Growth Monitoring - Some Basic Issues
Item
- Title
- Growth Monitoring - Some Basic Issues
- Creator
- C Gopalan
- Date
- 1988
- extracted text
-
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GROWTH MONITORING - SOME BASIC ISSUES.
0. Gopalan.
In most discussions on growth monitoring, it is the
technical details of actual growth measurement and growth
charting that generally claim central attention. The more
fundamental issues regarding the basic objective of growth
monitoring, and its feasibility and relevance in the prevailing
total context of primary health care in developing countries,
are hardly addressed adequately. In an earlier communication ri 1 • > ’. i e
global experience with regard to growth monitoring had been
critically reviewed (Gopalan, C. and Chatterjee, M. Nutr. Found.
India, Spl. Publ. Series 2, 198^.)
Growth monitoring is by no means a new discovery.
Paediatricians and nutrition scientists have long relied
heavily on growth measurements for assessments of health and
nutritional status of children. Anthropometry has always been
a widely used tool in nutrition surveys of communities. What
is relatively new is the attempt to introduce a system of
periodic (longitudinal) growth measurements of individual
children in a community and charting their growth as an
integral part of routine primary health/nutrition care at the
community level.
At the risk of stating the obvious, it must be emphasi
sed that growth monitoring is. no, mwe than a. diagnostic and .
(possibly) educational tool.. If wisely used,- it could guide
and facilitate actioijicn the- part of the health worker and the
mother. Growth monitoring.by itself,however' efficiently exec
uted, cannot bring about nutritional improvement; it must
always be followed by act?on on the part of the health worker
and the mother - the action consisting of appropriate and
necessary improvements in child-feeding and child-rearing
practices. Thus, growth monitoring is not even a means to
an end; it is-only a means to the means-. ■ In this respect,
it stands on an entirely different footing from the rest of
the items in GOBI. It is necessary to emphasise this in viewof the fact that growth monitoring is -some times-being
pursued as an end in itself with no adequate thought and
preparation for the follow-up action.
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- 2 If the necessary conditions exist - and only if they dogrowth monitoring could become a suseful adjunct to primary
Two important conditions stand
health and nutrition care,
out in this connection.
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"Th the first-place', it. iff‘hmpohtant .to.;.be. ;.clear about
the1basic objective'of -growth monitoring.; -'Secondly, it: is ■'
iffipoitarit ‘to 'ensure 'that .we have a--health System and health ?
infrastructure which -ean' effectively apply and'utilise 'grdw'th
monitoring techhology'-'ir. a meinirigfulmanner; consistent, with the
realisation of.:.the ."bbye'etive-;.' '"m
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aThe■'■cb-jeotive -'ofngrbwthJmdhitdringy as'- 'origihail'y'' !
envisaged' 'by'fi'Orie/ and others’,' “is-preventi'dri' ;o’f "gr'dwth'1'"'^'" JO
retardation through'timely -and edr'iy'-''deiectibri 1'.bi* growth"
faltering'';". Indeed, prombtidri df ■ gr^wth’^'briit'biirlg^s "an
inte gral apart ■ ?©f: prevent iv§-' and pr'ombtive "fte aith'"' dare ’ cSn'r only"
be'-'jSstifie'd'tif' tK'i§ I'd^the ot> je'et;ife'.'3j;This makfe's’rdehge?'>fdr ' w'
two godd reaSohg;^?"'^
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E arlys ta ge s;. of.' grow th ■- f alt^ P ing i may. -be mi s s e d fby s the t
health fwork-er -and mother, not (being.!.obvious td 'the 'naked■ eye;n
and it is heio taat weigliing scales can. help. Growth monitoring
could help in timely detection of growth failure and in
alerting uhe health worker and mother to take immediate appropri
-ate remedial measures. On the other hand, weighing scales
are hardly necessary to detect growth retardation in children
who are' already sc-undernourished that they-are 'Ohly 70 per- ' ■
cent' cr 60 percent of their expected body weight. Even the"
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• illiterate gradmother in the village ' cotild’ identify 'these "I "
children as malnourished. Weightmerit exercises resorted to-for
the purpose of arriving"'at administrative decisions as to
which malnourished children'should b^'included in feeding '
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operations and which Should be excluded, and when, can hardly
oe claimed to be part of preventive and priomotive health care5
they are no more than screening procedures for a rehabilita
tion and relief programme.
