FREQUENCY OF

AGE ACTIVITY
CHECKUP
•Physical examination
•Examination by MO at 1 month old
0-6 month Monthly •Evaluation of development and growth
•Immunisation
•Breast Feeding counselling
•Physical examination
•Dental check up 0-9month
•Evaluation of development and growth
6-12 month 2 monthly
•Immunisation
•Breast Feeding and weaning counselling

•Physical examination
•Examination by Mo at 18month
•Dental check up 10-23month
•Evaluation of development and growth
1-2years 3 monthly
•M-chart
•Additional immunisation
•Diet counselling
 •Physical examination by Mo at 2-4 years
•Visual Check up
•Dental check up 2-4 years
2-4 years 6monthly •Evaluation of development and growth
•M-chart
•Diet counselling

•Physical examination
5-6 years once yearly •Evaluation of development and growth
•Diet counselling

Reference : Rekod Kesihatan bayi dan kanak-kanak, Kementerian Kesihatan Malaysia

 Normal growth
• Deviation in growth patterns may be nonspecific or
may be important indicators of serious and chronic
medical disorders.
• An accurate measurement of length/height, weight,
and head circumference should be obtained at every
health supervision visit and compared with statistical
norms on growth charts.
• Serial measurements are more useful than single
measurement. Following the trend helps define
whether growth is within acceptable limits or warrants
further evaluations.
• Growth is assessed by plotting accurate
measurements on growth charts and comparing
each set of measurements with previous
measurements obtained at health visits.
• Normal growth patterns have spurts and
plateaus, so some shifting on percentile graphs
can be expected.
• Large shifts in percentiles warrant attention.
• When calories intake is inadequate, the weight
percentile falls first, then the height, and the
head circumference is last.
• Serial measurements of head circumference are
crucial during infancy, a period of rapid brain
development.
• Therefore should be plotted until the child is 2
years old.
• A child is considered microcephalic if the head
circumference is less than the third percentile.
• Separate growth charts should be used for very
low birth weight infants (<1500g), Turner
syndrome, Down’s syndrome and various other
dysmorphology syndromes.
 Rules of thumb of growth
• Weight:
– Weight loss in first 7 - 10days : 10-15% of birth weight
, they regain their birth weight by 2nd week.
– In the first 3 months, the rate of weight gain is
25gm/day.
– Double birth weight : 4-5 months
– Triple birth weight : 1 year
– Daily weight gain :
• 20-30g for first 3-4 months
• 15-20g for rest of the first year
• Height:
– Average length : 20in at birth, 30in at 1 year
– At age of 4, the average child is double birth length

• Head circumference:
– Average : 35cm at birth
– Increases 12cm for the first year (6cm in 1st three
months, 3cm in 2nd three months and 3cm in last
three months )
 How to interpret a growth chart?
• Obtain accurate measurement
• Select appropriate growth chart
– Birth up to 2 years of age
– Aged 2 through 19 years
• Record data
– Patient’s name
– Date of birth
– Birth weight and length
• Calculate BMI when a child is aged 2 to 20 years
old
• Plot measurements
– The WHO growth standard charts use the 2nd and the
98th percentiles as the outer most percentile cutoff
values indicating abnormal growth
– The CDC growth reference charts use the 5th and 95th
percentile as the outer most percentile cutoff values
indicating abnormal growth
 Developmental milestones
• Development can be monitored by documenting
achievement of age-appropriate milestones for
intellectual, motor and social skills.
• Early identification of developmental delays allows
timely implementation of appropriate interventions.
• There are 4 fields of developmental skills to consider
whenever a young child is seen:
 Gross motor
 Vision and fine motor
 Hearing, speech and language
 Social, emotional and behavioral

