A_Guide_to_your_Child_Growth___Assessment

A GUIDE TO YOUR CHILD’S
GROWTH AND ASSESSMENT

PRACTICAL E-BOOK

0

Guide to your Child’s growth and assessment – Practical Book
The E-Book is directed towards parents to assess breastfeeding and complementary
feeding in their growing children. Parents will be taught to measure their child, plot
their measurements on growth charts and interpret growth indicators.
The book follows feeding practices recommended by WHO/UNICEF. It guides
mothers/caregivers to follow WHO/UNICEF recommended feeding practices for their
infants and young children.
The sessions of this course have learning objectives to guide parents to track the
achievement of necessary skills and competencies. The course also aims to address
practices that lead to Undernourishment or accumulation of excessive weight in your
child.
Guide to your Child’s growth and assessment – Practical Book is interesting and
enjoyable, and the skills that you as a parent will learn will make your work as a
mother/caregiver more helpful for your babies and more rewarding for you.

Good Luck!

1

TABLE OF CONTENTS
I. Start a Growth Record ...................................................................... 4

Growth record booklet ...................................................................... 4
Age ................................................................................................... 5
Assessment notes ............................................................................... 5
Number of growth charts...................................................................... 5

Measure Height/Length and Weight for your child................................. 6
II. Plotting the points of growth charts .................................................. 10

Plot Length/height for age .................................................................. 12
Plot Weight for age............................................................................ 15
Plot Weight for Length/height ............................................................. 17

Interpreting plotted points for growth indicators................................. 22
III. Growth Problem Indicators and Interpreting growth trends .................. 24

Growth Problem ............................................................................ 24
Interpret trends on Growth Chart ..................................................... 36
Line crossing z-score & keep going ...................................................... 38
Decline or Incline growth line .............................................................. 40
Flat growth line................................................................................. 42
IV. Investigating causes of Growth problem................................................ 45
Undernourishment ......................................................................... 45
Overweight ................................................................................... 48
V. Feeding for first Six months of Life ........................................................ 52
Breastfeeding................................................................................ 52
Problems in breastfeeding ............................................................... 54
Assessing Breastfeeding ................................................................. 55
Breast, nipple health problems and its treatment ............................... 66
VI. Feeding low birth babies ..................................................................... 70
VII. Feeding during illness........................................................................ 71
VIII. Feeding after 6 months of life – Complementary Foods ......................... 72
Complementary feeding.................................................................. 72
Foods that fill energy gap ............................................................... 74
Food rich in Iron and Vitamin A........................................................ 76
Vitamin A ..................................................................................... 78
Fluid needs of the young child ......................................................... 81

2

Feeding Frequency and quantity ...................................................... 82
Important points to remember ................................................................. 85
Growth charts ........................................................................................ 87
Answers ................................................................................................ 99

3

I. Start a Growth Record

Objective

 Use growth record to assess growth trend.
 Measure height/length and weight to plot on the growth chart.

Growth record booklet

Maintain a growth record booklet for your child. A growth record booklet will
record the entire growth for assessing the growth trend. It will contain growth
charts from birth up to 5 years of age.
It will also contain recommendations on breastfeeding, supplementary feeding and
any other recommendations given to you by your practitioner. Growth booklet will
serve as an important reference for all you mothers or caregivers.
Note that each child will hold his own ‘growth record’. You will maintain a separate
growth record for girl and boy as their height and weight differs right from their birth.
A growth record booklet contains the following information

 Personal data
 Assessment notes (immunization history)
 Special care
 Feeding recommendations
 Food safety and hygiene
 Growth charts (0 to 6 months, 6 to 24 months and 2 to 5 years)

4

Age

Start a growth record booklet by entering the name of your child. While counting your
child’s age remember to count the number of weeks completed if your child is less
than 3 months old. If your child is more than 3 months but less than one year, you
will count the number of months completed since birth. For children more than 1 year
of age count the number of full years the child has completed to determine his age.

Alternatively you can use a stationary calendar and locate today’s date and count
how many months your child has completed since birth or his last birthday.

Notice that, 13 weeks make 3 months exactly.

Assessment notes

Assessment notes will contain assessment date, your child’s measurements of
height/length and weight. It will contain other information on his health, immunization
and everything else that you think will be useful for his growth assessment.
Also mention any adverse events and feeding history (if any) in your growth record.
Growth assessment depends on the correctness of the birth date and measurements
hence accuracy is of utmost importance. Mention the correct date of birth and correct
measurements that was taken at birth which includes weight, height or length of
your child.

Date of visit Weight Length Other information
01-Jan-13 4.2 Kg 54.8 cm Immunization in Dec 12

Number of growth charts

The following are the number of charts available for growth assessment of children
of various age bands.