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In the early stages of .growth faltering in late infancy'
and early childhood, marginal changes, in .child -feeding and ? •
rearing practices, which are feasible and within 'the meansand
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resources of poorfamilies, might suffice to arrest growth
retardation as Ccwan and co-workers in Punjab have ably demonstr
ated (Das, D., Dhanoa, Ji and Cowan, B.- Bull.Wutr. Found.
India, 3.2.19o2)< In laterstages, whore growth retardation
has already proceeded to any significant degree, the inputs
needed for tis reversal will be clearly well beyond the
resources of poor families? and 'such children are bound to end
up as stunted adults. Atthis late stage, education of the
mother may not be of much avail in reversing the child's
undernutrition? what the child would then need is intensive
rehabilitation. Hence it is good strategy to help poor
families to prevent growth e retardation- in their children
through timely action at the early, stages of growth faltering
when effective and successful action by the mother in her own
home is still possible. In short,.the battle against growth
retardation must be fought, and canpossibly be won, by even
poor families at the very early stages of childhood? what can
be accomplished at latestages is at best a relief operation
limitedto ensuring "survival". Herein lies the strong case
for growth monitoring.
RECENT MISLEADING POSTULATES;
Unfortunately, however, today there seems to be
considerable confusion with regard to the basic objective
of growth monitoring. Though lip service is still being
paid to early detection of growth faltering as being the
objective, in actual practice this is apparently not being
taken seriously.
Several recent pronouncements by noted experts have
served to generate confusion and doubts as to the real pur
pose of growth monitoring. The messages which boradly stand out
from these pronouncements are; (i) it is not all that
important for developing countries to be concerned about the
'less severe" forms of growth retardation in their children;
(ii) growth retardation, other than that of the so-called
'severe" degree, would no doubt result in "stunting", but
such stunting should not matter as this would still not
unduly compromise "function" and jeopardise "survival";
indeed, such growth retardation could be no more than
"adaptation" to the prevailing eva environmental and
economic situation.
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- >+ Thus, in a recent publication (Pacey, A. and Payne, p.
Agr. Dev. and Nutrition, Hutchinson Press, London 1985)? it
has been suggested that "even if all human groups hdVe basica
lly the same genetic potential", national standards for growth
norms should "take into account environmental and economic
status", and, further, that the utilisation of the internati
onal standard of growth by developing countries will "overstate
the case concerning malnutrition" among their child population.
The clear message here is that, even though all recent
studies have' clearly demonstrated that differences in current
levels of growth and physical development as between children
of developed and developing countries are attributable to
environmental and not to genetic factors, developing countries
need not strive to improve growth and development of their
children to levels which will allow them to express their
genetic potential but could settle S for lower levels of
growth in consonance with their "environment and economic
status" • a euphemism for poverty. This is a plea for
acquiescence in growth retardation up to a point, which
runs clearly counter to the professed goals of growth
monitoring and has rightly been rejected (Rao, Kamala S. Jaya;
Economic & Political Weekly, 21. 2h-, 1986) as an exercise
in "perpetuation of undernutrition."
Seder (Seder, D? Newer Concepts in Nutrition and
their Implication for Policy; Ed. Sukhatme, P.V .Maharashtra
Assocn. for cultivation of Science,1982, p. 2S.7) had
earlier been equally forthright and had argued that
"smallness" is an appropriate and welcome attribute of poor
people consistent with their good health. He had .advised
Indian nutrition scientists not only not to use "international
standards" of growth (as this would yield "overestimation"
of undernutriticn) but also not to use the "best indigenous
standard" of the Indian high socio-economic group because
even these will be "abnormally large" for the majority of
Indians who are poor. We had dealt with Seder's hypothesis
earlier in this Bulletin (Gopalan C,: Bull, Nut. Found.
Indian, October 1983).
Waterlow's otheiwise useful cla.ssification of growth
retardation is often being mistakenly invested with functional
significance. Itis being assumed that "stunted" children with
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weights appropriate to their height are functionally normal
despite clear evidence pointing to the contrary from the
extensive and fascinating studies of -Spurr and colleagues
(Spurr et al: Am. J. Clin. Nutr. 39- h-52-^59, 198*+; 37?
