Pediatric cases for final year

clinics
Compiled by-
Med Cdt Arnab Patra
Med Cdt Daanish
E3 batch

kilroy was here

Chief complaints :
1. Failure to gain height adequately as compared to the peer group (neighbours/elder siblings/
cousins / friends)

2. Delayed onset of puberty (menarche in girls) ??

- if present suspect constitutional delay of growth or hypothyroidism or chronic anaemia

3. Deformities in the limbs (if any in suspect case of rickets)

HOPI :
The child was apparently asymptomatic till 3 years of age when his/her mother noticed that the child
was not growing adequately as per his/her peer groups.

It was associated with inward bowing of the legs and thinning of limbs.

1. h/o headache, seizures, loss of consciousness, nausea, vomiting and visual field defects (rule out
CNS causes - infections, Craniopharyngioma, hypothalamus/pituitary space occupying lesion)

2.h/o chest pain, palpitations, difficulty in breathing on exertion (exertional dyspnea),syncope,

fatiguability (CVS causes - Congenital heart disease)
h/o bluish discoloration on feeding or crying (Tet or cyanotic spells as seen in Tetralogy of Fallot)
Exertional dyspnea with claudication pain - suspect Coarctation of Aorta

3. h/o breathlessness, difficulty in breathing, cough, blood in sputum (haemoptysis) and Wheezing
(Respiratory causes - Asthma, Pneumonia, TB)

4. h/o Abdominal distension, yellowish discoloration of sclera and skin (jaundice), blood in vomitus
(haematemesis), passage of dark colored, tarry, sticky stool (melena) - suspect chronic liver disease
leading to portal hypertension
h/o easy bruisabilty, loss of appetite

5. h/o chronic diarrhoea, large volume greasy stools (Malabsorption syndromes like IBD, Celiac
disease and Tropical sprue)

6. h/o polyuria, blood in urine, flank pain, decreased urine output ( suspect renal involvement -
Chronic Kidney Disease, Renal Tubular Acidosis)

7. h/o easy fatiguabilty, difficulty in breathing, pale face, blood transfusion - chronic Anaemia 8. h/o
recurrent blood transfusion - Thalassemia

9. h/o recurrent infections, blood transfusion - AIDS

10. h/o lethargy, constipation, hair loss, weight gain (Hypothyroidism)

Family history :
h/o short stature in parents (familial)
h/o delayed onset of puberty in parents (constitutional growth delay)
h/o Hypothyroidism or any Endocrine disorders in family
h/o AIDS in parents
Antenatal and Birth history :
Antepartum :
Any fever with rash (TORCH infections)
Abnormal serology or viral markers
Any exposure to teratogenic drugs, radiation
Multifoetal gestation - leads to growth retardation
Maternal conditions like Hypertension (PIH), Hypothyroidism

Intrapartum:
h/o low birth weight (Small for Gestational Age child)
Term or Preterm birth
Any h/o Neonatal hypoglycemia or Neonatal jaundice or micropenis (in boys) - suspect
Hypopituitarism
(Hypoglycemia - Neonate developed seizures 24 - 48 hours after birth for which he/she was given i.v.
glucose)

Developmental history :
Delayed motor development milestones (Cerebral palsy)

Nutritional history :
h/o inadequate dietary intake - suspect Undernutrition
h/o Breastfeeding exclusively for 6 months - if not suspect chronic infections

Immunization history :
Inadequate immunization - suspect infections

Socioeconomic history : (suspect Psychosocial dwarfism)

Overcrowding
Poverty
Multiple siblings
Lack of Breastfeeding
Lack of knowledge about diet and feeding
 Tachycardia - Anaemia, Congenital heart disease
Bradycardia - Hypothyroidism

Hypertension - Chronic Kidney Disease

ANTHROPOMETRY
For less than 5 years,
Low height for age
Normal Weight for age
Weight for Height may be normal or slightly increased

