, hypertension, allergy, mental illness, heart disease
• Chronic illness like Tuberculosis exposure

Social/Environmental History:
• Educational attainment of parents/caregivers
• Occupation of parents/caregivers
• Adequacy of income
• Typical day of patient
• Environment: house structure and number of persons in the household, access to potable
water, electricity, waste and garbage disposal, density of population in neighborhood
• Establish family structure or who takes care of the patient for behavioural or developmental
problems and present health condition.
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

BASICS IN PEDIATRIC PHYSICAL EXAMINATION

GENERAL SURVEY Sensorium, distress, acute or chronically ill, color, activity, consolability,
pain, irritability
VITAL SIGNS Temperature per axilla/oral/rectal
Pulse/Heart Rate
Respiratory Rate
Blood Pressure
Oxygen saturation
Pain (see Appendices A & B)
ANTHROPOMETRICS Weight
Length/Height
Head Circumference
Arm Circumference
BMI
MUAC (6 – 59 months)
*include z-scores and interpretation each parameter (see Table 1)
SKIN Color, moisture, turgor
Rash: distribution, color, pruritus, description
Lesions: description
Hemorrhages: petechiae, ecchymoses, hematoma
Nails
HEENT • hair, head lesions
• eyelids: ptosis, conjunctivae, sclera, cornea, pupils, movements,
nystagmus, visual fields, exophthalmos, tension, visual acuity,
fundoscopy
• lesions of external ear, ear discharge, tympanic membranes,
mastoids, hearing
• patency, mucosa, nasal septum, nasal discharge, sinus tenderness,
transillumination
• lips, teeth, gums, oral mucosa, tongue, breath, salivary glands
• tonsils, posterior pharynx, post-nasal drip
• thyroid gland, vessels, trachea, stiffness, masses
LYMPH NODES cervical, occipital, supraclavicular, axillary, inguinal, epitrochlear, others
BREAST masses, breast discharge, others
HEART Inspection: precordium;
Palpation: point of maximum impulse, heaves, thrills;
Auscultation: S1, S2, S3, rate and rhythm;
Adventitious sounds: murmurs, gallop, clicks, others
BLOOD VESSELS Pulses: location, quality
CHEST and LUNGS Inspection: shape, symmetry, respiration, others;
Palpation: fremitus;
Percussion; Auscultation: breath sounds, adventitious sounds
ABDOMEN Inspection: contour, scars, peristalsis, blood vessels, hernia
Auscultation: presence and number of bowel sounds
Percussion; Palpation: tenderness, rigidity, fluid, liver and spleen,
kidneys, bladder
GENITALIA Male: penis, scrotum and testes, discharge, epididymis
Female: vulva, discharge, others
For adolescents: Tanner Staging
MUSCULOSKELETAL Posture, deformities of extremities, spine, range of motion
NEUROLOGIC Infants: primitive reflexes
Cerebral Status
Deep Tendon Reflexes
Motor Strength
Sensory Examination
Cranial Nerves
Cerebellar Assessment
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

PHYSICAL EXAMINATION OF AN INFANT

(Transcribed from Bates’ Guide to Physical Examination and History Taking Video)

• Try to examine infants one to two hours after feeding, when they are most
responsive.
• Examine the infant in the presence of the parents.
o Parents often can help to calm a restless or screaming baby.
• Observe parents’ interaction with the baby – bonding or behavior during
feeding.
o Assess parenting strengths and to advise or instruct.
APPROACH TO THE • Start with the infant swaddled and comfortable. Then undress the infant
INFANT PATIENT in stages.
• Observe transitions as the baby arouses, and teach parents about them.
• Encourage the baby’s eyes to open by dimming the lights and rocking or
placing the baby on a parent’s shoulder.
o Employ calming maneuvers if the baby becomes agitated.
• Provide a pacifier or bottle of formula or allow the baby to suck on your gloved
finger or the baby’s own hand.
• Try reswaddling to silence the infant.

a. Observe the quality of child-parent interactions and parental discipline.

b. Look for the signs of stress or depression occurrence
c. Observe how the infant performs a simple developmental task, such as hearing
GENERAL SURVEY and smiling
d. Sign of infant strength and movement
e. Individual characteristics such as skin markings and facial features.

