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Dr. G.N.V. Brahmam Dy. Director (Sr. Gr.), HoD, Division of Community Studies,

CURRENT USE OF CHILD GROWTH STANDARDS IN INDIA --- An Overview. Dr. G.N.V. Brahmam Dy. Director (Sr. Gr.), HoD, Division of Community Studies, National Institute of Nutrition, (I.C.M.R.) Jamai-Osmania (P.O.), HYDERABAD – 500 007.

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Dr. G.N.V. Brahmam Dy. Director (Sr. Gr.), HoD, Division of Community Studies,

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  1. CURRENT USE OF CHILD GROWTH STANDARDS IN INDIA --- An Overview Dr. G.N.V. Brahmam Dy. Director (Sr. Gr.), HoD, Division of Community Studies, National Institute of Nutrition, (I.C.M.R.) Jamai-Osmania (P.O.), HYDERABAD – 500 007. Telefax : 040-27019141 Mobile: 094414 91797 Email: gnvbrahmam@yahoo.com

  2. INDICATORS OF NUTRITIONAL STATUS Direct Indicators: -- Nutritional Anthropometry -- Clinical Assessment -- Bio-chemical Estimations -- Biophysical Tests Indirect Indicators: -- Dietary assessment -- Prevalence of Morbidities -- Vital Statistics In addition, Secondary Data: -- Socio-economic -- Demographic -- Environmental

  3. NUTRITIONAL ANTHROPOMETRY

  4. NUTRITIONAL ANTHROPOMETRY • MEASUREMENTS • - Using Instruments • REFERENCE VALUES / STANDARDS • - National, International • INDICES • - Computed; Age dependent / Independent • CLASSIFICATIONS • - For Grading of Nutritional Status

  5. ANTHROPOMETRIC MEASUREMENTS - Weight (kgs) - Height (cms) - Mid Upper Arm Circumference (cms) - Waist Circumference (cms) - Hip Circumference (cms) - Fat fold thickness (mms) : at Triceps, Biceps, Supra-Iliac, Sub-scapular regions

  6. Nutritional Anthropometry Weight : - Total Body mass - Simple, widely used - Sensitive to small changes in nutrition Height : - Genetically Determined - Environmentally influenced - Stunting Reflects long duration undernutrition MUAC : - Reflects muscle/fat - Easy to measure, used for quick screening - Independent of age (1-5 years) FFT: - Measures body fat - Correlates well with total body fat

  7. REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY Standard equipment: - Accuracy / Consistency, Appropriate techniques: - Training & Standardization Correct assessment of age: - Wrong age vitiates the results Reference values: - For comparison and computation of indices Classification: - For grading nutritional status

  8. Reference Values Anthropometric measurements obtained on statistically adequate number of individuals who are well nourished, representing cross section of community living in an environment free from constraints of any sort and have capacity to reach maximum growth potential at each age group/Gender. -- National Eg. Well-to-do Hyderabad pre-school children -- International Eg. NCHS, Harvard, MGRS

  9. CURRENT REFERENCE VALUES • NCHS (0- 18 years / By gender) • (Hamill et. al. AJCN, 1979 - WHO/1983) • HARVARD (0-60 months / Gender pooled) • (Jelliffe et. al. WHO Mono. 53 - 1966) • NHANES (9-17 years/Gender Specific • BMI Centiles) • (WHO/1995)

  10. MGRS Multicentre Growth Reference Study Provides : Median, SD, Percentile values of • Weight for Age • Height for Age • Weight for Height • Body Mass Index for 0-60 months boys & girls

  11. Multicentre Growth Reference Study Based on study on 0-60 months children in : Brazil, Ghana, India, Norway, Oman & USA, Who were predominantly Exclusively breastfed up to 6 mths • A total of about 8500 children • Predominantly breastfed up to 6 months • No environmental constraints • Data collection- by trained staff • Longitudinal study 0-24 months • Cross sectional 18-60months

  12. ANTHROPOMETRIC INDICES Weight for age Height for age Weight for Height Body Mass Index

  13. NUTRITIONAL GRADING / CLASSIFICATIONS Preschool Children: GOMEZ CLASSIFICATION

  14. GOMEZ CLASSIFICATION • Gomez et. al. (J Trop Ped 1956) • Based on Prognosis of children admitted to • Hospitals in Mexico • Significantly higher incidence of mortality among • children with <60% of standard wt for age • - Significantly higher morbidity among children • with 60-75% of standard weight for age