S3^-8!+7,- 1933 M Parac-Nieto World Review of Nutrition and
Dietetics, 1+9-22,> 59, 1987-
Chen's observations based on his studies in Bangladesh
(Chen, L., et al, Am. J. Clin. Nutr. 33- 1836-181+5, 1980)
that risks of mortality in "mild" and "moderately" growth-?
retarded children were no greater than in normal children,
but were significantly increased only in "severely" mainour
shed children with weights for age less than 60 percent of
the standard, have been widely interpreted to mean that the
goal of "child survival" (which now seems to have replaced
old-fashioned "maternal and child health" as the target of
international agencies) is quite consistent with, and is not
compromised by, mild and moderate degrees of growth retardattion. Chen's subsequent clarification of his earlier
observations in a later publication rebutting such inference
(Chen, L: Bull. Nutr. Found. India, October 1982) has
unfortunately not received the same hearing as his earlier
communication.
The confusion with regard to the real objective of
growth monitoring is being reflected in the use (misuse)
to which growth monitoring operations are being put. While
lip service is still being paid to "education of the mother",
the emphasis seems to have clearly shifted from early
detection of growth faltering to the identification of childred
who have drifted far enough away from normalcy, and whose
retardation has become sufficiently "severe" to merit relief
and rehabilitation through feeding programmes.
Growth monitoring has thus been used extensively as
a screening procedure to choose beneficiaries for supplem
entary feeding operations in ICDS (Integrated Child
Development Service) and the World Bank-assisted Tamil Nadu
project, and to carefully exclude the so-called mild and
moderately growth retarded children from supplementary
feeding. This is in consonance with the advice of Payne
(referred to above) who has warned developing countries
against "diversion of resources" to children who are not as
yet severely growth retarded. Growth monitoring, under the
6 circumstances, instead of being used as an instrument for
preventive and promotive health care, is becoming a tool for
the implementation of a nutrition policy of brinkmanship and
as an adjunct to supplementary feeding programmes which, in
any case, are of doubtful value.
To be sure, it being claimed with respect to both
ICES and the World Bank-assisted Tamil Nadu project that growth
monitoring in these programmes is also being used to "educate"
the mothers of less severely malnourished children as well.
But the cursory manner is which such "education" is now being
conducted in ICDS, and the great emphasis on the elaborate
and time-consuming so-called "no-weight-Gain strategy"
employed just for selection of beneficiaries for feeding
operations in the World Bank project, would indicate that the
choice cf beneficiaries for feeding programmes, rather than
early detection of growth faltering has now become the
central purpose.
If it is the intention that growth monitoring need
be used mainly for categorisation of established cases of
undernutrition into different grades for the purpose of
screening children for relief operations, then such weighment
operations should not be glorified as an integral part of
preventive and promotive primary health care but must be
restructured and limited to rehabilitation centres and
clinics and made much less elaborate and less expensive than
at present for this restricted purpose.
FEASIBILITY AND RELEVANCE
It was earlier pointed out that meaningful growth
monitoring implies the fulfilment cf two basic conditions a clear understanding of the objective, and a health
infrastructure which is capable of effectively utilising
the technology. We have discussed the first5 we will now
consider the second.
Even very heavy investments on growth monitoring will
fail to yield expected results if the health system as a
whole is not adequately geared to utilise the technology.
For any meaningful growth monitoring to take place, the
out-reach of the health system must be such that a reasonable
proportion of pregnant women and children under three years
7 in the community are covered. In' india# for example, nearly
a third of infants start their lives with the initial
disadvantage of low birth weight. The elegant and pioneering
longitudinal studies of Shanti Ghosh and her colleagues
(Ghosh, S. and Bhargava, S.K.s Twenty Year Longitudinal
Studies on Growth and Development of a Birth Cohort, to be
published) demonstrated that these low-birth-weight babies
continue to grow and develop in a developmental trajectory
which is significantly and consistently poorer than that of
babies of the same socio-economic group who did not start
with such initial disadvantage. Proper antenatal care, and
hnyrnved diets during pregnancy could serve to. reduce the
Incidence of "small-for-date" births and enable a larger
number of infants in the community to start their journey with
out this initial handicap; and growth monitoring' will then
become' a far less frustrating operation. If the mother
had been contacted even during her pregnancy and rapport
had already been thus established between her and the health
worker, the follow-up after delivery and monitoring the
growth of her infant would be easy. It is absolutely essen
tial for successful growth monitoring that a significant
proportion of under-threes is thus captured.
