Statistical Principles in Assessment of Growth

GAUSSIAN DISTRIBUTION
If measurements of any of the growth parameters (e.g., weight and height)
are obtained in a large population of normal children and then arranged in a
regular order starting from the lowest to the highest, a bell-shaped curve is
formed.
This symmetrical curve illustrates a typical Gaussian (Normal) distribution, in
which maximum values lie around the middle of the curve. The curve tapers
off on the either side, with fewer observations at both the ends of the curve.
Mean and median are equal in a Gaussian distribution.

MEAN AND STANDARD DEVIATION

Measurement of a parameter in a sample and its recording in a continuous
numerical manner generates several measurements the most important of
them being mean and standard deviation (SD).
Mean (m): It is obtained by dividing the sum of all observations by the
number of observations. In a Gaussian distribution, the maximum number of
values cluster around the average or mean.
Standard deviation (s): It denotes the degree of dispersion or the scatter of
observations away from the mean. It is estimated that:
m ± s → 68.3% of values [15% to 85%]
m ± 2s → 95.4% of values [3% to 97%]
m ± 3s → 99.7% of values [<1% to >99%]
MEDIAN AND PERCENT MEDIAN
When data are arranged in ascending or descending order of magnitude,
median indicates that 50% of observations are above and 50% are below
this point. In a typical Gaussian distribution, the median is expected to be
equivalent to the arithmetic mean. Median, rather than the mean, is
considered as the central value for most of the anthropometric
parameters since the population data has a non-Gaussian (skewed)
distribution.
PERCENTILES
Percentile indicates the position that a measurement would hold in a typical
series of 100 arranged in ascending order. The median lies at the 50th
percentile, on either side of which lie half the observations. Another example
is the 85th percentile curve, which denotes that 15% of observations are
expected to be above and 84% below it.
The WHO growth standards show curves at 3rd, 15th, 50th, 85th and
97th percentiles corresponding to distances from the average values.
One standard deviation above or below the mean coincides with the
84th or 16th percentile curve, respectively.
80% of the weight/height measurements of healthy children at a given age
are expected to lie between 10th and 90th percentiles, Further, 95% of the
weight/height measurements of healthy children at a given age are expected
to lie between 3rd and 97th percentile values. Thus, allowable normal range
of variation in observations is between 3rd and 97th percentiles, which
roughly corresponds to ± 2 SD. A healthy child normally remains and follows
the same percentile curve during the entire period of his/her growth.
Z (SD)-SCORE
It represents the deviation of anthropometric measurement from the
reference median and is calculated as follows:
(Observed value - Median reference value) / Standard Deviation (SD) of the
Reference Population = (x – m) / s
An SD score value of +1.5 means that the difference between the present
(observed) and the expected (reference median value) is 1.5 times of the
standard deviation of the reference population.
A negative value of Z-score means that the observed value is less than the
expected; and vice versa. Similarly, a positive (+) value of Z-score indicates
that the observed value of the measurement/ index is more than the
reference median.
Usually, -1, -2, and -3 Z-scores correspond to 15.8, 2.28, and 0.13th
percentiles; while 1st, 3rd, and 10th percentiles corresponds to -2.33, -1.88,
and -1.29 Z-scores, respectively. Thus the 3rd percentile roughly corresponds
to -2SD.
Abnormal values refer to measurements below -2 Z-score (2.3rd percentile) or
above +2 Z-score (97.7th percentile), relative to the reference median.

IN A NUTSHELL
Statistical Principles in Assessment of Growth
1, Median, rather than mean is considered as the central value for most
anthropometric parameters
2. Percentile indicates the position that a value will hold arranged
chronologically in a series of 100 values. Median is thus, the 50th %-ile
3. Most normal children are expected to have their anthropometric
measurements between 3rd and 97th percentiles
4. Z-score (≡ SD score) represents deviation from the central value.
5. Usually, values between ± 2 Z-scores are considered normal.
Growth Charts, Growth References, and Growth Standards
GROWTH CHARTS
The growth charts comprise an X-axis that corresponds to the in months or
years; and Y-axis denoting the value of the anthropometric parameter, for
example, weight (kg), height (cm), body mass index (kg/m 2), etc. WHO
growth chart are available for both percentiles and Z-score, separately.

The WHO percentile charts depict 5 percentiles lines corresponding to

3rd, 15th, 50th, 85th, and 97th percentiles (from below to above). Any
child who is below the 3rd or above the 97th centile is likely to be abnormal.
The WHO Z-score charts display curves for median, -2Z, -3Z, 2Z, and 3Z-
scores. Abnormal is defined as any discrepancy of more than -2Z-scores. A
deviation by more than -3Z-score denotes severe malnutrition. On the
charts of growth velocity, the cut-off line for defining low-height velocity is
below the 25th centile.

WHO growth standards for children <5 years have been adopted in many
countries including India as the universal global standard, for monitoring
growth in under-5 children. In 2015, Indian Academy of Pediatrics published
new revised growth charts for Indian children 5-18 years of age in view of
the changing trend in nutritional status of older children.

