Continuing Education Activity
Height assessment is important from a clinical, anthropological, forensic as well as medico-legal standpoint. This activity describes the significance associated with height assessment, the different methods that can be used for its assessment across age groups, and the methods employed for skeletal remains. These methods often require a deeper understanding of the subject, best known to trained nursing staff and clinicians in living individuals and forensic anthropologists when it comes to skeletal remains.
- Identify the importance and associated indications of height assessment.
- Describe the equipment, personnel, preparation, and technique with regards to height assessment.
- Review the potential complications, clinical, anthropological, and forensic significance of height assessment.
- Explain methods for improving coordination among the interprofessional team and communication to advance the techniques for height assessment and improve outcomes.
The stature or height of an individual is an inherent characteristic that constitutes one of the parameters of personal identification. In layman’s terms, height or stature is defined as the measurement of an individual from head to foot, taking into consideration the standard landmarks. It has implications in scenarios of clinical significance ranging from estimating the BMI (body mass index) to diagnosing certain physical growth disorders and assessment of nutritional status. Prediction of height may also be important in cases of limb and/or spine deformities, trauma or surgical procedures, skeletal dysplasia, and in estimating the age-related loss in stature. There is no lack of standardization as far as the procedures for height assessment are concerned, with different methods applied for different age groups. Stature estimation is also possible on dry, skeletal remains found at a scene of a crime and in other cases of medicolegal importance. The bones of both the axial and appendicular skeleton have been researched in the past to estimate stature. Thus, height assessment is important from a clinical, forensic, and anthropologic standpoint.
Physical growth is a process with its trajectory inching towards the attainment of a fully developed adult form. Stunted growth in children indicates either genetic dysfunctions or inadequate nutritional fulfillment. Early detection of such conditions through the regular monitoring of growth indicators such as height and body weight can diagnose these at an early stage leading to modifications in the dietary needs of the child. This results in “catch up” growth in the child. Height measurement in adults fulfills a similar function by indicating the physical health status of individuals. This presents as the basis for selection into sports and certain professions.
The World Health Organisation (WHO) growth standards can be used to monitor the physical growth and development of children and infants. It estimates the percentile and z-scores for length/height for age, weight for age, weight for length, weight for height, and BMI for age. The standards depict normal early childhood growth under optimal conditions. These various parameters listed under the growth chart can be used to diagnose growth disorders or address the nutritional needs of children regardless of their ethnicity, socioeconomic status, and type of feeding.
Commonly Used Instruments for Measuring Height
- Measuring tape
- Horizontal length scale- HLS is a flexible horizontal scale used for measuring the recumbent length of an infant.
- Infantometer- The infantometer measures the recumbent length of an infant with greater accuracy by holding the infant in position securely.
- Anthropometer rod - The anthropometer rod consists of four equal rods and can be used to measure height up to a range of 2 meters.
- Stadiometer - The stadiometer consists of a ruler and a sliding horizontal headpiece which can be fixed above the head to measure height.
- Osteometric board - It is an anthropometric instrument consisting of a flat board with a fixed end and a crosspiece. It is used to measure the length of long bones.
Trained personnel or those with significant prior experience with these different instruments and the techniques used for height assessment across varying age groups should be hired as measurements taken by a layman may be inaccurate. Trained and experienced nursing professionals and physical anthropologists possess the required skills.
Methods for Height Assessment Across Different Age Groups/Technique
Methods for height assessment may be broadly grouped into two classes based on the sample of the study, i.e., living or dead. Methods used on the living may further be classified based on the age group for which it is applicable. The broad classification is:
- Height assessment in the living
- Height assessment methods in infants (up to 2 years)
- Height assessment methods in children
- Height assessment methods in adults and the elderly
- Height assessment in the dead
Height Assessment Methods in Infants
Height measurement in infants poses a problem, given their small size, limited control over their body, and the inability to follow instructions. In infants, the attribute of height goes more commonly by the term “recumbent length” or “crown-heel length.” The recumbent length of an infant is measured using a simple horizontal length scale (HLS), tape measure, anthropometric rod, and an infantometer. To measure the length of the infant clothes, diapers, hair ornaments, and objects of similar nature require removal. The head gets placed against the headboard in the Frankfurt vertical plane with the body in the supine position. The infant is then positioned along the center of the device with the footboard against the soles of the feet. The length is noted to the nearest millimeter.
Surrogate measures to full-length measurement in infants offer certain advantages over the conventional methods. They permit estimation of length through formulae and often are more accurate than the full-length measures. Additionally, they offer an insight into the differential growth of body segments as a function of age, sex, ethnicity, and pathological conditions. Alternative measures researched include arm span and ulnar length.