Plot them onto the WHO MGRS chart and find in which percentile/Z-score the child lies

Mid upper arm circumference Occipitofrontal or Head circumference Chest circumference

For children > 5 years

Height for age
Weight for age
BMI for age

Mid parental height (MPH) =

(Mother's height + Father's height +/- 13) / 2
Target range = MPH +- 6
Plot them on the IAP growth charts and find the child's growth lies in which percentile

US:LS
Normal 1.7 at birth, 1.3 at 3 years, 1.1 at 6 years, 1 at 10 years and 0.9 in adults Disproportionate
body
US Upper segment(vertebra) anomalies like Spondyloepiphyseal dysplasia and vertebral defects lead
to decreased US:LS
LS Lower segment(upper limb and lower limb) defects like Rickets, Achondroplasia, Osteogenesis
imperfecta and Epiphyseal/Metaphyseal/Diaphyseal dysplasias lead to increased US:LS
Hypothyroidism presents as both proportionate as well as disproportionate short stature

HEAD TO TOE EXAMINATION

Pallor - Anaemia, Chronic Kidney Disease Icterus - Chronic liver disease
Cyanosis and clubbing - Respiratory distress
Signs of Micronutrient deficiency - Undernutrition
Frontal bossing, depressed nasal bridge, crowded teeth, small penis (in boys) - Hypopituitarism

Haemolytic facies with Malar prominence - Thalassemia Simian facies - Marasmus

Goiter, coarse skin - Hypothyroidism

Dysmorphic features
Mongolian slant, epicanthus folds - Down's syndrome Webbed neck, widely spaced nipples -
Turner's syndrome
Moon like face with buffalo hump, Central obesity, Abdominal striae - Cushing's syndrome Spider
naevi, dilated umbilical veins - Chronic liver disease
3 year old male child, 1st child of a non-consanguineous marriage, presented with complaints
of not gaining adequate height as per his peer groups and there is inward bowing of the legs
for the last 9 months
No family history of short stature or delayed puberty

On examination the child was found to have reduced height for age below 3rd centile which
indicates stunting
There is genu varum deformity in the lower limb

Diagnosis :
Pathological short stature most likely due to Rickets

Bone
age !
growth velocity
!
Height

For infants (who cannot stand without support) - measure length using infantometer

For children who can stand without support - measure height using staediometer

General rules for height measurement :

1. The child should stand upright with legs straight, arms by the side of tge body, shoulders
are level and the feet close by
2. 4 points of the child's body should touch the wall - head (occiput), shoulders, buttocks
and heels
3. The child should look straight such that the Frankfurt's plane (the plane passing through
the tragus and inferior orbital border) is parallel to the ground

After measuring the height, plot on the height for age chart

For <= 5 years : use WHO growth charts (gives result in SD)
For > 5 - 18 years : use IAP growth charts (gives results in percentiles)
Now we can also use combined IAP WHO growth charts for 0 - 18 years (gives results in
percentiles)

Calculate the Mid parental height :

Boys: (Mother's height + Father's height)/2 + 6.5 cm

Girls: (Mother's height + Father's height)/2 - 6.5 cm

Plot the mid parental height at 18 years on the height for age chart and mark it with a ↔

Calculate the Target Height range :

Target height range = Mid parental height +/- 6 cm

Plot it at 18 years with vertical arrows and then trace them backwards along the growth curves
till 0 years and then shade the area between the 2 curves.

