Growth Monitoring

Introduction & issue of malnutrition

In India, about 1/3rd population is food insecure leading to inadequate food intake.

Jharkhand is a state in eastern India.

Public health profile of state

1/3rd of population do not have access to safe drinking water.

½ of population below the poverty line- food insecurity

½ of children <3yrs malnourished highest mortality rates for children under

five ½ children do not have full immunization

against childhood diseases.

Malnutrition

When a person – is not getting enough food or not

getting the right sort of food.– food lacks in proper amounts of

micronutrients - vitamins and minerals to meet daily nutritional requirements. 

– Disease is contributing factor and result . Even if people get enough to eat

Why Monitor Growth

Growth is the most sensitive indicator of health (normal growth only occurs if a child is healthy)

Growth assessment is an essential part of the examination or investigation of any child.

Allows objective detection of growth disorders at population level at earliest opportunity.

Early identification and treatment improves outcome.

Identify under or over nutrition

What is Growth monitoring

Weighing of the child at regular interval– by plotting of that weight on a graph

(called growth chart)– For observing changes in weight &– giving advice to the mother based on

this weight change is called ‘Growth Monitoring’.

In growth monitoring a change in weight over a period of time is more important than the weight .

Methods of growth monitoring

Length for age or Stunting (Health dept.) – whether an infant is an

appropriate length for their age Weight for age (ICDS):

– whether an infant is an appropriate weight for their age

Weight for length(Wasting): – whether the weight and length of an infant

are in proportion Mid upper arm circumference for

age(quick identification): – be especially useful at the onset of a crisis

Growth chart

Growth chart represent curves (Weight for age) with reference population and can be used to identify the child’s rank relative to other children of the same sex and similar age.

Growth chart monitoring

Growth Monitoring is done by the Anganwari Worker (AWW) along with

ANM. On Village Health Nutrition Day every month.

GM process

GM includes plotting the child’s weight on the

‘Mother and Child’ Protection Card, by Anganwadi worker

analyzing the growth of the child by comparing with reference population

discussing the progress of the child with the caretaker

Reading

Upward growth curve- Normal Flat growth curve- Dangerous Downward growth curve- very dangerous Plotted weight in Orange zone-moderate under

nutrition Plotted weight in yellow zone- severe under

nutrition

Decision guide & activities to be undertaken

         Group Counseling         Supplementary nutrition(if above six months)         Investigate – talk with thecaregiver o        If sick – follow IMNCI protocoland refer if needed         Referral to a health centre         Follow up visits at home         Group Counselling         Supplementary nutrition(if above six months)         Referral to a health centre         Follow up visits at home         Extra Nutrition supplements         Group Counselling         Supplementary nutrition(if above six months)

Good Upward slope ofcurve

Dangerous Flat growthcurve

Moderate undernutrition

Plotted weightin Orange zone

Severe undernutrition

Plotted weightin yellow zone

MUAC measurement

For children aged 6 to 59 months used for detecting individuals in need of

treatment. good indicator of muscle mass

Process of measurement

Ask the mother to remove clothing that may cover the child’s left arm.

Calculate the midpoint of the child’s left upper arm by first locating the tip of the child’s shoulder with your finger tips. Bend the child’s elbow to make the right angle .

Pull the thread from tip of the shoulder till elbow.

Fold the thread to half to estimate the midpoint and again pull it from shoulder tip. Mark the midpoint with a pen on the arm.

Straighten the child’s arm and wrap the tape around the arm at the midpoint. Make sure the numbers are right side up. Make sure the tape is flat around the skin.

When the tape is in the correct position on the arm with correct tension, read and call out the measurement to the nearest 0.1cm .

Immediately record the measurement

Interpretation of Mid-Upper Arm Circumference (MUAC) indicators

< 110mm (11.0cm),

RED COLOUR, indicates Severe Acute Malnutrition (SAM)immediate referrel for management and

treatment.

between 110mm (11.0cm) and 125mm (12.5cm)– RED COLOUR (3-colour Tape) or ORANGE

COLOUR (4-colour Tape), – indicates Moderate Acute Malnutrition

(MAM)- – immediate referrel for supplementation.

between 125mm (12.5cm) and 135mm (13.5cm), – YELLOW COLOUR, – indicates child at risk for acute

malnutrition- – counselling & followed-up for Growth

Promotion & Monitoring (GPM).

MUAC over 135mm (13.5cm), – GREEN COLOUR, – indicates that the child is well nourished

Responsibilities of Stakeholders

ICDS Anganwadi Worker & Anganwadi Helper Services

– Regular Weighing during VHND– Plotting Growth chart– Supplementary nutrition

Health department ANM Services

– Record of height and weight of children at periodic intervals

– Reading of growth chart– General check up for detection of diseases–  Treatment of diseases like ARI, diarrhoea etc– Deworming–   Prophylaxis against vitamin A deficiency and

aneamia– Children under six: vaccinations – BCG, OPV, DPT,

and measles – Referral services

Growth Monitoring & Promotion comprises - package of activities

regularly measuring the weight of children; plotting the information on a growth chart to

make abnormal growth visible; if growth is abnormal (usually faltering), the

health worker does something, in concert with the mother;

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.

Growth monitoring:Issues

Proximal causes Proximal causes Proximal causes

Limited materials for Growth Monitoring

1.No guidelines available for maintenance and repairs of weighing scales-Maintenance and replacement still at CDPO or District level causing time-lags.2. Unable to facilitate delivery of new Mother and Child Protection

cards to AWCs.

11.Less than one third of AWWs had functional weighing scales for both infants and children.·   2. The turnaround time for repairs of scales exceeded 3 months. 3.24 out of 60 AWWs interviewed reported not having the new growth charts

Proximal causes Proximal causes Proximal causes

Growth Monitoring tagged to Supplementary food distribution.

1.Funds for SNP are insufficient and not available in time. 2. Inordinate delay in filling vacant supervisory positions resulting in overburdened supervisors and poor supervision.

11.Only 3 of 60 AWWs interviewed, received SN funds on time.    2. 24 of 60 AWWs reported unavailability of funds is the main obstacle in SN distribution.   3.  Despite the rules 26 of 60 AWWs report procuring food materials on credit    4. A little more than half of the sanctioned supervisor positions were filled as of March 2011    5.No Mid-Level Training Centers (MLTCs) in the state         Supervisors interviewed reported a range of 36 to 182 AWCs in their jurisdiction despite recommended coverage being 20 to 25.Fresh recruitment of supervisors has been frozen

Proximal causes Proximal causes Proximal causes

Incomplete and or inaccurate knowledge on Growth Monitoring, plotting and interpreting the growth trajectory

1.Some AWWs not trained in GM and most lacking a follow-up on GM training . 2.Inordinate delay in filling vacant supervisory positions resulting in overburdened supervisors and poor supervision.

11. Half of AWWs interviewed reported problems with growth monitoring. 2. Only one tenth of AWWs recalled receiving any training on the growth charts. 3. No guidelines for counseling, referral and follow-up services for children with faltering growth at the field. 4. Only three of the 24 supervisors recalled being trained on new growth charts. 5.Only half of the 10 CDPOs interviewed mentioned ‘growth monitoring’ to be one of the key job responsibilities of the AWWs

Proximal causes Proximal causes Proximal causes

Chaotic Village Health and Nutrition Day

Poor event management Unable to facilitate delivery of new Mother and Child Protection cards to AWCs.