INTRODUCTION- Growth charts were popularised by David Morley. Well baby clinics, PHC, and ICDS programmes utilize growth charts. The wt.measurments of a child over a period of time are plotted on the growth chart and any deviation from the normal pattern can be visualised and interpreted. An upward curve in the road to health is ideal. A flat and downward curves are not desirable. WHO charts – blue for boys and pink for girls
AIMS AND RATIONALE Primarily to identify children with growth deviation and diseases and conditions that manifest through abnormal growth. Secondarily to discuss health promotion related to feeding, hygiene, immunisation and other aspects , education of parents to allay their anxiety about their childs growth also to sensitize health care workers to use growth charts.
USES OF GROWTH CHARTS- Diagnostic tool-To identify high risk children. Planning and policy making Education tool for educating mothers Tool for action helps in type of intervention that is needed Evaluation- of effectiveness of corrective measure and impact of a programme of special interventions for improving Childs growth and development Tool for teaching.
BACKGROUND The ICMR undertook a nationwide cross sectional study during 1956-1965 to establish indian referance charts. Irrelevant now as they were done on lower socio-economic class. The growth charts compiled by Agarwal et al were based on affluent urban children from all major zones of India measured 1989-1991.the data is now 20 years old and irrelevant now. In 2010-2011 Khadilkar et al have published the growth charts on affluent children 5-18 years and have also compared the growth of 2-5 years old indian children with the new WHO growth charts.
WHO GROWTH CHARTS MULTICENTRIC GROWTH REFERENCE STUDY(MGRS)- Participating countries include Brazil, Ghana, India, Norway, Oman, and USA. Data collected by trained staff using a common protocol Sample selected from communities where there were no environmental constraints to growth. The new growth reference is based on breastfeeding as the bilogical norm. Measurements include weight/age, height/age, and
BASICS OF GROWTH CHARTS- Consists of X axis which is usually in years or months and y axis that changes according to the reference e.g. cm, inches, kg, kg/m2. the x axis is usually devided into 12 equal parts (months) for each year. Standard growth chart has 7 percentile lines and include 3,10,25,50,75, and 97 percentiles. The correlation between Z scores and percentiles can be confusing and in recent WHO MGRS study these are tabulated below for clarity.
Since previous table is difficult to interpret it is further simplified as follows:Z score Height for age Weight for age BMI for age>3 May be abnormal May be abnormal obese>2 Normal Use BMI Overweight>1 Normal Use BMI Risk of overweight0 normal Use BMI normal<-1 normal normal normal<-2 stunted underweight wasted<-3 Severely stunted Severely Severe wasted underweight
GROWTH STANDARDS VS REFERENCES Growth standards are prescriptive and define how a population of children should grow given the optimal nutrition and optimal health . Growth reference on the other hand are descriptive and are prepared from a population which is thought to be growing in the best possible state of nutrition and health in a given community. They represent how children are growing rather than how they should be growing. WHO 2006 growth charts are ex for growth standards. 1989 Agarwal data and 2007 Khadilkar for affluent
Advantages of growth standard is that children of all countries, races, ethnicity can be compared against a single standard thus assessment becomes more objective and easy to compare. The disadvantage is that these are likely to over diagnose underweight and stunting in a large no. of children in developing countries such as India. Advantages of references is that they are true representative of the existing growth pattern of children and allow us to study the secular trend in terms of height, weight and obesity. Disadvantages include they need to be updated at least once in a decade and in modern times likely to define overweight children as normal
THE INDIAN SCENARIO In a recent multicentric study done on 1493 affluent preschool indian children (selected from all zones of India) the mean Z score for height , weight, BMI and weight for height were below the WHO 2006 standards. The overall incidence of stunting was 13.6 % and the underweight was 8.5 % under the age of 5 years. This % is likely to be higher in rural areas and in underprivileged urban areas although at present no such data is available from India.
NEW 2007 AFFLUENT INDIAN GROWTH CHARTS THE NEED FOR NEW CHARTS- previously available growth reference curves in india are almost 2 decades old and WHO recommends that each country should update its growth references every decade and hence new growth references were produced in 2009. DATA COLLECTION-The IAP divides Indial into 5 zones-north, south, east, west and central.the nutritionally well areas were identied based on per capita income of cities. The differences between zones were not signifiacant Data collection lasted from june 2007 to january 2008.
OBSERVATIONS- SECULAR TRENDS IN HEIGHT- The 50th percentiles for boys height >1989 values at all ages. 97th percentile at 18 years was 1.7 cm >1989. The 50th percentiles for girls height >1989 values at all ages. ALARMING RISE IN OBESITY- The overall prevalence overweight and obesity was 18.2% by IOTF classification and 23.9% by WHO standards. Prevalence of overweight and obesity in boys>in girls Mean BMI values were significantly >1989 data. This rising trend of BMI in this multicentric study rings alarm bells in terms of associated health
REFERENCES- IAP-RECENT ADVANCES IN PEDIATRICS PARKS TEXTBOOK OF PSM NUTRITION AND CHILD DEVELOPMENT - ELZABETH