If the child's height is < - 3 SD, but still within the target height range it means it is a familial
short stature

If the child's height is less than the target height range but is between - 2 SD and - 3 SD it is
most likely a Constitutional short stature

If Height for age < - 2 SD - STUNTING (Chronic Malnutrition)

If Height for age < - 3 SD - SEVERE STUNTING
Rate of growth -
For the 1st year : 25 cm per year
2nd year : 12.5 cm per year
3rd year : 7.5 cm per year
4 - 12 years : 5 - 7 cm 0er year

Length at birth = 50 cm +/- 5 cm

Height doubles the birth length by 4 years
Height triples the birth length by 12 years

Weech formula for estimated height calculation for age : (Age × 6) + 77 cm

 Length-for-age GIRLS
6 months to 2 years (z-scores)

3
95 95

90 90

0
85 85

-2
Length (cm)

80 80

-3
75 75

70 70

65 65

60 60

Months 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11
1 year 2 years
Age (completed months and years)
WHO Child Growth Standards
 Height-for-age GIRLS
2 to 5 years (z-scores)

125 125
3

120 120
2

115 115

110 0 110

105 105
Height (cm)

100 -2 100

95 -3 95

90 90

85 85

80 80

Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
 Length-for-age BOYS
6 months to 2 years (z-scores)

100 100

3
95 95
2

90 90

85 85
Length (cm)

-2
80 80
-3

75 75

70 70

65 65

Months 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11
1 year 2 years
Age (completed months and years)
WHO Child Growth Standards
 Height-for-age BOYS
2 to 5 years (z-scores)

125 125
3

120 120
2

115 115

110 0 110

105 105
Height (cm)

100
-2 100

-3
95 95

90 90

85 85

80 80

Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
Weight

Measured using the basket weighing scale for small children

For newborns, keep a warm cloth on the weighing scale and reset it to 0 g
Remove all the child's clothing and place the child on the warm cloth and measure the weight

Average weight of baby at birth : 2.5 - 4 kg

< 2.5 kg - low birth weight

< 1.5 kg - very low birth weight
< 1 kg - extremely low birth weight

After birth, the baby loses around 10% of the birth weight in the first 7-10 days due to loss of
extracellular fluid
Thereafter the child starts regaining weight when adequately breastfed

First 3 months : 30 g perr day

3 - 6 months : 15 g per day
6 - 9 months : 12 g per day
9 - 12 months : 9 g per day
> 12 months : 6 g per day

Birth weight doubles by 5 months

Birth weight triples by 1 year
Birth weight quadruples by 2 years

Weech's formula for estimated weight as per weight of the child as per age for chikdren > 2
years : (Age × 2) + 8 kg

If Weight for age < - 2 SD - UNDERWEIGHT (can be due to both Acute and Chronic
Malnutrition)
 Weight-for-age GIRLS
Birth to 2 years (z-scores)

17 3 17

16 16

15 2 15

14 14

13 13

12 12
0
11 11
Weight (kg)

10 10

9 -2 9

8 -3 8

7 7

6 6

5 5

4 4

3 3

2 2

Months 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11
Birth 1 year 2 years
Age (completed months and years)
WHO Child Growth Standards
 Weight-for-age GIRLS
2 to 5 years (z-scores)

30 30
3
29 29

28 28

27 27

26 26

25 2 25

24 24

23 23

22 22

21 21
Weight (kg)

20 20

19 19

18 0 18

17 17

16 16

15 15

14 14
-2
13 13

12 -3 12

11 11

10 10

9 9

8 8

7 7
Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
 Weight-for-age BOYS
Birth to 2 years (z-scores)

17 3 17

16 16

15
2 15

14 14

13 13

12 0 12

11 11
Weight (kg)

10 10
-2
9 9
-3
8 8

7 7

6 6

5 5

4 4

3 3

2 2

Months 1 2 3 4 5 6 7 8 9 10 11 1 2 3 4 5 6 7 8 9 10 11
Birth 1 year 2 years
Age (completed months and years)
WHO Child Growth Standards
 Weight-for-age BOYS
2 to 5 years (z-scores)

28 28
3
27 27

26 26

25 25

24 2 24

23 23

22 22

21 21

20 20
Weight (kg)

19 19
0
18 18

17 17

16 16

15 15

14 -2 14

13 13
-3
12 12

11 11

10 10

9 9

8 8
Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
Plot the weight on the Weight for Age charts