Age Band Growth Chart Growth Chart
0 to 6 months Weight for length Weight for Age
6 months to 2 years Length for Age Weight for Age
2 years to 5 years Height for Age Weight for Height
0 to 2 years Weight for length

# Growth charts are separately for girls and boys.

5

Measure Height/Length and Weight for your child.

You need to get acquainted to measuring your baby’s weight and length/height. For
this, you need to learn using the equipments needed for measurement. The following
are a list of equipment needed for measuring your child.
The Equipments needed for measurement:

 Height board set to measure height
 Length board set to measure length
 Taring scale (if available)
 Soft linen to cover the height/length board.

Measuring Height
Place a height board against the wall. Place it on the floor and don’t let it tip
backward.
Stand at the right side of the board. Kneel down so that you are at your
child’s level.
Ask your child to stand on the baseboard. Make sure that his heels, calves,
buttocks, shoulder blades and back of head touches the vertical board.
If required, push the child back. Do this very gently. This will help him to
stand straight with his chin parallel to the ground.
Now, bring the headboard on top of your child’s head. Read the
measurements and record it to the last completed 0.1 cm. (It is the last line
– millimetre that you see).

6

Measuring Length
Place the length board on a strong surface. Cover it with soft linen.
Place the baby on the board on his back. Keep the baby’s head against the
headboard.
You will stand on the side of the headboard. This way the measuring tape will be
visible and you can move the footboard easily.
Person assisting should stand behind the headboard & hold the child in position.
Check that the child lies straight and does not change position. Hold the child at
his knees and gently press them down with one hand and move the footboard with
the other.
Move the footboard against the soles of the child’s feet and his toes pointing
upwards.
Read the measurement and record the child’s length. Record it in centimetres
thelast completed 0.1 cm.

Points to remember…
If the child is less than 2 years or is otherwise unable to
stand, you will measure child’s length while lying down

(recumbent).
Standing height is about 0.7 cm less than recumbent

height.
This is considered while making the WHO growth charts.
Hence to convert the length into height subtract 0.7 cm

and to convert it to length add 0.7 cm to height.

7

Measuring Weight: Taring scale
Undress the baby and remove his shoes.
Wait till the number on the taring scale appears to 0.0
Now, ask the mother to step on the scale and stand still. Mother should remain
on the scale even after her weight appears.
Tare the scale by covering the solar panel, after mother’s weight is displayed.
(Tare means to deduct mother’s weight & to weigh only the baby).
Wait till the number on the panel appears 0.0
Now give the baby to her mother. Immediately the baby’s weight will appear.
(Note: Baby may be less than 2.5 kg. Hence, if the mother is heavy, the baby’s
weight may not appear on the scale. Hence in such cases, ask a lighter person
to hold the baby).

Points to remember…
If the child is less than 2 years or is otherwise unable to

stand, you will do tared weighing. You will measure
child’s length while lying down (recumbent).

Babies should be weighed naked, as wet diaper or shoes
can weight more than 0.5 kg. Older children can weigh

with their underclothes.

8

Growth Record

Name Anay Sahani Date of Birth 01-Jun-13
Measurements Age Other birth Observations
at birth: details:

Date Measurements

Completed Weight (kg) Height/Length (Growth trend,
years, months, 2.9 (cm) Immunization)
weeks 3.6
45 Normal limit
01-Jun-13 0
50 Upwards trend
01-Aug-13 2

01-Oct-13

01-Dec-13

01-Feb-13

01-Apr-13

01-Jun-14

Growth charts (All growth charts as per sex)
Weight for Age Length for Age Weight for Length

Feeding recommendations / special care

9

II. Plotting the points of growth charts

Objective
 Locate measurements on girl/boy growth chart
 Interpret plotted points for growth indicators.

In the previous chapter we studied to measure height and weight of a child. We will
now learn to plot these measurements on the growth chart. This will help us to
assess if the child is growing ‘normally’ or if the growth trend indicates any future
concern. In case of concern please consult your medical practitioner without delay.
In order to plot points, you must understand terminologies related to graphs as well
as other plotting conventions. Below are a few graphs that help us in identifying axes
and plot measurements. There are separate growth charts for boys and girls.
In the following graphs, we will identify axes and plot points on height for age chart,
weight for age chart and weight for height charts for both boys & girls.
Let us look at one growth chart that belongs to children between 6 months to 2 years
of age. The graph has a measurement of a boy of a certain weight and age.

10

17 17

16 16

15 15

14 14

13 Plotted 13

y axis (weight) point. -3

12 (16, 11) 12 -2

11 11 -1
0 (median)

10 10 -2

-3
99

-1

88

77

66

55
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

x axis (age)

The x axis is the horizontal line at the bottom of the graphs and the y axis is the
vertical line at the left of the graphs.

