Assessment Techniques in Child
Health
Growth, Development,
Immunization
Growth
Assessment
• Anthropometry: • • Weight
• • Length/Height
• • Head circumference
• • Chest circumference
• • Mid-upper arm circumference
(MUAC)
• • Skinfold thickness
Weight
Measurement
• • Most sensitive indicator of
growth
• • Measure with calibrated scale
• • Infant: naked/minimal
clothing
• • Record to nearest 10 g
(infants)
Length / Height
• • <2 years: Recumbent length
(infantometer)
• • >2 years: Standing height
(stadiometer)
• • Measure without shoes
Head
Circumference
• • Measured from supra-orbital
ridge to occipital prominence
• • Important up to 2 years of
age
• • Helps detect
microcephaly/macrocephaly
Growth
Monitoring Tools
• • WHO growth charts
• • Weight-for-age
• • Height-for-age
• • Weight-for-height
• • Z scores (Normal: −2 to +2 SD)
ASSESSMENT OF PHYSICAL
GROWTH
• Weight: The child’s weight in the
nude (for newborns or infants) or
in minimal light clothing and
without footwear, is recorded
accurately on a lever or electronic
weighing scale .
• Spring balances are less accurate.
The child must be placed in the
middle of the weighing pan.
• Correct the zero error before
weighing. Weigh a small baby with
the mother/caregiver
Steps in weighing a small
baby with the mother
• Use an adult weighing scale.
• Place the weighing scale on a flat,
hard and even surface. Correct zero
error of the scale.
• Mothers should be weighed barefoot
or with minimal clothing.
• Ask the mother to stand in the middle
of the scale with feet slightly apart
and remain still. Take the weight of
the mother alone without the baby
(W1).
• Now weigh the mother while holding
the baby (W2).
• Calculate baby’s weight = W2 − W1.
• Length: Length is recorded for
children under two years of age.
Hairpins are removed, and braids
are undone.
• Bulky diapers should be removed.
• The child is placed supine on a
rigid measuring table or an
infantometer.
• One person holds the head firmly
in position against a fixed
headboard. Legs are straightened,
keeping feet at right angles to legs
with toes pointing upward.
•
The free footboard is brought
into contact with the heels.
• The baby’s length is measured
from a scale set on the
measuring table.
• Measuring the length of a child
lying on the measuring table
with a tape is inaccurate and
not recommended
Height: For height
measurement, the child stands
upright.
•
• Heels are slightly separated,
and the weight is borne evenly
on both feet.
• Heels, buttocks, shoulder
blades, and the back of the
head are brought in contact
with a
vertical surface such as a wall,
height measuring rod, or
stadiometer Frankfort plane
(the line joining the root of the
external auditory meatus to the
lower margin of the orbit).
•
• The measuring rod is lowered
to compress the hair
Steps in
measuring length
• Place the infant on a clean
length board (use a clean sheet
to make the board
comfortable).
• Ensure that the head is in
contact with the headboard.
• Position the head so that the
child is looking straight up
(Frankfort plane).
• The external auditory meatus
and the lower border of the
eye orbit should be in line.
• The shoulders should be in
touch with the board and the
knees should be gently
straightened.
• The footboard should be
moved so that the feet are flat
against it.
• Be gentle with newborns; their
knees may not straighten fully.
To position both knees,
measure the length with one
leg in position.
Head circumference:-
• Hair ornaments are removed
and the braid undone.
• Using a non-stretchable tape,
the maximum circumference of
the head is measured from the
occipital prominence to the
supraorbital ridges.
Steps in
measuring standing
height
• The child’s footwear and any hair
tie-up should be removed.
• The child should stand on the
height board with the back of the
head, shoulders, buttocks, calves,
and heels touching the vertical
board.
• Position the head such that the
child is looking straight ahead (the
line joining the external auditory
meatus and the lower border of
the eyeball should be parallel to
the floor).