a. Height is measured as body length

SOMATIC GROWTH b. Weight
ASSESSMENT - Use an infant’s scale
*Growth is one of the - Infant should be naked
most important
indicators of a child’s c. Head circumference.
health. d. Chest circumference
( chart Percentile)
e. Mid-upper arm circumference
a. Pulse
- May palpate the femoral or brachial artery or auscultate the heart
VITAL SIGNS b. Respiratory rate (RR)
Check Normal for age c. Blood pressure (BP)
- Cuff should cover the 2/3 of upper arm
d. Temperature

a. Texture and appearance

- Vernix caseosa
- Edema
- Milia
SKIN - Miliaria rubra
- Erythema toxicum
- Pustular melanosis
Note for:
b. Birthmarks
c. Skin turgor
d. Jaundice
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS
a. Palpate fontanelles, cranial sutures
b. Assess symmetry of skull
c. Examine the face, look for symmetry, presence of facies
d. Palpate the neck
HEAD AND NECK - Lymph node
- Presence of masses
- Check the position of thyroid cartilage and trachea
- Neck mobility – if supple
e. Palpate clavicles and look for evidence of fracture

a. Inspect the sclerae and pupils

EYES
b. Check the red orange reflex

a. Determine if the position, shape and features are normal

- Skin tags, clefts or pits
b. Test for hearing
EARS AND NOSE c. Inspect the nose
- Nasal septum is midline
d. Patency of nasal passage

a. Inspect the mouth and pharynx (best seen when crying)

MOUTH AND - Epstein pearls
PHARYNX b. Oral thrush

a. Observe pattern of respiration

- RR
- Color
- Nasal component of breathing
THORAX AND - Audible breath sounds including nasal flaring, grunting, or retractions
LUNGS (chest indrawing)
b. Auscultation
c. Crackles, wheezes and rhonchi

a. Observe skin for cyanosis

- mouth
b. Palpate the peripheral pulses
- brachial, radial, femoral, dorsalis pedis pulse
- PMI
- Place your hand in the chest to feel for thrill
c. Auscultate using the diaphragm of your stethoscope
CARDIOVASCULAR - 2nd right ICS (aortic area)
SYSTEM
- 2nd left ICS (pulmonic area)
- Left lower sternal border (right ventricular area)
- apex (left ventricular area)
- Listen for S1, S2, S3, S4
- Listen for murmurs (also at the back and axillary areas)
* then use the bell side of your stethoscope to auscultate again

a. Breasts of male and female newborns are normally enlarged

BREASTS The breasts may be engorged with a white liquid, sometimes colloquially called
“witch’s milk.” This finding may last for the first week or two of life.
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

a. Inspect the abdomen with the baby lying supine.

- Observe shape and symmetry of the abdomen
- Check the umbilicus for redness or swelling
- Diastasis recti

ABDOMEN b. Auscultate for bowel sounds (hold the legs flex at the knees and hips)
c. Palpation
- Liver edge
- Spleen tip
d. Kidneys

a. Inspect for the appearance of penis, foreskin, testis and scrotum (males)
MALE, FEMALE b. Inspect for labia majora and minora (females)
GENITALIA and c. For infants the rectal examination consists of visual inspection of the anus.
RECTUM
Digital examination is not routinely performed unless pathology is suspected.

a. Look for congenital abnormalities.

b. With a little practice, you will be able to combine the musculoskeletal
examination with the developmental and nervous system examinations.
c. Inspect the hands, fingers and elbows for any defect
d. Examine the hips for any dislocation
MUSCULOSKELETAL - Barlow
SYSTEM - Ortolani
e. Check for symmetry of legs
- Some normal infants exhibit twisting (torsion of the tibia) inwardly or
outwardly on the tibia’s longitudinal axis.
f. Examine the feet (pes planus, inversion, metatarsus adductus)
g. Inspect the spine for patches, hair

a. The examination of the nervous system in infants includes techniques specific

to their particular age and is highly dependent on
- Internal factors: alertness and timing with respect to feeding and sleeping
- External factors: presence of parents, or the presence of fearful stimuli
- Primitive reflexes, present only at certain ages and then disappear
- Neurologic changes, often present as developmental abnormalities

b. Assess motor tone

- Spastic or flaccid

c. Assess for pain sensation

NERVOUS SYSTEM
d. Cranial nerve
CN I- mediates sense of smell

CN II- mediates vision

- Regard and tracking

CN II & III- control response to light

- Optic blink reflex, papillary response

CN III, IV & VI- mediate extraocular movement

- Tracking moving from side to side
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