A plotted point on a graph is a point that denotes a value on the growth chart. It has
value of both x-axis and y-axis. What it means is; if you extend a line from your
measurement on x axis and extend a line from a measurement on y axis it will
intersect at a point which is known as ‘plotted point.’

On the above graph, x axis represents the age of the child in the months and the y
axis represents the weight of the child in kilograms. Plot your child’s age on y axis
and his weight on y axis. Extend a line from these measurements and plot a point
where these lines intersect. The ‘plotted point’ is the measurement of your child.

11

In the above chart the plotted point has a value of 16 months from x axis and a value
of 11 kg from the y axis. This indicates that at the age of 16 months the child is 11 kg
in weight.
There are different growth chart for different age groups. In some graphs y axis can
represent the length/height and in a few others it can represent weight. X axis in few
growth graphs represents age and in few other graphs represent length/height.
For accurate growth assessment, you should precisely plot points on the lines
corresponding to your baby’s length/height or weight.

Plot Length/height for age
“Length/height for age” growth chart is a chart that represents the child’s

length or height at any given age. The chart indicates the standard height or
length for the age. This helps to identify if the child is growing normally or
have stunted growth. Stunted growth can be due to prolonged illness or the
child may be undernourished. In cases of excessive growth, it can also
indicate some kind of endocrine disorder.

12

Length-for-age growth chart for Girls (6 months to 2 years)

100 100

95 95

90 90

85 85

-3
80 80 -2

-1

75 75 0

2

70 70 3

Girl is 1 yr 1

1 month

65 old & her 65

height is

75 cm.

60 60

55 55

On the above growth chart, x axis represents age in months and the y axis
represents length or height in centimeters.

To plot a point, follow up the line up from the x axis to wherever it intersects with the
height/length measurement. For example; if the girl is 1 year 1 month old, her height
will be 75 cm as per the growth standards.

Note:

 If the child is 9 ½ months, you will have to plot the point on the line for 9
months and not between 9 to 10 months. Always consider completing age of
the child.

 If the height of the child is 70.5 cm, then plot the point midway between the
horizontal lines 70 to 71 cm.

13

When you plot more than 2 points on the graph (after an interval of time)
connect the points with a straight line. This will help to study the growth trend
accurately.

Lastly, the measurements that you plot on the growth chart should look sensible for
studying the growth of your child. For example; Child’s height can never be shorter
than the previous reading/plotted point. If this happens, then it means the last
measurement was inaccurate and cannot be considered for studying the trend. In
such case you may choose to ignore the previous incorrect measurement and plot
the present reading correctly.

Exercise 2.1

2.1 Length for Age growth chart for Girls (6 months to 2 years) 100
100

95 95

Height (cm)90 90

85 85 -3
-2

80 80
-1

75 75 0

70 70 2
3

65 65
1

60 60

55 55
6 7 8 9 10 111 Year 1 2 3 4 5 6 7 8 9 10 112 Years

Age (months)

1. The girl is 75 cm in length at 1 year 1 month. What is her length when she ages 1
year 6 months?

2. What is the girl’s height at the age of 2 years?

3. Connect the points.

14

Plot Weight for age

“Weight for age” growth chart reflects the body weight of the child to the
child’s age on the day when you measure it. This growth chart is used to
assess if the child is underweight or severely thin which happens when the
child is undernourished. But It cannot be used to classify if the child is
overweight or obese.

Weight-for-age growth chart for Boys (6 months to 2 years)

17 17

16 16

15 15

14 14

13 13 -3
-2
12 12 -1
0
11 11 -2
-3
10 10 -1

99

88

77

Boy is 10

6 months old 6

& weighs

9.2 Kgs

55
6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

15

The x axis represents age and y axis represents the weight of the child in kilograms.
Age is plotted in completing weeks or months or years depending on the child’s age.
In the above graph, the boy weighs 9.2 kg at 10 months of age.
When you plot more than 2 points on the graph (after an interval of time) connect the
points with a straight line as shown in the graph. This will help to study the growth
trend accurately.
A growing trend should always be upwards. If the trend is downwards it can indicate
a lack of nutrition and will require medical intervention. If the trend is upwards that it
indicates an increase in weight. Slight weight increases will not a problem.
Note that, the child shows falsely overweight, if the child has oedema of both feet. In
such cases, increase in weight is due to water retention and that the child may
actually be very low weight. Please consult a physician to treat the underlying cause.