• With the child still in this
position, the headboard is
gently pulled down to rest
firmly on the head.
• Measure the height in this
position.
• Chest circumference:
The chest circumference is
measured at the level of nipples,
midway between inspiration and
expiration
Mid-upper arm circumference
To measure the mid-upper arm
circumference (MUAC), first mark
a point midway between the tip
of the acromion process of the
scapula and the olecranon of the
ulna on the left side. Take the
measurement while the child
keeps the arm by his side,
straight at the elbow
Ensure the tape is tight enough to
avoid any gap and compression
of soft tissues.
DEVELOPMEN
TAL ASSESSMENT
• Developmental delay is
estimated to be present in
about 10% of children.
• Severe developmental
impairment occurs in about 1–
3%.
• Speech impairment,
hyperactivity, and emotional
disturbances are often not
detected until 3–4 years, when
the child starts school.
• Prerequisites
• The place should feel
comfortable and free from
distractions.
• The child should be in a good
mood.
• The mother should remain with
the child.
• The development assessment
of a sick child can be deferred
unless necessary
EQUIPMENT FOR
DEVELOPMENT
ASSESSMENT
• A red ring
• Nine red cubes
• Paper pellets
• Spoon
• Cup with handle
• A boom with thick pages
• Picture book
• Red pencil, paper
• Doll and mirror
• Red ball
• Red wool
• A bell
History
• A well-taken history provides
information regarding prenatal,
perinatal, and postnatal factors,
helps differentiate
developmental delay from
regression, and aids in selecting
appropriate evaluation tools.
• Examination includes:
• Anthropometry – weight, height, head
circumference.
•
• Dysmorphic features – abnormal facial
features, lowset ears, abnormal eye
spacing.
• Signs of hypothyroidism.
• Vision and hearing assessment.
• Neurological status, including
presence of primitive reflexes.
• Stigmata of intrauterine infection
(microcephaly, cataract)
Perform the developmental
assessment before the
systematic examination.
• Observe the child for alertness,
interest in the surroundings,
and vocal responses.
• Assess reflexes, measuring the
head circumference, and
performing ventral suspension
or pull-to-sit should be done at
the end.
•
Significant delay on screening is
an indication for a detailed
formal assessment of
development status
• developmental quotient (DQ):-
Average age at attainment × 100
Observed age at attainment
DQ below
70%→Developmental delay
• evaluated by a trained child
psychologist. • IQ tests:-
•
1) Stanford-Binet intelligence
scales:- from 2 years
However, in younger children (<5
years), it is more meaningful to
have a global assessment of
abilities; hence DQ testing is more
comprehensive.
Use corrected age for
developmental status till two
years of age in preterm babies.
For example, a child born at 32
•
weeks gestation (postnatal age)
and at 12 weeks of age
(postnatal age) should be
considered a 4week-old baby
for developmental assessment.
Single assessment or isolated
examination finding should not
be the basis for the diagnosis of
retardation
• . Consider factors such as
recent illness, significant
•
malnutrition, emotional
deprivation, sensory deficits,
and neuromuscular disorders.
• Repeat the assessment
especially if there is no gross
delay.
• If a child does not attain a
milestone by the upper age
limit, the cause of
developmental delay should be
evaluated.
Windows of achievement
of six major
motor
milestones.
Upper limit of age for
attainment of milestones
• Milestone
age
• Visual fixation or following – 2
months
• Vocalization -6
months
• Sitting without support - 10
months
• Standing with assistance - 12
months
• Hands and knees crawling -14
months
• Standing alone - 17
months
• Walking alone - 18 months
• Single words - 3 years
• Imaginative play - 3 years
• Loss of comprehension, single
word or phrases at any age is
Abnormal
• Lack of achievement of milestones
in multiple domains may indicate a
general developmental delay.
• The predictive value of milestones
for subsequent intelligence is not
the same.
