Assessment

Clinical Assessmentof

Nutritional Status

Physical signs and symptoms of malnutri-tion can be valuable aids in detecting nutritionaldeficiencies. These may include delayed growthand development as determined by comparing anindividual or a group with normal values ongrowth charts; pallor of the skin, mucous mem-branes of the mouth and eyes, nail beds or palmsurfaces; and the more serious signs of advancedprotein-calorie malnutrition such as changes oc-curring in hair color and body appearance, as byedema. Obviously, the sooner the diagnosis ofnutritional status is made in individuals and inpopulations the sooner clinical public health inter-vention programs can be formulated.

One does not have to be a physician torecognize major signs of nutritional deprivation.Auxiliary health workers can be trained in nutri-tional diagnosis so that they may be alerted to themajor signs of clinical deficiencies. They, in turn,can alert physicians who may then conduct a moredetailed examination so that the presence orabsence of nutritional deficiencies can be moredefinitively ascertained. In 1962 the World HealthOrganization Expert Committee on Medical As-sessment of Nutritional Status proposed a classi-fication of physical signs to be used in nutritionsurveys. Updated in 1966, this is a most valuableguide* in the diagnosis and interpretation of theclinical signs of malnutrition.

It must be emphasized that 1) signs of mal-nutrition may not be specific-that is, they may berelated to non-nutritional factors such as poorhygiene or excessive exposure to the sun-and 2)they may not correlate with dietary intake data orthe biochemical values in the individual or thepopulation. This should not discourage the healthworker from participating in the clinical evaluationof children and adults.

The W.H.O. Committee has convenientlyclassified the physical signs most often associatedwith malnutrition into the following three groups:

Group One Signs that are considered to be ofvalue in nutritional assessment.These are often associated withnutritional deficiency status. Signsof malnutrition may often bemixed and may be due to the de-

* W.H.O. Monograph No. 53. (See Se/ected Reterences)

ficiency of two or more micronu-trients.

Group Two-Signs that need further investiga-tion. They may be related to mal-nutrition, perhaps of a chronictype, but are often found in popu-lations of developing countrieswhere other health and environ-mental problems, such as povertyand illiteracy, are co-existent.

Group Three-These include physical signs thathave no relation to malnutrition,although they may be similar tophysical signs found in personswith malnutrition ^'nd must becarefully delineated from them.This usually takes the particularexpertise of a physician or otherhealth worker expertly trained innutritional diagnosis.

Table 1 has been adapted from the W.H.O.Expert Committee on Medical Assessment of Nu-tritional Status, and further reported in the volume"The Assessment of Nutritional Status of the Com-munity" (see Selected References).

Although it is important to recognize thatvarious signs have different degrees of reliability,signs of malnutrition falling in Groups One andTwo have been combined' in Table 1 and aredescribed in less technical terminology so thathealth workers of all categories may better under-stand their clinical significance. The W.H.O. classi-fication is particularly helpful when the survey islimited in scope and aimed at rapid clinicalscreening of the community, or consists of aresearch project possibly including an evaluationof less certain signs (Group Two). The more re-liable the signs, and the more experienced theobserver, the more definitive the nutritional diag-nosis is likely to be. A comprehensive list of signsis found in Appendix A. A definition of physicalsigns and nutritional terms associated with malnu-trition will be found in Appendix B.

Physical signs should be recorded as pre-cisely and practicably as possible. There are, infact, signs that are associated with malnutritionwhich may be explained by future knowledge.These include skin discolorations, inflammation ofthe eyelids, and other signs. An important consid-eration in interpreting physical signs is the need

18 AJPH SUPPLEMENT, Vol. 63, NOVEMBER, 1973

Table 1-Physical Signs Indicative or Suggestive of Malnutrition

Body Area Normal Appearance Signs Associated with Malnutriton

Hair Shiny; firm; not easily plucked Lack of natural shine; hair dull and dry; thin and sparse; hairfine, silky and straight; color changes (flag sign); can be easilyplucked

Face Skin color uniform; smooth, pink, healthy Skin color loss (depigmentation); skin dark over cheeks andappearance; not swollen under eyes (malar and supra-orbital pigmentation); lumpiness

or flakiness of skin of nose and mouth; swollen face; enlargedparotid glands; scaling of skin around nostrils (nasolabialseborrhea)

