Clinical assessment of nutritional status

Clinical Assessment
of
Nutritional Status
Physical signs and symptoms of malnutri-
tion can be valuable aids in detecting nutritional
deficiencies. These may include delayed growth
and development as determined by comparing an
individual or a group with normal values on
growth charts; pallor of the skin, mucous mem-
branes of the mouth and eyes, nail beds or palm
surfaces; and the more serious signs of advanced
protein-calorie malnutrition such as changes oc-
curring in hair color and body appearance, as by
edema. Obviously, the sooner the diagnosis of
nutritional status is made in individuals and in
populations the sooner clinical public health inter-
vention programs can be formulated.
One does not have to be a physician to
recognize major signs of nutritional deprivation.
Auxiliary health workers can be trained in nutri-
tional diagnosis so that they may be alerted to the
major signs of clinical deficiencies. They, in turn,
can alert physicians who may then conduct a more
detailed examination so that the presence or
absence of nutritional deficiencies can be more
definitively ascertained. In 1962 the World Health
Organization Expert Committee on Medical As-
sessment of Nutritional Status proposed a classi-
fication of physical signs to be used in nutrition
surveys. Updated in 1966, this is a most valuable
guide* in the diagnosis and interpretation of the
clinical signs of malnutrition.
It must be emphasized that 1) signs of mal-
nutrition may not be specific-that is, they may be
related to non-nutritional factors such as poor
hygiene or excessive exposure to the sun-and 2)
they may not correlate with dietary intake data or
the biochemical values in the individual or the
population. This should not discourage the health
worker from participating in the clinical evaluation
of children and adults.
The W.H.O. Committee has conveniently
classified the physical signs most often associated
with malnutrition into the following three groups:
Group One Signs that are considered to be of
value in nutritional assessment.
These are often associated with
nutritional deficiency status. Signs
of malnutrition may often be
mixed 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 chronic
type, but are often found in popu-
lations of developing countries
where other health and environ-
mental problems, such as poverty
and illiteracy, are co-existent.
Group Three-These include physical signs that
have no relation to malnutrition,
although they may be similar to
physical signs found in persons
with malnutrition ^'nd must be
carefully delineated from them.
This usually takes the particular
expertise of a physician or other
health worker expertly trained in
nutritional 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 that
various signs have different degrees of reliability,
signs of malnutrition falling in Groups One and
Two have been combined' in Table 1 and are
described in less technical terminology so that
health workers of all categories may better under-
stand their clinical significance. The W.H.O. classi-
fication is particularly helpful when the survey is
limited in scope and aimed at rapid clinical
screening of the community, or consists of a
research project possibly including an evaluation
of less certain signs (Group Two). The more re-
liable the signs, and the more experienced the
observer, the more definitive the nutritional diag-
nosis is likely to be. A comprehensive list of signs
is found in Appendix A. A definition of physical
signs 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, in
fact, signs that are associated with malnutrition
which may be explained by future knowledge.
These include skin discolorations, inflammation of
the 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; hair
fine, silky and straight; color changes (flag sign); can be easily
plucked
Face Skin color uniform; smooth, pink, healthy Skin color loss (depigmentation); skin dark over cheeks and
appearance; not swollen under eyes (malar and supra-orbital pigmentation); lumpiness
or flakiness of skin of nose and mouth; swollen face; enlarged
parotid glands; scaling of skin around nostrils (nasolabial
seborrhea)
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 (circumcorneal
injection)
Lips Smooth, not chapped or swollen Redness and swelling of mouth or lips (cheilosis); especially
at corners of mouth (angular fissures and scars)
Tongue Deep red in appearance; not swollen or Swelling; scarlet and raw tongue; magenta (purplish color) of
smooth tongue; smooth tongue; swollen sores; hyperemic and hyper-
trophic papillae; and atrophic papillae
Teeth 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 gums
Glands 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; red
swollen pigmentation of exposed areas (pellagrous dermatosis);
excessive lightness or darkness of skin (dyspigmentation); black
and blue marks due to skin bleeding (petechiae); lack of fat
under skin
Nails Firm, pink Nails are spoon-shape (koilonychia); brittle, ridged nails
Muscular 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 of
head (frontal and parietal bossing); swelling of ends of bones
(epiphyseal enlargement); small bumps on both sides of chest
wall (on ribs)-beading of ribs; baby's soft spot on head does
not 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 pressure
pressure for age
Gastrointestinal No palpable organs or masses (in Liver enlargement; enlargement of spleen (usually indicates
children, however, liver edge may be other associated diseases)
palpable)
Nervous Psychological stability; normal reflexes Mental irritability and confusion; burning and tingling of hands
and feet (paresthesia); loss of position and vibratory sense;
weakness and tenderness of muscles (may result In inability
to walk); decrease and loss of ankle and knee reflexes
to standardize the definition of a particular sign
before a survey or other health evaluation is
launched. Thus, a nutrition survey team is often
given substantial orientation sessions by physi-
cians with formal experience in the identification
and 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 is
coming into greater use by health personnel, to
determine thickness of subcutaneous fat (such as
the Lange® skinfold caliper.*)
*
Cambridge Scientific Instruments, Inc., Cambridge, Md.