CN V
- Motor portion innervates muscles of mastication
o Rooting and sucking reflex
- Sensory portion mediates facial sensation and the sensory part of the
corneal reflex

CN VII- innervates all muscles of facial movement and expression

- Crying, smiling and note symmetry of face and forehead

CN VIII –innervate hearing and vestibular function

- Acoustic blink reflex and response to sound

CN IX and X- mediate sensory and motor functions of the palate, pharynx, and
larynx
- Coordination during swallowing

CN XI- innervates SCM and upper trapezius muscles

- Symmetry of shoulders

CN XII- mediates motor functions of the tongue, affecting articulation of words

- Coordination of swallowing, sucking and tongue

e. Deep tendon reflexes

- biceps, quadriceps
- triceps, brachioradialis & abdominal reflexes are difficult to elicit before
six months of age.
- Babinski

f. Primitive reflexes
- Palmar grasp, rooting, moro or startle reflexes
* Absent primitive reflexes, or retention of those reflexes past the usual age
they disappear, may signify abnormalities.

a. Apply gentle traction to the pinna thru the back of the head.
b. Hold the otoscope with the handle up between your thumb and first two
OTOSCOPIC EXAM fingers.
c. Resting the pinky and palm against the head
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

PHYSICAL EXAMINATION OF A CHILD

(Transcribed from Bates’ Guide to Physical Examination and History Taking Video)

•
Children vary greatly in their levels of cooperation requiring adaptation
to situation at hand.
• Adjust order and style of examination to child’s mood, behavior and
level of development but make sure when recording to place findings in
the proper sequence.
• Engage the patient by adjusting your voice, style, and actions to the
child’s developmental level.
• Use a playful, reassuring voice.
• Play with the child if necessary.
APPROACH TO THE • Engage the parents.
CHILD PATIENT • Let the child see and touch the tools you will use during the
examination.
• Avoid asking the child’s permission to examine a body part. Instead ask
the child which ear or part of the body he or she would like you to
examine first.
• Examine the apprehensive child in the parent’s lap, and let the parent
undress the child.
• Complete the examination expeditiously if you cannot console the child,
or give the child a short break.
• Make a game out of the examination.
Typical Examination Sequence

a. Observe for abnormalities: behavioral problems, sibling rivalry, inappropriate

parental discipline, overall intense temperament.
b. Look for signs of developmental delay in areas such as gross and fine motor
skills, cognitive abilities, language, and social and emotional tasks.
GENERAL SURVEY c. Observe for signs of social or environmental problems, including parental
difficulties such as stress or depression, and risk for abuse or neglect.
d. Look for neurologic problems, including weakness; abnormal posture,
dexterity, or gait; spasticity; clumsiness; attention problems or hyperactivity;
and autistic features.

SOMATIC GROWTH
ASSESSMENT a. Height
*One of the most - Pre-school child: standing height or stature
important indicators - If using a wall with a marked ruler, make sure to place a flat surface across
of a child’s health. A top of child’s head at a right angle to the ruler.
deviation from
- Stand-up weight scales with height attachments are relatively inaccurate.
normal may be an
early sign of an b. Weight
underlying problem. c. Body mass index (BMI)
*Growth chart: plot d. Weight (kg)/Height (m2)
growth parameters over
time

a. Blood pressure
- Routinely measured in children over 2 years
- Children have elevated blood pressure during exercise, crying, and anxiety.
VITAL SIGNS - Cuff should cover the 2/3 of upper arm.
Check Normal for age - Elevated readings must always be confirmed by subsequent
measurements.
- Be sure to employ the appropriate tables when ranking a child’s blood
pressure level.
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

b. Pulse
- may palpate the femoral or brachial artery or auscultate the heart
c. Respiratory rate
- Auscultate or observe with shirt removed
d. Temperature
- Body temperature in children is less constant than in adults and may
fluctuate as much as 16oC during a single day.
Normal readings may approach 38.3oC, particularly in the late afternoon and
after vigorous activity.

a. Inspecting and palpating the fingernails

- clubbing
- cyanosis
b. Color and pigmentation
c. Texture
SKIN d. Hair distribution and thickness
e. Lesions
f. Common skin conditions
- Birthmarks
- Nevi (ABCDE method)
- Scars

a. Examine the face, look for symmetry, presence of facies

b. Palpate the scalp
c. Inspect the hair and texture
d. Palpate the neck
HEAD AND NECK - Swellings and abnormal posture
- Enlargement of glands
- Lymph nodes
- Suppleness of neck
e. Palpate the clavicles

a. Inspect each cornea, iris and lens.