Exercise 2.2

16

Weight (kg) Ex 2.2 Weight for Age growth chart for GIRLS (6 months to 2 years) 17 -3
17 16 -1
16 15 0
15 14 1
14 13 2
13 12 3
12 11 -2
11 10
10 9
8
9 7
8 6
7 5
6
5

Age (months)

1. What is the girl’s weight at age 16 months?

2. What is the girl’s age when she weighed 10 kg?

3. A line is drawn to connect the plotted points representing girl’s growth. What trend
do you see in his graph & what does it indicate?

Plot Weight for Length/height

“Weight for length or height” growth chart reflects the body weight of the child
in proportion to attain growth in length/height. This chart will identify if the
child is thin or underweight or severely underweight. This can indicate any
recent illness that the child underwent. It may also indicate a food shortage or
undernourishment that the child is suffering from. These charts also identify
overweight or obese children or children with higher weight.

17

Weight-for-height growth chart for Boys (2 years to 5 years)

18

Weight in kg 30 30

28 28

26 26

24 24

22 22

20 20
-3

18 18 -2
-1

16 16 1
14 14 2

3
12 12 0
10 10

88

66

44
65 70 75 80 85 90 95 100 105 110 115 120
length in cm

The x axis represents length/height in cm and the y axis represents weight in Kg.
If the height is 88 cm, it is necessary to use the nearest whole number. I.e. the height
to be considered in this scenario is 90 cm.
(Round down 0.1 to 0.4 and round up 0.5 to 0.9)
Follow up the line up from the x axis to wherever it intersects with the weight
measurement.
When you plot more than 2 points on the graph (after an interval of time) connect the
points with a straight line which will help to study the growth trend accurately

19

The weight for height growth chart is used to identify extremely low weights in
children. This can indicate any recent illness or heath problem that the child may
have suffered.
Exercise 2.3
1. The girl is 1 yr 5 months old. She looks healthy and is very active. What is her
weight, when her height is 80 cm?
2. Plot the next adjacent points and study girl’s growth trend.

All the Growth charts for different age group are given at the end of the
course. Use them to plot and assess your child’s growth record.

20

Weight (kg) Case study: 2.4
Plot the points on the growth chart for a 1 year old girl with below height and weight
measurements. Connect the points and study the growth trend.

Weight for Age growth chart for Girls (6 months to 2 years)
17 17
16 16
15 15
14 14
13 13

-3
12 12

-1
11 11 0

1
10 10 2

9 93
-2

88
77
66
55

Age (months)

1 year: 9.8 kg
1 year 5 months: 10.8 kg
1 year 10 months: 11.8 kg

21

Interpreting plotted points for growth indicators

The growth line in the growth chart indicates the growth in a child.

For studying this, you will refer the growth charts where you plotted the points that
represented your child’s growth trend. The curved lines printed on the charts help
you to interpret your child’s growth status.
The middle line in the growth chart has a value of ‘0’. It is called a ‘median’. This
refers to the average growth of the child.
The other curved lines are known as ‘z scores’ and are numbered as 1, 2, 3. These z
score lines are on both sides of the median. 3 curved lines above the median are
positive and the lines below the median are valued negatively.
Median refers average growth. Lines on either side of the median indicates a growth
problem in children.
While interpreting the plotted points, also consider factors such as family’s height
and other health condition.
The point between z score line -2 and Z score line -3 is considered as below -2. The
point between z score line 2 and z score line 3 is considered as above 2.
If the point is plotted on the z-score line, it is considered not in a severe category. I.e.
if a child has a score of 3 on a z-line on a weight for age chart, then he is considered
‘overweight’ and not severely overweight or obese.

Points to remember…
Median (0) includes all points from 0.1 to 1 on the

graphs.
z-score column refers to a range. Example; above 2
refers to all points between 2.1 to 3.0. Below -2 refers

to all the points between -2.1 to -3.0 and so on.

22

Let us look at the following chart, to understand growth indicators of a growth chart.

Lenght for Age growth chart for Girls (6 months to 2 years)
100 100

95 95

90 90

Height (cm)85 85

-3
80 80 -2

-1
75 75 0

2
70 70 3

1

65 65

60 60

55 55

Age (months)

The Top most line in blue is a Z score line representing +3
The second line from top in red is a Z score line representing +2
The third line from top in dark green is a Z score line representing +1
The middle line is called as ‘median’ representing ‘0’
The last line from bottom in purple is a Z score line representing -3
The second line from bottom in orange is a Z score line representing -2
The third line from bottom in green is a Z score line representing -1

23

III. Growth Problem Indicators and Interpreting growth
trends

Objective
 Identify underlying growth problem on a growth chart.
 Interpret growth trend.