CLINICAL ASSESSMENT 19

Color slides** are available to assist health
personnel in identification and standardization of
signs 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 is
associated with anemia. However, the anemia may
be 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 of
malnutrition are multiple. The finding of one sign
will at least nudge the observer to go to a more
careful assessment of the body for other signs.
Environmental factors (such as excessive heat or
sun, wind or cold air), lack of general personal
hygiene, 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 also
plays a role in the way the signs present them-
selves and in the interpretation of the signs. For
example, signs of vitamin A deficiency in early
childhood are different from those found in school
age children. Scurvy, or vitamin C deficiency, often
presents in the child as painful swollen joints, due
to bleeding into the bones, whereas in elderly
people, 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 clue
rather than a diagnosis and, as such, should be
pursued further. For example, pallor should not be
considered diagnostic of anemia but should be
used as a clue to obtain the laboratory confirma-
tion for anemia. Similarly, epiphyseal enlargement
or costochondral beading should not be inter-
preted as evidence of rickets without x-ray con-
firmation, and enlargement of the thyroid gland
should only be interpreted as evidence of iodine de-
ficiency after appropriate laboratory confirmation.
The detailed clinical examination for signs
of malnutrition must also include a search for
signs related to metabolic diseases which have
nutritional relationships. Notable among these are
diabetes and the hyperlipidemias. Table 2 sum-
marizes the physical findings of hyperlipidemia
which 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 use
of 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 Evidence
of 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 disease
Enlargement of liver and spleen
Turbid or creamy appearance of serum
High serum levels of cholesterol and/or
triglycerides
Abnormal blood lipoprotein patterns
they may greatly assist in providing a picture of
the 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 standardized
formats, our increased knowledge will enable us to
make 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 different
examiners.
However, physical examinations should be
an integral part of most nutrition surveys for the
following reasons:
* A physical examination may reveal evi-
dence of certain nutritional deficiencies which
will not be detected by dietary or laboratory
methods.
* The identification of even a few cases of
clear-cut nutritional deficiency may be particularly
revealing and provide a clue to other pockets of
malnutrition in a community.
* The nutritional examination may reveal
signs 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 health
facilities.
Physical signs vary from population to pop-
ulation. For example, in one study, underweight
Jamaican children displayed dental caries and
xerosis (dryness of eye membranes), while normal
weight children in Jamaica and even underweight
children examined in Barbados rarely showed
these signs.
Physical signs may also vary over time
periods which may witness rapid changes in the
nutritional and social environment. Thus, angular
stomatitis (fissuring at the side of the lips) was
found in Jamaican children by a team of nutrition-

ists on one occasion, but not detected until three
years later by another group of investigators.
Moreover, the physical signs of protein-calorie
malnutrition display one constellation in the Carib-
bean and another in the Far East.
Several studies have revealed the inability
to relate clinical signs suggestive of nutritional
deficiency and other evidence of malnutrition in
patients 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 of
clinical signs of malnutrition that may be found
useful. A child having one or more of the follow-
ing signs may be classified as suffering from
protein-calorie malnutrition: edema, dyspigmenta-
tion of the hair, easy pluckability of the hair, thin
sparse hair, muscle wasting, moonface, flaky-paint
rash, 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, whereas
angular stomatitis, cheilosis, glossitis and atrophic
or 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 ages
of one to five years between weight, height-weight
index, calf circumference, and the clinical signs
of protein-calorie malnutrition. On the other hand,
such anthropometric measures did not identify
children with vitamin deficiencies. Similarly, a
relationship among children in southern Iran be-
tween body weight and malnutrition has also been
reported. Growth retardation was associated with
lower hemoglobin, serum protein, and serum albu-
min levels.
