WPRO 5601 30 June 1972

ENGLISH ONLY

THE EARLY DETEcrION OF CHILDHOOD MALNUTRITION IN THE SOUTH PACIFIC

by

A.A.J. Jansen, M.D. 1

and

K.V. Bailey, M.D. 2

1wH0 Medical Nutritionist, Applied Nutrition Education and Tra1ning ProJect in the South Pacific.

2Regional Adviser on Nutrition, Western Pacific Regional Office of the World Health Organization, Manila.

1.

2.

3.

CONTENTS

EPIDEMIOLOGY Of' MALNUTRITION •••••••••••••••••••••••••••••••••••• 1

NtrrRITIONAL ASSESSMENT •..•••••••••••••••••••••••••••••••••••••••

Clinical examination'................................................................................ 2 Anthropometric examination .•.•..•....•••.••••.••.•••••....•• 4 Anaemia .......................................................................................................... e

HIGH RISK FAMILIES AND INDIVIIXlALS •••••••••••••••••••••••••••••• 8

LITERA'ruRE ............................................................................................................. 11

ANNEXES -

Annex 1 - Principal Features of Protein-calorie Deficiency ••• 13 Annex 2 - Salnple Survey Fonn ........ oo........................................................ 15 Annex 3 - Anthropometric Standards •••••.•..•••••••••••••.•••• 17 Annex 4 - Sample Weight Charts for Health Centre ••••••••••••• 23

PLATES -

Plate I Plate II Plate III Plate IV

Clinical Malnutrition Growth Retardation in G11bertese Children V1tamin A Def1ciency Anthropometric Equ1pment

1. EPIDEMIOLOGY OF MALNUTRITION

Protein-calorie naalnutrition. often combined with vitamin and mineral def1ciencies, is ore of the major public health problems in moat tropical and subtropical countries. Unfortunately, SClDe countries in the South Pac1fic suffer frCID the same problem. It seems fUrthennore that ma1-nutri tion is occurring more frequently. especially in urban areas, due to the influx of large numbers of labourers and to changes in food and food habits.

'!bere are several reascns why protein-calorie malnutrition should be considered a serious disease. In milder degrees, it causes retarded physical growth (weight, height, etc.) and this is often associated with impainnent of intellectual development or performance. It also opens the door for other diseases. Malnourished children suffer more severely from a variety of common infectious diseases than well-nourished children.

Apart frCID purely economic factors, other ones such as the size and spacing of the family, and age of the mother, are usually important. Even when the income is high enough to ensure an adequate diet, it still does occur that, due to religious, social or cultural traditicns ("pecking order") and lack of knowledge, the food intake is quantitatively insufficient (causing caloric deficiency or undernutrition) or qualitatively deficient in certain nutrients (causing malnutrition).

The diet is also influenced by the prestige value of foods. This may vary frCID one group or area to another. Tubers have a high prestige value in most countries of the South Pacific. Green leafy vegetables and fruits often lack this "status". Many imported foods have acquired status. Some of them are nutritionally valuable, e.g. milk, tinned meat and tinned fish. Others, such as refined flour and sugar, may cause or accentuate certain deficiencies.

The main traditional vulnerable groups are infants (6-12 months), toddlers and pre-schoolchildren, pregnant women and in some areas, old "non-productive" people. Schoolchildren and lactating women also often have deficient diets, but the consequences are generally less obvious than in smaller children and pregnant women.

Recently and especially in urban areas, new vulnerable groups have appeared: artificially fed and low birth weight infants. Especially when the mother is unmarried and has to leave her chlld with somebody else, there is great danger of the child becoming malnourished. There are several contributing factors. The lactation period tends to shorten among urbanized mothers. New values taken fran movies, newspapers, magazines and radiO, and a d1fferent body-image, make women want not to "spoil" their figure. The chlld 1s fed some kind of a milk mixture, which all too often ccns1sts of little milk, much tea and sugar and many bacteria. Another complication is that the interval bet_en successive children tends to become shorter, so that even the breastfed child will be forced off the breast as soon as the mother realizes she is pregnant or at latest, when

- 2 -

the new sibling is born. Finally, the low birthweight infant may have difficulty with either breastfeeding or artificial feeding, and is very vulnerable to infections, which further undermine his nutritional state, causing a vicious circle.

The main concern of the doctor and his staff is the young child. Because it is growing fast, deficiencies in the diet cause clinical signs relatively early. When diagnosed early, treatment will be successful, unless the child suffers from a serious concomitant disease. However, the mortality among severely malnourished children is high, especially as many parents will not take the child to the hospital or to a health centre. These children have to be looked for!

Frank protein-calorie malnutrition can be diagnosed at a glance. The main types are marasmus or kwashiorkor, the most characteristic or distinguishing features of which are given in Annex 1. It is likely also that more vitamin A deficiency will occur in the future, especially in poor urban groups.

It is obviously important to diagnose and treat the so-called borderli~~ malnutrition cases, children who are underweight but not malnourished enOUi ' to be hospitalized. They are at risk of becoming severely malnourished whenever the precarious equilibrium they find themselves in is disturbed by infections, particularly if these are recurrent or chronic and severe, e.g. gastro-enteritis, bronchitis, pneumonia, measles, a common cold, or otitis media, skin infections, etc.

2. NUTRITIONAL ASSESSMENT

2.1 Clinical examination

A quick evaluation of the nutritional status of children visiting MCH clinics, and of schoolchildren, should be a routine procedure for the doctor and the nurse. Clinical assessment should always be made, with emphasis on the signs listed in Annex 2, and an attempt to classify the subject as well-nourished, mild malnutrition or frank malnutrition. '!'he child must be undressed.

Amongst these Signs, the follOWing deserve some priority:

(a) Muscle wasting is best seen by lifting the child by the armpits, and examining the buttocks (loose skinfolds are obvious), the trunk, ~houlder blades, ribs, etc.; also the upper arms and thighs.

(b)

(c)

Cd)

(e)

(f)

- 3 -

Oedema may be a presentins symptan if it is generalized, or obvious in the feet/legs • Examination requires fim pressure for three seconds over the tibia or dorsum of the foot. When bilateral oedema is present, the differential diagnosis includes (inter alia) nephritis, severe anaemia, cardiac failure, hepatic cirrhosis with ascites. The urine should be examined microscopically and tor albumin. Typically, the urine hae neither albumin nor casts in kwashiorkor (uncomplicated) but SCDe albumin and casts are sometimes present. In nephritis, albumin and casts are usually present in quantity.

Skin changeS, e.pecially the flalq-paint or enamel dematosi. (Piate 2) are dramatic, but only present in a minority of subjects in this P.esion. Patches of skin tum reddish then purple (mawles and vesicles) and then dark brown patches fom, which become dry and peel off, sometimes leaVing raw weeping areas like bums. These changes are seen mostly in the covered parts of the body - buttocks and groins and the trunk, but sometimes extend to the face and limbs. They respond to treatment with high-protein or even amino-acid diets.

Hair ChangeS are variable. The dyspigmentation may be reddish brown or grayish-white. (Hair dyes are sometimes used by Pacific islanders, however.)

Anaemia is suspected by pallor of the mucous membrane, especially of the mouth (see illustration), or of the conjunctiva. (&1t the conjunctiva is red if there is conjunctivitis, even in the presence of anaemia.) See also section 2.3 below.

