Growth monitoring, screening and survillence

GROWTH MONITORING ,

SCREENING, & SURVILLENCE

1

Rakesh Kumar Verma

Refences

Ghai Essential Pediatrics

Nelson

IAP Guideline

IAP guideline new 2014

Park Community Medicine

Bulletin of the World Health Organization 2009;87:116-122. doi: 10.2471/BLT.08.051789

Growth monitoring manual NIPCCD

Indian Pediatrics: Revised IAP Growth Charts for Height, Weight and Body Mass Index for 5- to 18-year-old Indian Children

Growth monitoring in children (Review) Panpanich R, Garner P: Cochrane review

2

Over View

Definition

Aims

Importance of growth monitoring

Assessment of physical growth

Growth indices

Growth charts:-

Schedules

IAP recommendation for interval and

parameters

3

Definition

Growth denotes a net increase in the size or mass of tissue

Occurring because of two factors:-

- Multiplication of cells

- Increase of intra cellular substance

4

Growth monitoring is a screening tool to

diagnose nutritional, chronic systemic and

endocrine disease at an early stage.

5

Growth monitoring is widely accepted and

strongly supported by health professionals,

and is a standard component of community

Paediatric services throughout the world

Experience in Tamilnadu, Maharashtra and

other states in India indicates that individual

growth monitoring of children is both feasible

and extremely useful.

6

A significant impact on mortality…

even in the absence of nutrition

supplementation or education”

(Gwatkin et al 1980).

7

AIMS OF

GROWTH MONITORING

8

9Primary aims:1. To identify children with growth deviation i.e.,

under nutrition and over nutrition

2. To identify diseases and conditions that

manifest through abnormal growth.

Secondary aims:1. To discuss health promotion related to feeding,

hygiene, immunization and other aspects of the

child’s health and behavior.

2. Sensitize to use growth charts

Ultimately, the aim of growth monitoring is to minimise

illness and avoid unnecessary child death

Importance of growth monitoring

10

Growth monitoring helps

detect three main problems:

1. Feeding difficulties, particularly in the younger child;

2. Chronic ill health from whatever cause, including

respiratory infection, malaria, tuberculosis, and

growth hormone deficiency;

3. Social deprivation, where poverty and home

circumstances are such that one outcome is poor

nutrition;

11

Remedial actions can be:

a) counselling of the mother;

b) counselling of the mother, aided by the growth chart;

c) nutritional supplement;

d) treatment of concurrent disease, such as diarrhoea;

e) investigation for disease by the practitioner;

f) referral to a specialist for investigation and diagnosis;

g) professional health worker or social support.

12

Utility in health programs

Growth monitoring is viewed in most programs

as an activity for

weighing children regularly and plotting weight on

growth charts to identify undernutrition,

for feeding programs

to provide data on nutritional status.

13

GROWTH MONITORING COMPRISES

PACKAGES OF ACTIVITIES:

1. Regularly anthropometry of children;

2. Plotting the information on a growth chart to make

pattern of growth visible;

3. If growth is abnormal (usually faltering), appropriate

measures, in concert with the mother;

4. As a result of these actions, the child’s nutrition improves,

the child receives appropriate social or medical support,

or doctors are able to diagnose early serious disease.

14

STEPS IN GROWTH MONITORING

Growth Monitoring involves five steps

Step 1: Determining correct age of the child

Step 2: Accurate weighing of the child

Step 3: Plotting the weight accurately on a growth chart of

appropriate gender

Step 4: Interpreting the direction of the growth curve and

recognising if the child is growing properly

Step 5: Discussing the child’s growth and follow-up action

needed, with the mother

15

ASSESSEMENT OF

PHYSICAL GROWTH

16

Age dependent Age Independent

-Weight -MAC

-Height -BMI

-HC -Rao’s Index

-Chest circumference -Kanawatis index

17By two types of parameters

Other Growth indices 18

Body proportion:-US:LS ratio

Skeletal maturation

Dental development

19

Many bio physiologic and psychosocial problems

can adversely affect growth, and aberrant growth

may be the first sign of an underlying problem.

The most powerful tool in growth assessment is the

GROWTH CHARTS

20

In 2006 the World Health Organization released

growth charts based on the Multicenter Growth

Reference Study (MGRS).

Six study sites representing 5 continents were included: USA, Brazil, Norway, Ghana, Oman, and India.

21

The data are presented in 5 standard

gender-specific charts:

(1) weight for age;

(2) height (length and stature) for age;

(3) head circumference for age;

(4) weight for height (length and

stature) for infants; and

(5) BMI for age for children

All the points on the growth chart should be marked only as dots and not circles around the dot.

The height and weight should be recorded (and head circumference till 3 years) and plotted on the chart. At all subsequent visits join the dot up to the previous dot.

Remind parents of the time for the next measurement.

22

23

24

25

26

27

28

29

In a study, substantial discrepancies in underweight prevalence

estimates when using IAP versus WHO Child Growth Standards were

found. This could be explained by the fact that the new WHO standards

are based on data from predominantly breastfed infants of a

heterogeneous sample of children from developing and developed

countries, whereas IAP standards were based on Harvard unisex tables

of height and weight for age derived from predominantly formula-fed

infants of North European descent.

..recommend that professional bodies such as the IAP, the Indian

Association of Preventive and Social Medicine, the Indian Public Health

Association and the Indian Medical Association endorse the use of the

new WHO Child Growth Standards for the monitoring of the growth and

development of children in clinical and public health practice in India

IAP versus WHO Child Growth Standards

Pilot testing of WHO Child Growth Standards in Chandigarh: implications

for India’s child health programmes. Bulletin of the World Health

Organization 2009;87:116-122.