Examination of the thyroid gland is an im-
portant part of the nutritional examination. The
following grading system has been recommended
by W.H.O. nutritionists: with normal being one lobe
the size of the first phalanx of the subject's thumb;
grade 1 is one lobe greater than the size of the
first phalanx of the subject's thumb; grade 2, a
gland that is visible with the neck extended; grade
3, a gland that is visible with the neck in the nor-
mal position; and grade 4, a gland that is visible
from a considerable distance, such as from across
the room.
To illustrate inter-observer variability, Table
3 indicates the percentage of agreement between
two examiners on selected physical signs during a
nutrition survey in a developing country.
Table 4 compares the recording of three
examiners working in an area included during the
Ten State Nutrition Survey. No way has yet been
found to eliminate such biases on the part of
examiners although it can be presumably reduced
by prior agreement and comparisons during a
survey.
Table 3-Percent Positive Agreement of Physical
Signs in 895 Duplicate Examinations *
Angular lesions -75
Goiter -63
Filiform papillary atrophy -50
Follicular hyperkeratosis -50
Abnormal hair -36
Swollen red gums -33
Glossitis 0
* Source: Hansen, R. G., and Monroe, H. N. (eds.) Problems of as-
sessment and alleviation of malnutrition in the United
States. Proceedings of a workshop sponsored by Vander-
bilt University, January 13-14, 1970.
Table 4 Percentage of Adult Clinical Findings by
Three Examiners in a Selected Area of
the Ten State Nutrition Survey *
Examiners
1 2 3
Number of examinations - 1,123 1,127 589
Filiform papillary atrophy 4.1 1.1 11.2
Follicular hyperkeratosis 4.0 0.6 6.8
Swollen red gums -2.8 3.7 4.1
Angular lesions -0.4 0.4 1.2
Glossitis -0.6 0.4 0.5
Goiter 3.6 6.6 3.6
* Source: Hansen, R. G., and Monroe, H. N. (eds.) Problems of as-
States. Proceedings of a workshop sponsored by Vander-
Anthropometric Methods
At the 1968 White House Conference on
Food, Nutrition and Health, the following recom-
mendations on anthropometric methods of clinical
evaluation were made:
Neonates and Infants
Weight
Recumbent length (crown-heel)
Head circumference
Chest circumference
Triceps skinfold
Pre-schoolers
The same as preceding category
Standing height replaces recumbent
Arm circumference
School Age Through Adolescence
Delete head and chest circumferences
Standing height
Otherwise 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 --137 141 149 148 148 144 133
63 --140 145 152 152 151 148 138
64 --144 150 156 156 155 151 143
65 ..- 147 154 160 160 158 154 148
66 --151 159 164 164 162 158 154
67 --154 163 168 168 166 161 159
68 --158 168 171 173 169 165 164
69 --161 172 175 177 173 168 169
70 --165 177 179 181 176 171 174
71 168 181 182 185 180 175 179
72 --172 186 186 189 184 178 184
73 --175 190 190 193 187 182 189
74 --179 194 194 197 191 185 194
Women
57 --116 112 131 129 138 132 125
58 --118 116 134 132 141 135 129
59 -- 120 120 136 136 144 138 132
60 --122 124 138 140 149 142 136
61 --125 128 140 143 150 145 139
62 -- 127 132 143 147 152 149 143
63 -- 129 136 145 150 155 152 146
64 --131 140 147 154 158 156 150
65 --134 144 149 158 161 159 153
66 --136 148 152 161 164 163 157
67 -- 138 152 154 165 167 166 160
68 -- 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 Aging
Height, standing
Weight
Triceps skinfold
Subscapular skinfold
Arm circumference
These measurements can be accomplished
with efficiency, speed, and accuracy by trained
non-professional personnel. Measuring length and
weight for gestational age and skinfold thickness
in neonates is helpful in distinguishing intra-
uterine growth retardation, small-for-date babies,
dysmaturity, and post-maturity. The gathering of
these anthropometric measurements on newborn
infants would also help to identify target popula-
tions and groups in need of nutritional assistance.