For <= 5 years : use WHO growth charts (gives result in SD)
For > 5 - 18 years : use IAP growth charts (gives results in percentiles)
Now we can also use combined IAP WHO growth charts for 0 - 18 years (gives results in
percentiles

For < 5 years, calculate the weight for height percentile from the WHO growth charts
For > 5 years, calculate the BMI = (weight in kg/(height in m)²) and Plot on the BMI for age IAP
charts

If Weight for Height/ BMI for age < - 2 SD - WASTING (Acute Malnutrition)
If Weight for Height / BMI for age < - 3 SD - SEVERE WASTING
 Weight-for-length GIRLS
Birth to 2 years (z-scores)

3
24 24

22
2 22

20
1 20

0
18 18

-1
16 16
-2
Weight (kg)

14 -3 14

12 12

10 10

8 8

6 6

4 4

2 2

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)
WHO Child Growth Standards
 Weight-for-Height GIRLS
2 to 5 years (z-scores)

32 32
3
30 30

28 2 28

26 26
1
24 24
0
22 22

-1
Weight (kg)

20 20

-2
18 18
-3
16 16

14 14

12 12

10 10

8 8

6 6

65 70 75 80 85 90 95 100 105 110 115 120

Height (cm)
WHO Child Growth Standards
 Weight-for-length BOYS
Birth to 2 years (z-scores)

24 3 24

22 2 22

20 1 20

18
0 18

-1
16 16
-2
Weight (kg)

14
-3 14

12 12

10 10

8 8

6 6

4 4

2 2

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)
WHO Child Growth Standards
 Weight-for-height BOYS
2 to 5 years (z-scores)

30 3 30

28 28
2
26 26

1
24 24

0
22 22

-1
20 20
Weight (kg)

-2
18 18
-3
16 16

14 14

12 12

10 10

8 8

6 6

65 70 75 80 85 90 95 100 105 110 115 120

Height (cm)
WHO Child Growth Standards
Occipitofrontal circumference or Head circumference

Measure by cross tape method i.e. not from 0 to avoid errors

Place the tape over the occiput posteriorly and Superior orbital ridge anteriorly

Keep the metallic end towards the side to avoid injury to the child

Take 3 readings and calculate the average of the readings which gives the occipitofrontal
circumference or Head circumference of the baby

At birth, the OFC is 33 - 35 cm

First 3 months, it increases by 2 cm per month

3 - 6 months, OFC increases by 1 cm per month
Next 6 months, OFC increases by 0.5 cm per month

Average increase in OFC in 1 year is 12 cm

Maximum increase I Head circumference takes place in the first 2 years to accommodate for the
growing brain as brain development tales place mostly in the first 2 years of life

Head circumference at 5 years : 51 - 52 cm

We so not measure OFC beyond 5 years

Plot the OFC on the OFC for age WHO charts

If OFC for age > + 2 SD - Macrocephaly (Hydrocephalus, Neurofibromatosis)

If OFC for age < - 3 SD - Microcephaly (Edward's syndrome, Patau syndrome)

 Head circumference-for-age GIRLS
Birth to 5 years (z-scores)

54 3 54

2
52 52
1
50 0 50

48
-1 48
-2
Head circumference (cm)

46 46
-3
44 44

42 42

40 40

38 38

36 36

34 34

32 32

30 30
Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
Birth 1 year 2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
 Head circumference-for-age BOYS
Birth to 5 years (z-scores)

3
54 54
2
52 1 52

0
50 50
-1
48 48
-2
Head circumference (cm)

46 -3 46

44 44

42 42

40 40

38 38

36 36

34 34

32 32

30 30
Months 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10 2 4 6 8 10
Birth 1 year 2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
Chest circumference

Measured by the cross tape method at the level of the nipple

Take 3 readings and calculate the average of the readings which is the chest circumference