• Fine motor, personal-social, and
language milestones predict
intelligence far better than gross
motor skills.
• In particular, advanced language
predicts high intelligence in a
child.
Development
Screening Tests
• Screening is a brief assessment
procedure designed to identify
children requiring detailed
assessment
Developmental
Surveillance
• Child development is dynamic
• Screening tests popular in the
West include
• Parents’ Evaluation of
Developmental Status (PEDS)
• Ages and Stages Questionnaires
(ASQ)
• Phatak’s Baroda screening test
• This is India’s best-known
development testing system
developed by Dr. Promila
Phatak.
• It is meant to be used by child
psychologists rather than
physicians.
• It is the Indian adaptation of the
Bayley developmental scale and
is applied to children up to 30
months.
• Ages and Stages Questionnaire
(ASQ-3)It consists of age-based,
parent-completed questionnaires
for children from one month to 5½
years of age.
• It assesses the following domains
• Communication
• Gross motor
• Fine motor
• Problem-solving
• Personal-social
Denver II
The revised Denver
Developmental Screening Test
(DDST II) assesses child
development in four domains:
1) Gross motor
2) Fine motor adaptive
3) Language
4) Personal-social behavio
•
Trivandrum Development
Screening Chart (TDSC):-
It consists of 51 items for children
0–6 years is primarily a screening
tool for use in the community to
identify children between 0 and 6
years with developmental delay.
Clinical adaptive test and
clinical linguistic and auditory
milestone scale (CAT/CLAMS):-
•
assesses the child’s cognitive and
language skills
. It uses parental reports and
direct testing of children from
birth to 36 months.
Goodenough–Harris drawing
test:-
• The child draws a man in the
best possible manner, and the
detail of the drawing
determines the score
•
• The more mature grip of pen,
the higher the score.
• One can determine the mental
age by comparing scores
obtained with a normative
sample.
• Definitive Tests:-
• Tests are required once
screening tests or clinical
assessment is abnormal
• gives domain-wise scores for
verbal, motor, personal, and
social skills domains.
• Early Stimulation
• Brain development is most rapid
during pregnancy and early years (first
1000 days of life—fetal and
postnatal).
• On average, 1.8 million synapses are
formed per second between 2 months
gestation and two years of life
• Infants with suspected or early
developmental delays need additional
support to develop motor skills,
language or cognitive abilities. These
extra efforts (early stimulation)
include making the child sit or walk,
•
giving toys to manipulate, playing and
speaking with the child, etc.
Child Guidance Clinics
• These multidisciplinary clinics
provide diagnostic and
therapeutic services to children
with intellectual disability,
learning disability or behavioral
disorders, along with
counseling for parents and
children.
•
Promoting Development by
Effective
ParentingParenting has an
immense impact on emotional,
social, and cognitive
development and also plays a
role in later occurrence of
mental illness, educational
failure, and criminal behavior
Television, Mobile Devices and
Development
• exposure to mobile devices at a
young age can impact language
•
development, sleep, and social
connectivity
• Excessive and addictive use of
mobile media in children can
impair their executive function,
impulse control, and emotional
regulation.
Screen time is also associated
with obesity.
Screen time
• 0 to 2 years → avoid
• >2years →1 hour /day
•
• >6 years →place consistent
limits on the time spent using
media and types of media
• Excessive use of mobile devices
reduces the attention and
responsiveness of caregivers to
children.
Early Childhood Development
(ECD) as a High Public Health
Priority
• Nurturing Care :- Nurturing care
refers to the stable
•
environment of integrated and
multisectoral caring from fertile
through early childhood (up to
3 years
• Five Components of Nurturing
Child Care
1. Good health
2. Adequate nutrition
3. Safety and security
4. Opportunities for early
learning
5. Responsive caregiving
•
Learning promotion should be
based on the interest and the
developmental stage of the
child. The following are
examples of activities:
1. Conversation
2. Responsibility 3.
Imaginative
play:
4. Facilitating motor ability
•
5. Playing
Mother and Child Protection
Card (MCP Card)
• It provides information on
antenatal care, delivery,
immunization, nutrition, and
milestones in addition to
growth monitoring. It also
helps in early identification of
developmental delay and
encourages family
•
participation in monitoring
child development.