Vitamin A deficiency. General malnutrition and infectious diseases (e.g. measles) increase the risk of vitamin A deficiency and blindness. The importance of early diagnosis cannot be over-emphasized. Inspection of the conjunctiva and comea of both eyes is an essential part of all examinations ot children. For a small child, this should be done at the beginning, before he is frightened by unfamiliar procedures. Good light is essential and efforts should be made to get the child to move the eyes to both sides (e.g. by producing a bright object) so that both the medial and the lateral conjunctiva can be etaIIIined. A child brought with the complaint of sore eyes or not opening the eyes may have keratomalacia. Great caution is required to avoid perforation of the comea by the examination. A canplaint by the parent that he stumbles

- 4 -

or gropes in dim light suggests vitamin A deficiency. Bitat's spots, dry conjunctiva (xerosis) or dry cornea (xerophthalmia) and keratomalacia (sottened, cloudy cornea, sometimes ulcerated) are suggestive signs, and call for urgent treatment.

(g) Riboflavin deficiency. The ccmmcnest manif •• tation of this is angular stanatitis, with fissures or ulcers at the corners of the mouth and/or vertical fissuNs in the lips (cheilosis). These lesians are ao.ett.ea due to other causes, e.g., deficiencies of other vitamins or iron, or to irritation from certain foods (gre.n mangoes, pandanus). Angular stomatitis is usually iliON common in schoolchildren •. Another lesion caused by riboflavin deficiency is nasolabial seborrhoea. Th. presence of any of these lesians, or other signs listed in Annex 2, should alert the examiner to the increased probability of general malnutrition in that subject.

2.2 Anthropometric examination

FOr objective assessment of protein-calorie status, body •• asure.ants are usually simplest and best.

In view of the fact that doctors, as well as nurses, can only spend a lilllited amount of time on each patient, the nutritional eXU\ination should be rapid and the l!Juipment used easily available. Ideally, one needa a scale in good condition - which should be checked Nsularly; a measuring rod to measure the body height; an infantometer to meawN the body length of infants and small toddlers; and a tape measure tor measuring the arm, head and chest circumferences. The _aauring rod and infantometer can be made locally. The tape measure should be unstretchab1e (steel or fibre-glass).

<a) Body weight. The first indication of a decline in nutritional status is otten failure to gain weight steadily or loss of weight. This is usually a slow process, but any infectious disease can cause a sudden and severe loss of weight. Repeated examinations are necessary to evaluate adequately the growth of a child.

Young children should be weighed at least monthly in the first year of life. Thereafter, three-lIIonthly is usually sufficient, but monthly wei&h1n&s should be resumed if growth is not ~roKreaaing satisfactorily.

*

- 5 -

Standards. It is also necessary to campare the weight with a standard. As local standards for the South Pacific countries have not been established, the standards given in Annex 3 (Tables 1 and 2)*, may be used, based on the Harvard standards (2). Experience shows that weights above the 8~ level in this table are seldom associated with malnutrition. Weights between the 60 and 8~ levels may be described as pre-clinical or mild/moderate protein-calorie malnutrition. Weights below the 6~ level usually indicate severe malnutrition (primary or secondary). Any child whose weight falls below the 8~ level, or whose weight is not increasb g adequately at successive examinations, should receive prompt attention and'measures should be taken to reverse the situation.

Technique. When weighing the child, he/she should wear a minfmum of clothes (infants and small children could be weighed in the nude). When the subject ~mes back again, it is important that he/she wears the same type , of clothes (e.g. shorts and underpants or a light dress and underwear) to prevent errors due to more or less clothes. If there is oedema, this should be recorded.

~. The stand .. ds and the charts can only be used if the age of the children is known to the nearest month. Not rarely, the parents will not remember the child's birthday. For children aged 6 months to 24 months, age may be roughly estimated in months, as the number of teeth erupted plus 6. Another method is to take the subject's height and compare it with standard height (e.g. Nelson's Text­book of Paediatrics (3» and assuming his height is normal for his age, see if the normal weight for the height and age is attained. For this purpose, a table of heights is also attached (Annex 3, Tables 3 and 4).

In cases of definite or suspected malnutrition, other measurements should be made: height or length, arm circumference, and chest/head circumference ratio. These measurements may however be omitted for routine purposes in busy clinics.

The same standards are reproduced in Kg and an in the WHOjlo1anlla manual, Health aspects of food and nutrition, Annex IV (SecQ'ld Edition, 1972) •

- 6 -

(b) Height or length. To measure the height, the subject stands on a horizontal platform without shoes or socks and with his heels together. He is then asked to stretch upwards to his fUllest length (by taking a deep breath and/or by the measurer exerting gentle upward pressure on the mastoid processes). The subJect should stand as straight as poSsible and the line ot sight must be horizontal. This procedure is somet1llles difficult with children who are shy or timid. Others may become afraid. The horizontal arm of the anthro­paneter is brought down till it touches gently but firmly the crown of the subject's head. The exact height is recorded to the nearest DIll or the nearest 1/10 of an inch.* In case an anthropometer isrot available, a non-stretchable steel or fibreglass measuring tape can be fixed to the wall, and an L­shaped or right-angle triangle block lowered down on to the crown of the head. For children below two years, length is preferred rather than height.

When measuring small children with an infantOllleter, the head of the child should be placed against a fixed headboard. A movable footboard is then placed against the feet and the exact length is read to the nearest mm or the nearest 1/10 of an inch. The legs should be well stretched, the knees flat, and the feet must pOint vertically upward.

Height or length measurements can be made even when no weighing scale is available, and should be measured routinely every three months if no scales are available. e.g. in schools.

(c) Arm circumference. This measurement includes bone. muscle, subcutaneous fat and skin, but since bone size and skin are relatively little affected by malnutrition, it reflects mainly the combined calorie status (subcutaneous fat) and prote in status (muscle). This measurement can also be conveniently used where no scales are available.

TeChnique. A fibreglass tape is placed around the arm in such a way that the soft tissues are not compressed and the circumference is measured to the nearest mm or the nearest 1/10 of an inch. The arm should hang down freely; it often requires sane

*The "nearest II1II" (etc.) means the nearest completed mrn, in this and subsequent paragraphs.

I

~ ! I

- 7 -

patience to teach the proponent to relax the muscle of his ann. The measuring is done halfway between the acromial process of the scapula md the olecranon (both of which must be identified, the distance between them measured, and halved). It is important to measure always the left arm and to define carefully the same mid-way spot.

Standards. The circumference can be compared with a standard and a malnutrition borderline which is calculated at 20J' below the standard (Annex 3, Table 5). It may be noted that there is rather little change between 1 and 5 years. If age is not mown exactly, arm circumference can therefore provide a quick indication if there is definite malnutrition. However, one difficulty is that a small error in measurement, e.g. by squeezing when measuring, may easily cause many subjects to be placed below the borderline incorrectly.

(d) Chest-head circumference ratio. This is another useful quick indicator, not requiring use of scales, and relatively independent of age. At birth, the head circumference is larger than the chest circumference and it continues to be larger until after the age of three months. Some time between 3 and 9 months (usually closer to 3 months in boys and 9 months in girls) the chest circumference normally becomes larger than the head circumference.

In malnourished children, the head may remain larger than the chest: in severe cases, even up till the end of the third year of life. If head cir­cumference exceeds chest circumference at 12 months or beyond, malnutrition should be suspected. Closure of the fontanelle should be checked; normal closure is at fifteen months. Late closure can indicate mild rickets.