Growth Problem

You need to compare the points plotted on the growth charts to the z-score lines.
This will help us to determine the underlying growth problem.
On the basis of the observation, we will categorize growth trends into the
following categories

 Severely underweight
 Underweight
 Thin (no noticeable fat)
 Normal limit
 Heavy (sturdy)
 Overweight (noticeable fat)
 Obese (excess fat)

24

Z-score Length/Height for Age Growth Indicators

above 3 Very tall Tallness can rarely be a problem, except if it
above 2 Normal limit indicates some endocrine disorder like a growth-
above 1 Normal limit hormone-producing tumour).
0 (median) Normal limit
below -1 Normal limit

below -2 Stunted If the child is stunted, there is a possibility to
become overweight.
below -3
Severely Stunted If the child is stunted, there is a possibility to
become overweight.

Z-score Weight for Age Growth Indicators

above 3 Child falling in this range may have a growth
problem. You will have to assess the child using
above 2 weight for the length/height chart.

above 1 Child falling in this range may have a growth
0 (median) problem. You will have to assess the child using
below -1 weight for the length/height chart.
below -2
Child falling in this range may have a growth
below -3 problem. You will have to assess the child using
weight for length/height chart or BMI for age chart.

Normal limit The child is considered to be very low weighted. 25
Thin
Underweight

Severely
Underweight

Z-score Weight for Length/Height Growth Indicators
above 3
above 2 Obese
Overweight

above 1 Possible risk of Child showing a growth trend above 1 z-score line is
0 (median) overweight at possible risk and child showing a growing trend
below -1 towards 2 z-score line is at risk.
below -2 Normal limit

below -3 Thin

Underweight

Severely
Underweight

Calculate BMI

BMI is body mass index is a measurement of human body shape. It is based on
body’s mass and height and is calculated using the formula;

Hence, If a boy’s height is 160 cm and weighs 55 kg, his BMI will be 21. (160
cm = 1.6 m).
Optimal weight is between BMI 18 to 25.
Use of BMI can be made for older children
.

26

Z-score BMI for Age Growth Indicators
above 3
above 2 Obese
Overweight

above 1 Possible risk of Child showing a growth trend above 1 z-score line is
0 (median) overweight at possible risk and child showing a growing trend
below -1 towards 2 z-score line is at risk.
below -2 Normal

below -3 Thin

Underweight

Severely
Underweight

27

Example 1 Weight for Age growth chart for Boys (Birth to 6 months)

12 12
11
10 11

9 10
8
7 9
6
5Weight (kg) 8 -2
4 -1
3
2 70
1

62
3

5
-3

4

3

2

0
1
2
3
1 month
5
6
7
2 months
9
10
11
12
3 months
14
15
16
4 months
18
19
20
21
5 months
23
24
25
6 months
Age (weeks)

In the above weight for age chart, the boy at 12 weeks weighs 5 kg.
Notice that his weight is below the -1 Z score line. This is considered as severely
underweight.

28

Weight (kg)Example 2

Weight for Age growth chart for GIRLS (6 months to 2 years)
17 17
16 16
15 15
14 14
13 13

-3
12 12

-1
11 11 0

1
10 10 2

9 93
-2

88
77
66
55

Age (months)

The girl weighs 13 kg at 1 year 6 months of age. Her height is 85 cm.
Notice that she is above the +1 z score line. But before considering her overweight it
is necessary to look at her weight for length and length for age growth charts. The
girl looks normal in appearance.

29

Example 2 continued…

Weight (kg) Weight for Length growth chart for girls (Birth to 2 years) -3
26 26 -2
24 24 -1
22 22 0
20 20 2
18 18 3
16 16 1
14 14
12 12
10 10

88
66
44
22
00

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)

Her weight for length growth chart shows her weight falling in the ‘possible risk of
overweight’ category (+1). Let us now plot her growth on weight for height/length
chart.

30

Example 2 continued…

Height (cm) Length for Age growth chart for Girls (6 months to 2 years)
100 100

95 95

90 90

85 85
-3

80 80 -2
-1

75 75 0
2

70 70 3
1

65 65

60 60

55 55

Age (months)

The girl’s height falls on +1 z score line. This indicates that she is tall for her age and
her weight is in normal limit.

In the above case, the child will look taller than other children of average height.

Always correlate readings on the graph with the child’s appearance.

31

Example 3

Weight (kg) Weight for Height growth chart for Boys (2 years to 5 years) -3
30 30 -2
28 28 -1
26 26 1
24 24 2
22 22 3
20 20 0
18 18
16 16
14 14
12 12
10 10

88
66
44

65 70 75 80 85 90 95 100 105 110 115 120
Length (cm)

In the above graph, the boy weighs 22 kg. His height is 100 cm. It indicates the boy
is obese for his height. Observe his weight is above +3 z score line.