Eyes Bright, clear, shiny; no sores at corners Eye membranes are pale (pale conjunctivae); redness of mem-of eyelids; membranes a healthy pink branes (conjunctival injection); Bitot's spots; redness and fissur-and are moist. No prominent blood ing of eyelid corners (angular palpebritis); dryness of eye mem-vessels or mound of tissue or sclera branes (conjunctival xerosis); cornea has dull appearance

(corneal xerosis); comea is soft (keratomalacia); scar on cor-nea; rlng of fine blood vessels around corner (circumcornealinjection)

Lips Smooth, not chapped or swollen Redness and swelling of mouth or lips (cheilosis); especiallyat corners of mouth (angular fissures and scars)

Tongue Deep red in appearance; not swollen or Swelling; scarlet and raw tongue; magenta (purplish color) ofsmooth tongue; smooth tongue; swollen sores; hyperemic and hyper-

trophic papillae; and atrophic papillaeTeeth No cavities; no pain; bright May be missing or erupting abnormally; gray or black spots

(fluorosis); cavities (caries)Gums Healthy; red; do not bleed; not swollen "Spongy" and bleed easily; recession of gumsGlands Face not swollen Thyroid enlargement (front of neck); parotid enlargement

(cheeks become swollen)Skin No signs of rashes, swellings, dark or Dryness of skin (xerosis); sandpaper feel of skin (follicular

light spots hyperkeratosis); flakiness of skin; skin swollen and dark; redswollen pigmentation of exposed areas (pellagrous dermatosis);excessive lightness or darkness of skin (dyspigmentation); blackand blue marks due to skin bleeding (petechiae); lack of fatunder skin

Nails Firm, pink Nails are spoon-shape (koilonychia); brittle, ridged nailsMuscular and Good muscle tone; some fat under skin; Muscles have "wasted" appearance; baby's skull bones are

skeletal systems can walk or run without pain thin and soft (craniotabes); round swelling of front and side ofhead (frontal and parietal bossing); swelling of ends of bones(epiphyseal enlargement); small bumps on both sides of chestwall (on ribs)-beading of ribs; baby's soft spot on head doesnot harden at proper time (persistently open anterior fontanelle);knock-knees or bow-legs; bleeding into muscle (musculo-skeletal hemorrhages); person cannot get up or walk properly

Internal Systems:Cardiovascular Normal heart rate and rhythm; no mur- Rapid heart rate (above 100 tachycardia); enlarged heart;

murs or abnormal rhythms; normal blood abnormal rhythm; elevated blood pressurepressure for age

Gastrointestinal No palpable organs or masses (in Liver enlargement; enlargement of spleen (usually indicateschildren, however, liver edge may be other associated diseases)palpable)

Nervous Psychological stability; normal reflexes Mental irritability and confusion; burning and tingling of handsand feet (paresthesia); loss of position and vibratory sense;weakness and tenderness of muscles (may result In inabilityto walk); decrease and loss of ankle and knee reflexes

to standardize the definition of a particular signbefore a survey or other health evaluation islaunched. Thus, a nutrition survey team is oftengiven substantial orientation sessions by physi-cians with formal experience in the identificationand interpretation of the physical signs of malnu-trition. Other factors of importance are:

1. The avoidance of such terms as "poor","fair", or "good", in terms of nutritional status

unless criteria for these terms are properly iden-tified.

2. Considering the use of an easily avail-able and standardized skinfold caliper, which iscoming into greater use by health personnel, todetermine thickness of subcutaneous fat (such asthe Lange® skinfold caliper.*)

* Cambridge Scientific Instruments, Inc., Cambridge, Md.

CLINICAL ASSESSMENT 19

Color slides** are available to assist healthpersonnel in identification and standardization ofsigns of physical deficiencies.

Few signs of nutritional deficiency are spe-cifically due to the lack of a particular nutrient.Iodine deficiency is associated with thyroid en-largement, and severe paleness of the skin isassociated with anemia. However, the anemia maybe due to blood loss due to non-nutritional dis-eases; and, though unlikely on a probability basis,the thyroid enlargement may be due to a cancer.

As emphasized previously, the signs ofmalnutrition are multiple. The finding of one signwill at least nudge the observer to go to a morecareful assessment of the body for other signs.Environmental factors (such as excessive heat orsun, wind or cold air), lack of general personalhygiene, and cultural factors can cause or con-tribute to the physical signs which are also as-sociated with malnutrition.