Technique. The head should be measured by placing the tape firmly aro'.md the head over the occipital prominence and Just above the supra­orbital ridges. The tape should be read to the nearest 1/10 of an inch or nearest mm.

To measure the chest circumference, the tape Is placed over the nipples and the tape is read in mid­inspiration. To prevent crying and "wrestling" with scared children, the child should be sitting on its mother's lap. Again, the tape must be read to the nearest 1/10 of an inch or nearest mm.

- 8 -

In case a tape is not available, even a p1ece of strtnc will do, as it is only a matter of comparing two measure­ments. Another big advantage is that one is not dependatt on the age of the child. Even it the mother doe. not know exactly when the child waa bOm , it will generally be possible to determine whether the child is yownser or older than 12 months.

Standards. The figures 1n Annex }, Table 6 Olin

be used as reference whenever looal standards do not exist.

2.3 Anaemia

Protein-calorie malnutrition seldom ccmes alone. A common findinl is anaemia. '!bere may be several dietary and/or other factors responsible, e.g. defioiency of iron or folate; hookworm, malaria, other infeotion., genetio factors, etc.: the causes shOuld be studied further.

Recently, new international haemoglobin standards have been establ1shed( 4). It is recClllllended that a person sl'D uld be considered to suffer fran anaemia when his/her haemoglobin level is lower than the figures mentioned below:

children aged 6 months to 6 years 11 s/'lOO m1.

children aged 6-14 years 12 " adult males 13 " adult females, non-pregnant 12 " adult females, pregnant 11 It

Children fran one to two years and pregnant women are most coaaonll affected.

Technique. Tallquist and Sahli methods are unrel1able, bl.tt the latter will do for screening. In case ot doubt, subjects should be referred to a centre where meaaurement can be made with a colorimeter, photometer or special haemoglobincmeter.

:3. HIGH RISK FAMIUES AND INDIVIDUALS

Just as some individuals are more accident-prone than others, some families suffer more trom malnutrition and complicating diseaae than other

II

i I II , I

- 9/10 -

famili... These families should receive special care. Indication.- tor special care are:

1. Maternal weight below 100 lbs (45 q) tor F1Jim. and below 92 lbs (42 kg) for Indians.

2. Maternal age over 40 years

3. Birthweight below 5 lbs (2.3 kg)

4. '!Yins

5. Failure to gain at least 1 lb monthly (0.45 kg) in first trimester of life

6. Failure to gain at least 1/2 lb (0.23 kg) monthly in second trimester of life

7. Difficulties in breastfeeding

8. Measles, whooping oough and severe diarrhoea in the early months of life

9. Death of more than 4 siblings due to malnutrition and/or infectious diseases

10. Birthorder greater than 6

11. Weekly incane of less than (F1Ji) $10, if the family does not have a garden and does not reoeive assistance from others

12. Problem families, e.g. absent father, low IQ mother, etc.

*Adapted from D. Morley, J. Bickness and M. Woodland, Factors Influencing the Growth and Nutritional Status ot Infants and Young Children in a Nigerian Village. Trans. Roy. Soc. Trop. Med. Hyg. 1968, 62, 164-195.

- 11/12 -

LITERATURE

1. 'lbe Health Aspects of Foodllld Nutrition (1969). World Health Organization, Western Pacific Regional OffIce, Manila

2. Jelliffe, D.B. (1966). The Assessment of Nutritional Status in the COIIIIIWli ty. World Health Organization: Monograph Series No. 53, Geneva

3. Nelson, W.E. (1964). Textbook of Pediatrics, 8th Ed1tion W.B. Saunders Co., Philadelphia, Laldon

4. Nutritional Anaemias. WHO Technical Report Series No. 405 (1968), Geneva.

- 13/14 -

ANNEX 1

PRINCIPAL PEATURES OF PR<Y1'EIN-CALORIE IEFICIENCY (1)

A. Usual age

B. Essential features

1. Oedema

2. Wasting

3. Muscle wasting

4. Growth retardation

5. Mental changes

C. Variable features

1. Appetite

2. Diarrhoea

3. Skinohanges

4. Hair changes

5. Moonface

6. Hepatic enlargement

Marasmus

0-2 years

None

*GroSII losll of subcutaneous fat "all skin and bone"

Obvious

Obvious

Usually apathetic, quiet

Usually good

Often (past or present)

Seldom

Seldom

Seldom

Seldom

Kwashiorkor

1-3 years

*Lower lega, aometimes tace or generalized.

Sometimes hidden; sometimes fat, blubbery

Sometimes hidden

SOmetimes hidden

Usually irritable, moaning; also apathetic

Usually poor

Often (past or present)

Often - diffuse depigmentation

Occasional - *flaky-paint or enamel dermatosis

Often - sparse, straight, silk7; dyspigmentat1on: greyish or reddish

Often

Alwa,ys

*'!'he .. aN the most characteristic or useful dist1nguishing features.

- 15/16 -ANNEX 2

SAMPLE SURVEY FORM

Location •...••••.•.•..• '" .•.•..•.•.•..•.•.••.•.... .•... Date ••.•.•..•.•..•.•....•.••.•. Serial No.

Child's Name •..•.. " ..................... , ••••.•.•.••.••••• Ethnic group •••.•.••.•.•.••.•• Reltgl'on O)umame nrst name . .. ............ ..

Date of blnh ••.•..•.••..••.•.•.••.••• Sex ••.•.••.•.•••• Mother pregnant? No. of months ........................ .

Mother's name .......................................... Mother breastfeedlng now? .............................. .

Father's name ........................................... Ages of living brothers & sisters •••••••• , ................. .

Father's occupation. . • . • • . • • • • • • . • • • • •• • • • • • . • . • • . • . • • • • .• Ages at death of dead brothers 8< sis ten •••••.•••..•.•....•

ChUd's weight (kg)

Child's height (cm)

...................................... ......................................

Child's skinfold thickness Arm (mm)

Subscapular (mrn)

Mother's weight (kg)

Mother's height (cm)

Mother's Iklnfold thickness Arm (mm) ................... .

Subleapular (mm) ..... : ........... ..

CUNICAL EXAMINATION

1. THYROID

2.

3.

4.

5.

6.

7.

8.

9.

(a) Grade -------­

(b) Adenomatous

PAROTID

ENLARGEMENT

HAIR CHANGES

MOONFACE

EYE SIGNS

(a) Xerosis

conjunctivae

(b) BilOt's spot

(c) Xerophthalmia

(d) Keratomalacia

(e) Malnutrition

scar

(f) Other sca r

NASOLABIAL

SEBORRHOEA

ANGULAR

STOMATITIS

(a) Active

(b) Scar

CHEILOSIS

TONGUE

(a) Papillary

atrophy

(b) Magenta

( )

( )

( )

( )

( )

( )

( )

( )

( )

( )

( )

( )

( )

( )

10.

11.

12.

13.

14.

15.

16.

17.