32

Example 4

Weight (kg) Weight for Age growth chart for GIRLS (6 months to 2 years)
17 17

16 16

15 15

14 14
13 13 -3
12 12 -1
11 11 0
10 10 1

9 92
8 83
7 7 -2

66

55

Age (months)

Weight (kg) Weight for Length growth chart for girls (Birth to 2 years) -3
26 26 -2
24 24 -1
22 22 0
20 20 2
18 18 3
16 16 1
14 14
12 12 33
10 10

88
66
44
22
00

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)

100 Lenght for Age growth chart for Girls (6 months to 2 years) 100

95 95

90 90

85 85 -3
-2
Height (cm)80 80 -1
0
75 75 2
3
70 70 1

65 65

60 60

55 55

6 7 8 9 10 11 1 Year 1 2 3 4 5 6 7 8 9 10 112 Years

Age (months)

In the above charts, the girl’s age is 1 year 9 months. She weighs 10 kg and is 75 cm
in length.

As per the weight for age chart the girl is below the median but still in the normal
range. If we look at the weight for length chart she is over the median but again has
a little risk of getting overweight. In appearance she looks normal in regards to height
and weight. However if you look at the height for age chart she is on Z score -3 line.
This indicates she has a stunted growth.

Important observation

 If on studying weight for age and weight for length charts, the trend is
towards -3 z scores then your child needs immediate medical attention.
Such children are often seen suffering from Kwashiorkor or marasmus.

 Look for other indicators such as, if the child appears to be fat but
scores below -3 on growth chart then it can be a clear sign of Oedema.
In such cases due to water retention the child looks fat but actually the
child is severely underweight.

 Please consult a pediatrician without delay.

34

Points to remember

 Always consider all the growth charts together to determine the correct problem.

 If your child is underweight in his weight for age growth chart, consider the child's
length for age and weight for length charts to analyze his growth trend.

 A child who has a stunted growth will have normal weight for height but has low
weight for age due to shortness. In such cases, you should consider weight for
length and height/length for age growth charts. This will give you a correct analysis
of the trend.

 Remember, it is advised that you consider all the growth charts together to
determine the growth problem.

 Please also consider your child’s appearance when interpreting the growth charts.

Case study: 3.1

Rahul’s growth record is given below.

Date Height Weight

2 months 63 6
6 months 67 6.9
9 months 72 7.8
15 months 78 8.8

1. Select appropriate growth charts.
2. Plot his measurements & draw trend line on growth charts
3. Analyze his growth trend & determine if the growth is positive or negative.

35

Interpret trends on Growth Chart

Interpreting growth by studying the growth chart helps you to determine if the child is
growing normally or has a growth problem or is at a risk of growing a problem.
To study the trend, you must look at the plotted points on the growth chart on the day
of assessments. This trend will show if the child is growing well or is showing any
growth problem. If a problem occurs, the child should be reassessed soon.
The below conditions/trend on the growth chart will indicate risk or possible risk in
the child:

 When the growth line crosses a z-score and keeps going.
 When there is a sharp decline or incline in the growth line.
 When the growth line remains flat (parallel to x-axis). This happens when

there is no growth in height or weight.
There are some exceptions when the sharp decline or incline is a good sign in the
growth chart of the child. Situation in which the child has gained weight after an
illness, he will recover by gaining healthy weight.
On the other hand, if an overweight child shows a declining growth line towards the
median on a weight for age or weight for height chart indicates desirable health.
Hence it is important to consider whole situation before interpreting the growth trend
of a child.
Growing and developing Children fall in between -2 and 2 z-scores of a given
indicator. A growth lines towards a median is always good.
Growth lines that is inclining or declining & that cross z-score lines indicate possible
risk and needs to be determines if the change is problematic. For example if the
growth line is declining in a weight for age chart then it can also indicate that the
child is trending towards stunting and the necessary action can be taken accordingly.

36

Height (cm) Height -for-Age growth chart for Girls (2 years to 5 years)
125 125

120 120

115 115

110 110 -3
-2

105 105
-1

100 100 0
95 95 1
3
90 90
2
85 85

80 80

75 75

Age (months)

The above chart shows a growth trend on z scores line +1. The child is above
average in height as the plotted points are on +1 z score. This chart shows an
upwards moving trends.
We will now look at various line trends on the growth chart that indicates possible
effects on a child’s health.

37

Line crosses z-score & keep going
Growing and developing Children measurements are between -2 and 2 z-scores of a
given indicator. A growth lines towards a median is always preferable. But if the
growth line continues to grow and crosses z-score lines, it can represent a growing
problem in the child. A detailed assessment needs to be done immediately.