b. Check the color of the sclera.
c. Look for jaundice and redness.
EYES d. Compare the pupils and reactions.
e. Test visual acuity in each eye.
f. Determine whether gaze is conjugate and symmetric.
g. Check for convergence.
h. Perform ophthalmologic exam.

a. Determine if the position, shape and features are normal

- Skin tags, clefts or pits
b. Test for hearing in a formal session
EARS AND NOSE c. Inspect the nose using a wide speculum
- Nasal septum deviation
- Polyps
d. Nasal mucous membranes

a. Keep the child calm by sitting on the parent’s lap

OTOSCOPIC b. Pull the auricle upward, outward and backward
EXAMINATION
c. Hold the otoscope with your other hand using the widest possible speculum
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS
a. Look at upper lip and staining of the teeth.
b. Once open, examine upper and lower lips
MOUTH AND c. Examine the tongue.
PHARYNX
d. Ask child to open mouth wider to inspect oral pharynx.
e. Note the quality of the child’s voice.
a. Observe pattern of respiration
- RR
- Color
- Nasal component of breathing
THORAX AND - Audible breath sounds including stridor or grunting
LUNGS - The work of breathing, including nasal flaring, grunting, or retractions
(chest indrawing)
b. Check for tactile fremitus
c. Auscultation
- Crackles, wheezes and rhonchi
a. Observe for cyanosis
- Inspect the tongue
b. Palpate the peripheral pulses
- brachial, radial, femoral, dorsalis pedis pulse
- PMI
- Place your hand in the chest to feel for thrill
CARDIOVASCULAR c. Auscultate first using the diaphragm of your stethoscope
SYSTEM - 2nd right ICS (aortic area)
- 2nd left ICS (pulmonic area)
- Left lower sternal border (right ventricular area)
- apex (left ventricular area)
• then use the bell side of your stethoscope to auscultate again
- Listen for S1, S2, S3, S4
- Listen for murmurs: Stills murmur, venous hum
a. Inspect breasts of both male and female
b. Inspect the abdomen with the patient lying supine with knees flexed.
c. Auscultate for bowel sounds (hold the legs flex at the knees and hips)
BREASTS and d. Palpation
ABDOMEN - For tenderness, observe child’s reaction to your palpation
- Palpate the liver edge
- Spleen may be palpable
e. Palpate for the kidneys on both sides
Male Genitalia
a. Inspect the penis.
b. Examine the male child when he is relaxed, so as not to stimulate the
cremasteric reflex.
c. Palpate the lower abdomen going down the scrotum along the inguinal canal.
d. Examine the foreskin, then the glans.

MALE, FEMALE Female Genitalia

GENITALIA and a. Understand the normal female genitalia to detect rashes, infections, or signs of
RECTUM
sexual abuse.
b. Put child in supine, frog-leg position or while sitting on parent’s lap.
c. Inspect the external genitalia for pubic hair, the size of the clitoris, the color and
size of the labia majora, and any rashes, bruises or other lesions.
d. Separate the labia majora laterally and posteriorly to visualize the inner
structures.
e. Note the condition of the labia minora, urethra, hymen, and proximal vagina.
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS
a. Compared with the adult, the normal child has increased lumbar concavity,
decreased thoracic convexity, and often a protruberant abdomen.
b. Examine the feet.
MUSCULOSKELETAL c. Observe the child rising from a sitting position, standing, and walking barefoot.
SYSTEM d. Ask the child to touch her toes, pick up objects, hop and run a short distance.
e. To check for scoliosis, have the child stand with her bare feet together and bend
forward with her knees straight and her hands hanging straight down. Check
for leg length discrepancy.
a. The examination of the nervous system in children includes the developmental
examination
- The Denver Developmental Screening Test
b. Gross motor development and balance
- Balance on 1 foot and hop (3-4 year old)
- Walk on heels (older child)
c. Fine motor development and hand preference
-Copy a circle or square
d. Language development
e. Cranial nerve
CN I- mediates sense of smell
CN II- mediates vision
CN II & III- control response to light
- assessed during eye assessment
CN III, IV & VI- mediate extraocular movement
- Tracking moving from side to side
CN V
- Motor portion innervates muscles of mastication
o Have the child smile
XIV. NERVOUS - Sensory portion mediates facial sensation and the sensory part of the
SYSTEM corneal reflex
CN VII- innervates all muscles of facial movement and expression
- Ask the child to make faces
CN VIII –innervate hearing and vestibular function
- Formal hearing testing session
CN IX and X- mediate sensory and motor functions of the palate, pharynx, and
larynx
- Ask child to stick out her whole tongue and move it back and forth
CN XI- innervates SCM and upper trapezius muscles
- Ask child to push your hand away using the head
CN XII- mediates motor functions of the tongue, affecting articulation of words
- Observe child speaking
f. Motor strength
- Ask child to push or pull you with hands or legs
g. Sensory system
- Ask child to close eyes and ask whether they feel the tickling
h. Deep tendon reflexes
i. Cerebellar exam
j. Ask the child to touch her fingers and her nose and
do rapid alternating movements
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

