Going for growth.

Abstract

Monitoring growth, as it is now practised in most health systems in developing countries, is widely misunderstood and largely ineffective (1-5). So, it is no surprise that the process itself has been controversial, leading some academicians and practitioners to urge its elimination from community-based programmes (6-9). And still, monitoring growth is universally found in paediatric offices and academic centres throughout the world, seen as an integral part of good paediatric practice. As introduced by Morley in clinics that treated children aged under five years in Nigeria in the 1960s (10), monthly monitoring of growth has provided the foundation of good promotive child healthcare in large projects in India (11), Bangladesh (12), and Honduras (13), and in thousands of village of Indonesia (14). How did growth monitoring and promotion (GMP), once seen as the essential foundation of the United Nations Children's Fund (UNICEF)-promoted GOBI strategy for young children (growth monitoring, oral rehydration, breastfeeding, and immunization) fall into such disrepute, while the other GOBI components have proven highly robust? Part of the answer indeed lies in the poor understanding of its purposes and procedures by medical officers and health and nutrition workers as reported by Roberfroid et al. in this issue of the Journal (15). First, as well-documented in that paper, the primary purpose of GMP is rarely understood even by its implementers and much less by participating mothers. The emphasis is on the measuring--the 'monitoring' rather than the 'promotion' of growth. The growth card, all too often, is seen as a diagnostic tool for use by the health worker to detect existing malnutrition rather than a communication aid to encourage early action by the mother before malnutrition supervenes. The card, designed to draw a mother's attention to the pattern of growth of her own child, is instead used by workers as an anthropometric standard for measuring nutritional status. Thus, from the start, the primary purpose of GMP is diverted. This leads automatically to the second major error: GMP activities focus on the wrong age-group--the already-malnourished older child becomes the object of the greatest attention rather than the infant and one-year old child where most unseen and significant growth faltering is encountered (16). The opportunity for early preventive intervention to reverse growth faltering is lost in exchange for late and often ineffective, difficult, and costly therapy for established under-nutrition. There has been, in fact, anecdotal evidence in some programmes of desperately poor mothers hoping for poor growth or 'bad nutrition' with the expectation of then receiving free food for their children and families. Growth 'promotion' should begin at or even before birth, helping mothers understand that the overall well-being of her child depends on her own behaviour, even during pregnancy: how she exerts herself or rests, her personal hygiene and healthcare, exposure to smoke and other toxins, and what she eats. Early and exclusive breastfeeding has been shown to be the single most effective intervention to improve child survival and nutrition, requiring support and promotion from the moment of delivery (17). Timely introduction of adequate complimentary foods is another critical intervention in mid-infancy. These opportunities to establish healthy growth too often are lost in the attention given to the older, more obviously failing child whose weight is "below the line." GMP was designed as a communication strategy to alert mothers and workers to early signs of inadequate attention to childcare, to underlying illness or social pathology. Faltering growth, once visualized through the 'monitoring' and charting, would lead, as early GMP advocates expected, to a careful investigation of the childrearing practices and home environment, with practical actions identified to resume growth, and to appropriate positive reinforcement of those measures when successful, as seen with improved growth the following month. …