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COMMENTARY |
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Year : 2017 | Volume
: 10
| Issue : 1 | Page : 26-27 |
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Road to Health: Comparison of World Health Organization and Indian Academy of Pediatrics growth charts in assessing undernutrition
Puja Dudeja, Santosh Swain
Department of Community Medicine, Armed Forces Medical College, Pune, Maharashtra, India
Date of Web Publication | 9-Jan-2017 |
Correspondence Address: Dr. Puja Dudeja Department of Community Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra India
Source of Support: None, Conflict of Interest: None | Check |
DOI: 10.4103/0975-2870.197911
How to cite this article: Dudeja P, Swain S. Road to Health: Comparison of World Health Organization and Indian Academy of Pediatrics growth charts in assessing undernutrition. Med J DY Patil Univ 2017;10:26-7 |
Mere change is not growth. Growth is the synthesis of change and continuity, and where there is no continuity there is no growth.
CS Lewis
A growth chart is an example of “appropriate technology” to diagnose malnutrition at the grass-root level. It is a powerful screening tool which can detect growth faltering and malnutrition and play a significant impact on reduction in childhood mortality.[1]
In 1977, growth charts were developed by the National Center for Health Statistics as a clinical tool for health professionals to determine if the growth of a child is adequate.[2] The 1977 charts were adopted by the World Health Organization (WHO) for international use and considered standard deviation (SD) or Z-scores for classifying children in moderate (between − 2 and − 3SD) and severe (<−3SD) categories. At the same time, the Indian Academy of Pediatrics (IAP) adopted these charts too but with a different classification. It classified 0 SD or 50th percentile as 100% of expected weight for age and then Grade I (70%–80% of expected), Grade II (60%–70% of expected), Grade III (50%–60% of expected), and Grade IV. These charts were derived predominantly from formula-fed infants of North European descent. In the last three decades, innumerable studies measured child nutritional status in developing countries using these reference growth charts introduced in 1977. However, researchers found that there were inherent problems in use of these charts, especially in developing countries. To overcome this problem, the WHO in 1997 initiated the Multicenter Growth Reference Study (MGRS), with the purpose of constructing new standards for normal early childhood growth under ideal environmental conditions. These were constructed with data from 8440 healthy breastfed infants and young children from Brazil, Ghana, India, Norway, Oman, and the United States (WHO). These could be used to assess the nutritional status of children under 5 years of age regardless of ethnicity, socioeconomic status, and feeding practice. These were given the status of “gold standard” in terms of growth. The WHO MGRS growth charts were approved by the Ministry of Health and Family Welfare in 2007 and implemented under the Integrated Child Development Scheme since 2009.
In the present study, the authors have assessed malnutrition status of children based on the WHO and IAP charts and compared the findings. They found that there was not much difference between the two charts for weight in boys and girls. However, significant difference existed in terms of height. The controversy over the agreement of results by these charts for assessing nutritional status of a child has existed over years in our country. Various studies have been done to compare the WHO charts with those of these charts [Table 1]. The studies have documented that the WHO classification is more sensitive in detecting undernutrition and detects more number of severe undernutrition. | Table 1: Summary of studies on comparison of World Health Organization growth charts with Indian Academy of Pediatrics charts
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Review of literature shows that no existing growth chart is perfect. There are benefits and limitations of both reference charts used by IAP and WHO. The main limitation of WHO chart is that these do not reflect current feeding practices in India. Moreover, the rapid weight gain demonstrated in the breastfed infants first 6 months may not apply equally to all breastfed babies. Moreover, mothers of breastfed babies who do not show the rapid growth rates in the WHO 2006 chart in the first 2–4 months may also be at greater risk of introducing complementary feeding at an early age.
A growth reference describes the growth of a sample of individuals who are representative of the general population, without making any association with health. In comparison to this, a standard such as WHO charts describes the growth of a healthy population and provides a reference to which all populations can aspire.
It is important to emphasize here that irrespective of the type of chart, the effectiveness of using growth charts depends heavily on the knowledge and understanding the grass-root level worker (Anganwadi workers) using them. Their training and understanding of these charts are the keys to effective and meaningful use. Researchers have also found that the community or the caretakers of the child do not always define their children's growth patterns according to the standards set by growth charts or by the health professionals who use them. The parents' perceptions of the ideal weight for their children are actually culturally embedded.
Estimates from the National Family Health Survey 3 brought out that nearly two-thirds (80 million) children under 5 year of age in India suffer from undernutrition (as per WHO classification).[8] Hence, effective utilization of growth charts under the Integrated Disease Surveillance Program can go a long way in early diagnosing and timely intervention in cases of undernutrition. Further, it will be an ideal situation for us to develop our own standard charts or local reference charts. Although this will require an adequate sample size, raw data from birth to adolescents, standardized quality control, and measurements, etc.; however, it will have a significant impact on reduction of under-five mortality through early diagnosis and timely intervention.
References | | |
1. | Garner P, Panpanich R, Logan S. Is routine growth monitoring effective? A systematic review of trials. Arch Dis Child 2000;82:197-201. |
2. | National Center for Health Statistics (US). NCHS growth curves for children, birth-18 years, United States. 1977. |
3. | Patel B, Gandhi G. WHO classification detecting more severe malnutrition: A comparative study with IAP classification. Indian J Basic Appl Med Res 2016;5:628-34. |
4. | Dhone AB, Chitnis UB, Jethani S. Comparison of WHO growth standards with Indian academy of pediatrics standards of under five children in an urban slum. Indian J Community Med 2013;25:277-80. |
5. | Prinja S, Thakur JS, Bhatia SS. Pilot testing of WHO child growth standards in Chandigarh: Implications for India's child health programmes. Bull World Health Organ 2009;87:116-22. |
6. | Seetharaman N, Chacko TV, Shankar SL, Mathew AC. Measuring malnutrition – The role of Z scores and the composite index of anthropometric failure (CIAF). Indian J Community Med 2007;32:35. |
7. | Deshmukh PR, Dongre AR, Gupta SS, Garg BS. Newly developed WHO growth standards: Implications for demographic surveys and child health programs. Indian J Pediatr 2007;74:987-90. |
8. | International Institute for Population Sciences. National Family Health Survey 3, 2005-2006. Mumbai, India: International Institute of Population Sciences; 2006. |
[Table 1]
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