Programs undertaken by the
Government of India for early
childhood development
include:
• Integrated Child Development
Services (ICDS)
• Rashtriya Bal Swasthya
Karyakram (RBSK)
• Anganwadi services
•
• National Early Childhood Care
and Education (ECCE) program
Age Parenting tips for nurturing Warning
development flag sign
0 to 3 months Encourage babies to lie on At 3 mon
tummy for some time smile N
everyday Massage gently; Persisten
stretch and exercise arms
Does
and legs Cuddle and play
respond
with babies daily Respond
to the cry Talk to babies in Head pu
your mother tongue Hang stiff ar
colorful objects at 30 cm Persisten
above them Avoid digital
media in children <24
months of age
4 to 6 months Communicate with babies; At 6 mon
imitate their sound and control
praise them when they Cannot s
imitate yours Put Does no
interesting things on the within re
7 to 9 months Give clean utensils and At 9 mo
other item to play, bang over or s
and throw Play games like Does n
peek-a-boo, play by hiding Does no
toys under cloth, or in a box pa-pa, m
Tilt head
side whe
objects
10 to 12 months Tell stories Show picture At 12 m
books Tell names of stretch h
objects and body parts Let up
them explore home safely Does no
with fin
Does no
name
Does no
hidden to
13 to 18 months Provide push toys for At 18 m
babies to learn walking stand
Ask simple questions and small o
encourage them to talk containe
Provide picture books and Does no
colorful toys Let them equally
explore indoor and finger a
outdoor safely under named
to moth
supervision
seems t
own wo
single w
or
“dada”
19 to 24 months Provide opportunity for At 24 m
babies to walk, run, or walk ste
climb in safe a toy
environments Allow Does no
children to imitate phrases
and allow them to do such as “
25 to 36 months Play outdoor games Continuous dro
Encourage interactional unclear speech
play with peers Give morecommunicate
complex games like and frequently
puzzles, blocks, jigsaw others’ speech
Allow them to do simple speak simple s
household work safely “mummy give
Continuous drooling,
unclear speech Does not
communicate meaningfully
and frequently repeats
others’ speech Cannot
speak simple sentences like
“mummy give milk/water”
IMMUNIZATION
• NATIONAL IMMUNIZATION
SCHEDULE
• Birth:BCG , OPV ,Hep B
• 6 weeks :- pentavalalent (1), OPV
(1), rota virus
(1), iPV (1 ) , PCV (1)
• 10 weeks :- pentavalalent (2),
OPV (2), RV (2)
• 14 weeks :- pentavalalent (3),
OPV (3), RV (3), iPV ( 2), PCV (2 )
• 9 months :- MR(1), Vit A (1 ) , PCV
Booster, JE -1
• 16 to 24 months – MR(2), JE(2),
OPV booster, DPT booster
• 5 to 6 years – DPT booster
• 10 to 16 years – Td
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Cold Chain
• Cold chain is the system of
storing and transporting
vaccines at recommended
temperatures from
manufacturer to the
beneficiary to maintain
potency.
• Recommended temperature:
• +2°C to +8°C
• Components of Cold Chain
E
q
u
i
p
m
e
n
t
:
1
.
1. Walk-in freezer
2. Walk-in cooler
3. Deep freezer
4. Ice-lined refrigerator (ILR)
5. Cold box
6. Vaccine carrier
7. Ice packs
2) Personnel
1. Cold chain handlers
2. Health workers
3. Program managers
3) Temperature Monitoring
• Thermometers
• Vaccine Vial Monitor (VVM)
• Temperature log book
• Vaccine Vial Monitor (VVM):-A
heat-sensitive label on vaccine
vial that changes color with
heat exposure.
