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Co-Director, University of Florida College of Medicine

A computer software program is available from the Child Growth Foundation that will calculate z scores from height, weight and age data. The calculation of height for age, height age and weight for height are useful when assessing nutritional status initially or when monitoring progress in children who are short for their chronological age. Calculation of height age is necessary when determining nutrient requirements for children who are much smaller (or larger) than their chronological age (see p. A number of methods of classification of malnutrition have been used in developing countries. Clinical assessment Clinical assessment of the child involves a medical history and a physical examination. The medical history will identify medical, social or environmental factors that may be risk factors for the development of nutritional problems. Such factors include parental knowledge and money available for food purchase, underlying disease, changes in weight, food allergies and medications. Clinical signs of poor nutrition, revealed in the physical examination, only appear at a late stage in the development of a deficiency disease and absence of clinical signs should not be taken as indicating that a deficiency is not present. Typical physical signs associated with poor nutrition that have been described in children in western countries are summarised in Table 1. Physical signs represent very general changes and may not be caused by nutrient deficiencies alone. Other indications such as poor weight gain and/or low dietary intake are needed in order to reinforce suspicions, and a blood test should be carried out to confirm the diagnosis. Food and nutrient intake, anthropometric measurements and clinical examination and history form the basis of routine nutritional assessment. None of these are diagnostic tests and can only predict which nutrients may be deficient and which children need further investigation. If a nutrient deficiency (or excess) is suspected as a result of the first line assessment tools, then confirmation using other objective measures should be sought. Lips Tongue Teeth Gums Face Nails Subcutaneous tissue Muscles Bones Biochemistry and haematology Methods of confirming suspicion of a nutritional problem include analysis of levels of nutrients or nutrient-dependent metabolites in body fluids or tissues, or measuring functional impairment of a nutrient-dependent metabolic process. Although an objective measurement is obtained from a blood test, there are a number of factors that can affect the validity of such biochemical or haematological investigations. Age specific normal ranges need to be established for the individual centre unless the laboratory participates in a regional or national quality control scheme. Recent food intake and time of sampling can affect levels and it may be necessary to take a fasting blood sample for some nutrients. Physiological processes such as infection, disease or drugs may alter normal levels. Contamination from exogenous materials such as equipment or endogenous sources such as sweat or interstitial fluid is important for nutrients such as trace elements, and care must be taken to choose the correct sampling procedure. A summary of some biochemical and haematological measurements is given in Table 1. Urine is often used for adult investigations, but many tests require the collection of a 24-hour urine sample and this is difficult in babies and children. The usefulness of a single urine sample for nutritional tests is limited and needs to be compared with a standard metabolite, usually creatinine. However, creatinine excretion itself is age dependent and this needs to be taken into consideration. Tissues that store certain nutrients, such as the liver and bone, would be useful materials to investigate, but sampling is too invasive for routine clinical use. However, this method assumes a constant state of hydration, which has shown not to be true for obese individuals.

The follicular cells synthesize Tg, a large tyrosine-rich glycoprotein, and secrete it into the lumen of the follicle; colloid is essentially a pool of Tg. Only 1% of total thyroid hormone is in the unbound or free state and available for metabolic purposes. Calcitonin is a peptide produced by the parafollicular cells of the thyroid gland. N Thyroid Hormones and Their Actions the thyroid gland releases two hormones into the blood, mostly T4 and some T3. T3 is the active hormone, whereas T4 is the prohormone and converts to T3 in many tissues of the body through a process called "peripheral deiodination. Evaluation may include blood tests and imaging (ultrasound), nuclear thyroid scans, and functional stimulation tests. Therefore, only 1% of the thyroid hormones are in the metabolically active "free" state. Assays of "total" T4 or T3 measure mainly the protein-bound hormone (plus the unbound or "free" hormone). Because drugs and illness can alter concentrations of binding proteins, it is therefore necessary to estimate free hormone concentrations. Thyroid Hormone Uptake Test the thyroid hormone uptake test (or the T3 resin uptake test) is inversely proportional to the protein-bound T4; accordingly, T3 resin uptake is low when T4 protein binding is increased and high when protein binding is reduced. This measurement helps clinicians distinguish protein-binding disorders from true thyroid diseases. Radioactive Iodine Uptake Thyroid follicular cells have iodine pumps that trap iodine in cells for thyroid hormone synthesis. This test is most useful in the differentiating of causes for thyrotoxicosis (Table 5. Thyroglobulin Measurements Thyroglobulin (Tg) measurements are taken based on two indications: 1. Differentiation of thyroiditis factitia (Tg suppressed) from all forms of endogenous hyperthyroidism (Tg normal or high) this test is not reliable in the presence of circulating anti-Tg antibodies. Ultrasound Ultrasound may distinguish between a single node or a multinodular goiter and differentiate between solid and cystic lesions. It has a 1 to 10% false-negative rate, depending on the experience of the cytologist. It is especially useful in the identification of papillary, medullary, and poorly differentiated carcinomas. It may also be used for diagnosing thyroid lymphoma, but it is not considered useful in distinguishing between follicular carcinoma and adenoma. The prevalence of cancer is higher in children, adults 30 years or 60 years old, patients with a history of head and neck radiation, and those with a family history of thyroid cancer. Contrary to this, the prevalence of cancer may be lower in patients with multinodular goiters. Symptoms associated with increased risk of malignancy include a rapid increase in size, dysphagia, hoarseness (nerve involvement), pain, a family history of thyroid cancer or multiple endocrine neoplasias, and a history of radiation exposure.