30

IAP

GROWTH

CHART

31

32

Age Growth status Indicator/ Parameter Percentile

0-5 years Underweight Weight for age < 3rd

Severe underweight Weight for age < 0.1st

Stunting Length /Height for age < 3rd

Severe stunting Length /Height for age < 0.1st

Wasting Weight for height < 3rd

Severe wasting Weight for height < 0.1st

5 -18 years Underweight BMI for age < 3rd

Stunted Height for age < 3rd

Overweight BMI for age > 23rd adult

equivalent line

Obese BMI for age > 27th adult

equivalent line

IAP Growth Charts: Cut offs and their

interpretation

33

Percentile z score

34

35

However, growth patterns differ amongst different

populations, especially in children above the age of 5

years, as nutritional, environmental and genetic

factors, and timing of puberty seem to play a major

role not only in the attainment of final height but also

in the characteristics of the growth curve.

Hence, it is necessary to have country-specific growth

charts to monitor growth of children between 5-18

years.

36

37

38

Most children tend to track along a percentile, referred to as

“following the curve.” A normal exception commonly occurs

between 6 and 18 mo of life.

Between 6 and 18 mo of age, infants may shift percentiles

upward or downward toward their genetic potential.

39

For full-term infants, size at birth reflects the influence

of the uterine environment; however, size at 2 yr

correlates with mean parental height, reflecting the

influence of genes.

This tracking often represents the mid-parental height

and a corresponding weight, where mid-parental

height is calculated in cm as follows:

• Boys: [(maternal height + 13) + paternal height]/2

• Girls: [maternal height + (paternal height − 13)]/2

40

It is important to correct for various factors in plotting and

interpreting growth charts.

For premature infants, over diagnosis of growth failure can

be avoided by using growth charts developed specifically for

this population.

A cruder method, subtracting the weeks of prematurity from

the postnatal age when plotting growth parameters.

41

While VLBW infants may continue to show catch-up

growth through early school age, most achieve weight

catch-up during the 2nd yr and height catch-up by 2.5 yr.

For children with particularly tall or short parents, there

is a risk of over diagnosing growth disorders if parental

height is not taken into account.

42

43

44

Growth monitoring is one of the basic activities of the

under 5 clinics where the child is weighed periodically at

(ideally)

monthly intervals during the 1st year,

every 2 months during the 2nd year and

every 3 months thereafter up to the age of 5 to 6 years.

There are no national policies for growth monitoring

beyond the age of 6 years.

SCHEDULE: Park

45

The AWW should weigh all

• new borns and children from birth- 1 month weekly,

• one month- 3 years every month and

• 3-5 years at every three months.

• However, children who are severely underweight, or who have

not gained weight for 2 months, or who are “at risk” of under

nutrition, should be weighed frequently preferably every month.

AWW were advised to conduct four weighing sessions in a month

at the AWC so that all children are weighed every month.

SCHEDULE: National Institute of Public

Cooperation and Child Development

Recommended intervals and

Parameters for Growth Monitoring by

IAP

Birth to 3 years:

Immunization contacts at birth, 6, 10 and 14

weeks, 6, 9, 12 months, 15 and 18 months may be

conveniently used for growth monitoring. An

opportunistic monitoring at other contacts (illness) is

recommended.

46

Normally growing babies should not be weighed more

than once per fortnight under 6 months and no more

than monthly thereafter, as this increases anxiety. After

18 months measurements are to be taken every 6

monthly.

It is recommended that the height, weight and head

circumference be measured up to 3 years of age. Penile

length (PL) and testicular descent should be

ascertained in the newborn period.

47

4 to 8 years: It is recommended that height and weight be

measured 6 monthly during this period and BMI, PL

and SMR should be assessed yearly from 6 years of

age.

9-18 years:It is recommended that height, weight, BMI

and SMR be assessed yearly during this period.

48

49

First five years

If the Weight for height is below -3 SD (red line on

Weight for height/ length growth charts) immediate

referral is needed.

Children below 3rd percentile for height/length and/or

weight need careful follow up for the growth trajectory.

Crossing of two major percentile lines i.e, going from

above 75th percentile to below 50th percentile on

height or weight chart.

When to refer

50

Weight loss or lack of weight gain for a month

in the first 6 months.

Absence of weight gain for 2-3 months from 6-

12 months of age.

Head circumference below 3rd percentile or

above 97th percentile on growth chart.

51

Five to eighteen years

Height below 3rd percentile or above 97th percentile on 5-

18 year IAP charts.

Crossing of two major percentile lines (upward or

downward)

A child below or above mid parental range for height

Rate of growth less than 5 cm/year.

When to refer

52

Watch growth trend carefully when the BMI is over

the 23 adult equivalent cut off line (yellow line on

BMI chart for 5-18 year). Refer when it crosses or is

above 27th adult equivalent line (red line on BMI

charts for 5-18 year).

Girls with axillary, pubic hair growth or breast

budding before 8 years and boys with axillary, pubic

hair growth, genital growth or and testicular

enlargement before 9 years.

53

• GOBIFFF: Growth Monitoring, Oral Rehydration, Breast

Feeding, Immunisation, Female Eduction, Family

Spacing, Food Supplements

• Udisha

• School health programme

• ICDS

• RMNCH+A

• The National Rural Health Mission

• Integrated programme for Street Children

• Creche Scheme for the children of working mothers

• Immunisation programme

• Mother and Child Tracking System

• RBSK

NATIONAL PROGRAMMES

54