Put + if Ilgn present - If sign absent

GUMS

(a) Gingivitis

(b) Scorbutic

DERMATOSIS

(a) Kwashiorkor

(b) Pel!agra

FOLUCULAR

KERATITIS

(a) Arms

(b) Back

(c) Legs

MUSCLE WASTING

(a) Arms

(b) Buttocks

(c) Legs

POT BELLY

SKELETON

(a) Costochondral

enlargement

(b) Knock-knees

(c) Enlargement of

epiphysis

CALF

TENDERNESS

REFLEXES

(a) Absent knee jerks

(b) Absent ankle jerks

( )

( )

( ) ( )

( )

( )

( )

)

( )

( )

( )

( )

( )

( )

18.

19.

20.

21.

22.

IS.

24.

OEDEMA

(a) Facial

(b) Dependent

(e) UnUateral

GENERAL

PAUOR

GROSS ANAEMIA

MENTAL

CONDITION

Ca) Apathettc

(b) Irritable

Cc) Mentally defiCient

fRANK

MALNUTRITION

(a) Marasmus

(b) Kwash'iorkor

(e) Rickets

(d) Other (Specify)

NUTRITIONAL

CONDITION

Specify one:

Good

Just adeCiu. te

Poor

OTHER FINDIWGS

(Specify)

( )

( )

( )

)

( )

( )

)

( )

AGE Stand- 12~ 11~

Yr Mos ard of std of ltd

0 0 7-8 9-0 8-3

1 9-8 11-6 10-6

~ J1-0 13-3 12-2

3

I 12-10 15-2 13-14

4 13-14 16-11 15-5

5 15-3 18-3 16-11

6 16-0 19-10 17-14

7 17-10 21-2 19-6

8 IP-S 22-3 20-6

9 I

21-10 I 1~·10 23-8

10 i 20-8 24-10 22-10

lJ I :1l-3 25-6 23-5

1 Q I 21-13 26-3 24-0

1 I

~2-8 27-0 24-13 ., 22-14 27-8 25-3

3 ~3-6 28-2 25-11

4 23-13 28-10 26-3

5 24-3 29-0 26-10 , 6 24-14 29-14 27-6

7 25-6 3o-B 27-14

8 25-13 31-0 28-6

~ I 26-3 31-6 28-13

10 I 26MI0 31-14 29-5

I 11 , 26M 14 32-5 29-10

2 0 27-5 32-13 30-0

1 27-13 33-6 30-10 ., 28-0 33-10 30-13 ,

i J 28-6 34-2 31-3 , , 4 28-14 34-11 31-13 I

5 20-5 35-3 32-3 :

32-13 : (; 2:1-13 35-13 I I

- 17 -

TABLE 1

WEIGHT FOR AGE 0 TO 4 YEARS (SEXES COMBINED)

Derived from JeUiffe2 and Nelson 3

Wei~ht in POWlds-Ounces

9~ 8~ 17~ 6~ AGE Stand- 12~ 11~

of std of std , of std of std Yr MOl ard of std of std -T

6-13 6-0 , , 0-3 4-8 2 6 29-13 35-13 32-13

8-10 7~10 , 6-10 S-11 7 30-3 36-3 33-3 9-14 8-13 ' 7-11 6-10 8 30-6 36-8 33-6 ,

11-5 10-2 ,8-13 7-10 9 30-14 37-2 34-0

12-8 11-2 , 9-11 8-5 10 31-5 37-10 34-6 1~-11 12-3 : 10-10 9-2 11 31-11 33-0 34-14

14-11 13-0 ,11-6 9-13 3 0 32-0 38-6 35-3

15-13 14-2 '12-5 , 10-10 1 32-6 38-14 35-10

16-10 14-13, 13-0 11-2 2 32-11 39-3 36-0

17-10 15-11 ' 13-11 11-13 3 33-2 39-11 36-6

18-6 16-6 14-6 12-5 4 33-8 40.3 36-13

19-2 17-0 14-13 12-11 5 33-13 40.10 37-3

19-10 17-6 15-5 13-2 6 34-3 41-0 37-10

20-3 18-0 15-13 13-8 7 34-10 41-B 3B-2

20-10 18-5 16-0 13-11 8 34-14 41-14 3B-6

21-2 18-11 16-6 14-0 9 35-5 42-6 38-13

21-6 19-0 16-11 14-5 10 35-11 42~13 39-5

21-13 19-6 16-14 14-8 11 36-0 43-3 39-10

22-6 19-14 17-6 14-14 4 0 36-6 43-11 40-0

22-14 20-5 17-13 IS-3 1 36-11 44-0 4o-B

23-3 20-10 18-2 15-8 2 37-0 44-6 40-11

23-10 21-0 IB-5 15-11 3 37-6 44-14 41-2

23-14 21-5 18~10 16-0 4 37-11 45M3 41-8

24-3 21-B IB-13 16M2 5 38-0 45-10 41M13

24-10 21-13,19-2 16-6 6 3B-6 46-2 42-3

25-0 22-3 '19-8 16-11 7 38-13 46-10 42-11

25M3 22-6 : 19-10 16-13 8 39-0 46-13 42-14

25MI0 22-11, 19-14 17-0 9 39-8 47M 6 43-6

26-0 23-2 ' 20-3 17-5 10 39-13 47~13 43-13 , 26-6 23-6 ,2o-B 17-10 11 40-3 48-3 44-3

26M13 23-13 , 20.14 17-14 5 0 40-10 48-J1 44-11 ,

ANNEX 3

9~ 8~ ,7~ G(J1jo

I of std of std ' of srd of std , , 26-13 23-13' 20-14

I 17-14 ,

I 27-3 24-3 , 21-2 18-2

27-6 24-5 ' 21-5 Id-3 , , 27-13 24-11, 21-10 18-b

, ,

28-3 25-0 , 21-14 18-13 I 28-8 25-6 ' 22-3 19-u I , 28-13 25-10, 22-6 1~-3 I 29-3 25-14' 22-11 ] ~J-0 , , 29-6 26-3 , 22-14 1;)-10 I

26-8 ' 23-3 I 29-13 19-14 , , 30-3 26-13, ~~-C 20-2

I 30-6 27-0 , 23-11 20 ... 5

30-13 27-6 ' 23-14 ~u-8 I , i 31-2 27-11' 24-3 20-1:3

31-6 27-14' 24-6 20-14 I , , , 31-13 2B-3 , 24-11 21-3 , 32-2 28-10' 25-0 21 .. 1~ , 32-6 28-13, 25-3 21-10 I 32-13 29-2 , 25-8 ~1-1 ~

33-0 29-6 ' 25-11 2~-" ; , 33-5 29-10, 25-14 22-3 I 33-11 29-14' 26-3 2'2 ... ( I , , 33-14 30-3 , 26-6 22M]O ;

34-3 30-6 ' 26M I0 22-13 I , ,

34-10 30-U, 26-14 23-0 I 34-14 31-0 , 27-3 23-5

35-2 31-3 ' 27-5 , 23-b ,

3S-10 31-10, 27-10 23~1l :

35-13 31-13' 27-14 23~141 , 36~3 32-3 ,28-2 24-2

36-8 32-B ' 28-6 24-6 ; ;

I , i I

Annex ,

BOYS AGE

Stand- 12"" 11"" 9"" Yean aId of ltd of ltd of ltd

6 42-13 51-6 47-2 38-8 5.5 45-10 M-ll 50003 41-0

6 48-5 68-0 53-2 43-8 6.5 51-2 61-S 56-3 46-0

7 54-0 64-13 69-6 48-10 7.5 57-2 68-8 62-13 51-6

8 60.3 72-3 66-3 M-3 8.5 63-0 75-10 69-6 56-11

9 65-14, 79-2 72-8 59-5 9.5 69-0 82-13 70.14 62-2

10 71-14 86-5 79-2 64-11 10.1 74-11 89-10 82-3 67-3

11 77-10 93-2 81i-& 69-13 11.6 80.14 97-2 89-0 72-13

12 84-6 101-6 920013 76-0 12.5 S8-10 106-6 97-8 79-11

13 93-0 111-10 102-5 83-11 13.5 100.5 120-6 110.5 90.5

14 107-10 129-2 118-6 96-13 14.5 114-0 136-13 125-6 102-10

15 120003 144-3 132-3 108003 15.5 124-13 10&8-13 137005 Il2oo5

16 129-10 lliW 1420010 116-10 16.6 132-14 16P0t8 148-3 1111-10

17 136-3 163006 10&8-13 122-10 17.6 137-10 165-2 151-6 123-13

18 138-14 166-11 10-13 126-0

- 18 -

. TABLE 2.

