GROWTH MONITORING (GM)

According to W.H.O. three children are added to the population of the world every second of the day. But in Nigeria,
Federal government reports an infant mortality rate (IMR) of 127/1000 for rural and 55/1000 for the urban communities.
The same report gives child mortality rate (CMR) of 193/1000 in rural and 94/1000 in urban areas. Malnutrition is found to
be the leading cause of death among Nigerian children of the estimated 850million children in the world under 5years of age
in the world in 1983, 350million of them were malnourished. Therefore, the importance of promoting healthy growth as a
strategy for preventing malnutrition cannot be overemphasized. It is on account of these facts that monitoring the growth of
children as a tool used in monitoring the health of children becomes a very important tool. More so when a recent Minister
for Health maintained and emphasized that "“due to our economic down-turn, malnutrition is on the increase”.

Definition Of Growth Monitoring: Internationally adopted definition is that it is "an operational strategy of enabling
mothers to visualize growth or the and country can act to assume health and continued regular growth in her child".

This means regular and sequential measurement of growth, recognizing developmental factors in the child and is based on a
strategy aimed at family and the community to promote optimal health: Thus the whole process should be viewed as a
communication strategy for making health and nutrition education more individualized, more convincing and more
effective. Growth monitoring is like a passenger in the front seat of a car driven by the Owner-driver which is the mother.
GM is viewed as a set of tools used to recognize health problems (the lack of growth) in children before they become serious
and it should start from the day a child is born.

1. Growth monitoring is a preventive, pre-emptive and promotive strategy aimed at actions before overt malnutrition occurs
and it recognises the crucial role of mothers in this respect.
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2. It is a home-based behavioural change strategy carried out through effective communication and must rely heavily
on the full participation of the mother. Thus it relates to the practical actions which the mothers themselves can take
as well as to those which relates to the occurrence of positive reinforcement of such actions.

It deals with the total environment of the child, encompassing his health, nutrition, psycho-social development,
physical environment and intellectual.

Characteristics of Growth Monitoring

(1) A child is registered at the earliest age, preferably from birth. Subsequent rapid growth rate is recorded on a
growth chart at this period positively reinforces and encourages the mother.
(2) Major growth faulting (usually at 16-18 months) calls for communication and action between the health
worker and the mother, such as the introduction of weaning foods, increasing the variety of feeding, frequency
of feeding or introduction of more calorie-dense foods to the baby.
(3) It has the potential of instigating synergistic actions on growth. These activities which reduce set backs on
growth include immunization, ORT. Adequate breast feeding etc
(4) Communication between health workers and the mothers reinforces dialogue which promotes and improves
child health behaviours. Sharing ideas and advice between health workers and mothers and between mothers
themselves facilitated and assisted by health workers, gives the health workers a focus and logical framework
from which they can deliver other intervention strategies. The health workers must listen and facilitate the
transfer of effective and creditable knowledge and its translation into action. Listening to the success stories of
mothers whose children are growing well becomes the best source of information for other mothers.
(5) Although it can be carried out in a clinic setting, it is best placed in the community.
(6) It is neither expected to, nor should it, rehabilitate malnourished children
(7) It serves as an entry-point for PHC and creates demands for related variety of services and shifts the emphasis
from professionals to parents, from clinics to homes and from dependence to empowerment.
Problems of Implementation of Growth Monitoring
a) The Calibre of Personnel: Many health workers do not have adequate knowledge of growth
monitoring and nutrition. They do not know how to plot growth charts and interpret filled charts.
Health workers who perform the duties of the nutrition educators are not adequately trained and do not
take sufficient interest in it. Some are not able to combine growth monitoring duties with their other
regular more clinically oriented duties hence, growth monitoring becomes everybody's interest but
nobody's business and there is rarely any adequate follow-up. Mothers too soon loose interest in the
value of growth monitoring.

b) Lack of clear conceptual understanding of growth monitoring: GM does not only mean weighing and
charting, it needs to be impressed upon health workers as well as the mothers. There is a difference
between a conventional nutritional assessment programme, in detecting malnutrition cases in order to
 rehabilitate an individual and GM which is a “positive, preventive, promotive and preemptive act”.
Although they both employ basic identical tools like weighing, measuring or even marking the
measurements on growth charts they differ in terms of conception, purpose and execution. Failure to
recognise the difference between the two has led to faulty GM implementation.

