In the state of Jharkhand in India, about half of children under 3 years old are malnourished. Growth monitoring is done monthly by Anganwadi workers to track children's weight gain and identify malnutrition early. However, growth monitoring efforts face challenges including a lack of guidelines, outdated materials like weighing scales and growth charts, delays in supplementary food funding, incomplete training of frontline workers, and supervisor vacancies limiting supervision. Addressing these challenges could help improve growth monitoring and reduce malnutrition rates among young children in Jharkhand.

1. Growth Monitoring

2. Introduction & issue of malnutrition
♦ In India, about 1/3rd population is food insecure
leading to inadequate food intake.
♦ Jharkhand is a state in eastern India.

3. Public health profile of state
♦ 1/3rd of population do not have access to
safe drinking water.
♦ ½ of population below the poverty line-
food insecurity
♦ ½ of children <3yrs malnourished
♦ highest mortality rates for children under
five
♦ ½ children do not have full immunization
against childhood diseases.

4. Malnutrition
When a person
– is not getting enough food or not
getting the right sort of food.
– food lacks in proper amounts of
micronutrients - vitamins and
minerals to meet daily nutritional
requirements.
– Disease is contributing factor and
result . Even if people get enough to
eat

5. Why Monitor Growth
♦ Growth is the most sensitive indicator of
health (normal growth only occurs if a child is
healthy)
♦ Growth assessment is an essential part of the
examination or investigation of any child.
♦ Allows objective detection of growth
disorders at population level at earliest
opportunity.
♦ Early identification and treatment improves
outcome.
♦ Identify under or over nutrition

6. What is Growth monitoring
♦ Weighing of the child at regular interval
– by plotting of that weight on a graph
(called growth chart)
– For observing changes in weight &
– giving advice to the mother based on
this weight change is called ‘Growth
Monitoring’.

7. ♦ In growth monitoring a change in weight over a
period of time is more important than the
weight .

8. Methods of growth monitoring
♦ Length for age or Stunting (Health
dept.)
– whether an infant is an
appropriate length for their age
♦ Weight for age (ICDS):
– whether an infant is an
appropriate weight for their age

9. ♦ Weight for length(Wasting):
– whether the weight and length of an infant
are in proportion
♦ Mid upper arm circumference for age(quick
identification):
– be especially useful at the onset of a crisis

10. Growth chart
♦ Growth chart represent curves (Weight for age)
with reference population and can be used to
identify the child’s rank relative to other
children of the same sex and similar age.

11. Growth chart monitoring
Growth Monitoring is done
♦ by the Anganwari Worker (AWW) along with
ANM.
♦ On Village Health Nutrition Day every month.

12. GM process
GM includes
♦ plotting the child’s weight on the ‘Mother
and Child’ Protection Card, by
Anganwadi worker
♦ analyzing the growth of the child by
comparing with reference population
♦ discussing the progress of the child with
the caretaker

13. Reading
♦ Upward growth curve- Normal
♦ Flat growth curve- Dangerous
♦ Downward growth curve- very dangerous
♦ Plotted weight in Orange zone-moderate under
nutrition
♦ Plotted weight in yellow zone- severe under
nutrition

14. Decision guide & activities to be undertaken

15. Good Upward slope of • Group Counseling
curve • Supplementary nutrition
(if above six months)
Dangerous Flat growth • Investigate – talk with the
curve caregiver
o If sick – follow IMNCI protocol
and refer if needed
Moderate Plotted weight • Referral to a health centre
undernutrition in Orange zone • Follow up visits at home
• Group Counselling
• Supplementary nutrition
(if above six months)
Severe Plotted weight • Referral to a health centre
undernutrition in yellow zone • Follow up visits at home
• Extra Nutrition supplements
• Group Counselling
• Supplementary nutrition
(if above six months)

16. MUAC measurement
♦ For children aged 6 to 59 months
♦ used for detecting individuals in need of
treatment.
♦ good indicator of muscle mass

17. Process of measurement
♦ Ask the mother to remove clothing that may
cover the child’s left arm.
♦ Calculate the midpoint of the child’s left upper
arm by first locating the tip of the child’s
shoulder with your finger tips. Bend the child’s
elbow to make the right angle .