WEIGHT Fat AGE 5 TO 18 YEARS Derived from Nelsoo 3

Weight In Pounds-Ounces

8 "" ; 7 O'J> 60'J> Stand- 12"" ofstd I of ltd of ltd aId of If"

: . 34-3 I 30.0 26-11 41-6 49-11 36-8 I 31-14

I 27-6 44-2 52-14

38-10 : 33-13 29-0 46-8 55-13 40.14 35-13 30.11 49-6 59-5

43-3 37-13 32-6 52-3 62-10 45-11 40.0 34-5 55-2 66-2

48-3 42-2 36-2 58-a 69-10 50.6 44-2 37-13 61-2 73-5

52-11 46-2 39-8 63-11 76-6 55-3 48-5 41-6 67-0 80.6

I 57-8 I 50-5 43-2 70.5 84-6 59-13 I 62-6

I 44-13 74-8 89-6

62-2 I I

54-5 46-10 78-11 94-6 64-111 56-10 48-8 83-2 99-11

I 67-8 I 69-2 50.10 87-8 105-0 70.14 : 62-0 63-3 93-S 112-3

I 65-2 74-8 I 55-13 99-0 118-13

80003 I 70003 60003 103-10 124-5 I

86-2 I 75-5 I

64-10 108-8 130003 91-3 I 79-13 88-6 110-14 133-2

I 96-3 I 84-2 '12-2 lla-8 136-3 9\Joo13 1 87-6

I 74-14 115-5 138-6

103-11: 90-11 '17-13 117-2 140-8 10&06 I 83000 ,..11 118-3 141-13

I 109-0 I 116-5 81-11 1111-0 142-13 110-2 I 96-5 82-10 119-8 143-6 I

I

111-2 I 9'1-3 I

83-6 1111-14 143-14 I

GIRLS

11"" 9"" 8"" ' I 7"" 6~

of ltd of IIxI of ltd I of ltd of .td I I

45-8 37-5 aa-2 129- 0 24-13

48-8 39-11 35-6 130-14 26-6 I

51-3 41-13 37-3 I 32-10 I

27-14 54-5 44-8 39-8 I 34-10 29-10

I 57-6 47-0 41-13 36-8 31-5 60.10 49-10 44-2 38-10 33-2

63-13 52-3 48-6 40-10 34-13 67-3 55-0 48-14 42-13 36-11

70.2 57-6 61-0 44-10 38-3 73-11 60.6 63-10 46-14 40.3

77-5 S3-6 56-3 49-3 42-3 82-0 67-0 69-10 162-3 44-11

I

a6-10 70.13 53-0 I 65-2 47-3 I

91-6 74-13 66-8 I 68-3 49-l4 I

96-3 78-13 70.0 I 61-3 52-8 102-13 84-3 74-13: 65-6 66-2

108-14 89-2 79-3 '69-5 I 59-6

114-0 93-3 82-14 I 72-8 62-3 I

119-6 97-10 86-13 I 76-0 65-2 122-0 99-13 I

88-11 I 77-10 66-6

124-13 102-3 90-13 : 79-6 68-2 126-13 103-13 92003 I 80-11 6\Joo3

I

128-13 IDs-e 113-11 I 82-0 70.5 130-0 108-6 116-10: 82-11 70-14

I 130..14 107-2 116-3 I 83-6 71-6 131-6 107-10 115-10 I S3-10 71-11

I I

131-14 107-14 95-14 1 83-14 71-l4 I

AGE Stand- 12~ 1l~ 90% SO%

Yr. Mos ard of sui of sui of sId of sId

0 0 19.6 23.6 21.6 17.6 15.6

1 21.6 25.9 23.6 19.4 17.3

2 22.8 27.4 25.1 20.5 18.2

3 23.6 28.3 26.0 21.2 lS,,9

4 24.5 29.4 27.0 22.0 19.6

5 25.4 30.5 27.9 22.9 20.3

6 25.9 31.1 2S.5 23.3 20.7

7 26.6 31.9 29.3 23.9 21.3

S 27.2 32.6 29.9 24.5 21.6

9 27.S 33.4 30.6 25.0 22.2

10 28.4 34.1 31.2 25.6 22.7

11 28.9 34.7 31.13 26.0 23.1

1 0 .29.4 35.3 32.3 26.5 23.5

1 29.9 35.9 32.9 26.9 23.9

2 30.4 36.5 33.4 27.4 24.3

3 30.7 36.8 33.8 27.6 24.6

4 31.2 37.4 34.3 2S.1 25.0

5 31.7 3S.0 34.9 2S.5 25.4

6 32.0 3S.4 35.2 2S.S 25.6

'1 32.6 39.1 35.9 29.3 26.1

S 32.9 39.5 36.2 29.6 26.3

9 33.2 39.13 36.5 29.9 26.6

10 33.6 40.3 37.0 30.2 26,.9

11 34.0 40.8 37.4 30.6 27.2

2 0 34.3 41.2 37.7 30.9 27.4

1 34.6 41.5 3S.1 31.1 27.7

2' 35.0 42.0 38.5 31.5 28.0

3 35.3 42.4 3S.6 31.8 28.2

4 35.6 42.'1 39.2 32.0 28.5

5 35.9 43.1 39.5 32.3 28.7

6 36.1 43.3 39.7 32,5 28.9

•

- 19 -

TABLE 3

LENGTH FOR AGE 0 TO 5 YEARS Derived from Jelliffe2 and Nelson3

Len~ in Inches

'1~ 60% AGE stand-

of sId of sId Yr. Mos. ard

13.9 11.9 2 6 36.1

15.1 13.0 7 36.4

16.0 13.7 S 36.7

16.5 14.2 9 3'1.0

17.2 14.7 10 37.3

17.8 15.2 11 37.5

lS.l 15.5 3 0 37.8

lS.6 16.0 1 38.0 .