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17
18
Gross motor

Vision

Social

Language
Gross motor

Fine Motor

Hearing
Gross motor
Fine Motor
Social

Hearing
Language
Umur 9 Bulan
Gross motor

Fine motor

Social

Language

Fine motor
Gross motor
Fine motor

Language

Social

Gross motor
IMMUNIZATION FOR CHILDREN
BY AGE
 Immunisations
• Immunity – Ability of the body to fight infection
• Immunity can be obtained:
Active – Antibodies production from disease or
vaccine.
Passive – Antibodies obtained from transfusion eg:
from mother to baby or from infusion of
immunoglobulin.
• Immunization – method of protecting children in a
safe, effective and simple method by vaccination, thus
producing antibodies against diseases.
• Vaccine can be weakened or dead virus/bacteria given
by injection or by orally.
 Classification of vaccines
Live Attenuated Inactivated/ whole
killed
BCG, MMR Poliomyelitis (IPV)
Varicella, Rotavirus, oral Diphtheria
typhoid vaccine Pertussis
Tetanus
Hepatitis A, B
Hib
Some influenza vaccines
(H1N1)
Rotavirus
At least 4-week-gap before the next dose of live vaccine given
 Herd Immunity

• Aim of vaccine– to
protect children who
have taken the vaccine.
• These group of children
rarely have the disease.
• Provide ‘indirect’
protection to children
who have yet to be
vaccinated.
Primary Oral Healthcare
The EARLY CHILDHOOD ORAL HEALTHCARE
PROGRAMME is an extension of the antenatal
programme and targets postnatal mothers and
parents/carers of children aged 4 years and below who
are seen under the Child Health Services of the
Ministry of Health (MOH). The main objective of the
early childhood oral healthcare programme is to
promote and maintain good oral health of toddlers
towards achieving their optimum growth and
development.

(Source: Division of Oral Health, MOH)

• Pre-School Service
The oral healthcare programme for PRESCHOOL
CHILDREN was launched in 1984 for kindergartens. This
programme utilizes a friendly, non-invasive approach
whereby dental nurses introduced dentistry to children
via promotional and preventive initiatives. These include
tooth brushing sessions, puppet shows, role-play and
other fun activities. In keeping with the non-invasive
approach, Atraumatic Restorative Technique (ART) is
adopted to provide necessary restorative care for the
children.
Nutrition/Diet for children
 From birth to 6 months
• Start breast feeding 1 hour after delivery
• Exclusive breast feeding up to 6 months
– Only breast milk, no additional food/ drink / water
• Breast feed on demand
– As often as child wants
• At least once every 3 hours
 Advantages of breast feeding
Protein: More easily digested curb
Lipid: Oleic acid improve digestion & absoprtion of
fat
InfantCalcium : Phosphorus (2:1) prevents hypocalceminc
• Provides
tetany &ideal
improve calcium aborption
nutrition
Low renal solute
• Life-saving
Iron in developmental countries
• Reduce
Long chain
riskspolyunsaturated fatty acid:
of GI infection/ imp retinal fascitis
necrotising
development
• Enhance mother-child relationship
• Reduce risk of insulin dependent diabetes,
hypertension, obesity later in life
Mother
• Adequate spacing between children
• Possible reduction of pre-menopausal breast
cancer
 Alternatives to breast feeding
Formula feeding
•Modified cow’s milk
– Unmodified milk
– has high protein and electrolytes, inadequate vitamins and iron
•Specialised infant formula
– Cow’s milk protein allergy, lactose intolerance
•Soya formula should not be used below 6 months
– High aluminum contents & phytoestrogens
 From 6 – 12 months
• Solid food introduced at 6 months of age
– Breast milk nutritionally inadequate (energy, vitamin,
iron)
– Oropharyngeal coordination immature before this
• Continue breast feeding up to 2 years old
• Start with small quantities
– Pureed fruit/root vegetables/ rice / meat/ fish/ eggs
• Frequency of meals:
– 6-8 months: 2-3x per day (snack: 1-2x per day)
– 9-11 months: 3-4x per day (snack: 1-2x per day)
 From 6 -12 months
• Readiness to start solid food
– Ability to hold head up
– Sit unassisted
– Bringing objects to mouth
– Show interest in food
– Ability to track a spoon and open mouth
• Prevent nutritional deficiencies & oral sensory
issues (texture and oral aversion)
• Cereals mixed with breast milk/ formula/water/
fruits
 From 1 y/o to 6 y/o
• Should be eating meals with the family
• Regular schedule of meals and snack
• Encourage to self feed with finger food
• Nutritional food: fruits, vegetables, milk, dairy
products
• Avoid high fat/ salt/ sugary food
• Excessive milk intake ( > 24oz/ 3 milk bottles)
– Reduce intake of nutritionally important food
– Excessive calorie intake
 Healthy eating habits for children
• Taking meals at fixed time
• Prepare more varieties of vegetables during
meals
• Encourage drinking plain water compare to sweet
drinks
• Encourage intake of fruits during main meals &
snacks
• Serve low salt and sugar food
• Avoid eating snack/ meals while watching tv
• Rancangan Makanan Tambahan (RMT) was
launched by the Ministry of education since
1979. The aim is provide healthy and nutritious
food for underprivileged primary school-children.
• Selection criteria : Students with household
income of less than RM400 per month.
• Objectives:
 Ensure the students (esp poor ones) obtain
sufficient nutrients for a proper growth and
development.
 Instill healthy eating habits among the students.
(Source : Bahagian Pemakanan, KKM)
• Program Susu 1Malaysia (formerly known as
Program Susu Sekolah, PSS) was launched
since 1983. It was a part of Rancangan
Makanan Tambahan (RMT). Year 1 to Year 6
pupils will benefit from this ‘free milk plan’
where everyone can get 2 packets of free DHT
milk.
Rekod Kesihatan Bayi dan
Kanak-kanak
(0 – 6 tahun)
 Rekod Kesihatan Bayi dan Kanak-
Kanak
 All babies born in the hospitals (KKM) will be given this book before discharge
and is free of charge.
 This book provides guidance, knowledge and advice to the parents/guardians in
the various aspects of child care. For example, the warning signs of a baby/child
who requires immediate treatment in clinics and hospitals; suitable types of food
according to the child’s age; immunization schedule; schedule to bring children
to the clinic and etc
 This book should be brought along every time a baby/child present to the clinics
and hospitals
 The nurses and physicians will record the following information during each
infant/child visits to the child health clinics, private clinics, KKIA, K1Malaysia,
government/private hospitals;
i) health inspection findings
ii) treatment provided
iii) types of immunization and immunization dates
iv) follow-up dates
 Contents of the Health Record
1. Appointment date - Parenting skills
2. Immunization schedule - Sexual harassment
3. Biodata - Nutrition guidelines
- Sociodemographic data according to age
- Siblings - Dentition
- Antenatal record 6. Clinic visits
- Birth record 7. Growth charts
- Newborn assessment - Weight: up to 5 years old
4. List of problems - Length/Height: up to 5 years
5. Guidelines for parents/guardians old
- Developmental milestone -Body mass index (BMI) : up to
5 years old
- Check-up schedule for well
child - Head circumference: up to
36 months old
- Breastfeeding
- Child safety
 crossing growth percentiles
decreasing growth parameters
 Causes
• Organic and nonorganic causes.
• The causes are multifactorial, including
biological, psychosocial and environmental
contributors.
• A practical way of considering potential causes
is looking at caloric intake, absorption and
expenditure.
• In many cases (>80%) no cause is found.
Pathophysiology