Unfortunately, however, in India, at present, accord
ing to some estimates, on an avera-e only less than 10 percent
of pregnant women in rural areas are reached through the
health centres and in the backward states the proportion is
even less. Health clinics and even the anganwadis of the
ICL'S system attract only a small proportion of children
under three in the community; a large.number of children
vesting them are older children.
Under the circumstances, the only way that pregnant
women and under-threes can be reached is through a wellstructured system of home visits by health workers.
Unfortunately, this is perhaps currently the weakest link
in the health care system. Home visits by auxiliary nurse
mJdwivos of the health system are too few and far between
to make any significant impact. Simple and relatively
inexpensive inputs like bicycles which could improve their
mobility are often not provided; also they are not
supported by a sensible record and management system which
would he.1 p to ident-'fy in advance the "households ar risk"
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the homes which need, to be visited as a priority - with the
result thateven the all-too-short precious time during their
infrequent visits is not used wisely and purposefully to
derive maximal benefit. Under the circumstances, it will be
neither feasible nor desirable to consider home-based growth
monitoring.
Effective functional linkage between the anganwadi
worker (of the Social Welfare sector) who is expected to
re-side in the village and the visiting auxiliary nurse
midwives could contribute greatly to the development and
implementation of a meaningful programme of domiciliary
visits, but this functional linkage is not evident in
may cases. The intersectoral linkage implicit in the
creation of the Human Resources Development Ministry at the
Centre embracing health, social welfare and education, is
not being reflected at the village level - the level which
matters most.
The anganwadi worker herself could do a great deal
on her own through home visits; but being rooted to the an
ganwadi (day care centre) most of the time, having to
implement the feeding programme and maintain a multiplicity
of records, she has little time; and moreover she is
cramped by lack of effective referral service facilities which require the cooperation of the health sector.
Furthermore, there is considerable scope for
improvement in the training of the health worker and the
anganwadi worker with respect to infant and child nutrition.
What they need to know is what concrete and feaible steps
they can suggest for the improvement of diets of young
children (between six months and two years) in the poorest
households - steps which the mother could implement within the time and resource constraints to which she is a
subject. If growth monitoring does reveal growth faltering,
what precise advice to the mother are they going to render?
This implies that the training must be specifically
tailored to suit local conditions and traditions. Not much
thought is going into this, at least not as much thought
as has gone into the training of the workers on the techni
ques of growth measurement and growth charting. And perhaps
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there are also not many trainers who can provide such very
practical training.
Pushing elaborate and expensive growth monitoring into
a health system which suffers from such major weaknesses is
bound to lead to aberrations. If the children that are
"available" for growth monitoring .are well over three years,
with a majority already in the socalled moderate and severe
grades of malnutrition, growth monitoring could turn out to
be a frustrating exercise for both health worker and mother
and education to the mother at that stage could not be of
much avail. Under the circumstances, it should not be
surprising if both the mother and the health' worker turn to
a tangible item on the anganwadi agenda, namely supplementary
feeding, which can at least provide some immediate relief.
Supplementary feeding thus becomes the centrepiece and
growth monitoring comes in handy to decide which children
should get single ration ("moderate malnutrition") and which
should get double, ration ("severe malnutrition"). Indeed,
the weaknesses in our health system thus actually favour the
observance of the policy of brinkmanship mentioned earlier.
Clearly, the first priority for developing countries
like India, with highly inadequate health systems, is to
over come current gross deficiencies with respect to
outreach and quality of their maternal and health services,
in situations where less than 10 percent of pregnant women
are being reached, where health and child welfare clinics
fail to attract the bulk of under-fives and where domiciliary
vxsits are cursory, few'anffar between, heavy investments
on elaborate growth monitoring are likely to prove infructuous. It will be naive to assumethat a liberal supply of
weighing scales and growth charts will automatically correct
these imbalances. To say this is not to argue against growth
monitoring as such but to emphasise that conditions that
would permit meaningful growth monitoring must first be
created. To concentrate our energies on supplies of
weighing scales and growth charts and on training of
workers in the techniques of growth measurements without
preceding, or at least parallel, intensive efforts.-1<*
strengthen the health system, is to. put.the tart bef*rd•he horse. Indeed, it will be sound and sensible strategy
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on the part of international agencies to support and streng
then the development of integrated programmes of maternal
and child health care which include growth monitoring as a
part, rather than promoting growth monitoring programmes as
such in isolation.