Weight should be recorded, using a beam
balance; spring balances are notoriously inaccu-
rate for this purpose. Height should be measured
without shoes. Either the Lange® or the Harpen-
den® calipers can be used to record triceps or
subscapular skinfold thickness. The integration of
triceps skinfold thickness and arm circumference
can be used to calculate lean body mass (see
Tables 5 and 6).
Height and weight of individuals over 60
years of age may not be accurate indices of body
composition and. nutritional status because of
osteoporotic changes.
In gathering anthropometric measurements
as part of a data collection system, standardized
equipment 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 being
examined;
* Availability of data on that segment of the
population presumed to have achieved
"optimal growth";

* Recommendations of various nutrition
agencies who have endeavored to stan-
dardize anthropometric data collection
from different parts of the world.
Table 6-Obesity Standards for Caucasian
Americans *
(minimum triceps skinfold thickness
in millimeters indicating obesity)**
Age Skinfold Measurements
(years) Male Female
5-12 --14
6-12 --15
7 - - 13 --16
8 -14 --17
9-15 --18
10 --- 16 --20
11 -17 - 21
12-18 --22
13-18 --23
14-17 --23
15-16 --24
16 - ----------------------- 15--25
17 - 14 --26
18-15 --27
19-15 --27
20-16 --28
21 - 17 --28
22 - 18 --28
23 - 18 --28
24 - 19 --28
25 -20 ---- 29
26 -- 20 -- 29
27 -21 --29
28 -22 -29
29-23 --29
30-50 -23 --30
* Adapted from Seltzer, C. C. and Mayer, J. A simple criterion of
obesity. 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 (see
Appendix A of the Section on Infants and Children)
are currently in use as reference standards in the
United States and abroad. In the near future, addi-
tional data on white and black children in the
United 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 standard
for use in these age groups.
Growth charts can be utilized by all levels
of 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 on
the chart. Growth charts can be important tools in
individual and community education for a wide
variety of different groups, including policy
makers, health workers, parents, and others.
It is evident that chronic undernutrition, or
malnutrition of sufficient degree, will retard
growth and development. It should also be clear
that retardation in growth and development is not
evidence of malnutrition per se, since many other
environmental and genetic factors influence
growth and development. Much could be learned
of the interrelationships between host and environ-
mental effects on growth and development, if an
adequate system of nutrition and health data col-
lection could be developed.
While the above measurements focus par-
ticularly on undernutrition, they will also detect
obesity, 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, first
priority be given to measurements in the age
group from birth to four years of age, and second
priority be given to those between seven and nine
years of age.
Dental Examinations
A dental examination is usually included as
part of the clinical assessment in most nutrition
surveys. This is important in the development or
evaluation of comprehensive health care pro-
grams. Although the dental examination may not
contribute greatly to the evaluation of nutritional
status, it may partially reflect fluoride intake and
the general effect of diet upon the induction of
dental caries. Severe dental problems, missing
teeth, pyorrhea, etc., may influence the nature of
the diet consumed and be partially responsible for
nutritional inadequacies.
Every person surveyed should be screened
for 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, or
retraction;
* Calculus deposit;
* Soft materia alba.
The recording of the presence or absence
of these findings, and some indication of the
degree of severity, is indicated. It may not be
necessary 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 of
the techniques and of the examiners. It has been
pointed out that, as with medical nutritionists
evaluating physical signs of malnutrition, even
fully-trained dentists may have difficulty in record-
ing these indices objectively, and inter-examiner
variation 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 disease
that is related to eating habits can then be coun-
seled with regard to improvement in their dietary
pattern. They can be referred for specific preven-
tive measures-such as topical fluoride applica-
tion or caries treatment, extractions, and/or other
treatments when indicated. With proper data col-
lection systems, the significance of dental findings
in relation to diet will be elucidated in the future.
Selected References
Bradfield, 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-
States. Proceedings of a Workshop sponsored by Vander-
Hillman, R. W. Concordance among clinical signs suggestive
of malnutrition. Amer. J. Clin. Nutr. 20:1118, 1967.
Jelliffe, D. B. The assessment of the nutritional status of the
community. WHO Monograph No. 53, Geneva, 1966.