Clinically, it appears as a solitary nodule which can be found in approximately 1% of the population. Besides the follicular adenoma, other conditions which may produce clinically apparent solitary nodule in the thyroid are a dominant nodule of nodular goitre and thyroid carcinoma. G/A the follicular adenoma is characterised by four features so as to distinguish it from a nodule of nodular goitre: 1. On cut section, the adenoma is grey-white to red-brown, less colloidal than the surrounding thyroid parenchyma. The tumour cells are benign follicular epithelial cells lining follicles of various sizes. These cells may also form trabecular, solid and cord patterns with little follicle formation. Microfollicular (foetal) adenoma consists of small follicles containing little or no colloid and separated by abundant loose stroma. Normofollicular (simple) adenoma has closely packed follicles like that of normal thyroid gland. Macrofollicular (colloid) adenoma contains large follicles of varying size and distended with colloid. Trabecular (embryonal) adenoma resembles embryonal thyroid and consists of closely packed solid or trabecular pattern of epithelial cells. Hurthle cell (oxyphilic) adenoma is an uncommon variant composed of solid trabeculae of large cells having abundant granular oxyphilic cytoplasm and vesicular nuclei. Atypical adenoma is the term used for a follicular adenoma which has more pronounced cellular proliferation so that features may be considered indicative of malignancy such as pleomorphism, increased mitoses and nuclear atypia. Primary lymphomas of the thyroid comprise less than 5% of thyroid cancers and majority of them possibly evolve from autoimmune (lymphocytic) thyroiditis. In line with most other thyroid lesions, most carcinomas of the thyroid too have female preponderance and are twice more common in women. Carcinoma of the thyroid gland has 4 major morphologic types with distinctly different clinical behaviour and variable prevalence. External radiation the single most important environmental factor associated with increased risk of developing thyroid carcinoma after many years of exposure to external radiation of high dose. Genetic basis Familial clustering of thyroid cancer has been observed, especially in medullary carcinoma. It can occur at all ages including children and young adults but the incidence is higher with advancing age. Involvement of the regional lymph nodes is common but distant metastases to organs are rare. G/A Papillary carcinoma may range from microscopic foci to nodules upto 10 cm in diameter and is generally poorly delineated. Papillary pattern Papillae composed of fibrovascular stalk and covered by single layer of tumour cells is the predominant feature. Tumour cells the tumour cells have characteristic nuclear features due to dispersed nuclear chromatin imparting it ground glass or optically clear appearance and clear or oxyphilic cytoplasm. Invasion the tumour cells invade the capsule and intrathyroid lymphatics but invasion of blood vessels is rare. Psammoma bodies Half of papillary carcinomas show typical small, concentric, calcified spherules called psammoma bodies in the stroma. It is more common in middle and old age and has preponderance in females (female-male ratio 2. In contrast to papillary carcinoma, follicular carcinoma has a positive correlation with endemic goitre but the role of external radiation in its etiology is unclear. Follicular carcinoma presents clinically either as a solitary nodule or as an irregular, firm and nodular thyroid enlargement. Distant metastases by haematogenous route are common, especially to the lungs and bones. G/A Follicular carcinoma may be either in the form of a solitary adenomalike circumscribed nodule or as an obvious cancerous irregular thyroid enlargement. The cut surface of the tumour is grey-white with areas of haemorrhages, necrosis and cyst formation and may extend to involve adjacent structures.

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