The World Health Organization is a specialized agency of the United Nations with

primary responsibility for international health matters and public health. Through this
organization, which was created in 1948, the health professions of some 165 countries
exchange their knowledge and experience with the aim of making possible the attainment
by all citizens of the world by the year 2000 of a level of health that will permit them to
lead a socially and economically productive life.
By means of direct technical cooperation with its Member States, and by stimulating
such cooperation among them, WHO promotes the development of comprehensive
health services, the prevention and control of diseases, the improvement of environmental
conditions, the development of health manpower, the coordination and development of
biomedical and health services research, and the planning and implementation of health
programmes.
These broad fields of endeavour encompass a wide variety of activities, such as
developing systems of primary health care that reach the whole population of Member
countries; promoting the health of mothers and children; combating malnutrition; con-
trolling malaria and other communicable diseases including tuberculosis and leprosy;
having achieved the eradication of smallpox, promoting mass immunization against a
number of other preventable diseases; improving mental health; providing safe water
supplies; and training health personnel of all categories.
Progress towards better health throughout the world also demands international
cooperation in such matters as establishing international standards for biological
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recommending international nonproprietary names for drugs; administering the Inter-
national Health Regulations; revising the International Classification of Diseases, Injuries,
and Causes of Death; and collecting and disseminating health statistical information.
Further information on many aspects of WHO's work is presented in the' Organiza-
tion's publications .

•
The Growth Uhart
A tool for use in infant and child health care

•
WORLD HEALTH ORGANIZATION
GENEVA 1986
 ISBN 92 4 154208 X

© World Health Organization 1986

Publications of the World Health Organization enjoy copyright protection in accor-

dance with the provisions of Protocol 2 of the Universal Copyright Convention. For
rights of reproduction or translation of WHO publications, in part or in toto, application
should be made to the Office of Publications, World Health Organization, Geneva,
Switzerland. The World Health Organization welcomes such appl ications.
The designations employed and the presentation of the material in this publication do
not imply the expression of any opinion whatsoever on the part of the Secretariat of the
World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries .
The mention of specific companies or of certain manufacturers' products does not
imply that they are endorsed or recommended by the World Health Organization in
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excepted, the names of proprietary products are distinguished by initial capital letters.

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 Contents

Page
Preface . . . . 5
Summary points 6
Introduction . . 7

Part 1. Principles of growth monitoring and the growth chart

A growing child is a healthy child 9
What to measure . 9
Length or height . 9
Weight for age . . 9
Weight for height. 10
Body circumferences 10
Normal variability . . 10
Choosing a reference population 10
When to measure . . 13
Types of chart . . . 13
Designing the chart . 20
Choosing a scale . . 22
How to use the growth chart in monitoring child health 23

Part 2. Training health workers to use the chart

Child growth . . . . . 26
The weighing procedure . . . . . . 26
Plotting the weight . . . . . . . . 26
Filling in the rest of the information 27
Interpreting the growth chart . 28
Direction of the growth curve 28
Position of the growth curve. 28
Use of examples . . . . . . 29
A tool for action . . . . . . . 30
Supporting the health workers . 30
References . . . . . . . . . . 33
 Preface

Growth monitoring is an important technique for identifying individuals, groups , or

communities whose growth is not keeping up with the expected pattern. Poor growth,
whether as a result of infection, malnutrition or other cause, and whether evident in
particular individuals or in population groups , needs to be detected in order that correc-
tive action may be taken. In this context, the individual child growth chart is widely
accepted as an important and practical tool that can contribute significantly to the
objective of health for all by the year 2000.
The growth chart offers a simple and inexpensive means of monitoring child health
and nutritional status and can be used by community health workers with very little
instruction and supervision. The chart represents a convenient means of presenting basic
health data and permits the assessment of current status as well as the observation of
trends in growth.
Being essentially visual, the chart also provides the health worker with a useful
instrument for educating the mother and the family. It promotes a clearer understanding
of the nature of growth and development, and portrays clearly the consequences of an
inadequate diet and of infectious diseases. In this way it contributes to a greater
acceptance of responsibility for child care by the mother and to the concept of family
self-reliance in health matters.
Although the general objectives of growth monitoring are the same in all settings, the
approaches and tools will vary according to the objectives of the particular child health
programme, the parameters considered of greatest concern and of local relevance, the
equipment and skills available, and the organization of health care services. The present
publication thus describes the principles of growth monitoring and stresses the need for
each health service to develop monitoring methods and a growth chart appropriate to
the communities served. Several examples are given to show how this has been done in
various countries. Guidelines are also given on training community health workers to jill
in the chart and to interpret the growth curve correctly.
This book has resulted from the growing experience of health workers throughout the
world who responded both with enthusiasm and constructive criticism to an earlier
publication on growth monitoring. 1 The World Health Organization would welcome a
continuation of that criticism, as the principles and information provided here are
adapted and implemented. Any comments or suggestions should be addressed to: Mater-
nal and Child Health, World Health Organization , I2II Geneva 27, Switzerland.
WHO is particularly indebted to Dr M. Behar, formerly Chief Medical Officer,
Nutrition, WHO, Geneva, and Dr W. A.M. Cutting, University of Edinburgh , Scotland,
for their extensive contributions to this book.

1
A growth chart for international use in maternal and child health care. Geneva, World Health Organiza-
tion, 1978.
Summary points
I . A growing child is a healthy one .
2. Growth is very sensitive to external factors , such as nutrition and disease,
and growth monitoring is therefore of great value in child health care.
3. Malnutrition can be detected by means of growth monitoring long before
signs and symptoms of it become apparent.
4. The most sensitive measure of growth is weight.
5. The most convenient way of monitoring weight is by means of growth
charts.
6. For purposes of comparison, growth charts are provided with reference
curves showing the limits of normal growth, since children naturally vary
in size for genetic reasons.
7. Reference curves are based on data from a large sample taken from a
population of well-nourished, healthy children.
8. In growth monitoring, the weight of a child is plotted on the growth chart
at monthly intervals and the points joined up to form a growth curve.
9. The direction of the growth curve, rather than its position, is of key
importance.
10. A rising growth curve means a healthy child .
II . A flat growth curve is a warning signal.
12. A growth curve that turns downward calls for immediate action .
13. Health workers must be trained to use the growth chart, not only in
monitoring child health, but also as a tool for the health education of
mothers.
 Introduction

Paediatricians have long recognized that meas- marily to programme managers to help them to
urement of growth is a simple and useful way of decide as to :
monitoring the health of children. A study carried
• the value of growth monitoring in their child
out by WHO in 1972 showed that the weighing of
care programmes and how it can best be done
children was already common practice in periph-
in the local circumstances and in line with local
eral health services in many countries and that
programme needs and resources;
many different growth charts had been developed.
• what measures of growth should be used and
There was, however, still some confusion about
what measuring instruments should be selected;
certain fundamental and practical issues such as
• how the chart should be designed so that it is
the reference values to be used and the way that
most helpful to health workers in implementing
the chart should be designed.
the child care programme activities, taking into
With the cooperation of experts and prac-
consideration the skills of the workers and the
titioners in different countries, WHO coordinated
time available to them ;
an effort to solve some of these problems and to
• how mothers can be stimulated to interpret
promote the more widespread use of the growth
correctly the growth curve, and to take appro-
chart in primary health care. The publication A
priate action, when necessary;
growth chart for international use in maternal and
• how the training curriculum for health workers
child health care: guidelines for primary health care
and guidelines for the better use of the chart can
personnel (1) appeared in I 978 as a result of this
be developed.
work. It contained recommendations on growth
standards, a prototype of a growth chart, and In other words, it is aimed at assisting pro-
guidelines for the chart's use in health services. gramme managers in deciding how to develop and
This publication stimulated the use of growth use an instrument that will facilitate child care
monitoring in child care. Growth charts based on programme activities and make them more effec-
the principles suggested and adapted to local cir- tive, rather than calling for the use of a standard
cumstances and programme characteristics were chart, which may not correspond to local pro-
developed in various countries, and have been gramme needs and circumstances. It has been
widely used by both paediatricians and communi- found that, when a chart does not meet local
ty health workers as an instrument for assessing requirements, health workers have often resisted
the health of children and orienting the necessary using it or have simply neglected it.
actions. This publication should be complemented by
Growth charts are also a valuable aid in teach- guidelines for the use of the chart addressed to
ing the mother the basic principles of child health personnel at different levels and, if appropriate, to
care and obtaining her closer cooperation with the mothers; ideally, such guidelines should be devel-
health services in this care. In some cases, the oped locally. Model guidelines intended to be
growth chart has also been used to promote com- adapted locally are included in another WHO
munity participation in child health care and to publication, entitled Guidelines for training com-
generate interest and support from national munity health workers in nutrition (2) .
authorities. This publication will be useful to those respon-
In contrast to the I 978 publication, this book sible for planning and managing activities aimed
does not present detailed guidelines for the use of at preserving one of the greatest assets of any
growth charts and does not recommend a model nation- its children's health .
chart for international use. It is addressed pri-
 Part l
Principles of growth JDonitoring
and the growth chart