  15. IAP CLASSIFICATION(Indian Academy of Paediatrics)

  16. IAP CLASSIFICATION(Indian Academy of Paediatrics) Nutrition Sub-committee of Indian Academy of Pediatrics: Report, Indian Pediatrics, 9:360, 1972. Suggested to use 50th Centile of Harvard standards (and also to develop suitable Growth norms for Indian Children) - Grading was arbitrary - To affix ‘ K ‘, if the child has Oedema - Gr. I & II Correspond to Underweight, - Gr. III & IV Correspond to Marasmus, - Gr. I & II with ‘K’ indicate Kwashiorkor, - Gr. III & IV with ‘K’ indicate Marasmic Kwashiorkor,

  17. STANDARD NORMAL DISTRIBUTION Normal 34% 34% 14% 14% 2% 2% -3.0 -2.0 -1.0 0.0 1.0 2.0 3.0 SD Score ( 2SD = 96 %) “Measuring Changes in Nutritional Status” (WHO, Geneva 1983).

  18. STANDARD DEVIATION (SD) CLASSIFICATION

  19. Z - Scores Measured Value – Median Value (reference) Z Score = ---------------------------------------------------------- SD of Reference

  20. WHO Child Growth Standards

  21. WHO Child Growth Standards

  22. World Health Organization Weight for age BOYS Birth to 5 years (z-scores) -2 SD -2.5 SD -3 SD Months 4 years Birth 1 year 2 years 3 years 5 years

  23. World Health Organization Weight for age GIRLS Birth to 5 years (z-scores) -2 SD -2.5 SD -3 SD Months 4 years Birth 1 year 2 years 3 years 5 years

  24. CLASSIFICATIONS CURRENTLY BEING USED BY VARIOUS ORGANIZATIONS FOR NUTRITIONAL GRADING OF < 5 YEAR CHILDREN

  25. Prevalence of Undernutrition - NCHS Vs MGRS Reference Values

  26. WEIGHT FOR AGE < Median – 3 SD Median – 3 SD to Median – 2 SD % % < Median – 2 SD %

  27. Boys % WEIGHT FOR AGE Median – 3 SD to Median – 2 SD < Median – 2 SD < Median – 3 SD  Median – 2 SD Girls % Median – 3 SD to Median – 2 SD < Median – 2 SD < Median – 3 SD  Median – 2 SD

  28. HEIGHT FOR AGE % < Median – 3 SD Median – 3 SD to Median – 2 SD % Median < – 2 SD %

  29. Boys % Median – 3 SD to Median – 2 SD < Median – 2 SD < Median – 3 SD  Median– 2 SD Girls HEIGHT FOR AGE % Median – 3 SD to Median – 2 SD < Median – 2 SD < Median – 3 SD  Median– 2 SD

  30. WEIGHT FOR HEIGHT < Median – 3 SD Median – 3 SD to Median – 2 SD % % < Median – 2 SD %

  31. Boys % WEIGHT FOR HEIGHT Median – 3 SD to Median – 2 SD  Median – 2 SD < Median – 3 SD < Median – 2 SD Girls % Median – 3 SD to Median – 2 SD  Median – 2 SD < Median – 3 SD < Median – 2 SD

  32. SALIENT OBSERVATIONS . . . Weight for Age: • Overall prevalence of underweight by MGRS was less by about 9%, compared to NCHS. • While the overall prevalence of severe underweight was similar, it was marginally less in 1-2 year age group, and was higher in 3-4 year age group. • No significant gender differentials were observed, both by MGRS and NCHS.

  33. Height for Age: • Overall prevalence of stunting by MGRS was higher by about 5-6% (about 4% in severe grade and 1.5% in moderate), compared to NCHS. • The magnitude of difference was marginally low in 1+ & 4+ age group (2%) compared to 2+ & 3+ age group (7-10%). • No significant gender differentials were observed, both by MGRS and NCHS.

  34. Weight for Height : • Overall prevalence of wasting by MGRS was marginally higher (2.5%) compared to NCHS. • The extent of difference was relatively higher among Boys (4%) compared to Girls (1%).

  35. Conclusions : • There is need to adopt the new WHO growth standards of <5 year Children by all. • The Growth charts in ICDS need to be modified using SD classification criteria • The functionaries have to be trained and oriented to these changes • The existing data need to be re-analysed using new reference values to enable comparisons

  36. Thank you

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