The age of the person being examined alsoplays a role in the way the signs present them-selves and in the interpretation of the signs. Forexample, signs of vitamin A deficiency in earlychildhood are different from those found in schoolage children. Scurvy, or vitamin C deficiency, oftenpresents in the child as painful swollen joints, dueto bleeding into the bones, whereas in elderlypeople, it appears as small "black and blue"marks which very often appear on the shinbones.

Any physical finding that suggests a nu-tritional abnormality should be considered a cluerather than a diagnosis and, as such, should bepursued further. For example, pallor should not beconsidered diagnostic of anemia but should beused as a clue to obtain the laboratory confirma-tion for anemia. Similarly, epiphyseal enlargementor costochondral beading should not be inter-preted as evidence of rickets without x-ray con-firmation, and enlargement of the thyroid glandshould only be interpreted as evidence of iodine de-ficiency after appropriate laboratory confirmation.

The detailed clinical examination for signsof malnutrition must also include a search forsigns related to metabolic diseases which havenutritional relationships. Notable among these arediabetes and the hyperlipidemias. Table 2 sum-marizes the physical findings of hyperlipidemiawhich are indicative of high levels of serum cho-lesterol and/or triglyceride in a nutritional assess-ment study.

Finally, it must be recognized that the useof clinical methods in detecting nutritional de-ficiencies has definite disadvantages when inter-preted alone. Used in a cautious manner in con-nection with dietary and biochemical methods,** How to Diagnose Nutritional Practices in Daily Practice,

No. 5. Nutrition Today, 1140 Connecticut Ave., NW, Wash.,D.C. 20036.

Table 2-Physical Signs and Laboratory Evidenceof Hyperlipidemia

Small, yellowish lumps around eyes (xanthelasma)Small or large tumors around joints of hands, legs,

or skin (xanthomas)White ring around both eyes (corneal arcus)Early coronary heart diseaseEnlargement of liver and spleenTurbid or creamy appearance of serumHigh serum levels of cholesterol and/or

triglyceridesAbnormal blood lipoprotein patterns

they may greatly assist in providing a picture ofthe nutritional status of individuals or of the com-munity. It is anticipated that, as biochemical pro-cedures become more refined and nutrition sur-veys are accomplished with more standardizedformats, our increased knowledge will enable us tomake more precise nutritional diagnoses.The major problems encountered in the clinical

assessment of nutritional status are:1. Their low general prevalence in devel-

oped countries except in high risk groups;2. The non-specificity of clinical signs in

most populations, particularly developed coun-tries; and

3. The substantial differences in the preva-lence of physical signs recorded by differentexaminers.

However, physical examinations should bean integral part of most nutrition surveys for thefollowing reasons:

* A physical examination may reveal evi-dence of certain nutritional deficiencies whichwill not be detected by dietary or laboratorymethods.

* The identification of even a few cases ofclear-cut nutritional deficiency may be particularlyrevealing and provide a clue to other pockets ofmalnutrition in a community.

* The nutritional examination may revealsigns of a host of other diseases which merit diag-nosis and treatment. Generally, these will be re-ferred to the patient's physician or to other healthfacilities.

Physical signs vary from population to pop-ulation. For example, in one study, underweightJamaican children displayed dental caries andxerosis (dryness of eye membranes), while normalweight children in Jamaica and even underweightchildren examined in Barbados rarely showedthese signs.

Physical signs may also vary over timeperiods which may witness rapid changes in thenutritional and social environment. Thus, angularstomatitis (fissuring at the side of the lips) wasfound in Jamaican children by a team of nutrition-


ists on one occasion, but not detected until threeyears later by another group of investigators.Moreover, the physical signs of protein-caloriemalnutrition display one constellation in the Carib-bean and another in the Far East.

Several studies have revealed the inabilityto relate clinical signs suggestive of nutritionaldeficiency and other evidence of malnutrition inpatients attending New York City nutrition clinics,Indian village children, and in the recently pub-lished Ten State Nutrition Survey.

Several authors have offered a grouping ofclinical signs of malnutrition that may be founduseful. A child having one or more of the follow-ing signs may be classified as suffering fromprotein-calorie malnutrition: edema, dyspigmenta-tion of the hair, easy pluckability of the hair, thinsparse hair, muscle wasting, moonface, flaky-paintrash, and dermatosis.