A growing child is a healthy child should not give rise to very great concern as long
as the child is growing adequatel y.
A child is by definition a growing individual. A knowledge of what adequate growth is, how
At birth, the size of the infant is the result of it can be properly observed, and how deviations
growth during the intrauterine period of life. from it can be recognized in good time is therefore
From then on there is a progressive increase in extremely useful in child care.
size until the child reaches adulthood. This
process is influenced by factors of two types:
(I) genetic or hereditary; and (2) environmental or
external. The genetic factors include ethnic What to measure
characteristics and the size of the parents, par-
ticularly of the mother. They are fixed , cannot be Three main types of anthropometric measure
modified, and will regulate growth from concep- are commonly used as indicators of size: length or
tion to adulthood. height, weight, and various body circumferences.
The environmental factors include primarily They all have advantages and disadvantages de-
nutrition, infections, intoxications, and other pending on the use to be made of the meas-
deleterious external influences that can prevent urements and the facilities available for making
the growth potential with which individuals are them.
genetically endowed from being fully realized.
These environmental factors can start to act
during intrauterine life; for instance, severe Length or height
malnutrition of the mother or heavy smoking
during pregnancy will result in the newborn being Length (height) is a very stable measure that
of smaller size than would otherwise have been reflects the total increase in size of the child up to
the case. the moment that it is determined , and therefore its
After birth, the influence of the external factors total previous health history; however, it changes
on growth becomes even more important because too slowly to be used in growth monitoring.
the child is more directly exposed to them. Infant It is also a fairly difficult measurement to make,
and child diet is, of course, of primary impor- particularly in infants and small children, for
tance. Any form of marginal or deficient supply whom monitoring is of greatest value. The possi-
of nutrients interferes with growth. Infections and ble inaccuracies, associated with the difficulties in
other diseases act in a similar way. making the measurement, make it much more
Because of the sensitivity of growth to external difficult to detect differences between two values
influences, its careful , continuous observation can determined within a short time interval.
be a valuable tool for monitoring the health of a Furthermore, length or height does not de-
child . Growth faltering can be detected in a child crease and therefore cannot indicate a deteriora-
long before any easily observable signs or symp- tion in health .
toms of malnutrition become evident. Similarly,
it can be the first manifestation of an infection or
other disease. Growth monitoring can therefore Weight for age
enable an early diagnosis of health problems to be
made and timely corrective measures instituted . The relative change of weight with age is more
The severity of a health problem can also be rapid than that of height and is much more sen-
assessed by its influence on growth. A chronic or sitive to any deterioration or improvement in the
unclearly defined health disturbance in a child health of the child.
10 The growth chart

Significant changes can be observed over ference seem to follow fairly closely those in body
periods of a few days. Making the measurement weight, it is a less sensitive measure for monitor-
is easy, so a high level of accuracy is possible. It ing purposes even than height.
is for these reasons that weight for age is the
measure usually employed in growth monitoring,
particularly in infants and young children. One Normal variability
possible disadvantage is that it may be affected by
abnormalities in body composition, for instance Normal variability is an important concept in
by the development of oedema, and this may the correct interpretation of body size and
confuse its interpretation . Particular attention growth.
should therefore be given to this possibility when Children of the same sex and of exactly the
dealing with severely malnourished children; same age, although all equally healthy and well
however, it should not interfere with the early nourished, have different weights- some are
detection of malnutrition, one of the main reasons smaller, some bigger.
for carrying out growth monitoring. These differences may be related to individual
characteristics of genetic origin, and have no
health significance whatsoever.
Weight for height In the weight-for-age chart obtained by plot-
ting the weights of a sample of healthy children
By relating the weight of a child to its height against age, a curve drawn in such a way that
or length an objective measure of the child's de- exactly 50% of the points are above it and 50%
gree of thinness can be obtained. below it is called the 50th percentile or median
Weight for height is more specific in this respect (Fig. I). On this chart, the limits of normal vari-
than the measurement of weight alone, which ability are indicated by a curve in the upper part,
does not distinguish between a tall, thin child and such that 97% of all points lie below it (97th
a short, fat one. However, for monitoring the percentile), and one in the lower part, leaving only
progress of an individual child, weight for height 3% of the points below it (3rd percentile). In other
has no advantage over weight for age. words, the 3% of children above the upper limit
Where the child health services are not able to and the 3% below the lower limit are regarded as
carry out periodic monitoring and children are exceptional- very big or very small- and are
seen irregularly or only once, weight for height is therefore not included in the "normal" range.
of value. Because it is independent of age, it can Since the main purpose of the growth chart is
be used in populations where children's ages are to identify children who, for health or other
not known. reasons, are not growing well, the two curves
A height/weight chart that can be fixed to a wall mentioned above may not be the most appropri-
or table has been developed (3) and is available ate.
from UNICEF. In the WHO prototype growth chart (see
Fig. 2), the upper reference curve represents the
50th percentile for boys (slightly higher than that
for girls) and the lower one the 3rd percentile for
Body circumferences
girls (slightly lower than that for boys).
The chart is thus suitable for use for the above-
The circumferences of the head or thorax may
mentioned purpose and can be used for both
be of specific clinical significance, but for health
sexes. As the only purpose of the reference lines
and particularly nutritional assessment the mid-
in the chart is for comparison, any one or several
arm circumference has been recommended .
such lines could be utilized.
Arm circumference can be a useful measure for
assessing thinness and therefore advanced malnu-
trition, particularly under field conditions when
weighing is impracticable. Choosing a reference population
It could thus be of value in screening large
populations, for instance, when it is necessary, The normal growth of children in a given pop-
under field conditions, to identify those children ulation can be determined in two ways: (a) a
in greater need of nutritional assistance. Simple, group of well-nourished, healthy children are
appropriate technology has been developed for followed from birth to a specific age and weighed
measuring it. Although changes in arm circum- at frequent intervals (prospective or longitudinal
 Principles of growth monitoring II

97 th percentile
• • • • •
• • •
• •
• 50th percentile
•
• • • • ••
• • • •
• • • • • •
• • • • •
• • • • • •• 3 rd percentile
• • • • •
•
•
"~
~
0

~~--------------------------------------------------------------------------~~
Fig. 1. Diagram showing 3rd , 50th, and 97th percentiles

method); and (b) children of all ages within the have been calculated for the distribution by the
desired range (0- 5 years of age, for example) are Centers for Disease Control. There are separate
weighed once (cross-sectional method). sets of data from two different child populations:
For reasons of convenience the second method for the 0- 36-month age group, from studies made
is usually adopted . The cross-sectional approach at the Fels Research Institute, Yellow Springs,
has its limitations in that children who have Ohio; and for the 2- 18-year age group, from
passed through a period of inadequate growth national samples of the National Center for
cannot be identified and excluded from the Health Statistics.
analysis of the data. The suitability of the NCHS values for use as
Data to be used as reference values should meet international standards has been questioned. It
the following conditions (4): has been suggested that it may not be valid to
compare the growth of Asian or African children
• The measurements should be made on a sample
with that of children in the United States of
drawn from a well-nourished population.
America because of racial differences in growth
• The sample should include at least 200 in-
patterns . However, it has been found that children
dividuals in each age and sex group.
living under optimal environmental conditions in
• The sampling procedures should be defined and
many different developing countries have growth
reproducible.
patterns very closely resembling those corre-
• The measurements should be carefully taken
sponding to the NCHS data. This observation
and recorded by trained observers, using equip-
was confirmed when the WHO prototype chart
ment of well-tested design and calibrated at
was tested in various countries (1).
frequent intervals.
It is believed that any weight differences be-
In the United States of America, data have been tween children from different countries that might
assembled by the National Center for Health be due to race would be relatively small in
Statistics (NCHS) that meet most of the above comparison with the large differences actually ob-
criteria (5). Centile distributions and the median served due to environmental factors (infectious
plus and minus I , 2, and 3 standard deviations diseases and insufficient dietary intake).
 A. Face of chart ;:::;
REASONS FOR SPECIAL CARE 22• I I I I I I I I I I I I I I I I I I I I I I I

Name
· 211 I I I I I I I I I I I I I I I I I I I I I I I I
Birth weight ....... ... . kg
201 I I I I I I I I I I I I I I I I I I I I I I I I

19

1~~~~~c 11111111 u1111111111 rllllll :1-1ttt:1~:: 15 /

H

· · · . ... ~ · ·
: ~ ~:. >~:-~
-nnnllllll ll
1
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - ....... ~ r.- - - . - - - - . .1.1 .1J IJ 1-1 J IJ IJ I.
WEIGHT 14 .- ~ 14

13
12
- ~~ -- - - : : :: : - : : :
~ l,.....o-
:: : :: : : ~ ~~ ~- <~ <' - :: 13 :
12 t-+t--!:-tiooot"'f-...H+Ic++-t-++t+++-+++
: ~~ - ]1111 ' -l
::r
11 - - - - - -~
- ~ J· - - - .. - - . - - - - - -- - - ;,;.~~ -- - - - - - - - . - . - - - - - - - - - - - - - . - - ,.:_:.~ 11 ~ - - - - - - - - - - - - - - - . - - - . -
(1)

..,
(JQ

0
~
10 -- v~ ~ / ----; : . .;. ~~~-:-:. ---------- ---- ---- ~ -- -:,:.pi---":":"~ - · - - - - 10 - - - · - - - - · - - - - - - - - - - - - - · -j :;.

