Growth monitoring, screening and survillence

growth monitoring, Indian Academy of Pediatrics (IAP): schedule, growth charts, who growth charts.

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2. 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

3. Over View Definition Aims Importance of growth monitoring Assessment of physical growth Growth indices Growth charts:- Schedules IAP recommendation for interval and parameters 3

4. 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

5. Growth monitoring is a screening tool to diagnose nutritional, chronic systemic and endocrine disease at an early stage. 5

6. 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

7. A significant impact on mortality … even in the absence of nutrition supplementation or education” ( Gwatkin et al 1980). 7

8. AIMS OF GROWTH MONITORING 8

9. 9 Primary aims: To identify children with growth deviation  i.e ., under nutrition and over nutrition To identify diseases and conditions that manifest through abnormal growth . Secondary aims: To discuss health promotion related to feeding, hygiene, immunization and other aspects of the child’s health and behavior . Sensitize to use growth charts Ultimately, the aim of growth monitoring is to minimise illness and avoid unnecessary child death

10. Importance of growth monitoring 10

11. Growth monitoring helps detect three main problems: Feeding difficulties , particularly in the younger child; Chronic ill health from whatever cause, including respiratory infection, malaria, tuberculosis, and growth hormone deficiency; Social deprivation, where poverty and home circumstances are such that one outcome is poor nutrition; 11

12. R emedial 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

13. 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

14. GROWTH MONITORING COMPRISES PACKAGES OF ACTIVITIES: Regularly anthropometry of children ; Plotting the information on a growth chart to make pattern of growth visible; If growth is abnormal (usually faltering), appropriate measures, 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 . 14

15. 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

16. ASSESSEMENT OF PHYSICAL GROWTH 16

17. Age dependent Age Independent -Weight -MAC -Height -BMI -HC -Rao’s Index -Chest circumference - Kanawatis index 17

18. Other Growth indices 18 Body proportion:-US:LS ratio Skeletal maturation Dental development

19. 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. 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. 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

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29. 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. 30 IAP GROWTH CHART

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32. 32 Age Growth status Indicator/ Parameter Percentile 0-5 years Underweight Weight for age < 3 rd   Severe underweight Weight for age < 0.1 st   Stunting Length /Height for age < 3 rd   Severe stunting Length /Height for age < 0.1 st   Wasting Weight for height < 3 rd   Severe wasting Weight for height < 0.1 st 5 -18 years Underweight BMI for age < 3 rd   Stunted Height for age < 3 rd   Overweight BMI for age > 23 rd adult equivalent line   Obese BMI for age > 27 th adult equivalent line IAP Growth Charts: Cut offs and their interpretation

33. 33 Percentile z score

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35. 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.

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39. 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

40. 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

41. 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

42. 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

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44. 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. 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

46. 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

47. 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

48. 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. 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 3 rd 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 75 th percentile to below 50th percentile on height or weight chart . When to refer

50. 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. 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. 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 27 th 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. 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

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