19.0 16.3 2 3S.3

19.5 16.7 3 3S.5

19.9 17.0 4 3S.7

20.2 17.3 5 39.0

20.6 1'1.6 6 39.2

20.9 17.9 7 39.5

21.3 lS.2 8 39.8

21.5 lS.4 9 40.0

21.8 lS.7 10 40.2

22.2 19.0 11 40.4

22.4 19.2 4 0 40.7

22.8 19.6 1 40.9

23.0 19.7 2 41.1

23.2 19.9 3 41.4

23.5 20.2 4 41.6

23.8 20.4 5 41.8

24.0 20.6 6 42.0

24.2 20.8 7 42.2

24.5 21.0 8 42.5

24.7 21.2 9 42.6

24.9 21.4 10 42.7

25.1 21.5 11 42.8

25.3 21.7 5 0 42.9

Annex 3

12~ 110% 9~ S~ '10% 60"/.

of sId of sId of sId ofstd ofstd of sId

43.3 39.7 32.5 2S.9 25.3 21.7

43.'1 40.0 32.6 29.1 25.5 21.S

44.0 40.4 33.0 29.4 25.7 22.0

44.4 40.7 33.3 29.6 25.9 22.2

44.S 41.0 33.6 29.8 26.1 22.4

45.0 41.2 33.8 30.0 26.2 22.5

45.4 41.6 34.0 30.2 26.5 22.7

45.6 41.8 34.2 30.4 26.6 22.8

46.0 42.1 34.5 30.6 26.S 23.0

46.2 42.4 34.6 30.S 27.0 23.1

46.4 42.6 34.S 31.0 27.1 23.2

46.S 42.9 35.1 31.2 2'1.3 23.4

47.0 43.1 35.3 31.4 2'1.4 23.5

47.4 43.4 35.6 31.6 2'1.6 23.7

47.8 43.8 35.S 31.8 2'1.9 23.9

4S.0 44.0 36.0 32.0 28.0 24.0

48.2 44.2 36.2 32.2 28.1 24.1

4S.5 44.4 36.4 32.3 28.3 24.2

48.S 44.8 36.6 32.6 28.5 24.4

49.1 45.0 36.8 32.7 2S.6 24.5

49.3 45.2 37.0 32.9 28.S 24.7

49.7 45.5 37.3 33.1 29.0 24.8 I

49.9 45.8 37.4 33.3 29.1 25.0

50.2 46.0 37.6 33.4 29.3 25.1

50.4 46.2 37.S 33.6 29.4 25.2

50.6 46.4 38.0 33.8 29.5 25.3

51.0 46.8 38.2 34,0 29.S 25.5 I

51.1 46.9 38.3 34.1 29.S 25.6

51.2 47.0 38.4 34.2 29.9 25.6

51.4 47.1 38.5 34.2 30.0 25.7

51,5 47.2 38,6 34.3 30.0 25.7

Annex 3

AGE Stand- 1200/. 110.,. 900/0 Yrs ard of std of std of std

5 43.8 52.6 48,2 39.4

5.5 45,0 54.0 49.5 40.5

6 46,2 55.4 50,8 41.6

6.5 47.6 57.1 52.4 42.8

7 48,8 58.6 53.7 43.9

7.5 50.0 60.0 55.0 45.0

8 51,2 61,4 56,3 46.1

8.5 52,3 62.8 57.5 47.1

9 53,3 64.0 5S.6 4S.0

9.5 54,3 65,2 59.7 48.9

10 55,2 66,2 60.7 49.'1

10.5 56.0 67,2 61.6 50.4

11 56.8 68,2 62.5 51.1

11.5 57.8 69,4 63.6 52.0

12 58.9 70.7 64.8 53.0

12,5 60.0 72.0 66.0 54.0

13 61,0 73,2 67.1 54.9

13.5 62,6 75,1 68.9 56,3

14 64.0 76,8 70.4 57,6

14.5 65.1 78.1 71.6 58.6

15 66.1 79,3 72.'1 59.5

15.5 66,8 SO,2 73.5 60,1

16 67.6 81.1 74.4 60.8

16.5 68.0 81.6 '14,8 61,2

17 68.4 82.1 75,2 61.6

17.5 68.5 82,2 75.4 61.6

18 68.7 82.4 75.6 61.8

- 20 -

TABLE 4

HEIGHT FOR AGE 5 TO 1~ YEARS

Deriyed from Nelson

Height in Inches

BOYS

800/. 700/0 600/. Stand. 1200/0 of std of std of std ard of std

35.0 30.7 26.3 43.2 51.8 36,0 31.5 27,0 44.4 53.3

37.0 32,3 27.7 45.6 54.7

3S.1 33,3 28.6 46.9 56,3

39.0 34,2 29,3 48.1 5'1.'1

40.0 35.0 30.0 49,3 59,2

41.0 35,8 30.7 50.4 60.5

41.8 36.6 31.4 51.4 61,7

42,6 37,3 32.0 52.3 62.8

43.4 38.0 32.6 53.5 64,2

44,2 38.6 33.1 54.6 65.5

44.8 39,2 33.6 55,8 67.0

45.4 39.8 34.1 5'1.0 68.4

46,2 40.5 34.7 58,3 70.0

47.1 41,2 35.3 59.8 '71.8

48.0 42.0 36.0 60.7 72.8

48.8 42,7 36.6 61,8 74,2

50,1 43,8 37.6 62.4 74,9

51,2 44.8 38.4 62.8 75.4

52.1 45.6 39.1 63.1 75.7

52.9 46.3 39.7 63.4 76.1

53.4 46.8 40.1 63.7 76.4

54.1 47,3 40.6 63,8 76.6

54.4 47.6 40.8 63.9 76,7

54.7 47.9 41.0 64.0 '16,8

54,8 48.0 41.1 64.0 76.8

55.0 48.1 41.2 64.0 76.8

GI1W5

1100/0 900/0 800/. '100/. 600/.

of std ofstd of std of std of std

47.5 38,9 34,6 30,2 25,9

48.8 40.0 35.5 31.1 26.6

50,2 41.0 36.5 31.9 27.4

51.6 42,2 37.5 32,8 28.1

52.9 43,3 38.5 33.7 28.9

54.2 44,4 39.4 34.5 29.6

55.4 45.4 40,3 35,3 30,2

56.5 46,3 41.1 36.0 30.S

57.5 47.1 41,8 36.6 31.4

58.8 48,2 42.8 37.4 32.1

60.1 49.1 43.'1 38,2 32.8

61.4 50,2 44.6 39.1 33.5

62.'7 51,3 45.6 39.9 34.2

64.1 52.5 46.6 40,8 35.0

65,8 53,8 47.8 41.9 35.9

66.8 54.6 48.6 42.5 36,4

68,0 55.6 49.4 43,3 37,1

68,6 56,2 49.9 43,7 37.4

69,1 56.:; 50,2 44.0 37.7

69.4 56.8 50.5 44.2 37.9

69.7 57.1 50.7 44.4 38.0

70.1 57,3 51.0 44.6 38,2

70,2 5'1.4 51.0 44.7 38,3

70,3 57.5 51.1 44.7 38,3

70.4 57.6 . 51,2 44.8 38.4

70.4 57.6 51,2 44.S 38.4

70.4 57.6 51.2 44.S 38.4

AGE hod- 120ft 110ft ~ Yr. Mol ani of.td of.td of.td

0 1 4.Ai 15.4 6.0 4,p 2 4,,9 11.9 6.4 4.4 3 6.0 6.0 6.Ai 4.Ai

4 5.7 6.8 e.a 5.1 5 5.8 7.0 6.4 5.2 6 5.7 6.8 6.3 5.1

7 6.8 7.1 6.6 .6.3 8 8.1 7.3 8.7 5.1 9 6.2 '1.4 8.8 5,.6

10 6.2 '1.4 6.8 5.6 11 e.2 7.4 6.8 5.6

1 0 6.3 '1,.6 8,,9 5.'1 3 6.3 '1.6 6,.9 5.'1 6 6.2 '1.4 6.8 5.6 9 6.4 7.7 '1.0 5.8