~.I /~-" --- -~ ~""'"~--""'" --

(")

--- - ::r
"'~
vv~~ -:.-1
9 9 - - - - -

; 8 - .:. -;..;;.- ~ -- -- -- -- - - -- - - - -- -- 8 -- - --

:
(,:)
7 v ~
- - - . - - / - - . - - - ~~ - - - - - --- -- - - - - - - - - - - . - - - - - - - - - - - -- - - -- -- - - -- -- - - - - -- - -
o 6 I
~ 1- ---~ / ------------------ ---------- ---- ---- -.- -----'--,----.- --------
n1nr11 iri i
5 -- --

::-~7 v- ::::::::: :: ::-:-_:-: ::: ::: :_:.-:::

4th YEAR 5th YEAR

_ ~ ___ ____ _ __ __ __ __ __ _. _ _ 13 14 15 16 17 18 19 20 21 22 23 24 3rd YEAR

2
,
1 1
2 3
1
4\ 6
1 1 1 1 1 1
7 8 9 10 11 ,12J IIIIIIIIIIJ 2nd YEAR

AGE IN MONTHS

Fig. 2. WHO prototype growth chart (face) (for reverse , see Fig. 12)
 Principles of growth monitoring 13

When to measure Types of chart

A growth chart is designed primarily for the The essential feature of a growth chart is a
longitudinal follow-up of a child, so that changes graph on which weight is plotted against age so
in weight over time can be interpreted. A single that growth can be followed graphically in com-
measurement of the weight of a child may be very parison with reference standards. The design of
difficult to interpret properly without additional the graph should be carefully thought out so as to
information. Periodic weighing is therefore neces- facilitate its use (plotting of periodic weight-for-
sary and a decision has to be made as to the age measurements) and interpretation (growth
periodicity. rate and deviations from growth pattern).
The first measure should be obtained at birth Weight units are marked on the vertical axis;
or as soon as possible afterwards. The birth these are usually kilograms, but if another unit
weight is itself of great importance in diagnosis (e.g., pounds) is normally used in the locality and
and prognosis (a subject that will not be discussed the balances to be employed are graduated in that
here), and for the purpose of growth monitoring unit, it may be preferable to use it in the graph.
it is extremely useful in the proper interpretation Subdivisions of half a kilogram are useful in in-
of the future pattern of growth. creasing the accuracy of the values plotted. The
Children who are small at birth, if their small- horizontal axis shows the age of the child, usually
ness is not due to prematurity or to intrauterine from birth to 5 years, divided into months and
malnutrition, will usually remain small; they will subdivisions of half a month, again in order to
follow a curve running parallel to but below the facilitate accurate plotting.
median . Without the information on birth weight, It has been found useful to give more space to
the small size of such a baby could be misinter- the first three years of age, and to compress the
preted as being due to insufficient dietary intake fourth and fifth, because the younger the child the
or other health problems. more rapid its growth and the greater the sensitiv-
ity to deviations; weighing should therefore be
How frequently children should be weighed more frequent during this initial period .
after birth must be decided in the light of the other
The type of calendar used in the WHO
activities scheduled (e.g., immunizations), the
prototype chart is that originally proposed by
ability of the mothers to attend the health centre
Morley (6) , which has the advantage, if it is
or clinic, the time available to the personnel for
properly used and the month of birth has been
this purpose, the health workers' schedule for
determined, of giving the age of the child auto-
home visiting, etc., and, for the individual case,
matically whenever his or her weight is measured
the health condition and health risks of the child.
subsequently.
Ideally, children should be weighed at least
Running diagonally across the graph are curves
once every month during the first year, every two
representing reference values. As indicated
months during the second year, and every three
previously (see page 10), the WHO prototype
months thereafter up to five years of age, the first
growth chart has two curves, the upper corre-
three years being the most critical period.
sponding to the 50th percentile of the reference
In addition to this schedule, however, every standard and the lower to the 3rd percentile (see
child should be weighed and the weight plotted on Fig. 2).
the chart every time he or she is brought to the Some charts have been prepared with more
health service for any reason, particularly if the than two curves (Fig. 3 and 4), leaving narrow
child is sick. spaces (channels) between them. The intention is
Personnel should see the weighing as a diagnos- to emphasize the fact that different children fol-
tic tool, valuable both at the time of the consulta- low different channels and to facilitate the visual
tion and in the follow-up . appreciation of deviations from a growth curve
When the child is first seen a long time after and changes of channel; colours having the con-
birth, the first weight measurement should be notation of health or disease in the local culture
interpreted with the help of a carefully taken his- have been added. In another chart, developed in
tory, including, if possible, the weight at birth (or Indonesia (Fig. 5), the coloured bands indicate
an approximation to it) and any other previous the limits of "normality" and different degrees ot
weight measurement, as well as a physical exam- malnutrition .
ination. Subsequent periodic weighing should The use of colours and channels could help to
substantiate the original interpretation. bring home to the mother the fact that her child's
14 The growth chart

WEIGHT CURVE FROM TO 5 YEARS OF AGE

.. BIRTH (fcti
16 ijl(~ ~ ~~ qr~ ~ ctil ~~ eli ~t:f cit t\CJT
-:1

15
I
14 DATE OF BIRTH
" " ' "'' ifl"fillll
r- ' .....
I« WEIGHT AT BIRTH
13 r- t::.:!
~tT;..
'1"1 ~ «•HI <1'1~
1- ilr "C
12 1- "" <
1-i< Oil~
fl) 1- Af .: ~
::! 11 1- R" r; ;;
c( 1-r.osQ.,
a: 10 ~~c: 0
Cl f-~ :,... -
0 1-t::::
..J 9 r-~e
~ 1- 'IT~
I- 'if
z 8 1--
1- 1!:
1- ~
:I: 7 :....;i;
Q '- ii
c-
Ill
6
~ 63 66 69 7
5
51 54 57 60
4
39 42 45 48
3 tl{ ~ - 27 30 33 36
2
15 18 21 24
1
3 6 9 12
0
0 AGE IN MONTHS

~·-(0 ~ '"""- 11~- • ..t _'too ~l'<ftm ~· ~ ~ ~ q';;rif, "'""" '1~ ll'f;1rnf <J:<'l'fl' '!m. ;nrr ~q';;rif q '!ll'
\!IT 'ttn ~l{<j;'j'fl' ;RC[T<f [tit ~ '!m. 'l'Cn: Cl!l ~ .T'1{T 'ttn ~ ~ ~ "''m.
~.-(''l) ~ ~~ q';;rif ~ ~"' arnrlr. ;nrr ~ q';;rif 'ttn ~ .. mll'l ~m. arol~'"'IT 31$>r ~anwmfmrJT•'lrft<ft
~'f <!flll'l'l'1it Cl!l'fT ~mrr '"' 'lm'!r. ;nrr ~ q';;rif .T'f q <fA' ll'l ~ mm arr~ Cl!l <rn?<f>l"ft ~ ~m ~
"''T'fT .. rnli'J!l1it «'lit! ~ m<!l. ;nrr ~~ q';;rif f<rtR~T wrerr 1iiT\'ft arr~ <ll't;ft ~ ~m;;r '!mit. ~ 'll¥ <ll'RT ~
'll'T'lT :;nfirr ;nri'f q';;rif "fi"'T wrerr lS('Wr arr~ am ~ ~ O!i<O!l • '34"1 1<1\116'1 q;r ~.