• Inner square lighter than outer
circle → Vaccine usable
• Inner square same color →
Discard
• Inner square darker → Discard
• Heat Sensitive Vaccines
• (Most heat sensitive → least)
• OPV
• BCG
• Measles / MR
• Rotavirus
• Pentavalent / DPT
• Hepatitis B
• PCV
Freeze Sensitive Vaccines (Never
Freeze)
• DPT
• DT
• TT
• Pentavalent
• Hepatitis B
• Hib
• PCV
• Inactivated influenza
• Storage in ILR
Position in ILR Vaccines Stored
Freezer OPV
Top shelf BCG, Measles, MR
Middle shelf DPT, DT, TT
Lower shelf Hepatitis B, diluents
• Shake Test:- Used to detect
freeze damage in adsorbed
vaccines.
• Vaccines tested:-
• DPT
• DT
• TT
• Pentavalent
• Hepatitis B
• Result:
• Sedimentation same or faster
than control → Discard
vaccine
Center Storage Temperature Duration of
storage
Manufacturer, Walk-in cooler +2°C to +8°C ≥3 months
national stores, / Walk-in
international freezer
stores
District vaccine Deep freezer / 25°C to −15°C / 1–3 months
store Ice-lined
+2°C to +8°C1–
1–3 months refrigerator
−25°C to −15°C 3
Vaccine vans
/ +2°C to +8°C monthsVaccine
1–3 months vans
Vaccine vans
Sub-district Ice-lined +2°C to +8°C 1–3 months
vaccine store / refrigerator
Primary health +2°C to +8°C
center 1–3 months
Vaccine vans
Implementati
on of Cold Chain
• 1. What is the most heat-
sensitive vaccine?
• 2. Which vaccines are freeze
sensitive?
• 3. 3. Which vaccines can
tolerate freezing?
• 4. What is the temperature
maintained in the cold chain?
1. OPV (Oral Polio Vaccine)
[Link], DT, TT ,Pentavalent
vaccine, Hepatitis B
Hib , PCV , Inactivated influenza
3. OPVMeasles /
MR, BCG (before
reconstitution) , 4.
+2°C to +8°C
• What is a Vaccine Vial Monitor
(VVM)?
• Which vaccine is given at birth?
• Which vaccine is given at 9
months?
1. A heat-sensitive label on
vaccine vials that changes
color with cumulative heat
exposure and indicates
vaccine potency.
2. BCG, OPV-0, Hepatitis B
3. MR-1 (Measles-Rubella),
Vitamin A (1st dose), JE-1 (in
endemic areas), PCV booster
1. What are the parenting tips for
nurturing development in infants aged
0–3 months?
Answer:
Encourage babies to lie on tummy for
some time every day
Massage gently; stretch and exercise
arms and legs
Cuddle and play with babies daily
Respond to the cry
Talk to babies in mother tongue
Hang colorful objects about 30 cm
above them Avoid digital media in
children <24 months
• What are the red flag signs at 3
months?
• Answer:
• No social smile
• No eye contact
• Persistent squint
• Does not startle or respond to
sound
• Head pushed back with stiff
arms and legs
• Persistent fisting
Developme
nt Assessment
• Developmental Domains:
• • Gross motor
• • Fine motor
• • Language
• • Social / adaptive
Immunizatio
n Assessment
• • Review immunization history
• • Verify vaccination card
• • Identify missed vaccines
• • Plan catch-up schedule
Integrated
Child Health
Assessment
• At every visit assess:
• • Growth
• • Development
• • Immunization status
• • Nutrition
• • Complete physical
examination
Conclusion
• Regular assessment of growth,
development and
immunization ensures early
detection of illness,
malnutrition and
developmental delay.