GROWTH REFERENCES VERSUS GROWTH STANDARDS

Growth standards: These represent data on how a population of children
should grow, under the given optimal nutritional and health conditions.
Growth references: These are descriptive data that define how children in the
population are growing under the best age possible state of nutrition and
health in a given community. They represent how children are actually
growing rather than how they should be growing.
The WHO growth charts published in 2006, based on the WHO Multicentre
Growth Reference Study (MGRS) for children under the age of 5 years,
are an example of growth standards.
Whereas the 2015 IAP growth charts are growth references which describe
how children in India were actually growing at that point of time.

WHO GROWTH STANDARDS

The 2006 growth curves and charts developed by the World Health
Organization (WHO) provide a single international standard that represents
the best description of physiological growth for all children from birth to 5
years of age. These charts are based on the growth of exclusively breastfed
infants.
The second unique feature of these standards is that it is based on growth of
children from many of the world's major regions: Brazil (South America),
Ghana (Africa), India (Asia), Norway (Europe), Oman (the Middle East), and
the USA (North America).
These standards show that all children of the world grow similarly till 5 years
of age, provided the optimal environment, regardless of ethnicity and
socioeconomic status. The standards show that nutrition, environment, and
healthcare are stronger factors in determining growth and development
than gender or ethnic background. The WHO standards differ from other
existing growth charts in a number of innovative ways:

 WHO standards are based on as longitudinally collected data opposed to

cross-sectional data in erstwhile NCHS reference (based on growth of
North American Children). This is particularly useful in development of
growth velocity regions standards.
 WHO standards describe "how children should grow," as compared to
earlier NCHS references which simply stated "how children are growing."
 WHO standards make breastfeeding the biological "norm" and
establishes the breasted infant as the normative growth model. NCHS
reference was based on the growth of artificially-fed children.
 WHO standards also include other growth indicators such as the skinfold
thickness, and body mass index. These are useful to define obesity and
overweight.
 MGRS also provide the Windows of Achievement standards for six motor
development milestones including sitting, standing, and walking.
 WHO charts have now replaced the National Center for Health Statistics
(NCHS)/ Centres for Disease Control and Prevention (CDC) Growth Charts
for assessing the growth of children upto 5 years of age. The WHO
growth charts are provided for weight- for-age (birth-5 years); length/
height-for-age. A single value only denotes the measurement at that
point of time (birth-5 years); weight-for-length (birth-2 years); and
weight-for-height (2-5 years).

GROWTH REFERENCE FOR INDIAN CHILDREN 5-18 YEARS

Even though growth occurs in a similar manner among under-5 children

throughout the world, but there do exist some regional variations among
the pattern of growth of older children. The average adult weight and height
are also different in different of the world because of the same reason. Thus,
for Indian children older than 5 years, the ideal reference standards would
be the ones derived from Indian population itself.

In 2015, Indian Academy of Pediatrics (IAP) published the revised growth

charts based on data collected from published studies on apparently healthy
Indian children and adolescents in the past one decade. IAP recommends
use of these charts as reference values for Indian children between 5 and 18
years of age. These reference curves are provided. Unlike WHO, IAP has 3%,
10%, 25%, 50%, 75%, 90% and 97% as the reference percentile curves.
GROWTH MONITORING
Growth monitoring is a screening tool used to diagnose nutritional
discrepancies, chronic systemic illnesses, and endocrine disorders. Growth
monitoring involves taking the same and multiple anthropometric
measurements at regular intervals, approximately at the same time of the
day and to see their changing trend.

National Health Mission encourages growth monitoring of children <3 years

of age. Children are monitored monthly in the Mother and Child Protection
(MCP) Card. The chart can detect whether a child is growing normally or
having faltering growth.

ASSESSMENT OF GROWTH
It is done by:
1. Measurement of growth parameters - weight, height /length, head
circumference, mid upper arm circumference (MUAC), chest circumference.
2. Assessing various growth indices/body proportions or ratios.
3. Assessing sexual maturation.

Assessment of Sexual Maturation

Sexual maturity is assessed by Sex Maturity Rating (SMR). Tanner's 5-stage
SMR is commonly followed, where stage-1 indicates no sexual maturity and
stage-5 indicates full maturity. The first sign of sexual maturation is
enlargement of breasts in girls and that of testes in boys. There is substantial
individual variation in maturation.
Anthropometric Measurements:
• Weight
• Height if > 2 years of age and physically fit to stand.
Length if < 2 years of age, or a child who is physically ill and unable to
stand.
• Head circumference.
• Mid-arm circumference (MUAC).

In relevant cases, e.g., growth retardation/ short stature or long stature -

• Crown-rump length / CRL (sitting height).
• Arm span.
• Upper segment (US), lower segment (LS), and the US: LS ratio.

