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High level of growth faltering among urban infants

05 Oct 2022

  • Clinical audit reveals sub-par growth monitoring practices
  • Calls for more regular measurements to make interventions 
BY Ruwan Laknath Jayakody Practices related to the monitoring of growth among urban infants are suboptimal, with a high prevalence of faltering growth, giving rise to the need to strengthen growth monitoring during infancy so that appropriate interventions can be made. These findings were made in an original article titled “Growth monitoring of infants in an urban area of Sri Lanka – A clinical audit”, authored by K. Sithamparapillai (attached to the Lady Ridgeway Hospital for Children, Colombo), D. Samaranayake, and P. Wickramasinghe (both attached to the Colombo University) and published in the Journal of the Postgraduate Institute of Medicine 9(2) in August 2022. The Health Ministry's national guidelines for infant and young child feeding and growth monitoring recommend that while weight should be monitored monthly, length should be checked at four and nine months during infancy. More frequent monitoring is recommended if there are any concerns regarding growth, such as weight gain or the impairment of general health. The most frequently monitored parameter in Sri Lankan infants is the weight for the age. The lack of use of other parameters could affect the achievement of optimum growth in children. Sithamparapillai et al. conducted a clinical audit to assess the level of adherence to the national guideline for growth monitoring during infancy in 141 children, between the ages of 12 and 18 months, who were attending an immunisation clinic of a tertiary care hospital in Colombo. The parents of the said children were recruited consecutive to the audit. Half of the data was collected prior to the Covid-19-related lockdown in 2020 and the balance was collected in the first four months after the lockdown, while only 18-months-old children were included in the audit subsequent to the lockdown. Data on growth monitoring was extracted from the Child Health Development Record (CHDR). Weight and length at the point of recruitment i.e. 12 and 18 months of age, were measured. The nutritional status was assessed using the weight for the age, the length for the age, and the weight for length at the point of recruitment. When infants were weighed nine times or less than nine times during the first year of life, it was considered per the Health Ministry’s “National Strategy for Infant and Young Child Feeding”, that regular growth monitoring had taken place. P. Wickramasinghe’s “Assessment of growth in children” defined weight faltering as a downward deviation of the weight for the age from the growth trajectory – i.e., less weight gain than expected. Of the 141 children in the study population, 77.3% were 18-months-old children and 41.8% were girls. The basic characteristics of the study population and the growth indices including nutritional status at recruitment included age (12 months; 18 months), sex, maturity at birth (37 weeks or less; over 37 weeks), the birth weight (2.5 kg or less; over 2.5 kg [all pre-term babies had low birth weight]), the weight for the age, the length for the age, and the weight for length. With regard to the frequency of the monitoring of growth parameters, in addition to the weight for the age, the length for the age, and the weight for length, the occipito-frontal circumference (the maximum circumference of the head to the nearest 0.1 cm, measured with a non-elastic, flexible, fiberglass measuring tape passing above the supra-orbital ridges and over the maximum occipital prominence) was also plotted in the CHDR, while the weight and length at birth were excluded in the growth parameters plotted in the CHDR. In the majority, the anthropometric parameters at birth were plotted in the CHDR.  The birth weight was recorded in all, while the length and the occipito-frontal circumference at birth were recorded in 132 (93.6%) and 138 (97.9%), respectively. There were nine or less than nine weight measurements plotted during the infancy in 75.9% and five to eight measurements in 18.4%. The frequency of the weight measurements was lower between seven to 12 months of age compared to the first six months.  The mean frequency of the weight measurement during the first six months was 5.39, while it was 4.28 between seven to 12 months. The frequency of the length measurements was also lower between seven to 12 months compared to the first six months. The mean frequency of the length measurement during the first six months was 1.1, while it was 0.89 during seven to 12 months. With regard to the regular weight for the age-related monitoring and associated factors, the characteristics that were considered included the birth weight, maturity, weight faltering during infancy (absent; present), and the mother's age (below 35 years; 35 years and above), education (primary or secondary; tertiary and above) and employment (employed; housewife) status. Weight faltering during infancy was noted in 85 (60.3%). Of them, the weight for the age was plotted nine times or less in 81.2% of cases. There were no significant associations between the infant’s and the mother’s characteristics and the frequency of the infant’s weight for the age monitoring. The frequency of the length-related measurements during infancy included visiting the clinic at four or nine months, measuring the length at four or nine months, measuring the length at different times during this period, not measuring the length during this period, and plotting the weight for the length at least once. Although 131 (92.9%) had attended the clinic, the length was plotted only in 79 (56%) at four months. A total of 27% had their length plotted on some other occasion between the first six months and the remaining 17% did not have their length measured during the first six months of life.  Clinic attendance at nine months was 80.1%, but the length was plotted only in 44.7% of cases. A total of 30% did not have their lengths measured between six to 12 months. A total of 6% did not have their length measured during the entire first year of life. Weight faltering was noted at some point during infancy in 85 (60.3%) and 67 (78.8%) of them had at least one weight for length plotted, while 24 (28.2%) of them had two or more recordings plotted. Panpanich et al. and UNICEF note that effective growth monitoring requires regular and accurate anthropometric measurements, plotting it in the CHDR with correct interpretations, and making appropriate interventions to address abnormal growth. According to the national guidelines, regular growth monitoring is defined when infants have undergone nine or less than nine weight measurements at designated times during the first year of life. The proportion of infants whose growth was monitored regularly in Sri Lanka in 2014 was reported to be 84.3% and the target was to achieve 90% in 2020. The results of the instant study revealed however that the regular weight-for-age monitoring was below this figure, and that the frequency of monitoring reduced significantly during the second half of infancy. Monitoring weight is the mainstay to monitor growth in the community, and it is operated by the preventive health sector. The national guidelines recommend monitoring length at specific points of time. The measurement of length is needed in order to determine the length for the age and the weight for the length and hence, assess the nutritional status. Regular growth assessment would assist in determining the nutritional status and any feeding intervention would be based on the weight for the length assessment.  Therefore, the value of these growth indices cannot be underestimated, especially when the prevalence of growth faltering is high. This audit showed that the length-related measurements were not plotted at the recommended time points, even though the infants have attended the clinic and it also showed that the weight for the length parameter was seldom used even in those with growth faltering. The reasons for these lapses in growth monitoring could be the lack of resources in the well-baby clinics, clinics being overcrowded with measurements and documentation taking an inordinate length of time or having inadequate knowledge about the importance of the length measurement and its interpretation. Issues related to suboptimal growth monitoring in the field need to be investigated and addressed.  Furthermore, in the hospital setting and other medical consultations, updating the CHDR with growth parameters seldom takes place. Although many do take anthropometric measurements, the practice of plotting them on a growth chart does not take place regularly. Health staff in the curative sector should be encouraged to document any growth parameter that is measured during any visit to a health-care facility. Effective growth monitoring would help to detect malnutrition at an early stage, thus making corrective interventions easy, timely, and effective, and in turn providing all children with the opportunity to grow to their highest potential.


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