GM is just like “teaching a man to fish and you feed him for life as against giving him for which can only
feed him for a day”. Mothers should understand and be permitted to internalize the process of growth by involving
them in the actual weighing and discussion of results. Mothers can be helped to measure their children's growth by
feeling for the size of the arm circumference which increases rapidly during the first year but stays almost the same
between one and five years. The Road-to-Health or the Weight-for-age Charts are used widely to monitor the growth
of small children. They also show other important facts such as the time of illness and the time the child comes off
the breast. Mothers with the help of health workers should be made to understand their children's growth curve and
how breastfeeding and weaning food can influence their children's growth.
(c) Initiation and follow-up of growth monitoring: Ideally children should be weighed immediately at birth followed
by 2weekly or monthly until lactation has been well established and the child is growing well. If the mother is
exposed to the growth chart early, she will be able to see by herself the rising curve which can assure her that her
child is a normal growing child. Children should be enrolled in growth monitoring from birth. Frequent weighing is
important in the early life of a child than later, initially 2weekly interval, by the 3rd month, monthly. Growth
monitoring sessions may be maintained until the 24th month of age, after this 3monthly may be adopted. If a child is
growing well, the workers should reinforce the mother's behaviour. If a child's growth falters effective
communication should be established with the mother by asking questions. The health worker needs “precise
message for the precise mother at the precise time of her precise need".
(d) The growth chart: there is no curve-all-growth card or chart but a mother-hand card should always be
designed from the point of view of the mother. It should be attractive and easily understandable. There are
two types of cards in use in Nigeria, the 3-line and the 2-line cards. The 3-line card is more colorful and
educative. The blue and black lines indicate good or normal growth while the red line indicates lack of
growth.

The more spacious, less colorful 2-line card may not be as attractive but it was the card launched by the Federal
Ministry of Health late in 1987.A rising curve means good growth while a falling curve means a lack of growth and
should alarm the mother, a flat curve should be a source of concern

(e) The weighing scale: There are a number of weighing scales in the market where cost is not the most
limiting factor, the most ideal weighing scale is the one which can automatically subtract the weight of the
mother from the combined weight of the mother and the child and then display the actual weight of the child.
In the meantime, New TALC (Teaching Aids At Low Cost) scale called Morley Scale the spring stretches
exactly 1cm for each kilogram.
 (f) Numbers of mothers per Growth Monitoring Session: Groups of 8 to 12 mothers with their children. This
fosters mothers to workers interactions as well as promotes one-on-one communication between mothers and
workers on specific advice to be given to each mother in-respect of her child. Growth monitoring session can
be conducted along with other PHC activities such as Immunization, Family planning e.t.c.
Recommendation for Successful
Growth Monitoring
(i) Proper training of Health workers to understand the symbolism of a growth curve so as to be able to explain this to
mothers. The training should include the communication aspect of growth monitoring.
(ii) Increase the coverage of GM activities at the community level: only the new born may be started monthly at first
then, other new born babies may be added to the cohort.
A health worker should be assigned to the mother of an “at risk child” who could easily adopt
feeding her infant with the needed colostrum which will permit such children to have a good start in life.
When there is significant growth faltering the mother should be encouraged to increase the frequency of
breast feeding, accompanied with increased food for the woman herself. Frequent feeding helps to get enough
calories into a weaning child. The size of a child's empty stomach is not bigger than the size of his fist.
Feeding should continue during and after illness.

The conduct of the GM sessions should be clearly stated. GM hours should be flexible for mothers
to participate. The mother of a child whose weight is faltering should neither be put down nor be subjected to
standard lecture. She needs precise message at the precise time of her precise needs. When growth failure
occurs, nutritional rehabilitation should not be incorporated into GM activities. Malnutrition management
requires medical care and professional surveillance which village-level-health-workers or community action
cannot provide.
(iii) An appropriate referral system should be undertaken. Health workers must take prompt action as growth faltering
occurs.
(iv) Mothers should be made to know the importance of child spacing as an essential component of growth
monitoring. Importance of adequate stressed. Mothers should be encouraged to receive adequate Ante-natal and Post-
natal care.

How to Assess the Nutritional Status of a Community

Nutritional assessment will tell us the state of nutrition/nutritional status of the individual families and the community
at large.

As a Community Health worker one of your concern should be the nutritional status of your community.