Example 1

Weight (kg) Weight-for-age growth chart for Boys (6 months to 2 years) -3
17 17 -2
16 16 -1
15 15 0
14 14 -2
13 13 -3
12 12 -1
11 11
10 10

99
88
77
66
55

6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

Age (months)

In the above growth chart boy’s weight is below median. It falls on the -2 z score.
However as the age increases we see an upward trend, nearing the median. This is
a positive sign as the child is gaining weight and is nearing the median into ‘normal
limit.’

38

Height (cm) Example 2 Height -for-Age growth chart for Girls (2 years to 5 years) 125
Age (months)
125 120
120
115 115
110
105 110 -3
100 -2

95 105
90 -1
85
80 100
75 0

95 1
3

90
2

85

80

75

The above chart shows a growth trend on z score line +1 that crosses the +2 z
score. The child is above average in height. The chart shows an upward moving
trend. If the child continues to grow and crosses z score line, he will need medical
attention to diagnose the underlying cause of sudden spurt in growth.

39

Decline or Incline growth line
Declining or inclining line represents that the child needs attention.
A sharp incline above the median can indicate changes in feeding practices that
will result in overweight. Before interpreting have a look at the weight for height
chart. If it has a steady growth along the z-score curves it indicates the child is
growing proportionally.
A sharp decline in the growth line of a normal or undernourished child indicates a
growth problem to be investigated and remedied.
Even an overweight child should not have a sharp decline in the growth line as it
may indicate losing weight too quickly and which is undesirable. He should keep
his weight constant and grow his height till the height and weight are proportional.
A sharp incline in weight is also seen when the child has recovered after a recent
illness. Such an incline growth line is much expected as the child is in re-feeding
period. In otherwise cases, incline line is not a good sign as it indicates a sudden
change in feeding pattern.

Example 1
In the below graph, we see a decrease in weight with sudden and sharp increase in
weight over the months. The child had lost 1 kg due to a recent illness. The child
recovered 1.2 kg on recovering the illness.

In such scenario, a sharp incline in growth line is a positive sign as shown in the
below chart.

40

Weight (kg) Weight for Age growth chart for GIRLS (6 months to 2 years)
17 17
16 16
15 15
14 14
13 13
12 12 -3

-1
11 11 0

1
10 10 2

3
9 9 -2
88
77
66
55

Age (months)

41

Height (cm)Flat growth line

The Flat growth line indicates a problem in a child. In children between 0 to 6 months
the growth rate is faster. If the growth chart shows a flat growth line it indicates a
problem. It indicates that the child is not growing at a normal rate.
Flat growth line in height for age chart also indicates a problem. It means that the
child’s height is not growing with his age.
Flat growth line in weight for age chart also indicates a problem. The only time when
a Flat growth line is accepted is in obese or an overweight child. When an
overweight children has flat line, it suggests that the child is growing into his weight.
A child’s graph should have a steep growth curve. Even 1 months flat growth line
indicates stagnation and possible problem.

Length for Age growth chart for Girls (6 months to 2 years)
100 100

95 95

90 90

85 85
-3

80 80 -2
-1

75 75 0
2

70 70 3
65 65 1

60 60

55 55

Age (months)

In the graph above, the girl shows a flat growth in height. This indicates a serious
problem as at this age the child’s growth rate is faster. She needs medical attention.

42

On the contrary, in the below growth chart the girl was overweight. She scored +2 on
z score. But as her height increased, her weight remained constant. This indicated a
good growth trend as she was no longer overweight.

Weight (kg) Weight for Length growth chart for girls (Birth to 2 years) -3
26 26 -2
24 24 -1
22 22 0
20 20 2
18 18 3
16 16 1
14 14
12 12
10 10

88
66
44
22
00

45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)

43

Case study: 3.2

Amol was born on 1st Jan 2011. His weight at the time of birth was 2.8 kg and
length was 48 cms. His mother started his growth record on 15th July 2011. His
measurements are given below. Choose correct growth charts for plotting his
readings and analyze his growth trend.
If you observe a specific trend, determine its cause. His appearance is normal.
(Charts are given at the end of the course)

Date Length Weight
15th July 11 71 10.35
15th Oct 11 76 11.4
17th Jan 12 79 12.25
16th Apr 12 83
16th Aug 12 85 12
16th Nov 12 89 13
15th Dec 12 89.5 13.5
13.6

44

IV. Investigating causes of Growth problem

Objective

 Investigate causes of Undernourishment and Overweight in children.

Undernourishment

Undernourishment in a child is categorized on a growth chart in following ways;

 Severely underweight with below -2 score on a weight for length/height chart
 Underweight with below -1 score on a weight for length/height chart
 Stunted with below -2 score on a length/height for age chart
 If the child has a growth trend towards one of the problems

Below given charts shows underweight and severely underweight children.