Modem Nutrition in Health and Disease: Dietotherapy, 5th
ed., 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 nutritional
status. Public Health Reports, 62:1073, 1947.
Screening children for nutritional status: suggestions for child
health programs, U.S. DHEW, PHS, Pub. #2158, 1971.
Standard, K. L., Lovell, H. G. and Garrow, J. S. The validity
of certain physical signs as indices of generalized malnutri-
tion in young children. J. Trop. Pediat. 11:100, 1966.

Appendix B
Physical Signs and Nutritional Terms
Associated with Malnutrition
1. General Appearance
Apathy: Unreactive, unresponsive, disinterested, and inatten-
tive to surroundings.
Clinical Marasmus: Evidence of pronounced wasting of sub-
cutaneous fat without edema. Significant apathy may be
present. Frequently the face and eyes of the child may appear
unusually bright due to the combination of wasting and
prominence of the eyes. The child is usually considerably
underdeveloped in relation to age and there may or may not
be associated hair changes such as dyspigmentation, thin-
ness, easily pluckable, or signs of avitaminosis.
Irritability: Hyperresponsive, excessive or overreaction to
minor stimuli, particularly manifest through crying or unusual
indication of fear as a result of minor or relatively insignificant
happenings.
Kwashlorkor: Pitting edema at least on the pretibial region,
underweight, undersize, underdeveloped for age. Muscular
wasting may be present but masked by edema. Apathy of
some degree is present. Changes in the hair are usually
noted, 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-paint
type, with or without hyperpigmentation. In severe cases the
dermatosis may resemble a relatively severe burn but lacks
erythema.
Pallor: Paleness and loss of color of skin, nail beds, mucosa
and lips.
Prekwashiorkor: An underweight, undersized, underdeveloped
child, without the evident pronounced wasting present in
marasmus. Child is thin and undersized, but has relatively
normal body proportions, has rather poor muscle tone, and
hair changes may be present. Not apathetic, though would
not be described as alert.
2. Hair
Dry staring: Dry wirelike, unkempt, stiff hair, often brittle,
sometimes may exhibit some bleaching of the normal color.
Dyspigmentation: Definite change from normal pigment of the
hair, most usually evident distally and best seen by carefully
combing hair strands upward and viewing the orderly array
of hair in good light. Dyspigmentation includes both change
of pigment (usually lightening of color) and depigmentation.
Not to be confused with dyed or tinted hair. Dyspigmentation
is often bandlike in character and usually is associated with
some change in texture of hair in the depigmented band. In
some ethnic groups, particularly among Negroid, the pigment
may be slightly reddish in color. In others, especially among
straight 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 few
strands are grasped between the finger and thumb and gently
pulled. In such cases there is a lack of reaction of the child,
indicating a lack of pain associated with removing of the hair.
3. Skin
Crackled skin: Definite scales larger in size than those seen
in xerosis. It is often congenital and is most prominent in cool
weather. It Is non-nutritional in origin.
Dependent edema: The presence of abnormally large amounts
of fluid In the intercellular tissue spaces of the body; usually
applied to demonstrable accumulation of excessive fluid in
the subcutaneous tissues which are dependent upon position
and gravity.
Dermatitis, with desquamatlon, or crazy-pavement type: Under
this heading should be recorded those desquamating changes
of the skin, usually with increased pigmentation, which occur
on the extremities, especially legs, thighs and buttocks, but
may occur over the trunk in association with kwashiorkor.
(These have been termed "flaky-paint" dermatoses.) Small
circumscribed bleblike lesions sometimes seen in association
with kwashiorkor and which on occasion may precede the
desquamation. In addition, any "crazy-pavement" type of
lesions observed should be noted. These are characterized
by 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. Follicular
hyperkeratosis is more readily detected by the sense of touch
than by the eye. The skin is rough, with papillae formed by
keratotic plugs which project from the hair follicles. The
surrounding skin is dry. and lacks the usual amount of mois-
ture or oiliness. Differentiation from adolescent folliculosis
can usually be made through recognition of the normal skin
between 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 or
chronic, mild or severe pellagra are observed; lesions are
usually red, often swollen or blistered like sunburn, pigmented,
scaly over expQsed areas; clearly demarcated from normal
skin.