Fig. 3. Growth chart in use in India, showing use of several reference curves to indicate the nutritional
status of the child

curve is moving in a wrong and dangerous direc- able, the need for understanding on the part of the
tion, but it might, on the other hand, present mothers, and other local circumstances.
problems of interpretation and give rise to un-
The chart must include a proper identification
necessary concern in the case of small children
of the child . The following information may also
who are growing normally but whose growth
be included :
curve lies on a low percentile. In contrast, natu-
rally large children who may not be growing well • important care interventions (e.g., immuni-
may fail to arouse concern because their growth zations, family planning) (see Fig. 2 and
curves are nevertheless still within the limits of Fig. 5- 7);
"normality" . • a graphic reminder of action to be taken at
Many other examples could be mentioned (see particular times (Fig. 8, page 19);
Fig. 6 and 7); all have certain advantages and • family data and other information that may
disadvantages. influence the child's health (risk factors) (Fig. 9,
Programme managers will have to find a suit- page 19);
able compromise between complexity and ease of • events of significance for the health of the child
use and interpretation, in accordance with the (e.g. , spacing between siblings, diseases,
programme objectives and with due consideration chemoprophylaxis, dietary changes) (Fig. 10
of cost, the skills of the workers, the time avail- and 11, page 20) .
 22 I I I I I I I I I I I I I I I I It I • 1 I I

:' .;·'' ~', I ~ _) e) ~:-"\ ~

~1VICU-n'Jnfl btm:LmtJnt1~reJ~'Yl~ ~dl-o~1f11~'a~fltlf11~
I

6( bflfl L~'ltl 'tnt! 0-5

., tJ 211 I I I I I I I I I I I I I I I I I I I I I 1-+-1

20 I I I I I I I I I I I I I I I I I I I I I I I I I
NORMAL WEIGHT AND OEGREE OF MALNUlRITION THAI CHILDREN, AGE 0-5 YEARS t9i I I! I I I I II I II II I I Il l I II I I

•" ol
U1VI'Uf1 w t.
ttl
13 ..,"0
:;·
n
12 .;·

11
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"'0....,
..,
OQ
0
10 :E
g.
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9 0
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~ 8 :;·
OQ
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3 16 17 t8 19 20 21 22 23 24

~!!II!IIJJIJJ!II!IIIII~
- . - - - .... ·z__I I
L__l_~_
lllWJJJJ211 • "' ~~·
.. I C' •

.:::II n?J~~.,·{u, m -7
;:;;
111 tJ, ( bf) fl'U ) AGE M0 " nfjlJ'f)\1.'1"--tl

Fig . 4. Thai growth chart, showing use of several growth cu rves and colours to indicate the nutritional status of the child
 PENCEGAHAN LEBIH BAlK DAN LEBIH MURAH
DARIPADA PENGOBATAN
RENCANAKANLAH KELAHIRAN BAYI ANDA
BERJARAK 3 TAHUN
UMUR 3-STAHUN 0\

AMATILAH SELALU DENGAN TERATUR BERAT

BADAN BAYI ANDA; BILA TERJAOI KEBERSIHAN LINGKUNGAN MENJAMIN BATASILAH JUMLAH ANAK ANDA
PENYIMPANGAN. HUBUNGILAH OOKTER KESEHATAN BAYI ANDA
ATAU PETUGAS KESEHATAN
PELIHARALAH LINGKUNGAN HIDUP ANDA
SECARA SEHAT DAN BERSIH
UMUR 2- 3 TAHUN
TIMBANGLAH PUTERA ANDA HINDARKANLAH GENANGAN AIR
SETIAP BULAN Dl LINGKUNGAN

W tt obesitas UMUR 1 - 2 TAHUN

I I gizi lebih
I I gizi baik
I I gizi kurang
gizi buruk

UMUR 0 -1 TAHUN

-l
::r
"...,
OC>
0
~
;:.
(")
::r
"'
;:l

CAT AT AN DOKTER/PETUGAS KESEHATAN

CATATAN DOKTER / PETUGAS KESEHATAN

TERUSKANLAH KEBIASAAN MENYUSUI

BAYI ANDA

lsilah kolom ini dengan bulan dan tahun kela- SETIAP BAYI BERHAK MEMPEROLEH
hiran anak. lsilah kolom -kolom berikutnya de- AIR SUSU IBU
ngan bulan-bulan selanjutnya .

Fig. 5. Indonesian growth chart, showing use of several growth curves and colours to indicate the nutritional status of the child
 0 a 3 MESES EDAD 1 a 2 ANOS EDAD 3 a 4 ANOS EDAD
23 23
Sostiene Ia cabeza. Cam ina y corre . Salta en un solo pie . +--+-1-f- --1-+---t --l- t--
lnten ta eager objetos. Al.Jre y cierra puertas . O ibuja una persona. 22 t 1- t 1 I t 1=1 =1 . -1-+-4--l--l-1- ~+-+--
I I I I I I I I I I I I I I I 122
Sonrie a Ia mama. Reconoce objetos y personas. _ __ Pid e lo que desea .
. -+ -1-- 1- +-+ -1 ---l- 1- 1- +- + --t -1-+ --l-1- +-+- -1-1-- /-

-· :~Lt-t-tl l1 t l i t ti t t :: : : : : : : : :::
Reacciona al sonajero. A yuda a vestirse y desvestirse . _ __ Sa be su nombre.

trltnr
3 a 6 MESES 2 a 3 ANOS 4 a 5 AriiOS
· - ,_ +--.--+- + -+--+ - + - f- +-+--+-1- -+-t- -
Se vol tea solo. Salta en dos pies. Da sal tos grandes.
Coge un objeto en cada mano . _ __ Traza ray as o circulos . ln icia trazos de letras .
1- -+- f-
Trata de imitar sonidos.
Reconoce ·personas.
Dice frases cortas.
Se identifica
nina.
como nif)o o
Nombra uno o mils colores .
Juega co n otros niiios imitan-
do a los adultos.
~: -- t - -·-- - ~
-r - -
- !-- --- ~-~
-- -- --
-: - ~~:
6 a 9 MESES -+--+ - I--+---+ - I--+ - ·- - ·-- _pp-k - --l- -t - 1--·
Se sienta solo 17}- ....... - 17"'
manes. _ __ -!-- · - - ! - - - - - - - · --~-!--+- -~I- - --!---- -· - - · - - ·- - - -~ ~ ·- - !-- ·-'- -f- - - 0
Pasa objetos de las
Dice Pa Pa · Ma · Ma .
Hace palmoteos.
16
- - f - - !-- -- -----I- - -~ ~ I- f- - - !-- - ·--- - - -- ~~
~
-
--
·- - -- · --
.
-1-i-1-- -- - -· ·-
16 =
~
I

9 a 12 MESES
Se para con apoyo.
15

14
-1- ·- -1- - -- - --- - - f.-!-- I_.......
....... --~ - !-- ·--
...-:f-- 1-- f---
-1-- ·- - -·-
- - - --
- - t1-- ··- - .. ' .
I
. -+-
. ·--
-· -- - - - ·- - ·-
15 0

14
<I>
~

Agarra con dos dedos. ·-f-1-- · - ·-- -- -- ·-- - ~~~ ~~

- - !-- - - -- - I- -- - -- - -- - -- t-
. -·
- ~--- ....... ~~ ~-
- -- -
Pronuncia clara Papa, Mam a. _ __ 13 ~- - f--- --- - e- -- - -f.-- - - I--- ;_..f.--~ 13
Introduce y saca objetos de } --1-- ----- - _::..;:;.;;;-~ ___ ,...-I- -- __ ,... - -·- -1-- ~p--"""'-::: -· r · . --- - ·---
. - f-.- ~ ~~ 1-- - 1- -· - - - · -- +-- -~
una caja .

11
12
---- ;;.;.;-1-->-::- . ___
-1---
-
- -!---
- -- i-- --f.-- -- ~- I - - · f.- f.-
-
- f-.-
---~i;ooo~~"::"--- -- - 1--
/--
-
-- ---+ - I- --1-- -f.- - - 1-- · -
12

11
::,0
5
Q.
~-"' 1 , . f.-P "0
-1-- - ·- - 1- - - -- - ;/~ .,... ~- - --. -+ -- -·. - ~~ .. . +-· · -
·- - - 1-- - - - - · - - f-
'0"
1 ......

-I- --· -. -- f-
10
--- -- - f-- -- - - ~~
,.... .
--- -1-- -- C - 1--
. - ~- -·
- _:::;.;-~- ·--··
-r----- -
_,... - - - - 1-- f. -- + -+- 1- f- -- ,_,_ +--+ --1 - --
10
</>

...,
9 / - -- ~- -- - ~ ~- -· f-.- -~· 9 ...,
()Q
0
~- - I- - -f-- - p- / - - -'-- - _.::::.;;.---...-:::::::--I- - - - - -- - - !--
1-- - I- - - - - - - .- -·- ·- - - - - - - - - - - - .- 8 :E
:;:.
8
--- -- v V -1-- -
....~
p- ---- ------ ··- ~- -- -- 1- - -- -·-
37 38 39 40 41 42 43 44 45 46 47 4 8 49 so 51 52 53 54 55 56 57 58 59 hn
3
0
7
- - ,__ _/ / _ - -1-- 7 ~ l- - - -- -I- -- - - - - - --!-- - -· - - -- =·
~
3 65 tt - ;,/ ·- - r- ~1 - - -- -~-- -- -- - - - -- c----
- -- 1-----·---f---4
--r·i ;::;·
()Q

~
64 ,
I --/- --+ --1 - +--t - l--+1- t-1..1+ ..-+1.-+.1 -1-
/
+-+ - 1- - 1- --+- -1- -+ - -+-+-+-+ - f-
.1 _l _l _l __ l _ I__ I_.I_ I __I __I __ I __I __ I_J _ I__ I_J __I__u
f-
1 I I 1
4 AriiOS 5 ANOS
"'..- - r - --- f - f--t -1--
~ 3 ,
- ;~ - - -- --· -- ---
2
- ·-+--· ·- - -· - - - -
Por Ia Salud de su hijo, evite nuevo embarazo
tf-r- --- -- --- -- - antes de los 2 enos de edad del nino.