CONCLUDING COMMENTS;
The ideal situation that we must strive for is one
in which our health system will be strengthened and geared
to effectively utilise the technology of growth monitoring
for the purpose of prevention of growth retardation and under
nutrition in our children. Despite the several limitations
which currently stand in the way of meaningful growth monit
oring, growth monitoring programmes have been sea successfully
’carried out in quite a few small scale projects. These have
been recently reviewed (Successful growth monitoring - some
lessons from India, UNICEF South Asia 1986) and this experi
ence should show that given the right leadership and the
proper conditions, growth monitoring will be a useful tool
for the promotion of child health and nutrition.
MERITS OF GROWTH-MONITORINGi
Growth monitoring, as an integral part of primary
health care, is welcome for three■reasons, apart from those
discussed in the earlier part of this paper.
1) Relative to family planning and immunisation,
nutrition currently receives very poor focus in the primary
health care package. This is because unlike immunisation"
and family planning which are well-charted operations, that
lend themselves to "achievement audit", nutrition inputs appe
ar vague and have tea no immediately demonstrable impact,
specially in the context of poverty. Nutrition education
is also currently largely a "blind operation", it being
impossible to measure its impact. A well-designed growth
monitoring programme could provide support and direction
to nutrition education efforts, enhance their credibility 5
enable the measurement of their impact and help build
better rapport between the mother and the health worker.
2) The Integrated Child Development Service (ICDS)
is a unique input which provides vast opportunities for
improvement of child health and nutrition. Unlike the
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conventional health system which is overburdened with curative
work load, the programme of ICDS can be wholly oriented towards
preventive and promotive health and nutrition care. Through
proper training, supportive supervision, and through effective
linkage between the health worker (of the health system) and
the anganwadi worker (of the ICDS) it w should be possible to
provide for each village in the country effective maternal
and child health care and nutrition services supported and
facilitated by meaningful growth monitoring.
3) It has indeed been demonstrated that with existing
resources, when the health system is properly supported
and managed, meaningful growth monitoring is possible and
could help in preventing growth retardation and improving
child nutrition even in the poorest households (Das. D.,
Dhanoa, J. and Cowan, B. Loc. cit.). Cowan’s model involved
the employment of facilitators who were not part of the
health system. An anganwadi worker of the ICDS system can
easily be now trained to play the role of such facilitators,
Now that we-have opted for the expansion and strengthening of
the ICDS system, we may use this valuable input to overcome
our deficiencies in primary health care.
MODEL DISTRICTS.
It may notbe possible to overcome overnight the
several shortcomings which currently beset our health
system. A practical approach could be to take up
immediately at least one district in each state for inten
sive efforts directed to promote the outreach and quality
of health services. In such efforts, emphasis must be
placed onbringing about close functional linkages between
the regular-health system and the CIDS. Growth monitoring
for the purpose of prevention of undernutrition and early
detection of growth faltering could be introduced as part of
a comprehensive system Ofmaternal' and child health,7nutrition
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care. A well-structured system of regular domiciliary
visits could.be organised and it could be ensured that all p
poor households. ..with.-pregnant women, -nursing ^mothers '
and children*under three are periodically visited, and that
the health workers spends sufficient ..time with. the. mothers ..
in these critical households not just, to carry out weighmant
and .growth-charting but;,, more, ■importantly,”to educate
them as-to how. child.- feeding. and sparing,, practices ..could •: e
be improved; ' a s w as empha'sipod. earlier, intensive, pra-cticali j
training- will be- needed for this - latter purpost.. Under "Such
circumstances,..rme.aningful''.grdwth; monitoring’ .will, become v Mt
possible, and will greatly reinforce maternal and. chiid-M ' /hl
health care, services. These model districts, could serve • ';
as demonstration-cum-training areas' for- 'each state.' There . ’
could be a- phased programme for extension of'the programme
to other districts in the state so- that by the turn of the
ceritry,we may be able to achieve impressive improvement
in maternal health and nutrition services all over the
country.
'
Inaugural address' at the Seminar on Growth Monitoring,
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National
Institute of
Public Cooperation
and Child
Development. Delhi
", February
13, 1987.
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