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 Causes to consider
• Inadequate caloric intake/retention
(most common)
– Inadequate amount of food provided
– Breastfeeding issues
– Physical reasons baby can’t feed well (e.g.
cleft palate)
– Persistent vomiting
– Chronic disease causing anorexia
• Inadequate absorption
– Coeliac disease
– Chronic liver disease
– Pancreatic insufficiency (e.g. CF)
– Chronic diarrhoea (e.g. protein-losing
enteropathy)
• Excessive caloric utilisation
– UTIs
– Chronic respiratory disease (e.g. severe
asthma, bronchiectasis)
– Congenital heart disease
– Diabetes mellitus
– Hyperthyroidism
• Other medical causes
– Genetic disorders
– Inborn errors of metabolism
• Psychosocial factors
– Parental depression
– Coercive feeding (feeding becomes a
battle)
– Distractions at meal times
– Poverty (the single biggest risk factor in
both developed and developing countries)
– Behavioural disorders
– Poor social support
– Neglect and abuse (risk of child abuse is
4x higher in children with FTT)
 History
• Antenatal/birth/postnatal history—including growth parameters
• Feeding history (most important aspect)
– Infants—BF/attachment, formula feeding, timing, volumes (e.g. weigh
infant before and after, mother expressing and measuring breast milk),
vomiting?, solids introduction
– Toddlers—types and amounts of foods/ liquids, especially iron
containing foods, food intake inside and outside home, mealtime
battles, distractions, food refusal, milk volume, parental food attitudes
• Medical history
• Developmental history (e.g. regression, syndromes)
• Family history (e.g. mid-parental height, parents’or siblings’
childhood weight gain)
• Social history (e.g. finance, supports)
• For a girl, midparental height is calculated as
follows:
(Paternal height (cm)-13) + Maternal height (cm)
2
• For a boy, midparental height is calculated as
follows:
Paternal height (cm) + (Maternal height (cm) + 13)
2
 Examination
• Growth charts
• General appearance (does the child look sick/ irritable/lethargic? dehydration?
loss of subcutaneous fat? pallor? inappropriate bruising or affect)
• Observation of infant feeding and child–parent interaction (a home visit, or
assessment by a lactation consultant/early childhood nurse may be useful here)
• Dysmorphic features
• Developmental assessment
• Jaundice/bruising/scratches
• Skin, hair and nails
• ENT
• Cardiac/respiratory
• Abdomen (e.g. distention, organomegaly)
• Endocrine (e.g. goitre, urinalysis, finger prick glucose)
• Lymphadenopathy
• Clinical signs of malnutrition
• Observation of feeding
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 Clinical signs of malnutrition