0
•Z
If 11f ilif I" 11' 1"11
2 0 2
AriiOS
JANOS

~11111 1 1 1 1
<
w
::;
I I- I- I- 1 ANO
VIGILANCIA DEL CRECIMIENTO Y DESARROLLO

Fig. 6. Colombian growth chart. This also gives information on child development and advises the mother not to become pregnant again until
Trazo Ltda . · Ot agr amact o n
'r1110 55~·10
--l

the child is two years old

 3C? ano
Motivos para cuidados espec:iaia: Anote no mis que ocorre 17 11
--t
00
Des marne
Diarre\1 JIIYC
Sarampo
Pneumonia
Outras doen~as graves
Problemas da alimenta~io
~· -· - - - -- - - ·

0 Peso ao nuoer iaual ou infe- 0 3 ou mais lnnios mortos

16
rior • 2,5 kl
Anemia vave Coqueluche Nova gravidez da mie
16
O Gemeo 0 Diferen~a inferior a 2 anos en· 2C? a no I -· f- - -- -- -- - - - - r-- --t
-

o 5' rllhP ou mai•

0 Irmios dcanutridos
tre innios

o ;:e;ou pai ausent• hi mwto

Miva~io recente da familia
0
I~ _ _ ~ _____ _ _ 'I . __
14
1-- _ _ _ - · _ _

-~
_ . ~n
14
14
I C? a no J- - - - - - - - ·- - - - - - J - - - ··· - - ~k:"'"~ -- - 1
13
~ --- ---f-Y -- --- ~ ·
13
- - -- -- - - ------w - - -- ·- --- - -- -13 --- ---
-~
I~
12 12 ~ ~,...- 12 I~
It - - -_: - -~@") - - - It - ,_:-_.:~~~ - -~~ --~ _:_~1
~L~
t- _
~/ f - -:
;fo::~ - ·- - - -- - - ~- ~ -=-~p"-- - - - - - ;t
,ft?p -- v -- + - - - - ~-w -- -, --------1
+ -

c ;
- - - -- - -

~ ---- - - - /v ---- 1 - ~ - - .;-~-:- - - --

-l
9 / 9 -- - 9 9
~ -t f- - - - - - - - - - - · - - - - - -
;:,-
(1)

..,
(JQ

8 8 1,...- 8 8 0
~
Cll ~ - - - - -- -- - / - - - - - - ·- - - ~ - 1-- - - - - - - - - - - i - - - -- e- - f- - - ~ - - - i :r

t - - --- - ---- -T-

<( n
:I
<(
a::
(!)
T -// ___.r v - - - -- -- --i
;:,-
po
;:l

I .- v -- vv - -
0
_I 6 / 6 6 6
~ ~ 1-- . - - - -- - - - - - -- 1-- - t-- - I I I I I I I I I I I
0 5 5 2!1 26 27 28 29 0 31 32 33 4 3!1

I -ITt- -v v- - - - . I I I I I I I I I I I I

1
~ ~
c /v _ . _ _ , _
__ __ . __ ._ ____ _
I 14 1!1 16

1
I
17 18 I~ 20 21 22 23 24

Repare a dir~io da linha que ..-ra a evolu~ da crian~a

2 • 0

I I I I I I I I I I I I CURVA SUPERIOR: peso medio da crian~a sadia e bern o/ ·-• ""'•

3 4 6 9 10 alimentada BOM SINAL DE PERIGO GRANDE PERIGO
I 2

I I Il
A crian~a esti. crescendo Acontdhc: que a cri~a A crian~a podc utar
CUR VA INFERIOR: peso medio da crian~a em lugarcs carcn- coma pek> mmot j vczes docnt.c, prcciae de cWda-
bem
tcs do mundo em desenvolvim~nto ao di1 dol apeciaia

Aconsclhc a mic a dar comida adicional maia vezes pan ajudar a crianc;a •
crncer. WHO ~S2 4 1
'--

Fig . 7. Brazilian growth chart. The significance of the two reference curves is explained, as well as that of the direction of the child's growth curve
 Principles of growth monitoring 19

TRIPLE ANTIGEN MEASLES

POLIO

~ ~ ~
0 0 0 <>o

15 g)
"'<>o
L_ J 0
~

Fig. 8. Illustrations on the growth chart as reminders of the appropriate

time to give immunizations

The decision as to what to include, in addition The tendency to record too much, thus making
to the identification data, should be based on the the chart difficult to read, should be avoided . It
programme for which the chart has been should always be remembered that the informa-
prepared, taking into consideration the need to tion recorded must have a use. The chart should
leave enough space to permit easy and clear re- be a tool for diagnosis, a reminder to the health
cording. Only information that is going to be used worker of actions to be taken, and an educational
should be recorded. Efforts should be made to instrument for the mother and family.
ensure that events, instructions, etc., are recorded
with the minimum of writing; the maximum use Reasons for
should be made of symbols, graphical repre- Special Care
sentations and checking of boxes, provided that Birthweight less
these indications are clearly understood both by than 2,5 kg [ ]
the health workers and by the mothers and that
they are adapted to the local culture. Fifth child D
or more
Important events, such as diseases, treatment,
or dietary changes, can be recorded on the graph Brothers or
itself, in the appropriate age column, above the sisters D
undernourished
growth reference curves. Appropriate feeding in-
structions can also be included on the graph; these
Birth less than 2
may be represented graphically or in any other years after D
way that is easy to understand, and should always last birth
be adapted to local practices and food availabil- Twins 0
ity, and consistent with the programme recom-
mendations.
3 or more
Special prophylactic measures, such as malaria children ll
prophylaxis or periodic vitamin A administration, in family died
may usefully be recorded on the chart, either in a ~ <>o
Single
special space provided for them or above the Parent [] ~
graph, depending on the importance of the activ-
ity in the programme. Child-spacipg methods can Fig. 9. List of risk factors that may influence the
similarly be included. child's health
20 The growth chart

Birth-1 year

Fig. 10. Recording of child-spacing

Designing the chart

~-r--- --- - ·- r- ·
2 The chart should be printed on material strong
,__ __ -- - - - --- - enough to withstand five years of frequent use.
Since the chart is primarily a home-based record,
Breast Feeding
a plastic envelope in which it can be kept is useful.
Food The chart should be big enough for the spaces
Malaria pill
between the lines of the grid to be clearly distin-
1 2 3 4 guished and the points corresponding to the
monthly weighings should be far enough apart for
the direction of the growth curve to be readily
appreciated. The size of a standard sheet of writ-
ing paper (for instance international standard A4
size, 297 x 210 mm) has proved to be adequate
Fig. 11. Recording of breast-feeding , the introduc-
tion of solids, and malaria prophylaxis and convenient for the suppliers. This also allows
enough space for recording the desired additional
information.
Since one of the main purposes of the chart is
to educate the mother and encourage her to par-
ticipate more actively in growth monitoring, it has
been found useful to have duplicate charts for
each child: one, on thick card , is kept by the
mother, who brings it with the child at every
consultation; a second, on thin card, is kept by the
Fig. 12 shows the reverse of the prototype chart health service. If this proves to be impracticable
developed by WHO, in which most of the above because of the extra work involved in keeping two
components are included. charts up to date or because of the extra cost, and
Useful suggestions as to the layout of the chart only one chart is provided, this should be given
and its use have been made elsewhere (7). A tech- to the mother and all the information of interest
nical review of growth monitoring, which includes to the health service contained in it kept in the
an analysis of a number of different growth ordinary service records.
charts, has been published by the American Pub- As far as the design of the chart itself is con-
lic Health Association (8). cerned, the following recommendations are made:
 APPOINTMENTS GROWTH CHART
Health centre Child's No.

Child's name

Date first seen IBirthday

--
Mother's name Registration No.

Father's name Registration No.

- -
1--· Where the family lives (address)
- - - - - - - - - - --------- - - - - 1--· -- - - - -
-------- - - - -----·
- - - - ---------------------·· - - - - -----
-------·--- - f- - - - - · - - -- - - - - - - - ...."0
BROTHERS AND SISTERS ::;-
- - - - - - - - - - - -- ------·- ----- - - -------------- -------- !:?.
Year/birth Boy / Girl Remarks Year/birth Boy/Girl Remarks '0
- - - -- - - - - -- -- - <>
--- "'0
...,
- -- - ------- -------- ()Q
....0
----- - - - - :!;
:;.
3
0
2.
0....
IMMUNIZATIONS :;·
()Q

TUBERCULOSIS Vaccine (BCG) - Date : ..

DIPHTHERIA, WHOOPING COUGH, TETANUS Vaccine (OPT)

Date : 1 dose 2 dose

3 dose
POLIOMYELITIS Vaccine (OPV)

Date : 1 dose ... 2 dose

3 dose ......

Has the mother had her tetan us vaccine? MEASLES Vaccine-Date : ....

