IAP GUIDEBOOK ON GROWTH MONITORING IN CHILDREN
IAP Growth Chart Committee 2014
(V Khadilkar (Convener), V Yewale (Chairperson), S Yadav, KK Agrawal, S Tamboli, M Banerjee)
Office Bearers and the Members of the Executive Board of IAP - 2014
President … Dr. Vijay N Yewale
President-Elect … Dr. S. S. Kamath
Imm. Past President … Dr. C. P. Bansal
Vice President … Dr. Neeli Ramchander
Secretary General … Dr. Pravin J. Mehta
Treasurer … Dr. Bakul Jayant Parekh
Editor-in-Chief, IP … Dr. Dheeraj Shah
Editor-in-Chief, IJPP … Dr. P Ramachandran
Joint Secretary … Dr. A. S. Vasudev
Andhra Pradesh Maharashtra
Dr. M. Surendranath Dr. Ashok A. Chougule
Dr. T. Himabindu Singh Dr. Atul A Kulkarni
Dr. Rhishikesh P. Thakre
Assam Dr. Vasant M. Khalatkar
Dr. Arati Deka
Orissa
Bihar Dr. Pravakar Mishra
Dr. Sheo Bachan Singh
Punjab
Chhattisgarh Dr. Vijay Kumar Ahuja
Dr. Anoop Kumar Verma
Rajasthan
Delhi Dr. Anil Kumar Jain
Dr. Dinesh Laroia Dr. Ashraf A Pathan
Dr. M.M.A. Faridi
Tamil Nadu
Goa Dr. K. M. Ganessan
Dr. V. N. Sawardekar Dr. N. C. Gowrishankar
Dr. V. Sivaprakasam
Gujarat
Dr. Ashwin J. Sanghavi Tripura
Dr. Sanjeev R. Goel Dr. S. K. Debbarma
Haryana Uttar Pradesh
Dr. Dinesh Tomar Dr. Dhiraj M. Gupta
Dr. Joginder Singh Dr. Ghanshyam Misra
Dr. Ruchira Gupta
Jammu & Kashmir
Dr. Ravinder K Gupta Uttarakhand
Dr. K. K. Agrawal
Jharkhand
Dr. Shyam S. Sidana West Bengal
Dr. Atanu Bhadra
Karnataka Dr. Jaydeep Choudhury
Dr. Deepak C.E.
Dr. G. V. Basavaraj Services
Dr. S. Srinivasa Dr. Brig. Kamer Singh Rana
Kerala President’s Representative
Dr. Jose Ouseph Dr. Panna Choudhury
Dr. M. K. Santosh A.A.A
Dr. T. P. Jayaraman Dr. Upendra Kinjawadekar
Madhya Pradesh
Dr. P. G. Walvekar
Dr. Rakesh Mishra
Introduction
Growth Monitoring is a screening tool to diagnose nutritional, chronic systemic and endocrine disease at
an early stage. It has been suggested that growth monitoring has the potential for significant impact on
mortality even in the absence of nutrition supplementation or education. Monitoring the growth of a child
requires taking the same measurements at regular intervals, approximately at the same time of the day,
and seeing how they change. A single measurement only indicates the child’s size at that moment
whereas serial measurements give more valuable information about growth trajectory and help in
diagnosing health and disease in children.
Primary aim of growth monitoring is to identify children with growth deviation i.e., undernutrition and
over nutrition and to identify diseases and conditions that manifest through abnormal growth. Secondary
aims include discussion of health promotion related to feeding, hygiene, immunization and other aspects
of child’s health and behavior and to sensitize pediatricians and health care workers to use growth charts. 1
The Indian Academy of Pediatrics and Govt. of India have adopted WHO 2006 under five standards for
monitoring children under the age of 5 years.