With regard to vitamin deficiency, the fol-lowing signs are of value: xerosis of the conjunc-tivae. Bitot's spots and corneal xerosis are con-sidered signs of vitamin A deficiency, whereasangular stomatitis, cheilosis, glossitis and atrophicor hypertrophic lingual papillae are signs of de-ficiency of the B-complex vitamins.

A rather good correlation has been docu-mented among children in India between the agesof one to five years between weight, height-weightindex, calf circumference, and the clinical signsof protein-calorie malnutrition. On the other hand,such anthropometric measures did not identifychildren with vitamin deficiencies. Similarly, arelationship among children in southern Iran be-tween body weight and malnutrition has also beenreported. Growth retardation was associated withlower hemoglobin, serum protein, and serum albu-min levels.

Examination of the thyroid gland is an im-portant part of the nutritional examination. Thefollowing grading system has been recommendedby W.H.O. nutritionists: with normal being one lobethe size of the first phalanx of the subject's thumb;grade 1 is one lobe greater than the size of thefirst phalanx of the subject's thumb; grade 2, agland that is visible with the neck extended; grade3, a gland that is visible with the neck in the nor-mal position; and grade 4, a gland that is visiblefrom a considerable distance, such as from acrossthe room.

To illustrate inter-observer variability, Table3 indicates the percentage of agreement betweentwo examiners on selected physical signs during anutrition survey in a developing country.

Table 4 compares the recording of threeexaminers working in an area included during theTen State Nutrition Survey. No way has yet beenfound to eliminate such biases on the part of

examiners although it can be presumably reducedby prior agreement and comparisons during asurvey.

Table 3-Percent Positive Agreement of PhysicalSigns in 895 Duplicate Examinations *

Angular lesions -75Goiter -63Filiform papillary atrophy -50Follicular hyperkeratosis -50Abnormal hair -36Swollen red gums -33Glossitis 0* Source: Hansen, R. G., and Monroe, H. N. (eds.) Problems of as-

sessment and alleviation of malnutrition in the UnitedStates. Proceedings of a workshop sponsored by Vander-bilt University, January 13-14, 1970.

Table 4 Percentage of Adult Clinical Findings byThree Examiners in a Selected Area ofthe Ten State Nutrition Survey *

Examiners1 2 3

Number of examinations- 1,123 1,127 589Filiform papillary atrophy 4.1 1.1 11.2Follicular hyperkeratosis 4.0 0.6 6.8Swollen red gums-2.8 3.7 4.1Angular lesions -0.4 0.4 1.2Glossitis -0.6 0.4 0.5Goiter 3.6 6.6 3.6* Source: Hansen, R. G., and Monroe, H. N. (eds.) Problems of as-

sessment and alleviation of malnutrition in the UnitedStates. Proceedings of a workshop sponsored by Vander-bilt University, January 13-14, 1970.

Anthropometric MethodsAt the 1968 White House Conference on

Food, Nutrition and Health, the following recom-mendations on anthropometric methods of clinicalevaluation were made:

Neonates and InfantsWeightRecumbent length (crown-heel)Head circumferenceChest circumferenceTriceps skinfold

Pre-schoolersThe same as preceding categoryStanding height replaces recumbentArm circumference

School Age Through AdolescenceDelete head and chest circumferencesStanding heightOtherwise the same as preceding

categories


Table 5-Smoothed Average Weights* for Men and Women(by age and height: United States 1960-1962 **)

Weight (in pounds)Height 18-24 25-34 35-44 45-54 55-64 65-74 75-79

(in Inches) years years years years years years years

Men

62 --137 141 149 148 148 144 13363 --140 145 152 152 151 148 13864 --144 150 156 156 155 151 14365 ..- 147 154 160 160 158 154 14866 --151 159 164 164 162 158 15467 --154 163 168 168 166 161 15968 --158 168 171 173 169 165 16469 --161 172 175 177 173 168 16970 --165 177 179 181 176 171 17471 168 181 182 185 180 175 17972 --172 186 186 189 184 178 18473 --175 190 190 193 187 182 18974 --179 194 194 197 191 185 194

Women

57 --116 112 131 129 138 132 12558 --118 116 134 132 141 135 12959 -- 120 120 136 136 144 138 13260 --122 124 138 140 149 142 13661 --125 128 140 143 150 145 13962 -- 127 132 143 147 152 149 14363 -- 129 136 145 150 155 152 14664 --131 140 147 154 158 156 15065 --134 144 149 158 161 159 15366 --136 148 152 161 164 163 15767 -- 138 152 154 165 167 166 16068 -- 140 156 156 168 170 170 164

*Estimated values from regression equations of weights for specified age groups.**Adapted from Weight, Height, and Selected Body Dimensions of Adults, United States 1960-1962, Series 11, No. 8, National Center for Health

Statistics, Washington, D.C.