2 0 6.4 7.'1 7.0 5.8 3 6.5 7.8 '1.2 5.8 6 6.4 7.'1 '1.0 5.8 9 6.4 7.7 7.0 5.8

3 0 6.4 7.'1 '1.0 5.8 3 6.6 '1,,9 '1.3 5.9 6 6.6 7.8 '1.2 5.8 9 6.6 '1,.9 'l.3 5,.9

4 0 6.6 '1,.9 7.3 5,.9 3 6.8 8.2 '1.Ai 6.1 6 6,.9 8.3 7.6 6.2 9 6.8 8.2 7.5 6.1

5 6.'1 8.0 7.4 6.0

6 6.8 8.2 7.6 6.1

7 7.0 8.4 '1.'1 e.a ~ '1.2 8.6 '1,.9 6.5

9 'l.5 9.0 8.2 6.8

0 '1.8 9.4 8.6 '1.0

1 8.0 9.6 8.8 '1.2

~ 8.3 10.0 9.1 '1.Ai

~ 8.7 10.4 9.6 'I.e ~ 9.1 10,,9 10~0 8.2

la 9.8 U.8 10.8 8.8

~6 10.2 12.2 11.2 9.2

1M 10.6 12:1 11.7 9.5

IAdult 11.5 13.8 12.6 10.4

- 21 -

TABLE 5

ARM CJlICtJNFElIENCE . From Jclliffe 2

AIm ~ in inches

MAUt

801ft 701ft 60ft Srand- 120ft alard ohtd ofatd ani of.td

S.e S.2 2.7 4.4 6..3 8,,9 SoIA 2.9 4.7 6.6 4.0 S.Ai 3.0 5.2 6.2

4.6 4.0 S.4 5.3 6.4 4.6 4.1 3.6 5.5 6.6 4.6 4.0 3.4 5.6 6.7

4.7 4.1 3':; 5.7 s.a ".8 4.3 3.7 5.9 7.1 5.0 4.3 3.'1 6.0 'l.2

5.0 4.3 3.'1 6.1 'l.3 5.0 4.3 S.'I 6.l '1.3

1.0 4.4 3.8 6.1 '1.3 5.0 4.4 S.8 6.2 '1.4 6.0 4,,9 3.'1 6.3 '1.6 5.1 4.5 3.8 6.2 7.4

5.1 4.5 3.8 6.2 7.4 5.2 4.6 3.9 6.4 7.'1 5.1 4.5 3.8 6.4 7.7 5.1 4.5 3.8 6.3 '1.6

5.1 4.5 3.8 6.2 7.4 5.3 4,.6 4.0 6.8 8.2 5.2 4,.6 3,.9 6.4 7.7 5.3 4,.6 4.0 6.6 7,.9

5.3 4.6 4.0 6.6 '1.9 5.4 4.8 4.1 6.6 7.9 5.5 4.8 4.1 6.5 7.8 5.4 4.8 4.1 6.6 7,.9

5.4 4.'1 4.0 6.6 7.9

5.4 4.8 4.1 6.8 8.2

5.6 4.9 4.2 '1.0 8.4

5.8 11.0 4.3 '1.2 8.6

6.0 5.2 4.5 '1.5 9.0

6.2 5.5 4.'1 '1.8 9.4

6.4 5.6 4.8 8.1 9.7

6.6 5.8 5.0 8.5 10.2

'1.0 6.1 5.2 8.8 10.6

'1.3 6.4 5.5 9.1 10,,9

'l.8 6,.9 5.9 9.6 11.5

8.2 'l.1 6.1 9.7 11,.6

8.1 '1.4 6.4 9.8 11.11

9.2 8.0 6.9 9.2 11.0

Annex 3

FEMALE

11"" 90ft 8~ 70ft 6"" ofatd ohtd of.td ofatd of sIAl

4.8 4,p S':; 3.1 2.6 6.2 4.2 a.s 3.3 2.8 !i.7 4.7 4.2 3.8 3.1

5.8 4.8 4.2 3.7 3.2 6.0 1.0 .'" 3.8 3.3 6.2 5.0 4.6 3.9 3.4

6.3 5.1 4.6 4.0 3.4 6.5 5.3 4.7 4.1 3.5 6.6 5.4 ".8 4.2 3.6

6.'1 5.5 4.9 4.3 3.7 6.'1 5':; 4,,9 4.3 3.7

6.'1 5.5 4,.9 4.3 3.'1 6.8 5.6 5.0 4.3 3.'1 6,.9 5.'1 5.0 4.4 3.8 6.8 5,.6 5.0 4.3 3.7

6.8 5.6 5.0 4.3 3.7 7.0 5.8 5.1 4.5 3.8 7.0 5.8 5.1 4':; 3.8 6.9 5.7 5.0 4.4 3.8

6.8 5.6 5.0 4.3 3.'1 7.5 6.1 5.4 4.8 4.1 7.0 5.8 5.1 4.5 3.8 '1.3 5.9 5,,9 4.6 4.0

7,,9 5,.9 5.3 4.6 4.0 'l.3 5.9 5.3 4.6 4.0 7.2 5.8 5.2 4.6 3.9 7.3 5.9 5.3 4.6 4.0

7;I 5.9 5.3 4.6 4.0

7) 6.1 5.4 4.8 4.1

7.'1 6.3 5.6 4.9 4.2

'1.9 6.5 5.8 5.0 4.3

8.2 6.8 6.0 5.2 4.5

8.6 '1.0 6.2 5.5 4.'1 8,,9 '1.a 6.5 5.7 4.9

9.4 7.6 6.8 6.0 5.1

9.'1 7.9 7.0 6.2 5.3

10.0 8.2 U 6.4 5.5

10.8 8.6 7.7 6.7 5.8

10.'1 8.7 '1.8 6.8 5.8

10.8 8.8 '1.11 6.9 :i,.9

10.1 8.3 '1.4 6.4 5.5

Annex :J

AGE Head

Yr. Mos. Stand- 110%

ard of std

0 0 13.9 15.3

3 lS.l 17.'1

6 17.3 19.0

9 18.1 19.9

1 0 18.6 20.5

3 18.9 20.8

6 19.2 21.1

2 0 19.6 21.6

6 19.8 21.8

3 19.8 21.8

- ;;? -

TABU 6

HEAD AND CHEST CIRCU¥FERENCES

Derived from Nwon

Circumference in Inches

MALE FEMALE

Chest Head

90"10 Stand- 110% 90% Stand- 110% 90%

of su ard of std of std arc! of std ofstd

. 12.5 13.1 14.4 11.8 13.'1 15.1 12.3

14':; 16.0 17.S 14.4 15.'1 17.3 14.1

15.6 17.2 IB.9 1:>.5 16.8 1B.5 15.1

16.3 1B.1 19.9 16.3 17.6 19.4 15.8

16.7 18.7 20.6 16.8 18.0 19.8 16.2

17.0 19.1 21.0 17.2 18.3 20.1 lS.5

17.'3 19.5 21.4 17.6 18.5 20.4 16.6

17.6 20.0 22.0 18.0 18.9 20.8 17.0

17.B 20.4 22.4 18.4 19.2 21.1 1'1.3

17.8 20.6 22.7 18.5 19.4 21.3 17.5

Chest

Stand- 1100/. 'J f'P/., ard of std of std

13.0 14.2 11.'1

15.'1 17.3 14.1

16.9 18.6 15.2

17.9 1~.7 16.1

18.5 20.4 16.6

18.8 20.7 16.9

19.2 21.1 17.3

19.7 21.7 17.7

20.2 22.2 lR .2

20.4 22.4 18.4

-2, - ANNEX 4

CHILD HEALTH RECORD Number

VlUAGE ________________________________ __ ~TmCT:-________________ ~-------------