Date : 1st dose 2n d dose OTHER Vaccines (specify with date) :

"'"'
0

Repeat dose
~I N

Fig . 12. WHO prototype growth chart (reverse)

22 The growth chart

(1) The weight-for-age graph should be printed

on one full side of the chart.
(2) The first three years, when growth is more
rapid and weighing more frequent, should cover
two-thirds of the space available. The next two
years should fit into the remaining third of the
card.
(3) In each of the year panels, sufficient boxes
should be included to cover the expected range of
weights of children of that age.
(4) Weights should be expressed in the unit
commonly used in the area (e.g., kg or lb).
(5) Unbroken lines should be used to indicate
each kilogram (or approximate equivalent) while
dotted lines should be used for half kilograms.
(6) The calendar should be divided into
months, which should be numbered. The box for
each month should be long enough to allow the
name of the month and the year to be inserted in
it. The year should be mentioned in the first box
and at the beginning of each subsequent year.
(7) A short line at the top of the month box can
be used to divide the boxes into two-week inter-
vals. This will make it easier to plot weights on the
chart in accordance with the period of the month Fig. 13. Beam balance for children under five
in which the child is seen. years old

Choosing a scale provided with a platform on which the child can

stand while being weighed (Fig. 14); both are very
Since the weight of a child provides very useful convenient when used in a fixed position but are
information in assessing its health status, it is expensive. The second type is the hanging beam
important that weighing should be as accurate as scale or bar scale (Fig. 15), traditionally used as
possible, particularly when measurements are market scales in many countries and recently
made at short intervals to monitor growth. adapted to weighing small children with the aid
What type of scale should be used? This is the of a locally made sling in which the child can be
first major decision to be made in ensuring that safely placed. It is easier to transport, particularly
weighing is accurate. Careful consideration if made of lightweight metal, and cheaper than the
should be given to this question, to which there clinic scales.
is no general answer. How and where the scale is Spring scales have been more popular because
going to be used- whether at home or at the they are compact, small, easy to transport and
health centre- the local conditions, the cost, the easier to read; they do not, however, retain their
durability, and the maintenance facilities are accuracy with prolonged use. There are two types
among the considerations to be taken into ac- of spring scale, the dial-faced (Fig. 16) and the
count in making the choice. tubular (Fig. 17), the first being easier to read but
Scales of two different types are generally avail- more expenstve.
able, namely beam scales and spring scales. In Whatever the model selected, it should be re-
general, beam scales are more accurate and have membered that, for monitoring the weight of chil-
greater durability, but they are also heavier and dren under 5 years of age, the capacity should be
more difficult to transport. Two types of beam at least 25 kg. The scale should be accurate to at
scale are commonly used, the first being the clinic least 250 g, but preferably to 100 g. Scales should
model. For infants, this can be placed on a table be fitted with an adjusting mechanism enabling
and is fitted with a pan in which the infant can be the needle to be returned exactly to zero when the
comfortably placed (Fig. 13), while for older chil- scale is empty and after the hanger or towel in
dren and adults, it is placed on the floor and is which the child is to be placed has been attached.
 Principles of growth monitoring 23

A good scale is a good beginning but its proper

use is even more important. Personnel should
therefore be carefully trained in the weighing
procedure (see page 26).

How to use the growth chart in monitoring

child health

The growth chart is primarily designed as a

means of monitoring and interpreting changes in
weight over time. A single measure of the weight
of a child cannot by itself be properly interpreted
on the chart. Ideally, the chart should be used
from birth. A curve running from the birth weight
of the infant, marked on the first column of the
chart at the level of the corresponding weight, to
the points representing the subsequent periodic
weighings (at least at monthly intervals during the
first year) represents the pattern of growth of that
particular infant and is an excellent indicator of
its health and nutritional status.

Fig. 15. Bar scale and comfortable sling seat for

weighing young children

Children growing normally will follow curves

running parallel to the reference curves.
When the median and the 3rd percentile are
used as references, the curves for the large major-
ity of healthy children will lie between or above
these reference curves. Some may, however, be
just below the lower curve, but if growth is at the
same rate and in the same direction as the refer-
ence curve, and there is no clinical reason for
concern, no action is needed . The children in
question should be observed closely but it is likely
that they are simply small, healthy children.
When some children are first weighed, the
Fig . 14. Beam balance for preschool and older corresponding point on the chart may be low
children because they are very thin (low weight for height).
24 The growth chart

Fig. 16. Spring scale with a dial Fig. 17. Tubular spring scale for weighing
newborns and infants

The weight-for-age chart does not take height into limits of " normal" weight for age, the child is
consideration; this is one of its limitations, but the losing weight- an indication of poor health; his
problem arises mainly on the first examination. If own normal pattern of growth would probably
children are followed up, with periodic weighing, run higher in the graph. If the curve is as shown
and are becoming thinner, this will show up in in B, the child is growing normally and the growth
their growth curves. A child may also have a low curve is parallel to the reference curves; he is
weight for age because he is retarded in height therefore doing well . If the curve is as shown in
(stunted) as a consequence of malnutrition at an C, the child is growing at a faster rate than expect-
early age; such a child may not be malnourished ed, which probably indicates that he is recovering
at the time of the examination. (catching up) from the effects of malnutrition or
A single point representing the weight of an some other cause of underweight.
infant at a particular time is not by itself sufficient It is therefore only by following children over
for the diagnosis of malnutrition particularly in time, with periodic weighing, that growth curves
older children, when the chances of a combination can be properly interpreted and used as a diagnos-
of low weight for age with normal weight for tic tool for preventive or corrective action . If, for
height are greater. What is important is not the example, a child fail s to gain weight for two
weight of the child at a given age but the path by months or more his growth curve will become flat.
which that weight was reached (see Fig. 18). This is a n alarm signal regardless of the position
Fig. 18 shows how any point on a growth curve of the curve in relation to the reference curves. It
can be arrived at in three ways. If it is arrived at is equally bad for a big child not to gain weight
from above, as in A, the present situation should as it is for a small one; both should normally be
be a cause for concern. Although still within the growing at the same rate.
 Principles of growth monitoring 25

Obviously if the growth curve of a child drops,

i.e., he weighs less than he did on a previous
occasion, something is wrong with his health. In
order to facilitate the identification of growth
faltering, and to show the mother that the child
has changed position, charts with many narrower
channels, sometimes coloured, have been devel-
oped, e.g., the Indonesian chart (Fig. 5). Their
possible advantages should be carefully balanced
against their higher cost and the possibility of
confusing even more a chart that many mothers
find difficult to interpret, particularly in cultures .
not accustomed to this type of symbolism.
The full interpretation of a child's growth curve
requires a carefully taken history and a clinical
examination.
Nevertheless any person, even with little or no
training in health, if taught to use the chart
properly, should be able to see the warning signs
indicating that something is going wrong. This
will frequently be possible before the child shows
any other signs or symptoms.
Furthermore, the graphical representation,
once understood, helps in the evaluation of
growth without the need to remember how much
a child should gain in weight at different ages-
something that even physicians tend to forget.
In addition to its use in monitoring and guiding
the care of the child by both the health service and
~
iii the mother, the chart can provide a useful record
L __ _ _ _ _ _ _ _ _ _ ___,
Q
i of important health-related events. Information
on the health history of the child that the mother
Fig. 18. Section of growth chart showing how the may forget and that is important for his care, e. g.,
same point can be reached from three directions diseases suffered and immunizations received, will
A-from above; 8-horizontally; be recorded whenever the mother takes the child
C-from below to the health centre, hospital, or day-care centre.
 Part2
Training health workers
to use ,the chart

As with any other instrument, appropriate will be using. The proper weighing procedure
training is essential for the correct use of the should be explained to them, with particular em-
growth chart. phasis on the following points:
At the end of the training, the health workers
• The scale should be checked each time it is
should be able to: moved by verifying that it reads zero when
- understand the concept of growth and the fac- empty and checking the reading for a known
tors that promote or retard normal growth; weight.
- weigh an infant or child accurately; • The needle should be adjusted to zero before
- record the weight on the growth chart used in each weighing session.
the service;
Instructions should be given on how to place
- insert correctly any other information required
the scale, how to place the child on the scale, and
in the chart;
how to obtain a correct reading.
- assess normal growth on a growth chart;
- assess deviations from normal growth on a A useful exercise when training a group of
growth chart; health workers is to make them all measure the
- interpret deviations in terms of health status; same weights and then compare the results; in-
- translate the. information on the growth chart dividual members of the group should also meas-
into appropriate advice and action; ure certain weights repeatedly and again compare
- recognize the need for , and make decisions the results. The great variations usually found will
regarding, the referral of patients to a higher convince them of the importance of careful weigh-
level of the health system; ing and stimulate their interest; the variability is
- use the growth chart as an integral part of the significantly reduced after proper training. It is
health care system; useful to repeat this exercise periodically.
- explain to mothers the use and significance of
the growth chart.
The training should therefore cover the items Plotting the weight
discussed below.
Health workers may not be used to graphical
Child growth representations and plotting graphs. The correct
way to record a weight-for-age point on the graph
should be carefully explained and practised.
Emphasis should be placed on the factors
The use of aids (e.g. , a ruler, a sheet of paper)
affecting growth, with special reference to the role
will be appropriate in the local setting. It must be
of diet and the effects of disease on child growth.
emphasized that, whenever the child is weighed,
A better understanding of the process of growth
the health worker must put a dot representing the
and development may be obtained by using exam-
weight at the point where the column of boxes
ples taken from the local setting (e. g., the growth
corresponding to the current month meets the
of plants and the role of water and fertilizers; the
horizontal line corresponding to the weight. A
growth of animals).
line should be drawn from the previous dot to this
new one, since the purpose of plotting the dots is
The weighing procedure to find the direction of the line formed by them.
Particularly when the weighings are very close
Health workers should be given an opportu- together (at intervals ofless than two months), the
nity to become familiar with the scale that they dot should be located in a way that indicates the
 Training health workers 27