Adulthood and AgingHeight, standingWeightTriceps skinfoldSubscapular skinfoldArm circumference

These measurements can be accomplishedwith efficiency, speed, and accuracy by trainednon-professional personnel. Measuring length andweight for gestational age and skinfold thicknessin neonates is helpful in distinguishing intra-uterine growth retardation, small-for-date babies,dysmaturity, and post-maturity. The gathering ofthese anthropometric measurements on newborninfants would also help to identify target popula-tions and groups in need of nutritional assistance.

Weight should be recorded, using a beambalance; spring balances are notoriously inaccu-rate for this purpose. Height should be measuredwithout shoes. Either the Lange® or the Harpen-

den® calipers can be used to record triceps orsubscapular skinfold thickness. The integration oftriceps skinfold thickness and arm circumferencecan be used to calculate lean body mass (seeTables 5 and 6).

Height and weight of individuals over 60years of age may not be accurate indices of bodycomposition and. nutritional status because ofosteoporotic changes.

In gathering anthropometric measurementsas part of a data collection system, standardizedequipment and procedures should be used. Ap-propriate reference standards for height, weight,head circumference, chest circumference, arm cir-cumference, triceps, and subscapular skinfolds,etc., must be selected based on the:

* Characteristics of the population beingexamined;

* Availability of data on that segment of thepopulation presumed to have achieved"optimal growth";


* Recommendations of various nutritionagencies who have endeavored to stan-dardize anthropometric data collectionfrom different parts of the world.

Table 6-Obesity Standards for CaucasianAmericans *

(minimum triceps skinfold thicknessin millimeters indicating obesity)**

Age Skinfold Measurements(years) Male Female

5-12 --146-12 --15

7 - - 13 --168 -14 --17

9-15 --1810 --- 16 --20

11 -17 - 2112 -18 --2213 -18 --2314 -17 --2315-16 --24

16 - ----------------------- 15--2517 - 14 --26

18-15 --2719 -15 --2720 -16 --28

21 - 17 --2822 - 18 --2823 - 18 --2824 - 19 --28

25 -20 ---- 2926 -- 20 -- 29

27 -21 --2928 -22 -2929-23 --29

30-50 -23 --30* Adapted from Seltzer, C. C. and Mayer, J. A simple criterion ofobesity. Postgrad. Med. 38: A101-107, 1965.

** Figures represent the logarithmic means of the frequency distri-butions plus one standard deviation.

The Iowa and Boston growth curves (seeAppendix A of the Section on Infants and Children)are currently in use as reference standards in theUnited States and abroad. In the near future, addi-tional data on white and black children in theUnited States, ages 6-11 and 12-17, will be avail-able from the National Center for Health Statistics.These data may provide a more suitable standardfor use in these age groups.

Growth charts can be utilized by all levelsof workers in health and nutritionally-related fields.Major events, such as illnesses, end of breast feed-ing, birth of a sibling, etc., should be recorded onthe chart. Growth charts can be important tools inindividual and community education for a widevariety of different groups, including policymakers, health workers, parents, and others.

It is evident that chronic undernutrition, ormalnutrition of sufficient degree, will retardgrowth and development. It should also be clearthat retardation in growth and development is notevidence of malnutrition per se, since many otherenvironmental and genetic factors influencegrowth and development. Much could be learnedof the interrelationships between host and environ-mental effects on growth and development, if anadequate system of nutrition and health data col-lection could be developed.

While the above measurements focus par-ticularly on undernutrition, they will also detectobesity, which is a combined medical and nutri-tional problem.

In 1971, the International Union of Nutri-tional Sciences recommended that, in the evalua-tion of the nutritional status of a population, firstpriority be given to measurements in the agegroup from birth to four years of age, and secondpriority be given to those between seven and nineyears of age.