STEPS IN TAKING THE BLOOD PRESSURE:

1. Greet the patient / companion of the patient and introduce yourself.

2. Acknowledged the patient’s mother after the interview.
3. Maintain good eye contact.
4. Be professional and courteous.
5. Explain what is to be done.
6. Choose the appropriate BP cuff size.
7. Correctly apply the BP cuff over the artery.
8. Check if the cuff is snug (1 finger fits between cuff and arm)
9. Check palpatory BP and deflate the manometer.
10. Reinflate the manometer and take auscultatory BP (inflate cuff to 20-30mmHg above
the palpatory BP)
11. Deflate manometer slowly or at around 3mmHg/beat.
12. Report the BP.

STEPS IN MEASURING MID-UPPER ARM

CIRCUMFERENCE (MUAC)

1. Determine the mid-point between the elbow and the shoulder (acromion and olecranon).

2. Place the tape measure around the left arm (arm should be relaxed and hanging down the
side of the body.
3. Measure the MUAC while ensuring that the tape neither pinches the arm nor is left loose.
4. Read the measurement from the window of the tape or from the tape.
5. Record the MUAC to the nearest 0.1 cm or 1mm.

Note: MUAC is used only for 6 – 59 months of age. See interpretation at Table 3.
 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

APPENDIX A.

WONG-BAKER FACES PAIN RATING SCALE

APPENDIX B.

0-10 NUMERIC PAIN INTENSITY SCALE

 UNIVERSITY OF THE EAST
Ramon Magsaysay Memorial Medical Center
Aurora Boulevard, Quezon City 1113
DEPARTMENT OF PEDIATRICS

Z-SCORE INTERPRETATION

TABLE 1.
GROWTH INDICATORS
Z-SCORE LENGTH/HEIGHT WEIGHT- WEIGHT-FOR- BMI-FOR-AGE MUAC
FOR AGE FOR-AGE LENGTH/HEIGHT (See note 6)
Above 3 See note 1 See note 2 Obese Obese -------
Above 2 Overweight Overweight -------
Above 1 Possible risk of Possible risk of -------
overweight overweight
(See note 3) (See note 3)
0 (Median) -------
Below -1 -------
Below -2 Stunted Underweight Wasted Wasted 11.5-12.5
(See note 4) cm
Below -3 Severely Stunted Severely Severely wasted Severely
(See note 4) underweight wasted Below
(See note 5) 11.5 cm
+/- Edema +/- Edema
1-both feet 1-both feet
2-legs hand 2-legs hand
3-generalized 3-generalized
(See note 7) (See note 7)

Notes:

1. A child in this range is very tall. Tallness is rarely a problem, unless it is so excessive that it may
indicate an endocrine disorder such as a growth-hormone-producing tumor. Refer a child in this
range for assessment if you suspect an endocrine disorder (e.g. if parents of normal height have
a child who is excessively tall for his or her age).

2. A child whose weight-for-age falls in this range may have a growth problem, but this is better
assessed from weight-for-length/height or BMI-for-age.

3. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line shows definite
risk.

4. It is possible for a stunted or severely stunted child to become overweight.

5. This is referred to as very low weight in IMCI training modules, In-service training. WHO,
Geneva, 1997).

6. MUAC is used only for 6 – 59 months of age.

7. The presence of edema regardless of grade places the patient under severe acute malnutrition.