18. ♦ Pull the thread from tip of the shoulder till
elbow.
♦ Fold the thread to half to estimate the midpoint
and again pull it from shoulder tip. Mark the
midpoint with a pen on the arm.
♦ Straighten the child’s arm and wrap the tape
around the arm at the midpoint. Make sure the
numbers are right side up. Make sure the tape
is flat around the skin.
♦ When the tape is in the correct position on the
arm with correct tension, read and call out the
measurement to the nearest 0.1cm .
♦ Immediately record the measurement

20. Interpretation of Mid-Upper Arm
Circumference (MUAC) indicators
♦ < 110mm (11.0cm),
∀ RED COLOUR,
∀ indicates Severe Acute Malnutrition (SAM)
∀ immediate referrel for management and
treatment.

21. ♦ between 110mm (11.0cm) and 125mm (12.5cm)
– RED COLOUR (3-colour Tape) or ORANGE
COLOUR (4-colour Tape),
– indicates Moderate Acute Malnutrition
(MAM)-
– immediate referrel for supplementation.

22. ♦ between 125mm (12.5cm) and 135mm
(13.5cm),
– YELLOW COLOUR,
– indicates child at risk for acute malnutrition-
– counselling & followed-up for Growth
Promotion & Monitoring (GPM).

23. ♦ MUAC over 135mm (13.5cm),
– GREEN COLOUR,
– indicates that the child is well nourished

24. Responsibilities of Stakeholders
♦ ICDS
♦ Anganwadi Worker & Anganwadi Helper
♦ Services
– Regular Weighing during VHND
– Plotting Growth chart
– Supplementary nutrition

25. ♦ Health department
♦ ANM
♦ Services
– Record of height and weight of children at
periodic intervals
– Reading of growth chart
– General check up for detection of diseases
– Treatment of diseases like ARI, diarrhoea etc
– Deworming
– Prophylaxis against vitamin A deficiency
and aneamia
– Children under six: vaccinations – BCG, OPV,
DPT, and measles
– Referral services

26. Growth Monitoring & Promotion comprises -
package of activities
♦ regularly measuring the weight of children;
♦ plotting the information on a growth chart to
make abnormal growth visible;
♦ if growth is abnormal (usually faltering), the
health worker does something, in concert with
the mother;
♦ as a result of these actions, the child's nutrition
improves, the child receives appropriate social
or medical support, or doctors are able to
diagnose early serious disease.

27. Growth monitoring:
Issues

28. Proximal causes Proximal causes Proximal causes
1.No guidelines
Limited materials available for
11.Less than one third
of AWWs had
for Growth maintenance and functional weighing
repairs of weighing scales for both infants
Monitoring scales-Maintenance and children.
and replacement still at · 2. The turnaround
CDPO or District level time for repairs of
causing time-lags. scales exceeded 3
♦2. Unable to facilitate months.
delivery of new Mother 3.24 out of 60 AWWs
and Child Protection interviewed reported
cards to AWCs. not having the new
growth charts

29. Proximal causes Proximal causes Proximal causes
1.Funds for SNP are 11.Only 3 of 60 AWWs
Growth Monitoring insufficient and not interviewed, received SN
tagged to available in time. funds on time.
2. Inordinate delay in filling • 2. 24 of 60 AWWs
Supplementary vacant supervisory positions reported unavailability of
food distribution. resulting in overburdened funds is the main
supervisors and poor obstacle in SN
supervision. distribution.
• 3. Despite the rules 26
of 60 AWWs report
procuring food materials
on credit
• 4. A little more than
half of the sanctioned
supervisor positions were
filled as of March 2011
• 5.No Mid-Level
Training Centers (MLTCs)
in the state
• Supervisors
interviewed reported a

30. Proximal causes Proximal causes Proximal causes
1.Some AWWs not 11. Half of AWWs
Incomplete and or trained in GM and most interviewed reported
inaccurate lacking a follow-up on problems with growth
GM training . monitoring.
knowledge on 2.Inordinate delay in 2. Only one tenth of
Growth filling vacant supervisory
positions resulting in
AWWs recalled receiving
any training on the
Monitoring, overburdened growth charts.
supervisors and poor
plotting and supervision.
3. No guidelines for
counseling, referral and
interpreting the follow-up services for
children with faltering
growth trajectory growth at the field.
4. Only three of the 24
supervisors recalled
being trained on new
growth charts.
5.Only half of the 10
CDPOs interviewed
mentioned ‘growth

31. Proximal causes Proximal causes Proximal causes
Poor event
Chaotic Village management
Health and Unable to facilitate
delivery of new Mother
Nutrition Day and Child Protection
cards to AWCs.