Dental ExaminationsA dental examination is usually included as

part of the clinical assessment in most nutritionsurveys. This is important in the development orevaluation of comprehensive health care pro-grams. Although the dental examination may notcontribute greatly to the evaluation of nutritionalstatus, it may partially reflect fluoride intake andthe general effect of diet upon the induction ofdental caries. Severe dental problems, missingteeth, pyorrhea, etc., may influence the nature ofthe diet consumed and be partially responsible fornutritional inadequacies.

Every person surveyed should be screenedfor dental caries and the status of gingival hygiene.The dental findings recorded should include:

* Obvious dental caries;* Periodontal disease as manifested by hy-

peremia, edema, ease of bleeding, orretraction;

* Calculus deposit;* Soft materia alba.The recording of the presence or absence

of these findings, and some indication of thedegree of severity, is indicated. It may not benecessary to quantitate these findings by calcu-lating the DMF (decayed-missing-filled), Pi (peri-odontol disease), and OHI (oral hygiene index)indices. These indices require standardization ofthe techniques and of the examiners. It has beenpointed out that, as with medical nutritionistsevaluating physical signs of malnutrition, evenfully-trained dentists may have difficulty in record-ing these indices objectively, and inter-examinervariation is likely to be considerable.

(continued page 25)


Appendix A

(continued next page)