Beyond five years of age new charts were produced by IAP growth chart committee in 2014 by collating
data from 9 studies (14 cities) published in the last decade. These charts are designed to represent growth
of modern Indian children living in the optimal health and nutritional environment. Since data collected
from middle and upper classes is likely to have children who are overweight there is a danger of
“normalizing” overweight and obese children while constructing growth charts. To avoid this the
committee used the method suggested by World health organization to remove unhealthy weight from
study population which removed children with weight to height z scores beyond +2. Thus, these charts
show weights of children which are lower than the recently published data where the weight scales of
children are much higher than optimal. Similarly BMI charts that correspond to adult equivalent of 23
and 27 cutoffs have been generated as these are more appropriate to define risk of overweight and risk of
obesity in Asian Indian children. This booklet provides these new charts for use in children from 5 to 18
years of age. IAP growth monitoring committee 2014 recommends use of these charts for monitoring
growth of children beyond 5 years of age for height, weight and BMI 2.
Many recent studies from India and developing world have shown that a large number of children under
the age of 5 years (in some studies up to 40%) are below the 3 rd percentile of WHO charts for height and
weight. Data from National family health survey of India has also shown the same results recently 3. If we
use WHO 3rd percentile cut off for referral to higher centers, a very large number of children will need
referral and hence would become impractical. It therefore seems appropriate to watch children closely
who are below 3rd percentile (for height and weight) for a trend and if the trend is downward or if the
child is below 1st percentile at the beginning referral may be made.
Technique of measuring accurate height/length and weight
Children below the age of 2 years should be measured on an infantometer and their length is measured
up to last millimeter. Two persons are needed to take length of a child accurately
In children older than 2 years standing height is measured using stadiometer in which a right angled
block slides down at 90 degrees to the vertical scale of the stadiometer. Using this technique an
accurate reading up to last millimeter can be obtained as shown in the diagram
Weight should be measured on an electronic scale
How to use growth charts?
Basics of growth charts:
X axis and y axis
Growth charts are graphical representations of statistically adjusted growth data on apparently healthy
normal children. Most growth charts have an x axis which represents the age in years or months and a y
axis that represents the parameter being studies such as height, weight, head circumference or BMI.
Growth charts give changing trend of a variable over time and hence are immensely useful in the
diagnosis and follow up of children with disease.
Percentile lines and their interpretation
For children from 5 -18 years of age - In case of height charts there are 7 percentile lines which
represent 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles. Any child under 3rd percentile is considered to
be abnormally short and above 97th is considered to be abnormally tall. Weight charts also have same
percentile lines whereas BMI charts have 3 rd, 5th, 10th, 50th, 23 adult equivalent (71st and 75th percentiles
for boys and girls respectively) and 27 adult equivalent (90 th and 95th percentiles for boys and girls
respectively) lines. On the BMI charts underweight may be defined as below 3 rd percentile, risk for
overweight as above 23 adult equivalent and risk for obesity as above 27 adult equivalent lines.
In this booklet WHO under five charts have been depicted to show only 4 percentile lines to keep it
simple. These lines are 1st, 3rd, 50th and 97th for height and weight charts, only 3rd, 50th and 97th for the
head circumference and .1st, 3rd, 50th and 99th for the weight for height charts.
Cut offs and their interpretation
WHO and 5-18 Charts
Age Growth status Indicator/ Percentile Z scores
Parameter
0-5 years Underweight Weight for age < 3rd -2
Severe Weight for age < 0.1st -3
underweight
Stunting Length /Height for < 3rd -2
age
Severe stunting Length /Height for < 0.1st -3
age
Wasting Weight for height < 3rd -2
Severe wasting Weight for height < 0.1st -3
5 -18 years Underweight BMI for age < 3rd -2
Stunted Height for age < 3rd -2
Overweight BMI for age > 23rd adult equivalent
line
Obese BMI for age > 27th adult equivalent
line
Although these parameters are important as one time cut offs, it is very important to study the trend of
growth parameters over a period of time. Trends give more important information and need for action.