Weight for Length growth chart for girls (Birth to 2 years)
26 26

24 24

22 22

20 20

18 18

16 16 -3
-2
Weight (kg) 14 14 -1
0
12 12 2
3
10 10 1

8 Underweight 8

66

Severely

4 underweight 4

22

00
45 50 55 60 65 70 75 80 85 90 95 100 105 110

Length (cm)

45

Height (cm) Height -for-Age growth chart for Girls (2 years to 5 years) 125

125 120
120
115 115
110
105 110 -3
100 105 -2

95 -1
90 100 0
85 stunted 95 1

growth 3
80 90
75
2
Age (years) 85

80

75

Causes of Undernourishment

 Change in child’s appetite
 Problems with breastfeeding,
 Infrequent frequency of feeding
 Mealtime habits
 Illnesses
 Recent trauma
 Social and environmental factors

46

Steps to identify causes of Undernourishment

There are several possible causes of Undernourishment in a child. It is advisable to
focus on the main causes that can be changed. Answer the following questions and
ask yourself what could be the most relevant cause for an Undernourishment in your
child.

Possible causes of Undernourishment Y/N

Are you referring an appropriate growth chart?
If the breastfeeding frequency changed and/or reduced
Does the child attaches well with the breast and empties it.
Are you facing any difficulty in breastfeeding?
The child takes any other food besides breast milk.
If the child takes water
Does the child take cow’s milk? How is the texture of the milk?
Do you give any semi-solid food or solid food?

What is the frequency of intake of semi-solid or solid food?
Do you keep your child to a caretaker?
Do you maintain proper sanitation for the child?
Is the child suffering from any illness or suffered in the past?
Is your child tired / sick with diarrhoea / cough / fever?
Do you maintain your home’s hygiene?
Has anyone in your family suffered any illness?
Is there some other family tension or recent trauma?

Note: Questions are framed for children from 0 to 6 months.

 Based on your answer, you will have to take appropriate care to treat
Undernourishment.

 If your child is currently ill or has a chronic disease, causing
Undernourishment, seek medical help immediately.

 If there is a feeding problem, then refer to our course on breastfeeding in the
next chapters.

 If the child’s feeding is getting neglected for any reason then 2 or more people
should share responsibilities for feeding the child and taking proper care.

47

 If the child has undergone trauma such as death in the family or a change in
caregiver, give the child the much needed attention.

 Remember, feeding practices must appropriate to the age of the child.
Improve the amount and availability of nutrients in the diet by increasing
consumption of animal-source foods. Animal-sourced foods are high in
nutrients.

 Follow correct sanitation practices.

Remember, our first aim is to stop Undernourishment and second is to reverse
the trend. Improvement will take time. Rate of improvement cannot be predicted
and will be different among children of the same age. If your child had suffered
recent illness, it may take around 3 months to normalize his weight.
The increase in weight should also be proportional to a child’s height and hence
emphasis should be on the overall increase in growth. Height-weight should be in
relation to one another.

Overweight

Overweight in a child is categorized on a growth chart in following ways;
 Growth trend towards overweight with above 1 z-score on a weight for
length/height chart.
 Highly overweight (obese) with above 2 z-score on a weight for length/height
chart.

Mother or caregiver needs to investigate causes of overweight. A stunted child can
be overweight or obese, as discussed earlier.
An obese child who has z-score above 3 needs medical assessment and
management.

48

Causes of overweight

 No physical activity
 Sedentary lifestyle
 Overfeeding
 Obesity in parents
 Poor dietary habits (consumption of energy dense foods)
 Family eating patterns / environment

Steps to identify causes of overweight

To identify the causes of overweight, you should analyze your child’s diet and
frequency of feeding/eating. It is often seen that some mothers tend to overfeed their
child to keep up the child’s weight. The chance of obesity is increased by 40% if one
of the child’s parents is obese and it is increased by 70% if both the parents are
obese.

Possible causes of overweight Y/N

Is your child taller than the average height
Is he breastfed or has outside food?
How much milk he drinks daily?

If he is not breastfed, what is the source of milk?

Do you add any sweetening agent in the milk?

How many meals does he have every day?

How much quantity does he eat each time?
Does he eat cakes or other sweets?
Does he drink soft drinks?

Does he eat deep fried snakes / chocolates / French fries?
Do you think he overeats?
Does he watch television while eating?

Is he seen playing or spends most of his time watching T.V or playing on 49
electronic gadgets?

Is either of his parents overweight?
Note: Questions are framed for children above 6 months.