Appendix A (continued)

~~~~~~~~~v. -

-~~~~~~~i

.S H- - X~~(continued from p. 24)

Individuals found to have dental diseasethat is related to eating habits can then be coun-seled with regard to improvement in their dietarypattern. They can be referred for specific preven-tive measures-such as topical fluoride applica-tion or caries treatment, extractions, and/or othertreatments when indicated. With proper data col-lection systems, the significance of dental findingsin relation to diet will be elucidated in the future.

Selected ReferencesBradfield, R. B. and Jelliffe, E. F. P. Early assessment of

malnutrition. Nature, 225:283, 1970.

Falkner, F., Buzina, R., Chapra, J., Gyorgy, P., Jelliffe, D. B.,Jelliffe, P., McKigney, J., Reed, M. S. and Roche, A. F.The creation of growth standards: a committee report.Amer. J. Clin. Nutr. 20:218, 1972.

Hansen, R. G. and Monroe, H. N. (editors): Problems of a°s-sessment and alleviation of malnutrition in the United

States. Proceedings of a Workshop sponsored by Vander-bilt University, January 13-14, 1970.

Hillman, R. W. Concordance among clinical signs suggestiveof malnutrition. Amer. J. Clin. Nutr. 20:1118, 1967.

Jelliffe, D. B. The assessment of the nutritional status of thecommunity. WHO Monograph No. 53, Geneva, 1966.

Modem Nutrition in Health and Disease: Dietotherapy, 5thed., Edited by Robert S. Goodhart and Maurice E. Shils.Lea & Febiger, Philadelphia (1973).

Perez, C., Scrimshaw, N. W., Munoz, J. A. Technique of en-demic goiter surveys. WHO Monog. Ser. 44:369-383, 1960.

Sandstead, H. R. and Anderson, R. K. Nutrition Studies. I.Description of physical signs possibly related to nutritionalstatus. Public Health Reports, 62:1073, 1947.

Screening children for nutritional status: suggestions for childhealth programs, U.S. DHEW, PHS, Pub. #2158, 1971.

Standard, K. L., Lovell, H. G. and Garrow, J. S. The validityof certain physical signs as indices of generalized malnutri-tion in young children. J. Trop. Pediat. 11:100, 1966.


Appendix BPhysical Signs and Nutritional Terms

Associated with Malnutrition

1. General AppearanceApathy: Unreactive, unresponsive, disinterested, and inatten-tive to surroundings.

Clinical Marasmus: Evidence of pronounced wasting of sub-cutaneous fat without edema. Significant apathy may bepresent. Frequently the face and eyes of the child may appearunusually bright due to the combination of wasting andprominence of the eyes. The child is usually considerablyunderdeveloped in relation to age and there may or may notbe associated hair changes such as dyspigmentation, thin-ness, easily pluckable, or signs of avitaminosis.

Irritability: Hyperresponsive, excessive or overreaction tominor stimuli, particularly manifest through crying or unusualindication of fear as a result of minor or relatively insignificanthappenings.

Kwashlorkor: Pitting edema at least on the pretibial region,underweight, undersize, underdeveloped for age. Muscularwasting may be present but masked by edema. Apathy ofsome degree is present. Changes in the hair are usuallynoted, such as thinning, easily pluckable with dyspigmenta-tion or flag sign, and change in texture to silken, sparse hair.Dermatosis with desquamation of the so-called flaky-painttype, with or without hyperpigmentation. In severe cases thedermatosis may resemble a relatively severe burn but lackserythema.

Pallor: Paleness and loss of color of skin, nail beds, mucosaand lips.

Prekwashiorkor: An underweight, undersized, underdevelopedchild, without the evident pronounced wasting present inmarasmus. Child is thin and undersized, but has relativelynormal body proportions, has rather poor muscle tone, andhair changes may be present. Not apathetic, though wouldnot be described as alert.

2. HairDry staring: Dry wirelike, unkempt, stiff hair, often brittle,sometimes may exhibit some bleaching of the normal color.

Dyspigmentation: Definite change from normal pigment of thehair, most usually evident distally and best seen by carefullycombing hair strands upward and viewing the orderly arrayof hair in good light. Dyspigmentation includes both changeof pigment (usually lightening of color) and depigmentation.Not to be confused with dyed or tinted hair. Dyspigmentationis often bandlike in character and usually is associated withsome change in texture of hair in the depigmented band. Insome ethnic groups, particularly among Negroid, the pigmentmay be slightly reddish in color. In others, especially amongstraight black-haired peoples, the bandlike depigmentation("flag sign") is common.

Easily pluckable: Easily pluckable hair is that in which the

shafts are readily removed with minimum tug when a fewstrands are grasped between the finger and thumb and gentlypulled. In such cases there is a lack of reaction of the child,indicating a lack of pain associated with removing of the hair.

3. SkinCrackled skin: Definite scales larger in size than those seenin xerosis. It is often congenital and is most prominent in coolweather. It Is non-nutritional in origin.

Dependent edema: The presence of abnormally large amountsof fluid In the intercellular tissue spaces of the body; usuallyapplied to demonstrable accumulation of excessive fluid inthe subcutaneous tissues which are dependent upon positionand gravity.

Dermatitis, with desquamatlon, or crazy-pavement type: Underthis heading should be recorded those desquamating changesof the skin, usually with increased pigmentation, which occuron the extremities, especially legs, thighs and buttocks, butmay occur over the trunk in association with kwashiorkor.(These have been termed "flaky-paint" dermatoses.) Smallcircumscribed bleblike lesions sometimes seen in associationwith kwashiorkor and which on occasion may precede thedesquamation. In addition, any "crazy-pavement" type oflesions observed should be noted. These are characterizedby a thin-appearing epithelium marked by striations usually re-sembling in outline the microscopic picture of epithelial cells.Not to be confused, however, with ichthyosis (scaly skin).

