Growth chart and its uses in psm

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Growth Chart and Its Uses in PSM

(Source: Park's Textbook of Preventive and Social Medicine)

Definition

The growth or "road-to-health" chart is a visible display of the child's physical growth and development. It was first designed by David Morley and later modified by WHO. It is designed primarily for the longitudinal follow-up (growth monitoring) of a child, so that changes over time can be interpreted.

Weight is used as the primary parameter because it is the most sensitive measure of growth - any deviation from "normal" can be detected easily by comparison with reference curves.
A child can lose weight but not height, making weight-for-age plots particularly useful.
The chart offers a simple and inexpensive way of monitoring weight gain and child health over time.

WHO Child Growth Standards (2006)

In 1993, WHO reviewed the older NCHS growth references and found they did not adequately represent early childhood growth. A Multicentre Growth Reference Study (MGRS) was conducted between 1997 and 2003 in 6 countries: Brazil, Ghana, India, Norway, Oman, and USA, gathering data from 9,440 healthy breast-fed infants and young children (0-60 months).

Standards generated include percentile and Z-score curves for:

Length/height-for-age
Weight-for-age
Weight-for-length
Weight-for-height
BMI-for-age (new addition compared to older NCHS/WHO reference)

The image below shows the comparison of WHO vs. NCHS weight-for-age Z-scores for girls:

Comparison of WHO with NCHS weight-for-age Z-scores for girls

Key differences with NCHS/WHO reference:

Stunting will be greater throughout childhood using new WHO standards
Underweight rates increase during first half of infancy for breast-fed infants, decrease thereafter
Wasting rates are substantially higher during infancy under new WHO standards
Overweight rates also differ

Growth Chart Used in India

India adopted the new WHO Child Growth Standards (2006) in February 2009 for use within:

National Rural Health Mission (NRHM)
Integrated Child Development Services (ICDS)

Mother and Child Protection (MCP) Card

A joint "Mother and Child Protection Card" was developed which includes:

Family identification and registration
Birth record and pregnancy record
Immunization schedule
Breast-feeding and supplementary food details
Baby's developmental milestones
Birth spacing information
Reasons for special care

The card is kept by the mother and brought to the health centre at every visit.

Zones on the Indian Growth Chart

Zone	SD Cutoff
Normal	Above -2 SD
Undernutrition	Below -2 SD
Severely underweight	Below -3 SD

In states like Maharashtra, the chart further grades undernutrition into Grade I, II, III, and IV.

Key principle: The direction of growth is more important than the position of dots on the line. Flattening or falling of the weight curve signals growth failure - the earliest sign of protein-energy malnutrition (PEM), which may precede clinical signs by weeks to months.

Uses of Growth Chart

The growth chart has been described as a "passport to child health care" (Park's PSM). It has seven major uses:

#	Use	Details
1	Growth Monitoring	Longitudinal tracking of weight gain; of great value in child health care
2	Diagnostic Tool	Identifies "high-risk" children; malnutrition detected long before clinical signs/symptoms appear
3	Planning and Policy Making	By grading malnutrition, provides an objective basis for planning at local and central levels
4	Educational Tool	Due to its visual nature, mothers can be educated about their child's care and encouraged to participate actively in growth monitoring
5	Tool for Action	Guides health workers on the type of intervention needed; helps make referrals easier
6	Evaluation	Assesses effectiveness of corrective measures and the impact of programmes or special interventions for improving child growth and development
7	Tool for Teaching	Used for teaching importance of adequate feeding, deleterious effects of diarrhoea, etc.

Summary Points for Exam

Originally designed by David Morley, modified by WHO
Also called "road-to-health card"
Uses weight-for-age as primary parameter (weight = most sensitive index of growth)
Based on WHO MGRS study (1997-2003), 9,440 children from 6 countries
India adopted WHO standards in February 2009 under NRHM/ICDS
Growth direction > position on chart
Growth faltering = earliest sign of PEM
Uses: monitoring, diagnosis, planning, education, action, evaluation, teaching
Park's Textbook of Preventive and Social Medicine, pp. 636-637

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