The head circumference is greater than the chest circumference at birth by 3 cm

By 1 year of age, HC = CC

After 1 year, CC > HC

If at birth, HC - CC > 3 cm, it may be a case of asymmetric IUGR

Mid upper arm circumference

Mark the Mid point between the Acromion process of the shoulder and the Olecranon process of
the elbow

At the midpoint measure the circumference by cross tape method and take the average of 3
readings as the Mid upper arm circumference (MUAC)

At 1 year, the average MUAC is between 12 - 16 cm

After 1 year, MUAC is 16 - 18 cm

If MUAC < 12.5 cm - Malnutrition

Moderate Acute Malnutrition: MUAC between 11.5 and 12.5 cm

Severe Acute Malnutrition: MUAC < 11.5 cm

Criteria for Severe Acute Malnutrition:

i) Weight for Height < - 3 SD
ii) MUAC < 11.5 cm
iii) Visible Severe wasting
iv) Bilateral pedal oedema
 Arm circumference-for-age GIRLS
3 months to 5 years (z-scores)

23 23

3
22 22

21 21

2
20 20

19 19
Arm circumference (cm)

1
18 18

17 17
0
16 16

-1
15 15

14 -2 14

13 13
-3
12 12

11 11

10 10
Months 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
1 year 2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
 Arm circumference-for-age BOYS
3 months to 5 years (z-scores)

22 22
3
21 21

20 20
2
19 19
Arm circumference (cm)

18 1 18

17 17

0
16 16

15 -1 15

14 -2 14

13 13
-3

12 12

11 11

Months 3 6 9 3 6 9 3 6 9 3 6 9 3 6 9
1 year 2 years 3 years 4 years 5 years
Age (completed months and years)
WHO Child Growth Standards
Arm span

Make the child stand straight with his/her back towards you

Ask him/her to touch the tip of the middle finger on one side wall
Mark the point of the tip of the other middle finger

Measure the distance between the wall and the marked point and that will give the arm span

Arm span < Height at birth

Arm span = Height at 9 - 10 years

Arm span > Height after 10 years

Increased Arm span for that age indicates probable MARFAN'S SYNDROME

Arm span is a measure of the lower segment, hence may be shortened in case of Rickets,
Osteogenesis imperfecta

Upper segment : Lower segment

If the child is standing, measure the lower segment

If the child is sitting, measure the upper segment

Lower segment (Appendicular skeleton) - Measure from the lower border of the pubic symphysis
to the heel and then upper segment = height - lower segment

Upper segment (Axial skeleton) - Measure from the vertex to the pubic symphysis and then the
lower segment = height - upper segment

At birth, US : LS is 1.9
At 1 year it is 1.7
At 3 years It is 1.3
At 7-9 years It is 1.1
At 10 years It is 1 US = LS
After 10 years, it is 0.9

If US : LS is decreased it indicates axial skeleton pathology like TB spine, Kyphoscoliosis,

Alagile syndrome (butterfly vertebrae)

If US : LS is increased it indicates Appendicular skeleton pathology like Rickets, Achondroplasia

Age independent anthropometric measurements :

1. Skin fold thickness :

Measured at 3 sites namely triceps, subscapular and suprailiac areas
Measure by Harpenden skinfold calipers
Normal is 10 cm
If < 6 cm - Malnutrition

2. Mid upper arm circumference - can be measured via Shakir's tape

3. Phadke's Bangle test (Dr Mrudula Phadke, ex VC MUHS)
The Bangle test involves two bangles –— one yellow coloured and the other red.
The inner diameter of the yellow bangle is 4 cm and has a circumference of 12.5 cm
The inner diameter of the red bangle is 3.7 cm and has a circumference of 11.5 cm

First, the yellow bangle is inserted in the child’s hand.