Follicular hyperkeratosis: This lesion has been likened to"gooseflesh" which is seen on chilling, but it is not general-ized and does not disappear with brisk rubbing of the skin.Readily felt, as it presents a "nutmeg grater" feel. Follicularhyperkeratosis is more readily detected by the sense of touchthan by the eye. The skin is rough, with papillae formed bykeratotic plugs which project from the hair follicles. Thesurrounding skin is dry. and lacks the usual amount of mois-ture or oiliness. Differentiation from adolescent folliculosiscan usually be made through recognition of the normal skinbetween the follicles in the adolescent disorder. It is distin-guished from perifolliculosis by the ring of capillary conges-tion which occurs about each follicle in scorbutic perifollicu-losis.

Pellagrous dermatitis: Symmetrical lesions typical of acute orchronic, mild or severe pellagra are observed; lesions areusually red, often swollen or blistered like sunburn, pigmented,scaly over expQsed areas; clearly demarcated from normalskin.

Purpura or petechia: Small localized extravasations of blood,red or purplish in color, depending on time elapsed sinceformation. Usually distributed at sites of pressure, and maybe perifollicular.

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Xerosls: Xerosis is a clinical term used to describe a dry andcrinkled skin which is accentuated by pushing the skin parallelto its surface. In more pronounced cases it is often mottledand pigmented, and may appear as scaly or alligator-likepseudo-plaques, usually not greater than 0.5 cm In diameter.Nutritional significance is not established. Differential diag-nosis must be made from changes due to dirt and exposureand ichthyosis.

4. SkeletalBowleg: An outward curve of one or both legs at or below theknee (genu varum).

Costochondral beading: Palpable and visible enlargement ofthe costochondral junctions.Cranial bossing: Abnormal prominence or protrusion of frontalof parietal areas.

Enlarged joints* When the more obvious ends of long bonesare enlarged; i.e., the wrist, ankles, knees.

Winged scapula: A scapula having a prominent vertebralborder.

5. MuscleMuscle wasting: When appearance Indicates abnormal loss ofmuscle substance, as exhibited by unusual prominence ofbony skeleton, undue degree of folding of the skin of thebuttocks, or the abnormal flabby feel (sometimes described asjelly-like) of the child with poor muscle tone.

6. EyesBitot's spots: Bitot's spots are small circumscribed grayish oryellowish gray, dull, dry, foamy superficial lesions of the con-junctiva. They most often occur on the lateral aspect of thebulbar conjunctiva In the interpalpebral area. Do not confusewith pterygium.

Blepharitis: Inflammation of eyelids.

Keratomalacia: Softening of the cornea.

Thickened opaque bulbar conjunctivae: All degrees of thick-ening may occur. The blueness of the sclera may disappearand the bulbar conjunctivae develop a wrinkled appearancewith increase in vascularity. The thickened conjunctivae mayresult in a glazed, porcelain-like appearance, obscuring thevascularity.

Xerosls conjunctivae: The conjunctivae, upon exposure byholding the lids open and having the subject rotate the eyes,appear dull, lusterless, and exhibit a striated or roughenedsurface.

7. FaceAngular lesions: Present bilaterally when mouth Is held halfopen. May appear as pink or moist whitish macerated angularlesions which blur the mucocutaneous junction. Angular fis-sures are recorded when there is definite break in continuityof epithelium at the angles of the mouth.

Angular scas: Scars at the angles, which, if recent, may bepink; If old, may appear blanched.

Chellosis: Cheilosis is when the lips are swollen, tense, orpuffy, and where it appears, the buccal mucosa extends outonto the lips. These lesions are also denuded. This categorymay be used to record vertical fissuring of the lips, but notfor lesions of the angles of the mouth only.Nasolablal seborrhea: Definite greasy yellowish scaling orfiliform excrescences In the nasolabial area which becomemore pronounced on slight scratching with the fingernail or atongue blade.

8. MouthFililform papillary atrophy: Filiform papillae exceedingly lowor absent, giving the tongue a smooth appearance which re-mains after scraping slightly with an applicator stick. "Mild"involves less than ¼4 of the tongue (tip and lateral marginsonly); "moderate" Involves V4 to ¾ of the tongue; "'severe"involves over 4.

Glossilts: Glossitis is any increase in redness, fissuring orswelling with color change (break in lingual mucosa) ordiffuse involvement of mucosa. Geographic tongue has thetypical Irregularly shaped and distributed areas of atrophywith Irregular white patches resembling leukoplakia. Glossitisis usually associated with some sensation of pain or burning,particularly upon eating.Magenta colored: The color of alkaline phenolphthalein.Swollen gums: Swollen red interdental papillae, with morethan one papilla involved.9. TeethCarious teeth: Molecular decay of a bone in which it becomesfriable, thinned, and dark, and gradually breaks down with theformation of pus.

Fluorosis: Opaque paper-white areas In the enamel of thetooth, ranging in size from a few flecks to entire enamelsurface. In the latter case brown stain is a frequent accom-paniment as Is attrition of opposing surfaces. The most severeforms of fluorosis include discrete or confluent pitting, withwidespread brown staining and a general, corroded appear-ance.

10. GlandsParotid enlargement: Because of various types of facial con-figuration, parotid enlargement may be easily missed incertain populations. Check by palpation, moving the glandwith fingers upward and backward toward the ear. Check Ifbilateral.

Thyroid enlargement: Thyroid enlargement is when a visuallyperceptible enlargement definitely palpable with or withoutswallowing Is noted. It is preferable to examine the subjectwith his head slightly extended in order to detect thyroldenlargement.

11. OrgansHepatomegaly: Liver edges more than 2 cm below the costalmargin. (In children, the liver edge may be normal palpable.)Splenomegaly: Spleen Is palpable.


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