6 kg
~
~v
"'co
:len
"'~ ..r::.
~ ·;::
..c
...,~~ Q)
LL "'
::!:
c.
4::

Fig. 19. Section of growth chart showing how to

place the dots correctly (for discussion, see text)

period of the month, i.e., closer to the left-hand Each of the components of the chart should be
side of the box if the child was weighed during the reviewed with the workers and the following
first I 0 days of the month, in the middle if he was points discussed with them:
weighed between the 1Oth and the 20th day of the
• precisely what information should be recorded
month, and closer to the right-hand side of the
in each place;
box if he was weighed after the 20th day. To assist
• why it is recorded and its present or future use;
in plotting the points, the chart may have dotted
• how the information should be obtained;
lines printed on the graph to represent half kilo-
• how it should be recorded .
grams. If the weight to be plotted is between half
a kilogram and a full kilogram it should be plot- Any possibility of misinterpretation or cause of
ted to the nearest 250 g. An example is shown in errors should be analysed, taking into considera-
Fig. 19 for a child who attended clinic on the 3rd tion the level of understanding of the workers,
of the month and weighed 6.300 kg, and returned their cultural and educational background , and
on the 25th of the following month and weighed the background of the mothers they are going to
6.700 kg. As will be seen from Fig. 19, if the work with.
weights had not been plotted to the nearest 250 g The workers should then practise filling in the
the direction of the line joining the two dots would chart, either with imaginary cases or with real
have been very different. For instance, if the two ones, under supervision. Familiarizing workers
weighings had been approximated to the nearest with the chart, giving them confidence in their
half kilogram the line would have been horizon- ability to fill it in correctly and an understanding
tal; alternatively, if the first had been approxi- of its purpose, will ensure that it is used properly.
mated to 6.0 kg and the second to 7.0 kg the line The convenience of recording directly on the
would have been much steeper. Similarly, if the graph events that may affect the child's growth,
two dots had been placed in the middle of the such as diseases or drastic changes in diet, should
corresponding month columns, the line would be explained. Such events can be recorded in the
again have been steeper. It should be emphasized vertical column corresponding to the month in
that it is the direction of this line that is important, which they take place (See Fig. 20) .
since it indicates the child's growth. Using this information, and by examining the
relationship between the various events and the
changes in the direction of growth, the health
worker will be able to discuss with the mother
Filling in the rest of the information what she can do to help her child. He or she could
discuss, for example, the use of oral rehydration
Qualified health workers will probably already therapy at home and the importance of hygienic
have experience of keeping patient records; most food preparation. The information recorded will
of the information recorded on the growth chart also be useful to other health service personnel in
will therefore be familiar. interpreting the growth curve.
28 The growth chart

'~
11 The corresponding fundamental messages for

~------~;
-- -- the health worker and for the mother are the
~
10 following:
~

9 (1) If a child's growth curve is climbing up-

-~--~V---- wards in the same direction as the reference curve,
8
-......:: / this is good. The child is growing adequately.
en
:!E
c:t 7
- - - - -- -- - -
v- - - - -- - -
~~
(2) If the growth curve is horizontal, this means
the child is not putting on weight. He has stopped
a:
(!)
0 6
-- - - -- -/ t7 I.-..
~ - !"
~~
~
- - -- growing. Because all healthy children put on
weight as they grow, this is a warning sign.

,~
V- ~ V-
..J -- - - - - - - -- -- -- - - (3) If the growth curve is moving downwards,
~
5 the child is losing weight. This is very dangerous.

4
--
~ v ~ It::.~ ~ - - -- - - -- -- ~
The child needs immediate help.

~ / V- -- ~
- - I~ -- -- -- -- -- The direction of the curve should also help in
I~ In: evaluating the effectiveness of corrective meas-
3
- ~ -- -- - - --~
~
~ - - -- -- -- - - ures. For instance, if the growth curve of a child
I~ is found to be like that shown in Fig. 23 as a
2
I I I I I ~ I I I I I I consequence of acute diarrhoea, oral rehydration
~1~ 3~4 5 6 7 8 9 10 11 12 and progressive refeeding are indicated. When the
~~ Clb~ I~ \J~ !'-.
~~
... " _.... ~~ ""'
§ ~ ~ q; ~ ~
child is seen one month later, the direction of the
curve should have changed to a steeply rising one
l'§r-\ ~~ ""~~~<:) (catch-up growth), as shown in Fig. 24. On t.he
other hand, if it is found that, although the ch1ld
Fig. 20. Recording of diseases or changes in feeding is clinically better, his growth curve has become
horizontal (see Fig. 25), this is a danger sign; it
may indicate that the infection persists or that the
child has not been properly fed after the attack of
diarrhoea.

Interpreting the growth chart

Position of the growth curve
Health workers should be trained to interpret
the growth chart and to explain its significance to
The direction of the growth curve of a child
mothers. The interpretation is based essentially
(upwards, horizontal or downwards) is what mat-
on the direction and position of the growth curve.
ters. The position of the curve in relation to the
reference curves printed on the chart is important
only in respect of children of different sizes who
Direction of the growth curve
are growing normally but following their own
"channels". This should be explained to health
The central purpose of the growth chart, with
workers, since it is particularly important for
its reference curves, is to provide a visual repre-
them to reassure mothers who may become con-
sentation of the growth of individual children. It
cerned if the curves of their children are in a lower
cannot be emphasized too strongly, during the
position than those of their friends' children .
training of health workers, that the growth curve
If small children whose growth is following a
is of vital importance, both as a diagnostic tool
low "channel" are active and clinically healthy,
and as an educational tool for mothers, in pro-
and their growth curves are running parallel to the
moting appropriate growth and stimulating and
reference curves, there is no cause for concern.
guiding preventive and corrective actions.
Only children whose growth curves are well
It must again be stressed that the direction of
below the lower reference curve, particularly if
growth is of prime importance. The growth curve
they seem to be moving still further away from it,
can take three directions, as follows:
need to be carefully examined because they may
(I) upwards (Fig. 21 ); be suffering from a congenital defect or a chronic
(2) horizontal (Fig. 22); condition that is responsible for their small size
(3) downwards (Fig. 23). and insufficient growth.
 Training health workers 29

When children who have not been followed

since birth are first weighed, they may be found
to be small for their age because of past malnutri-
tion. This can be confirmed by taking a history
and conducting a clinical examination; such chil-
dren should be carefully followed, particularly if
their growth curves tend to be fiat. If these chil-
dren are properly fed and cared for , their growth
curves may turn upwards in relation to the refer-
ence curves (catch-up growth), until they reach a
new channel that they follow thereafter.
Fig . 21 . Section of growth chart showing upward
direction of growth curve--good
It is also important to remember that, in the
weight-for-age chart, the height of the child is not
taken into consideration. If the child has a low
weight, not because he is small but because he is
very thin, this may be due to malnutrition. This
question arises particularly when a child is seen
for the first time. If the child has been followed
and his weight for age monitored by means of the
WHO 85112 chart, his growth curve would have become fiat or
Fig. 22. Section of growth chart showing horizontal turned downwards as he became thin. The advan-
growth curve--warning sign tages of growth monitoring, as compared with
any single measurement at a particular time, are
again obvious.