" ~AME ________________________________ __ BIRTH: - lingle

Date of hlrth __________ Sex M ( ) F ( )" Gescadoo:- full-term

P~eofNrth ______________________ _ AsphylIIa:. - yes

Blrthwelght ____________ Blrth order __ _ Birthplace: - hospitAl

No. ofslbUIl8" _________ lIvlDg( ) dead C )" AnaadaJlt:- doctor

Father's name: _________________ _

occupatloo: ________________ __

Mother's name: ________________ _

blrtbclate: ________________ _

Village head,

traditional

DEVELOPMENT: - slnlng

Cat flnt exam) talking

FEEIllNG: - bN&st ( ) artifiCial

(at tim eum) semi-solid

C .) IIIll111ple

plema_

DO

home

n_/mldwlfe

other

walking

No, of tuth

mixed

solid

IMMUNIZATIONS CON~ENITAL ABNORMALITIES AND PAST DISEASES:

Flnt Second Booster

Due Given Due Given Due Given

BCG

TTPH FAMILY ILLNESSES:

DPT .

POLIO

...... FIRST MEDICAL EXAMINA TION (history and findings) ~:

DATE Wt. PROGRESS (INCLUDING DEVELOPMENT AND FEEDING)I FINDINGS. ADVICE AND TlEATMENT INITIAL

"--

Instructions:

Enter the MONTH of blnh and the apptuprlate calendar

year, In the first black rectangle .t hottom of chart;

Then fill In all the monlh. in chronolo~ic ,eqllrncr,

like Ihls·

WEIGHT IN POUNDS

~ ;::

~ -l .. c ... ... .! i c .... ~ 1 <l: ~ ,~ ~ ~~ ~ ~ ..., ..,

(Th .. Is the appropnale entry for. chIld hom In (let. l~~O,)

Weigh the child. Place large dot in arprn: ri.te column for

weight (to nearest 0.1 lb) each time ,·.I,i ," I, weiRhed.

Connecl this dot to previous dOl. Enter illness., on chart.

BIRTII TO FOLR YEARS INeLl SIVE

Ih. Ih.

46rT~"~rrrr~6

44 4 lb.

42rr~'-.r.r.T,T.~,I,r.~_t,t.1;.~.H,~.~,t,111;42 4°rtttiiiHHrHrtttt~~Hr~~~0 Ih. • •••• ,- '-.'.' •• ' •• 'I-' •••

38rT~lrrrTTTTI1Hrrt111rHrrt11,.rt~~,.rtTP8 ... --_ .... -- ....... ----Ih. 3 6~.+.+.-t.-t.+I. -I. r. r, r_r_T.T.t-t_-t.-t_+l. H. r,t-t-t:.t-.1'.'t.1;. ~. ~. H. r. t-_T_t.tfl 6 34rT,,-rMr~,,-r~++;,~~++~"~++~Hf~++~rrtt+i~rr~4

... ------ .. --- -- .. ---lb. 32 2 30 1---... . .. - . . ... ,- 0 -- _ .. - _ .. --.... -_. _. _. . .. -28~t-t-t-~~~r-r-~r-r-~HrHHHHHHHHHH~HAHHHH;;;;~~,,~~~~~~~~8 261-- -- ••• -- ••••••• ---------.... "-"-"-""" .•• - •• ,-.'" - ••• 6

.: 2:4r-+-+-1-1--~r-r-+-~~-r-rt-t-t1~~rrr+t-t-t-t~+I~~t+t-t~~rrrrr+++~~HI-~t-t~4 22 -- .. . ....... -.. - - . . . .. -... . . . . . . . . . - : . . . - - . 2

20 •• - - -. - - • - -. - -... -. -~ V- - • - . • ,-' - - - - - - • - 0

181----------------;..-K ------.. . ••• ---. 18

1 - -. --1-- .- -- -:.,.f<.: ••• - - -:. ,':. -. - •.•. --1 -----.- ••• ~I-----. : ... -- .. -..... -- ... -- .... -. - :~

• - .~ :. .. .J.'- .. -- -- -- - + - - - --,,-... V- --.-.-- •• -- -----.- om yea ~

1 _ -V- _, __ • _1 __ 1-:": _. ___ • _ • __ • 8 .. .....

1~-~---~-r-~-~/~-~-~-,·-~,c--'----1-~-~---1~~~~~iii+++++t-t-t-+-t·t·ttt-~I· .. ~~ .... ~rrrrrrrrTT1 -- --V- _. '~I-- -- -.~""----.

.1. , two years

....... '-'"IL.:'-:-'~ ............ t one year

, Infant

Binhmonth

DATE Wt. PROGRESS (INCLUDING DEVELOPMENT AND FEEDING); FINDINGS, ADVICE AND TREA TMENT INITIAl

I j I

--- -1 j

PLATE I CLINiCAl MALNUTRITION

A. KWASHIORKOR WITH DERMATOSIS B. KWASHIORKOR WITHOUT DERMATOSIS

· .

C. MARASMUS AND KWASIiIORKOR D. EXAMINING THE ORAL MUCOSA FOR ANAEMIA

GRCMTH RETARDATION IN GILBERTESE CHILDREN

.. ,,0

The eldest and the youngest are three years apart in age but little difference in size.

Boyl Boy 2 Boy 3

Age 4 yrs. 9 mos. 3 yrs. 2 mos. 1 yr. 10 mos.

Weight (kg ) 10 9.5 9.5

~ of standard* <.60 .c.. 70 <:: 80

Height (em ) 87 .3 83.6 82 . 6

,,; of standard lf <::90 <90 within limits

*Derived from D.B. Jelliffe: The Assessment of Nutritional Status in the Communit y. WHO Monograph No. 53 (Annex 1) and W.E. Nelson: Textbook of Pediatrics (1964. 8th Ed. ) .

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PLATE III

VITAMIN A DEFICIENCY

VITAMIN A DEFICIENCY MAY HAVE VERY SERIOUS EFFECTS ON THE EYE. THIS PICTURE SHOWS HAZINESS OF THE CORNEA AND A 'BlTOT'S SPOT'. THESE ARE COMPARATIVELY

EARLY SIGNS BUT UNLESS TREATMENT WITH LARGE DOSES OF VITAMIN A IS GIVEN AT

THIS STAGE PERMANENT BLINDNESS MAY ENSUE.

Piclure by Professor H.A.P.C. OOMEN

•

I •

•

•

•

ANTHROPOMETRIC EQUIPMENT

ADULT AND INFANT SCALES AND INFANT LENGTH MEASURING TABLE

MEASUREMENT OF INFANT LENG'm

20 em 1

Groove or Canal for Moving

Board t

PLATE N

MEASUREMENT OF HEIGHT

INFANT LENGTH MEASURE

em

em

90 em

~ ~ INFANT LENGTH MEASURE