How to assess trend
Crossing 2 major centile or z score lines in weight and also in height should be immediately addressed
and appropriate referral should be done. Some SGA and LGA babies may show some catch-up or catch-
down to their genetic potential in the first few months of life but thereafter they maintain the same
percentile.
Calculation of mid parental height
At the first visit the child’s name, date of birth and other details should be entered on the growth chart and
the chart should be explained to the parents. This ensures that they are interested in it and are more likely
to keep it properly and bring it at each visit. The growth chart should be kept with the parents in a plastic
sleeve.
Measure the parents and make a note of their heights on the chart. Calculate the child’s target height and
plot it at 18 years and mark it with an arrow on the growth chart. This represents the child’s projected
height and his present height centile can be judged by tracing a line backward from this target height to
child’s current height. The target range is produced by plotting two points 6 cms above and below the
target height and this represents the 3rd and the 97th centile for that child. Taking those two points above
and below the target height 90th and 10th centiles are constructed by tracing lines backwards to match the
current age.
All the points on the growth chart should be marked only as dots and not circles around the dot. The
height and weight should be recorded (and head circumference till 3 years) and plotted on the chart. At all
subsequent visits join the dot up to the previous dot.
Calculation of Target Height and Target Height Percentile
TH
Calculation of Target Height and Target Height Percentile. Measure the parent’s heights and make a note of their
heights on the chart. Calculate the child’s target height (TH) and plot it at 18 years and mark it with an arrow on the
growth chart. This represents the child’s projected height and the target range is produced by plotting two points 6 cms
above and below (representing the 10th and the 90th centile for that child). In the example shown above the 50 th percentile
for this child is 167.5 CM and the target range is 161.5-173.5 CM. Thus, the 50th centile on the chart (173.5 CM) is the
90th centile for this child and the 10th centile for this child (161.5) is just below the 10th centile for the Chart.
How often to monitor
Birth to 3 years:
Immunization contacts at birth, 6, 10 and 14 weeks, 6, 9, 12, 15 and 18 months may be conveniently used
for growth monitoring. An opportunistic monitoring at other contacts (illness) is recommended. 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 upto 3 years of
age. Penile length (PL) and testicular descent should be ascertained in the newborn period.
4 to 8 years:
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:
Height, weight, BMI and SMR be assessed yearly during this period.
When to refer
First five years
Children below 3rd percentile on height/length or weight charts should first be plotted on weight for height
chart to determine degree of malnutrition.
If the Weight for height is below -3 SD (red line on Weight for height/ length growth charts) immediate
referral is needed.
Children below 3rd 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.
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.
Five to eighteen years
Length/Height below 3rd percentile or above 97th percentile on 5-18 year IAP charts.
Crossing of two major percentile lines (upward or downward) e.g., going from above 75th percentile to
below 50th percentile on height or weight chart.
A child below or above mid parental range for height (See calculation for target height range).
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).
Rate of growth less than 5 cm/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.
Growth Charts
0-5 Charts
5-15 charts
1
IAP Growth Monitoring Guidelines for Children from Birth to 18 Years, V.V. Khadilkar A.V. Khadilkar Panna Choudhury
K.N. Agarwal, Deepak Ugra, Nitin K. Shah , Indian Pediatrics Volume 44, March 17, 2007 pp 187- 197
2
Revised IAP Growth Charts for Height, Weight and Body Mass Index for 5-to 18-year-old Indian Children Vaman
Khadilkar, Sangeeta Yadav, KK Agrawal, Suchit Tamboli, Monidipa Banerjee, Alice Cherian, Jagdish P Goyal, Anuradha
Khadilkar, V Kumaravel, V Mohan, D Narayanapa, I Ray And Vijay Yewale, Indian Pediatrics, Volume 52, Jan 2015
3
Assessment of nutritional status in Indian preschool children using WHO 2006 Growth Standards. Prema
Ramachandran & Hema S. Gopalan
Nutrition Foundation of India, New Delhi, India. Received JanuaryIndian J Med Res 134, July 2011, pp 47-53.