For a child in the age group 5 - 10 years, the mid-arm circumference is constant at 13 cm
If this bangle holds on to the mid-arm, the child is well nourished, but if the bangle moves
up to the upper arm, then the child is moderately malnourished.
If it goes still further to the upper arm, the red bangle is inserted.
If the red bangle moves to the upper arm the child is detected as severely malnourished

4. Body mass index or Quetlet index

5. Kanawati index = MUAC / Head circumference, normal >= 0.33, < 0.25 - Severe
malnourished
6. Rao and Singh's index = Weight (in kg)/ (Height (in cm))² * 100 , < 0.15 - malnourished
Scanned by CamScanner
Scanned by CamScanner
Scanned by CamScanner
 General appearance:

 Vital signs: Temp: PR:

RR: BP:
CRT SPO2

 General physical examination:

PICCLE

8
 ANTHROPOMETRY

Actual Expected Inference

Weight

Height

Weight for height

Head circumference

Chest circumference

Mid arm circumference

Upper segment/ lower segment ratio

9
 HEAD TO FOOT EXAMINATION

Head
Face
Eyes
Ears
Nose
Mouth & oral cavity
Neck
Chest
Abdomen
External genitalia
Skin
Extremities
Back & spine
SMR stage (if required)
Developmental age assessment(if required):

10
 SYSTEMIC EXAMINATION‐RESPIRATORY SYSTEM
• Upper RT:
• Lower RT:
•Inspection
Flaring of nose: trachea: Shape of chest:
Accessory muscles: Chest wall retraction:
Movement of chest: Apex beat:
Bony cage:
•Palpation:
To confirm inspection findings: Tenderness:
Tactile vocal fremitus: Friction rub:
•Percussion:
•Auscultation:
Breath sounds
Adventitious sounds
Vocal resonance
11
 CARDIO VASCULAR SYSTEM
• Inspection:
Pulse: BP: JVP:
Precordium: Apex beat: Pulsations:
• Palpation
Confirm inspectory findings: Apex beat:
Heart sounds:
Parasternal heave: Epigastric
pulsation : Thrill:
• Percussion:
• Auscultation:
Heart sounds: Added sounds:
Murmurs:

12
 GIT EXAMINATION

 Upper GIT :
 Per abdomen:
• Inspection:
Shape: Movement:
Visible peristalsis: Pulsation/veins:
Hernial orifices: Ext. genitalia:
• Palpation:
Confirm inspection findings
Tender: Liver: Spleen:
Kidneys: Bladder: Any other mass:
Renal angle: Ext. genitalia:

13
 GIT EXAMINATION
 Percussion:

Liver span: Shifting dullness:

Fluid thrill:

 Auscultation:

BS

Bruit

 Rectal examination(if required):

14
 CENTRAL SYSTEM EXAMINATION

Higher mental function:

Conscious: Orientation: Emotional status:

Memory: Speech:

Delusions/Hallucinations:

15
• Cranial nerve examination:
Right Left

• Motor system:
Upper Limb Lower Limb
Right Left Right Left
Bulk
Tone
Power

16
 Reflexes Right Left
Superficial reflex
Deep tendon reflex
‐Biceps
‐Triceps
‐Supinator
‐Knee jerk
‐Ankle jerk
‐Clonus
Primitive reflex (if required)

17
Abnormal movements:

Tremor: Chorea: Athetosis:

Hemiballismus: Dystonia:

Any other:

18
Sensory system:
Upper Limb Lower Limb
R L R L
Touch
Pain
Temperature
Pressure
Position
Vibration
Cortical sensation

19
Cerebellar signs:
Nystagmus: Speech: Finger nose test:

Dysdiadochokinesia: Tremor: Knee to heel test:

Romberg’s sign: Tandem walking: Gait

20
 Signs of meningeal irritation:
• Neck rigidity:
• Kernig’s sign:
• Brudzinski’s sign‐ neck/leg sign
 Skull &spine
• Mac Ewan’s sign
• Cranial bruit/carotid bruit
• Transillumination of skull
• Tenderness over spine, gibbus, tuft of hair,
kyphoscoliosis

21
Differential diagnosis:

Investigation:

Treatment:

Follow up:

22