Angular stomatitis

Sparse hair

Poorly developed musculature & lack of subcutaneous tissue

75
 Investigations
• In a healthy infant with no concerns found on history and examination, no
investigations are required, and reassuring the family and further monitoring is
appropriate.
• If concerns are found, targeted investigation for these should be done. Simple first
line investigations may include:
• FBC – IDA, megaloblastic anemia
• RFT – signs of dehydration
• LFT – chronic liver failure [hypoalbuminemia]
• FERRITIN – to confirm IDA
• ESR/CRP – infection / inflammation
• TFT – thyroid level
• Depends on the clinical suspicion
• Barium swallowing in GERD
• Karyotyping in syndrome
 Failure to thrive (FTT)
• defined
• as children whose weight <3rd percentile on ≥
2 occasions,
• or whose weight crosses two centile line over
time.
 Short stature
• Short stature is considered to be below the 3rd percentile.
In general, it is important to differentiate between normal
physiological variants of growth and pathological causes.
• Causes
• Familial short stature—this follows the family trend of a
genetically small family.
• Constitutional delay in maturation—a common and normal
variant in which the growth spurt is later than average.
Bone age is delayed.
• Pathological causes—of the many causes, some are rare
but serious conditions, such as coeliac disease, Crohn
disease and chronic kidney failure. These may present with
slow growth as the only abnormal sign.
 Stunting/short stature
• Linear growth faltering
Example
• The growth pattern of a child with low weight,
length, and head circumference is commonly
associated with familial short stature. These
children are genetically normal but are smaller
than most children.
• A child who, by age, is preadolescent or
adolescent and who starts puberty later than
others may have the normal variant called
constitutional short stature; careful examination
for abnormalities of pubertal development
should be done, although most are normal.
 Tall stature
• Tall stature is considered to be above the 97th percentile. It is not a
common presenting childhood problem in general practice.
• Causes
• familial (predicted final height should roughly match mid-parental
height)
• precocious puberty
• growth hormone excess (pituitary gigantism)
• hyperthyroidism
• syndromic: Marfan, Klinefelter, homocystinuria
• Management
• As tall stature is generally socially acceptable, reassurance,
counselling and education may alleviate the family’s concerns. If
treatment is considered appropriate, the management should be
undertaken by endocrinologists.
 Tall stature
• Hgt > 97th centile
• Less common
 Management
• Intervention need to be taken as soon as FTT
detected
• Challenging and complicated
• Multidisciplinary approach
• Aims:
To provide sufficient nutrition
To treat underlying condition
To provide long-term social support

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Organic Failure to Thrive

• In children with renal failure

87
 Non-organic Failure to Thrive

Home visit Paeds dietician

- By health visitor
- Assess eating behavior
- Provide support
- Assess quantity &
Direct practical advice
composition of food intake
following observation
- Recommend strategies to
increase food intake

Nursery placement
Clinical psychologist & social
- Alleviate stress at home
services
- Assist feeding

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