Purpura or petechia: Small localized extravasations of blood,
red or purplish in color, depending on time elapsed since
formation. Usually distributed at sites of pressure, and may
be perifollicular.
(continued next page)

Xerosls: Xerosis is a clinical term used to describe a dry and
crinkled skin which is accentuated by pushing the skin parallel
to its surface. In more pronounced cases it is often mottled
and pigmented, and may appear as scaly or alligator-like
pseudo-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 exposure
and ichthyosis.
4. Skeletal
Bowleg: An outward curve of one or both legs at or below the
knee (genu varum).
Costochondral beading: Palpable and visible enlargement of
the costochondral junctions.
Cranial bossing: Abnormal prominence or protrusion of frontal
of parietal areas.
Enlarged joints* When the more obvious ends of long bones
are enlarged; i.e., the wrist, ankles, knees.
Winged scapula: A scapula having a prominent vertebral
border.
5. Muscle
Muscle wasting: When appearance Indicates abnormal loss of
muscle substance, as exhibited by unusual prominence of
bony skeleton, undue degree of folding of the skin of the
buttocks, or the abnormal flabby feel (sometimes described as
jelly-like) of the child with poor muscle tone.
6. Eyes
Bitot's spots: Bitot's spots are small circumscribed grayish or
yellowish gray, dull, dry, foamy superficial lesions of the con-
junctiva. They most often occur on the lateral aspect of the
bulbar conjunctiva In the interpalpebral area. Do not confuse
with 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 disappear
and the bulbar conjunctivae develop a wrinkled appearance
with increase in vascularity. The thickened conjunctivae may
result in a glazed, porcelain-like appearance, obscuring the
vascularity.
Xerosls conjunctivae: The conjunctivae, upon exposure by
holding the lids open and having the subject rotate the eyes,
appear dull, lusterless, and exhibit a striated or roughened
surface.
7. Face
Angular lesions: Present bilaterally when mouth Is held half
open. May appear as pink or moist whitish macerated angular
lesions which blur the mucocutaneous junction. Angular fis-
sures are recorded when there is definite break in continuity
of epithelium at the angles of the mouth.
Angular scas: Scars at the angles, which, if recent, may be
pink; If old, may appear blanched.
Chellosis: Cheilosis is when the lips are swollen, tense, or
puffy, and where it appears, the buccal mucosa extends out
onto the lips. These lesions are also denuded. This category
may be used to record vertical fissuring of the lips, but not
for lesions of the angles of the mouth only.
Nasolablal seborrhea: Definite greasy yellowish scaling or
filiform excrescences In the nasolabial area which become
more pronounced on slight scratching with the fingernail or a
tongue blade.
8. Mouth
Fililform papillary atrophy: Filiform papillae exceedingly low
or 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 margins
only); "moderate" Involves V4 to ¾ of the tongue; "'severe"
involves over 4.
Glossilts: Glossitis is any increase in redness, fissuring or
swelling with color change (break in lingual mucosa) or
diffuse involvement of mucosa. Geographic tongue has the
typical Irregularly shaped and distributed areas of atrophy
with Irregular white patches resembling leukoplakia. Glossitis
is 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 more
than one papilla involved.
9. Teeth
Carious teeth: Molecular decay of a bone in which it becomes
friable, thinned, and dark, and gradually breaks down with the
formation of pus.
Fluorosis: Opaque paper-white areas In the enamel of the
tooth, ranging in size from a few flecks to entire enamel
surface. In the latter case brown stain is a frequent accom-
paniment as Is attrition of opposing surfaces. The most severe
forms of fluorosis include discrete or confluent pitting, with
widespread brown staining and a general, corroded appear-
ance.
10. Glands
Parotid enlargement: Because of various types of facial con-
figuration, parotid enlargement may be easily missed in
certain populations. Check by palpation, moving the gland
with fingers upward and backward toward the ear. Check If
bilateral.
Thyroid enlargement: Thyroid enlargement is when a visually
perceptible enlargement definitely palpable with or without
swallowing Is noted. It is preferable to examine the subject
with his head slightly extended in order to detect thyrold
enlargement.
11. Organs
Hepatomegaly: Liver edges more than 2 cm below the costal
margin. (In children, the liver edge may be normal palpable.)
Splenomegaly: Spleen Is palpable.

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