Height Assessment Methods in Children
Height is measured in children (aged 3 or more) through the use of a stadiometer or an anthropometer rod. The stadiometer is mounted on the wall for this purpose, and the child is asked to remove any footwear and/or head ornaments before noting the measurement. With the buttocks, the shoulder blades, and the back of the head against the board, the head is oriented in the Frankfurt horizontal plane (FH plane), and the headpiece gets firmly placed on the head. The reading is noted to the nearest tenth of a centimeter. An alternative to standing height measures in children is the sitting height, measured from the vertex (topmost point of the head) to the sitting surface after orienting the head in the Frankfurt horizontal plane. The stadiometer is placed on a stool at a sufficient height to allow the participant’s legs to form a 90 angle with the ground. Bone age in children is also useful as an indicator of height (as given by Bayley and Pineau table).
Height Assessment Methods in Adults and the Elderly
The most common method used for measuring height in the case of adults and the elderly is through the use of a stadiometer or an anthropometer. Regression equations for arm span, lower leg, foot length, shoeprint length, and recumbent length may also be used in the case of the elderly as reliable indicators of stature when standing height cannot be measured. Radiological methods such as X-ray and CT of long bones have also been used to estimate stature.
Height Assessment in Case of Recently Dead
Stature estimation in the case of the dead becomes of prime importance from a forensic point of view. The methods used for measurement depend upon the state of decomposition of the body. In the case of the recently dead, a measuring tape is an option. A source of error here is the loss of muscle tone, causing an increase in body length and a loss of tension in the intervertebral discs once decomposition sets in, which tends to reduce the total height.
Height Assessment from Skeletal Remains
- Stature estimation from complete skeletal remains - Dwight (1894) piloted the method for stature estimation from complete skeletal remains. The use of the complete skeleton involves summing up measurements of all the skeletal elements followed by the addition of a correlation factor for soft skin and muscles. Fully (1956) individually measured the skull, the vertebral column from C2-S5, the femur, and tibial length, and the height of the calcaneus and talus. He then summed up these measurements to obtain skeletal height. Adding a soft tissue correction factor can help estimate the living stature of the same individual.
- Stature estimation from long bones and fragmentary skeletal remains- The former method requires the presence of the entire skeleton, which is not available in its entirety many times. In such situations, fragmentary skeletal remains are used. Research has shown cephalometric measurements to correlate with stature in the case of males and a correlation of craniometric measurements with stature in both males and females. Additionally, the bones of the body, including the sternum, sacrum, phalanges, calcaneum, and long bones, may be used to estimate the stature of the remains. Early research on deriving regression equations using long bones was carried out by Karl Pearson (1899), Pan (1924), Nat (1931), and Trotter- Gleser (1958), while research on using fragments of long bones was done by Steele and Mckern (1969). Tibia and femur have proved to be the best indicators of stature in individuals after taking into account the error margin. The length of these individual bones may be measured using an osteometric board. One end of the bone to be measured is placed at the fixed end of the board, and the other end is held in place using a crosspiece. The reading on the corresponding scale gives the physiological length of the bone.
Diurnal variations in height can be a source of error. Stature varies at different times of the day by up to 2 centimeters, with a reduction seen in the afternoons and evenings as a result of reduced elasticity of the intervertebral discs and vertebral muscles. This, along with the gradual reduction in height due to senile degeneration, needs to be taken into consideration when using stature as an identification parameter or for clinical diagnosis.
Clinically, height is necessary for maintaining physical growth records. This is especially significant when it comes to monitoring the growth patterns of infants and children. Height assessment and the growth patterns linked to it, either directly or indirectly, point towards the socioeconomic status of an individual, amongst other things. Growth indicators such as the height of the individual and hence the BMI (Body Mass Index) can help diagnose conditions such as Marasmus and Kwashiorkor in children. In the case of adolescents, height assessment constitutes a part of the selection criteria for certain sports activities. A cut-off height is established as the basis for selection into sports where height confers certain leverage. Accurate height assessment becomes crucial in these cases. Professions such as firefighters, military personnel, and lifeguards, among others, benefit from more height. Entry requirements for the same include a physical fitness test, which constitutes an assessment of height.
The significance of measuring the height of individuals for an anthropological setting comes into play while studying the physical growth patterns and secular trends across regions and population groups. We cannot apply established data for a particular population onto other populations and hope to expect accurate results. This can have clinical contraindications.
In forensics, stature is one of the four parameters used to identify an individual. The stature of an individual is used to identify the dead and sometimes link the individual to a scene of a crime by the process of
Enhancing Healthcare Team Outcomes
Even though the general presumption is that height assessment is a part of the preliminary examination/ routine check-ups carried out at hospitals and health care centers, it has many other underlying indications too. As previously described, it can indicate several abnormalities in individuals and can be used to diagnose these conditions. However, to arrive at a correct diagnosis or accurate identification parameters in the dead and skeletal remains, several individuals need to partake in the activity.
Diagnosis of clinically significant conditions require trained nursing staff to aid in the process of measuring height, and its correct interpretation requires the involvement of clinicians. Better outcomes are possible by involving an anthropologist. Anthropologists, based on the accurate assessment of height, can help shed light on varying growth patterns across regions and populations and use this information to indicate abnormalities if any.