Use of examples

Examples should be used to illustrate the im-

portance of the direction of growth as compared
with the position of the growth curve on the chart.
Thus Fig. 26, for instance, shows the growth
WHO 85113
curves of two children, both plotted on a single
Fig. 23. Section of growth chart showing downward chart for purposes of comparison. The first child
direction of growth curve--dangerous (Child A) grew very well during the first two years
of life and his growth curve always remained well
above the upper reference curve. In fact, there
were periods when his growth curve was rising
more rapidly than the reference one, i.e. , he was
becoming fat. This child was sent away to live
with a foster mother when his own mother remar-
ried. During the first six months with his foster
WHO 85114 mother he failed to grow, but nobody noticed this,
Fig . 24. Catch-up growth
because he was a fat child. Then he contracted
measles and lost a lot of weight in just a few
weeks. He was eventually admitted to hospital
with kwashiorkor, but his weight for age was still
above the upper reference curve. The second child
(Child B) was a low-birth-weight baby who was
fed artificially, suffered frequent bouts of diar-
rhoea, and failed to grow adequately. At one year
he developed marasmus. At the nutrition re-
habilitation centre, where he and his mother spent
WHO 85115 several months, the mother, with help from the
Fig. 25. Faltering of growth-warning sign nutrition staff, learned how to feed her child . The
30 The growth chart

baby then began to gain weight. He grew steadily The growth chart can also be an excellent tool
for the next 12 months and by the time he was 2 V2 for strengthening the interaction of health work-
years old his growth curve was just above the ers with mothers in the child-care activities carried
lower reference curve and he was in very good out by the health services. It has also been success-
health. fully used to stimulate communities to participate
If the position of the child's growth curve on in the health services' activities.
the chart alone was taken as the main indicator With help and practice, health workers will
of health, the first child would appear to be become familiar with the growth chart. There are,
healthier, but this was true only during the first however, a number of ideas and activities in-
year. The mistake would be even greater if only volved in the use of the growth chart that health
the last point on the curve was considered. By workers have found particularly difficult to un-
looking at both children's direction of growth, derstand or perform correctly. The major prob-
however, the real situation of the two children lems encountered include:
throughout their life becomes clear.
(I) an inability to record the child's age accu-
rately;
(2) difficulties in determining the month of
birth;
(3) incorrect weighing;
A tool for action (4) inaccurate plotting of the child's weight for
age;
Teaching health workers the use of the growth (5) difficulties in understanding the reference
chart will not be complete without clear and pre- curves;
cise indications as to the actions required in par- (6) problems with understanding the concept of
ticular circumstances. a child " at risk";
To go into detail on what the health worker (7) difficulties in interpreting the child's growth
should do as the natural follow-up of growth curve;
monitoring is beyond the scope of this pub- (8) difficulties in taking effective action.
lication . Such decisions will depend very much on
Particular care and extra time should be taken
the local conditions, i.e. , the capabilities of the
by the instructor to ensure that the trainees under-
worker concerned, the resources available to the
stand the concepts and are competent users of the
local health service and to the community, the
chart. The different exercises should be repeated
nature of the health problems, etc.
The growth chart should not be seen solely as after health workers have had practical experience
another tool for use in implementing child care in using the chart, when they may have questions
activities. It can also be used in teaching, for or need advice on matters that were not covered
instance, in demonstrating: (I) the importance of during the original training.
adequate feeding, how to achieve it, how to detect
problems and what should be done about them;
(2) the deleterious effects of diarrhoeal or other
common diseases, and the necessary preventive
and corrective measures; and (3) the value and Supporting the health workers
timing of immunizations, and of all the other
activities associated with child care. In addition to preparing or obtaining the ap-
Health workers will use the growth chart effec- propriate growth chart and training the health
tively only if they know that it increases their workers in its use, programme managers should
ability to make timely and adequate diagnoses ensure that the workers are given adequate techni-
and helps them in deciding what to do, particular- cal and logistic support. Technical support will
ly under difficult circumstances. include guidelines on where to weigh the children
When referral is being considered, for example, - should this be in the health facility? in their
the growth chart can provide valuable arguments homes? in a given place in the community? What
in favour of such a decision and will also help to children should be monitored? Should the weigh-
make the referral easier and more effective by ing be done every day or in every child clinic as
identifying the reasons for it and providing the a routine whenever children are examined? Or
required background information to the service to should special weighing sessions be organized?
which the child is referred. How frequently should the children be weighed?
 REASONS FOR SPECIAL CARE 22 1 I I I I I I I I I I I I I I I I I I I I I I I

N ame ..... ........... ........ ..... ..... .. .. ...... .. .. .. .

211 I I I I I I I I I I I I I I I I I I I I I I I I

Birth weight .. ... . kg 201 I I I I I I I I I I I I I I I I I I I I I I I I

..... . .. . .. . ... . ......... . ······ · ·· ... 191 _______ . --- ---- · ------ -I

Mo~ 1
8 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ 18 _______ ____ _____ ~"" .... ___ . _

~;~~1;:b- 17 ~ ~ -- -- ~ - - ~- - . - - - - - - - - 17 - - - - - - - - . ~~~~ - - ~ - - - - - - . -
16 ~ ~r- S? 1€ H+-t+H""~"H-~+++-HH-+-t+H
- - - - - - - - - - - - - - - - - - - - - - - - - - u.. ---- -- I - - - - - - - - - - _____ ,.. ____ ______ - - - - - - -·
• ~ Cfl ~~
15 t--+-+-+--+--+-+--+-+-+-+--+-•,.,....~"'-._di"-,••~d--t <! 15 H~~~+'·f-H-t++-HH-+++-f-H-t++-+1
WEIGHT
-------------------vt'·-----------!\ ---- ~· ~~~ ---------. ------------ -
-~

~.;: 71'" :..: ~ - :.; ;_;.!-"~- ~ -~1

14
l3 1st YEAR - - - - - - - - -- - - - ;: - - - - - - - - '
12 - - - - - - - - I~ ---------------.- it'~ - - . - -- . - ~~ .- - - - - - - - - - - - . - - .. - - - - - - - 12 - - - . - - - . . Ht -------- ,.,-l
Pol
s·
- - - - -- - ~ -- - - -- ~ ~ -- - - -- -- -- . - k ":"':' -- -- -- - - -- - - -- -- -- -- -- -- -- - - - - ~~~t'l - - - - - -1-1- - - -- - - - -. -· _,_,- . s·

!¢.'\~- '-' / :)/" ·:..r---.-":: .-: - - - -- - -- --- L~'""i='!- ":': -- ~- ~ - ~ - ~ - ~ -~ - ~ - ~ - ~ - ~ - ~ - ~ - ~-~ - ~ - ~-~-~ -~ - ~-~ -~-~-~ -~-
11
(JQ
11 0"
(1)
r::..
:;.

,:[~/~~~V':• - •--~~~~;e- • ~~(:;;;~-· ··· _ -__._.-_._.-,:

-- ,
~
,.,
0
:>1"
u : : • : : : ...,
(1)

~ 7 - - - - - - - - ,.- v -------- ~~ ~ ~ . --------------v---------------------------- "'

~ - (_:h~l~~.. ~ ~- .- - - //-~ -:;s - - -ul ~ -- -- - - - - - - ~i /- - - - - - - -- -- - - - - - - - - - - - - - - - - -- - -

~ :-tri :i~<"v ~ :..::..: E~ ~ ~;...--· - -- , .-- ---.--.----.--_----- ,

---- •.--_--••r1'!1'11'1'1'1 'i 11
::~~~/ I••~- J; ~;.~:~r· :.:: -_
4th YEAR 5th YEAR

~ ~-· 1 :\,_ 13 14 15 16 17 18 19 20 21 22 23 24 3rd YEAR

II I I I I I I I I I I
_ _ _ . , . . ...... ___ • _ _ _ _ _ _ _ _

2
• --- . I IC;ild : I I I I 1
1 2 3 4 5 6 7 8 9 10 11 12- I I I I I I I I I I I
2nd YEAR

AGE IN MONTHS
w
Fig . 26. Comparison of two growth curves (for explanation, see text)
32 The growth chart

It will also be necessary to answer questions or Logistic support will include: ensuring that the
solve problems that the health workers may find cards needed are available in the amounts re-
in the use of the chart, and to supervise and quired ; checking and maintaining the scales; and
evaluate the use of the charts and, if necessary, to providing transport if required . As with any other
modify them or the method of use. All these programme activity, the use of the growth chart
decisions will have to be taken in accordance with will be effectively implemented only if both the
the objectives and organization of the programme actual users and programme managers are in-
in which the growth charts are going to be used. terested, and find the charts to be helpful in their
No universal guidelines can be provided, since activities.
local conditions are the determining factor.
 References

J. WORLD HEALTH ORGANIZATION. A growth chart for inter- and weight data for comparing the nutritional status of
national use in maternal and child health care. Guidelines for groups of children under the age of I 0 years. Bulletin of the
primary health care personnel. Geneva, 1978. World Health Organization , 55: 489-498 (1977) .
2. WORLD HEALTH ORGANIZATION. Guidelines for training 5. WORLD HEALTH ORGANIZATION. Measuring change in
community health workers in nutrition , 2nd ed. Geneva, nutritional status. Geneva, 1983.
1986. 6. MORLEY, D. C. A health and weight chart for use in
3. NABARRO, D. & McNAB, S. A simple new technique for developing countries. Tropical and geographical medicine,
identifying thin children: a description of a wallchart which 20: 101 - 107 (1968).
enables minimally trained health workers to identify chil- 7. TREMLETT, G . ET AL. Guidelines for the design of national
dren who are so thin, or wasted, that they require im- weight-for-age charts . Assignment children, No. 61 /62:
mediate nutritional help. Journal of tropical medicine and 143- 175 (1983).
hygiene, 83: 21 - 23 (1980). 8. AMERICAN PUBLIC HEALTH ASSOCIATION. Primary health
4. W ATERLOW, 1. C. ET AL. The presentation and use of height care issues: growth monitoring. Washington, DC, 1981.
WHO publications may be obtained, direct or through booksellers, from :

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Nl / 86