There are three basic methods of determining the nutritional status of the community.
By Anthropometric Measurements of the Body: This is useful in detecting growth failure in children who are still
growing, especially under 5 years. In most of our rural pre-urban communities, the age of many children are not
known. This measurement can be divided into two.
Age Known: Use method of weight and height for age.
Age Unknown: Use method of mid-arm-circumference and head-chest circumference ratio.
METHOD: Weight is the most useful indicator for assessing the nutritional status of a child whose age is known.
Once the month of birth of this child is known he is then weighed on monthly basis that is regularly and this weight is
charted monthly in a chart called Growth Card or Road-to Health Chart.
This chart is a graph and it is plotted by joining the monthly marks made on the growth cart. The slope of this growth
line is compared with the normal average growth curve already printed on the card.
As a guide:
Weight between 80%-100% of the standard are good.
Weight between 60% and 80% are referred to a underweight and such a child is said to be at risk of malnutrition.
If a child’s weight is ˂60% of normal standard weight is said to be malnurished. He is either suffering from
Marasmus or Kwashiorkor.

To +be able to get the above, percentage is used:

Actual age of the child x 100/standard reference weight.

For example:
If the actual age of a child = 2.5years.
If the standard reference weight = 3.0kg
Therefore his standard weight = 2.5x100/3
= 83.3%

Remark: This child's standard weight is good.

HEIGHT: The height alone does not show the nutritional state of a child as height is more determined by heredity
than weight is. Height and weight measurement are combined. This is called Height/Weight ratio.= Ht(cm)/Wt(kg).

一 Age unknown: Mid-arm-circumference (M.A.C).There is little change in the M.A.C.between 1and5 years.
During this period the arm grows in length but does not grow fatter. At birth the M.A.C. is approximately 11cm, by 1
year it is 16cm and by 5 years approximately 17cm. If at over 1 year the MAC of a child is below 13.5cm, the child is
considered to be undernourished and at high risk of malnutrition. A child over one year with MAC below 12.5cm is
regarded as a clinical case that has malnutrition. ( kwashiorkor or marasmus).

Head-chest-circumference: A non-stretchable tape is used to measure the head circumference and then the chest
circumference The principle behind this is that when a child is malnourished, the bones of the skull continues to grow
whereas the bones of the chest and its muscles fail to develop well. In a child that is more than 6months, his chest
circumference is expected to be larger than the head. If it is otherwise the child is said to be malnourished.
Head circumference (cm)/Chest circumference (cm)

(B) Clinical Examination: This could be done on any child on general assessment. When a child starts to develop

malnutrition he may start to retain good observation a child could be picked at an early stage of malnutrition before

damage is done on him.

(C) Bio-Chemical/And Other Laboratory Tests: This is done to know the seriousness of malnutrition in the body.
Tests include Packed cell volume, Blood count, Urinalysis, e.t.c. However bio-chemical tests are not always possible
in most health centres because there may be no laboratory.

Assessment of Nutritional Status

The community health worker should be able to assess the nutritional status of the community using the Mid-Upper
Arm Circumference (MUAC) strip for children between 1 to 5 years of age.

Method:

 Remove or ask mother to remove clothing that will cover the child's left arm.
 Determine the mid-point of the child's left upper arm, by bending the child's elbow to make a right angle.
 Locate the tip of the shoulder with finger tip.
 Place the tape with the zero point on the tip of the shoulder and move down to the tip of the elbow, and mid-
point is the area between the shoulder and the elbow.
  Read the number to the nearest 0.1 cm, divide this number by 2 and take the mid-point
 Relax the child's arm parallel to the body, wrap the tape round the arm at the mid-point (avoid compression
of the soft tissue).

Interpretation of the Readings:

* GREEN Normal (commend good efforts)
* YELLOW Warning sign(child requires attention)
* RED Danger sign (child needs immediate attention

 Explain findings to mother/father/others looking after the child and

 Take appropriate steps depending on the health facilities availavle at the centre.
 Give health education:
 To prevent malnutrition:
 To give adequate diet for all family members.
 Immunization for all children.
 Personal and environmental hygiene.

Shakir's Strip

 Locate the child's upper arm following the procedure outlined above.
 Wrap the strip round the arm at the mid-point.
 Check the colour opposite point Oc.
 If the Ocm.mark touches the green part, the child is well nourished.
 If the Ocm. mark touches the yellow part, the child is moderately undernourished.
 If the Ocm. mark touches the red part, the child is severely undernourished.
 Table:Mid-Arm Circumference Using Tape Measure.

Reading in (cm) Interpretation

13.5-17.5 Normal(Green Colour)

12.5-13.5 Mildly Malnurished (Yellow Colour)

Below 12.5 Severely Malnourished (Red Colour)

Table: Format for Assessing Locally Available Foods

S/No Type Food Sufficiently Not Sufficiently

Not available
Stuff available Available