Monitoring Growth and Development in a child

Growth denotes increase in physical size of the body and development denotes improvement in skills and function of an individual. Together they denote physical, intellectual, emotional and social well being of a person.

Normal growth and development is observed only if there is proper nutrition, without any recurrent episodes of infections and if there is freedom from adverse and environmental influences.

Determinants of growth and development

• Genetic inheritance - especially height, weight, mental, social development and personality.
• Nutrition before and after birth - Retardation in an infant indicates malnutrition.
• Age - Growth rate is maximum during fetal life, first two years of life and during puberty.
• Sex - Men usually are larger in size than women. During puberty girls grow fast and earlier than boys, but boys grow more.
• Infections and infestations - Infection with TORCH during intrauterine life retards growth of fetus. Recurrent infections like diarrhea and measles especially in a malnourished child will adversely affect the growth.
• Physical surroundings - Sun shine, good housing, lighting ventilation have their effect on growth and development.
• Psychological factors - Love, tender care and proper child parent relationship are all found to influence growth in a child.
• Economic factors - Higher the family income better is the nutritional status of an infant.
• Other factors - Birth order, Birth spacing, Education of parents (higher the educational level better the growth).

Assessment of nutritional status

2.1 Normal growth

• In children, parameters used to measure growth are weight in kilograms, height in meters and head and chest circumferences. Assessment can be longitudinal where serial measurement of the same child is recorded over different periods of time or cross-sectional where recorded measurement is compared to that of his peers.
• In India, we are using the new WHO child Growth Standards (2006) for children. However values differ substantially among adults of different ethnic groups. We have ICMR values as Indian standard.

2.2 Physical growth

2.2.1 Weight

Most widely used and simplest, reproducible anthropometric measurements for the evaluation of nutritional status.

• It indicates body mass
• It is sensitive to even small changes in nutritional status due to childhood morbidity like diarrhea.
• Rapid loss of weight indicates a potential malnutrition
• Serial weight recording is more valuable for progressive growth of a child when age of a child is not known.

Technique for measurement

To measure weight beam or lever accentuated scales with an accuracy of 50-100 g are preferred. Portable Salter scale (CMS Weighing Equipment, Ltd. England): the child is suspended from the scale which is hung from a branch or a tripod. Special "pants" are used to weigh babies. Robust, cheap, and easy to carry, these scales should be replaced after one year because of stretching of the spring and inaccurate readings. The model with readings up to 25 kg (x 100 g) is recommended.

Bathroom scales are not recommended as errors up to 1.5 kgs can occur with this.

Precautions to be taken while weighing

• Zero error has to be adjusted.
• Minimal clothing should be worn and be without shoes.
• While recording the value do not lean against or hold anything.
• Preferably record under basal conditions in early morning.
• Most types of scales (especially beam scales) are sensitive to dust and mud.

Standards

• On an average, a baby weighs double the birth weight by five months, trebles its birth weight by one year and quadruples its birth weight by two years.
• A baby should gain at least 500g per month in the first three months of life. If the growth is less than this it points to malnutrition. In different parts of India, the average birth weight is between 2.7 to 2.9 kgs.
• Weight for age is used to classify malnutrition.

2.2.2. Height

• Height of an individual is influenced by genetic as well as environmental factors.
• Maximum growth potential is decided by genetic factors.
• Nutrition and incidences of infection determine the extent of exploitation of that genetic potential.
• Inadequate dietary intake and/ or infections reduce nutrients available at the cellular level.This results in growth retardation. A prolonged period of severe deprivation leads to stunting.

Technique for measurement

• Children below two years are measured by using an infantometer.
• Baby is made to lie on the scale and crown heel length is measured.
• For children above two years and adults a vertical measuring rod anthropometer- is used and maximum height is measured.
• Measuring scale should be capable of measuring to an accuracy of 0.1 cm.

Standards

• Length of the baby at birth is 50 cm.
• By first year it increases by 50% to 75cm.
• By third year end it increases by 12cm.
• During puberty, growth spurt, boys add 20cm to their height and girls gain about 16 cm.
• Indian girls reach 98% of their final height by 16.5 yrs. and boys reach the same stage by 17.75 yrs.
• Low height for age indicates nutritional stunting or dwarfing. It reflects past or chronic stunting. Cut off point for diagnosis of stunting is 90% NCHS values.

2.2.3. Mid upper arm circumference

• Mid upper arm circumference and calf circumference indicate the status of muscle development. Mid calf and mid upper arm are heavily muscled and is approximately circular.
• Mid upper arm circumference is simple, easily accessible in any age and sex and practical to measure.
• Well-nourished children have a nearly constant arm circumference (about 16 cm) between 1 and 5 years. Undernourished children have a thinner upper arm and a smaller AC.
• Children can be classified as malnourished if their AC falls below an arbitrarily specified level. If ages are not known, AC can be related to height (arm circumference or height).
• As poor musculature and wasting are cardinal features of PEM in early childhood, MUAC helps in identifying malnutrition and in determining mortality risk in children. It correlates well with weight, weight for height and clinical signs.( QUAC stick).

Technique

• Usually left arm is measured. Arm is flexed at the elbow.
• The circumference is measured on the left upper arm half way between the end of the shoulder (acromion and the tip of the elbow (olecranon). To locate this point, the arm is flexed at a right angle. Then the arm is allowed to hang freely and a tape-measure (preferably of fibreglass) put firmly round it. Do not pull too tight.
• Tapes or strips can be made locally from thin cardboard or X-ray films which are marked in centimeters. Special plastic tapes (insertion tapes) have been manufactured.
• Fibre glass tape is preferred to tailors cloth tape as it is seen to lose accuracy.

