Dr' G'N'V' Brahmam

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CURRENT USE OF CHILD GROWTH STANDARDS IN INDIA
--- An Overview
Dr. G.N.V. Brahmam Dy. Director (Sr. Gr.), HoD,
Division of Community Studies, National Institute
of Nutrition, (I.C.M.R.) Jamai-Osmania (P.O.),
HYDERABAD 500 007. Telefax 040-27019141
Mobile [phone] Email
gnvbrahmam_at_yahoo.com
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INDICATORS OF NUTRITIONAL STATUS

• Direct Indicators
• -- Nutritional Anthropometry
• -- Clinical Assessment
• -- Bio-chemical Estimations
• -- Biophysical Tests

Indirect Indicators -- Dietary assessment
-- Prevalence of Morbidities -- Vital
Statistics
In addition, Secondary Data -- Socio-economic
-- Demographic -- Environmental
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NUTRITIONAL ANTHROPOMETRY
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NUTRITIONAL ANTHROPOMETRY

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

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ANTHROPOMETRIC MEASUREMENTS - Weight (kgs) -
Height (cms) - Mid Upper Arm Circumference
(cms) - Waist Circumference (cms)
- Hip Circumference (cms) - Fat fold
thickness (mms) at
Triceps, Biceps, Supra-Iliac,
Sub-scapular
regions
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Nutritional Anthropometry
Weight - Total Body mass
- Simple, widely used -
Sensitive to small changes in nutrition Height
- Genetically Determined
- Environmentally influenced
- Stunting Reflects long duration undernutrition
MUAC - Reflects
muscle/fat - Easy to measure,
used for quick screening -
Independent of age (1-5 years) FFT -
Measures body fat - Correlates
well with total body fat
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REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY
Standard equipment - Accuracy /
Consistency, Appropriate techniques
- Training Standardization Correct assessment
of age - Wrong age vitiates the results
Reference values - For comparison and
computation of indices Classification
- For grading nutritional status
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Reference Values
Anthropometric measurements obtained on
statistically adequate number of individuals who
are well nourished, representing cross section of
community living in an environment free from
constraints of any sort and have capacity to
reach maximum growth potential at each age
group/Gender. -- National Eg. Well-to-do
Hyderabad pre-school children --
International Eg. NCHS, Harvard, MGRS
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CURRENT REFERENCE VALUES

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

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MGRS Multicentre Growth Reference Study
Provides Median, SD, Percentile values of

• Weight for Age
• Height for Age
• Weight for Height
• Body Mass Index

for 0-60 months boys girls
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Multicentre Growth Reference Study
Based on study on 0-60 months children in
Brazil, Ghana, India, Norway, Oman USA, Who
were predominantly Exclusively breastfed up to 6
mths

• A total of about 8500 children
• Predominantly breastfed up to 6 months
• No environmental constraints
• Data collection- by trained staff
• Longitudinal study 0-24 months
• Cross sectional 18-60months

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ANTHROPOMETRIC INDICES
Weight for age Height for age Weight for Height
Body Mass Index
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NUTRITIONAL GRADING / CLASSIFICATIONS
Preschool Children GOMEZ
CLASSIFICATION
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GOMEZ CLASSIFICATION

• Gomez et. al. (J Trop Ped 1956)
• Based on Prognosis of children admitted to
• Hospitals in Mexico
• Significantly higher incidence of mortality
  among
• children with lt60 of standard wt for age
• - Significantly higher morbidity among children
  
• with 60-75 of standard weight for age

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IAP CLASSIFICATION(Indian Academy of Paediatrics)
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IAP CLASSIFICATION(Indian Academy of Paediatrics)
Nutrition Sub-committee of Indian Academy of
Pediatrics Report, Indian Pediatrics, 9360,
1972. Suggested to use 50th Centile of Harvard
standards (and also to develop suitable Growth
norms for Indian Children) - Grading
was arbitrary - To affix K , if the child
has Oedema - Gr. I II Correspond to
Underweight, - Gr. III IV Correspond to
Marasmus, - Gr. I II with K indicate
Kwashiorkor, - Gr. III IV with K
indicate Marasmic Kwashiorkor,
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STANDARD NORMAL DISTRIBUTION
Measuring Changes in Nutritional Status
(WHO, Geneva 1983).
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STANDARD DEVIATION (SD) CLASSIFICATION
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Z - Scores
Measured Value Median Value
(reference) Z Score -------------------------
---------------------------------
SD of Reference
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Weight for age BOYS Birth to 5 years (z-scores)
World Health Organization
-2 SD
-2.5 SD
-3 SD
Months
4 years
Birth
1 year
2 years
3 years
5 years
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World Health Organization
Weight for age GIRLS Birth to 5 years (z-scores)
-2 SD
-2.5 SD
-3 SD
Months
4 years
Birth
1 year
2 years
3 years
5 years
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CLASSIFICATIONS CURRENTLY BEING USED BY VARIOUS
ORGANIZATIONS FOR NUTRITIONAL GRADING
OF lt 5 YEAR CHILDREN
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Prevalence of Undernutrition -
NCHS Vs MGRS Reference Values
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WEIGHT FOR AGE
lt Median 3 SD
Median 3 SD to Median 2 SD


lt Median 2 SD

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Boys

WEIGHT FOR AGE
Median 3 SD to Median 2 SD
lt Median 2 SD
lt Median 3 SD
? Median 2 SD
Girls

Median 3 SD to Median 2 SD
lt Median 2 SD
lt Median 3 SD
? Median 2 SD
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HEIGHT FOR AGE

lt Median 3 SD
Median 3 SD to Median 2 SD

Median lt 2 SD

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Boys

Median 3 SD to Median 2 SD
lt Median 2 SD
lt Median 3 SD
? Median 2 SD
Girls
HEIGHT FOR AGE

Median 3 SD to Median 2 SD
lt Median 2 SD
lt Median 3 SD
? Median 2 SD
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WEIGHT FOR HEIGHT
lt Median 3 SD
Median 3 SD to Median 2 SD


lt Median 2 SD

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Boys

WEIGHT FOR HEIGHT
Median 3 SD to Median 2 SD
? Median 2 SD
lt Median 3 SD
lt Median 2 SD
Girls

Median 3 SD to Median 2 SD
lt Median 3 SD
? Median 2 SD
lt Median 2 SD
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SALIENT OBSERVATIONS . . .

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

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

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

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• Conclusions
• There is need to adopt the new WHO growth
  standards of lt5 year Children by all.
• The Growth charts in ICDS need to be modified
  using SD classification criteria
• The functionaries have to be trained and oriented
  to these changes
• The existing data need to be re-analysed using
  new reference values to enable comparisons

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Thank you