2.2.4 Body Fat

• Subcutaneous fat constitutes body's main store of energy reserves. Muscle and fat constitute the soft tissues that vary most with a deficiency of protein and calories.
• Many accurate and near accurate methods like densitometry and DEXA but physical anthropometry using skin-fold calipers are practicable in field circumstances to determine the nutritional status of a person.
• For this a standard skin fold caliper has to be used. The skin fold measured consists of a double layer of skin and subcutaneous fat.
• For adults multiple sites are selected like triceps, the abdomen and the sub scapular and subcostal sites. By using different formulae we can derive at the amount of total body fat.
• In young children, the triceps skin-fold is used. The site is exactly at the mid upper arm as determined by the method used for mid arm circumference.
• The technique needs prolonged supervised practice and repetition to obtain reliable and reproducible results.
• Values differ in different communities thus necessitating local standards for comparisons.Hence it is used mostly by researchers and academics in the field.

2.2.5 Head and Chest circumference

• Head size relates to the size of the brain which increases rapidly during infancy.
• In a normally nourished child, chest grows faster than the head circumference during second and third years.

Technique

• Use a fibre glass tape.
• Head circumference is recorded by passing the tape around the head over the supraorbital ridges of frontal bone in front and the most protruding point of occiput on the back of the head.
• Chest circumference is measured at the level of nipple in mid inspiration.

Standards

• At birth head circumference is 34 cm and chest circumference is 32 cm.
• By 6-9 months both become equal.
• In PEM, due to poor growth of chest, the head circumference may remain to be higher than the chest even at the age of 2.5 to 3 years due to poor development of thoracic cage.
• Both the measurements are not useful beyond the preschool age.

2.2.6 Behavioral development

It is a complex affair spread in four fields

• Motor development
• Personal and social development
• Adaptive development
• Language development

For proper behavioral development, it is important to have

• Assured emotional and moral stability
• Regular discipline
• Accepting parents who provide him with models of balanced conduct.

2.2.7 Growth chart

• It is a visible display of the child's physical growth and development and it is useful for longitudinal follow-up of a child.
• We have growth charts for children below five years which compares weight for age of the child and for children in 5-19 years which compares their BMI for age.
• There are separate charts for boys and girls.

In a growth chart other information like identification and registration, date of birth, weight,chronological age, immunization record, introduction of supplementary foods, episodes of sickness etc, are recorded. This chart can be easily understood by the mother and the health worker thus motivating them to improve the nutrition of the child.

How to use the chart?

Growth charts for children below five years

• Pink border growth charts are for girls and blue border charts are for boys.
• Each growth chart has two axes. The horizontal line at the bottom of the chart is the X axis. This is for recording the age of the child and is called’’ month axis’’. It has sixty squares and can be used for a child up to five years or sixty months. Age is recorded in completed weeks /months/years.
• The vertical line at the far left of the chart is the Y axis. This is for recording the weight of the child in kilograms and grams. Each thick extended line represents 1 kg., each line extended from a small square represents 500 gms. and the very thin line represents 100 gms.
• A point on a growth chart where a line extended from a measurement on the ‘’month axis’’ i.e. age, intersects with a line extended from a measurement on the’’ weight axis’’ i.e. weight is called a plotted point. A circle is drawn around the dot so as to know the position of the plotted point.
• On each growth chart there are 3 printed growth curves. These are Reference Lines or Z Score Lines and are used to compare and interpret the growth pattern of the child. The 1st / top curved line on the growth chart is the median or average. The other 2 curved lines are below the average and are at a distance.
• Interpretation:
• When the plotted point is above the second curve the child’s growth is normal.
• When the plotted point is between the second and third curve the child is moderately underweight.
• When plotted point is below the third curve the child is severely underweight.
• If the child is severely underweight clinical signs of marasmus and Kwashiorkor may be observed.
• If a child has oedema of both the feet, mark clearly on the growth chart close to the plotted point that the child has oedema and refer the child for specialised care.
• The direction of curves is important. Interpretation:
• Upward growth curve: Good. Indicates adequate weight gain for the age of the child. The child is growing well and is healthy.
• Flat growth curve: Dangerous. Indicates that the child has nor gained weight and is not growing adequately. The child needs to be investigated.
• Downward growth curve: Very dangerous. Indicates loss of weight. The child requires immediate referral and health care.
• Flattening of curve or falling of curve signals growth failure- an early symptom of PEM.This may precede the clinical symptoms by weeks or by months. Such a child needs special care.

Uses of growth chart

• Useful tool for growth monitoring.
• Diagnostic tool to detect a high risk child.
• Educational tool for the mothers to participate more actively in growth monitoring and to teach them the importance of adequate feeds during illnesses like diarrhea.
• Tool for action on the type of intervention that is needed and helps make referrals easier.
• Helps in evaluating the effectiveness of corrective measures and thus to note the impact the programs.
• Helps in policy making at local and central levels.

Growth monitoring should be

• Every month- during first year
• Every two months – during second year
• Every three months up to five to six years.

Plot the growth curve and note that growth faltering can be deleterious.

Growth chart for 5-19 years.

• We have separate charts for boys and girls.
• Body mass index (BMI) of the child is taken. It is calculated with the formula BMI = Weight in Kgs /(Height in metres)².
• We can also use the simplified nomogram to calculate the BMI.
• Calculated BMI is plotted against the relevant age of the child.
• There are five reference lines .
• The third curve is the average or the median.
• The plotted point should be between the second and fourth curves of the graph.
• If it falls above the second curve it denotes over nutrition and if it falls below the fourth curve it denotes under nutrition. Both need to be appropriately handled.

Source: Portal Content Development Team

Related Resources

1. FAQs on new WHO child growth standards
2. Growth monitoring manual - Developed by National Institute of Public Cooperation and Child Development