Anthropometry is the measurement of size and proportions of the human

body.
In children these measurements are important for assessment and
monitoring of physical growth.
Parameters:
1. WEIGHT:
Instrument for measurement: Weighing machine or scale.
(a) Digital weighing scale:
Precision: 5 gm
Use mainly for infants.

(b) Spring balance:

• 'Pan' type: for infants, lying down on 'pan'.
Range: up to 10 kg.
Precision: 50 gm.
• 'Platform' type (Bathroom scale) to taking weight on standing position
(more than 1-year of age).
Range: 0-100 kg.
Precision: 100 gm.

Drawback of spring balance:

When spring gets loose due to repeated use, the result is erroneous, giving
more than actual weight.
When spring gets rusted and cannot move freely, result is again erroneous
and often giving less than actual weight.

(c) Beam or lever type of balance: More accurate; for taking weight on
standing position
Range: 0-100 kg.
Precision: 100 gm

How to record weight?

Recording weight on 'Pan' type of spring balance (supine weight):

• To check zero of machine

(The pointer must be at '0'
level)
• To remove extra clothing of
the infant (preferably naked)
• To handle the baby gently to
make it supine
• To remove parallax error
while taking reading
• To record the weight. (error/precision ± 50 gm)

Recording weight on 'Platform' type of spring balance (standing weight):

• To check and adjust the pointer at

'0' level

• To remove extra clothing and the

shoes
• To ask the child to stand on the
platform straight up making the
feet symmetrically placed
• To avoid parallax error while
recording the weight
• Record weight with the
precision/error ± 100 gm.

How to calculate expected weight,

according to age?
• Ideally from a nomogram with
age, sex and weight parameters.
A quick bed-side calculation can be done by Weech's formula.
Weech's formula for Weight by Age:
3-12 months: Weight (in kg) = [Age (in months) + 9] / 2
1-6 years: Weight (in kg) = 2 ⨯ Age (in years) + 8
7-12 years: Weight (in kg) = [7⨯Age (in years) - 5] / 2
2. LENGTH/ HEIGHT: (STATURE):
Length: for children up to 2 years of age (or when bed-ridden, due to
sickness).
Height: for children > 2 years of age.
Though the child can stand unsupported at 1 year of age, this is not straight,
steady standing; thus length, not height is taken upto 2 years of age.
Difference between height and length can be up to 2 cm as tissues at joints
get compressed on standing.
For Length: Infantometer For Height: Stadiometer

How to use Infantometer?

• The child should lie straight on the horizontal board, with head in
Frankfurt's plane (line joining ear canal and lower border of orbit at right
angle to horizontal board)
• One assistant should steady the head against the head board.
• The person taking length should now steady the legs (which should be
straight with no bending at knee), and slide the foot board to apply firmly
against the soles of the feet. The feet should be at right angle to legs.
• The scale on the horizontal board will give the measurement

How to use Stadiometer?

• The child should stand bare feet and both feet, knees close together. Arms
should be kept at sides
• Head should be at Frankfurt's plane.
• The shoulder blades, buttocks, calves and heels should touch the vertical
board/scale.
• The sliding head board/bar is moved down to place firmly on the top of
the head.
• The vertical scale will show the measurement.

How to calculate expected height?

Ideally from a nomogram with age, sex and length / height.
At bedside quick calculation can be done by Weech's formula.
Weech's formula for Height by Age:
2 to 12 years: Expected height (in cm) = 6 ⨯ Age (in years) + 77
[Average newborn length = 50 cm
At the end of 1st. year 50+25 = 75 cm.
At the end of 2nd, year = 75 +12 = 87 cm.]
*Expected Adult Height from Mid-Parental Height:
Adult Height (in cm) = [Father’s Height + Mother’s Height ± 13]/2
(+13 cm for Boys, -13 cm for Girls)

3. HEAD CIRCUMFERENCE:

It is measured by placing
non-stretchable tape
anteriorly over supraorbital
ridges and glabella, and
posteriorly over external
occipital protuberance.

Normal values:
At birth: 34-35 cm
At 3 months: 40 cm [First 3 months @ approximately 2 cm/month)
At 6 months: 42-43 cm [3 to 6 months @ approximately 1 cm/month)
At 1 year: 45-46 cm [7 to 12 months @ approximately 0.5 cm/month]
At 2 years: 47-48 cm [1 to 3years approximately 1 cm/6-months]
At 5 years: 50-51 cm [3 to 5 years @ approximately 1 cm/year]
Adult head circumference is achieved at around 5-6 years of age.

4. CHEST CIRCUMFERENCE:
Measured at the level of nipple in
mid-inspiration or

at the level of xiphi-sternum in mid-

inspiration

Instrument: A non-stretchable tape

How to interpret?
At birth: Head circumference > Chest circumference by 3 cm.
At 1-year of age: Head circumference = Chest circumference
More than 1 year of age: Chest circumference > Head circumference

5. MID UPPER ARM CIRCUMFERENCE (MUAC):

How to measure?

Elbow should be flexed at right angle

To palpate olecranon at the back of elbow
and acromion at the shoulder.
A tape is to be placed at mid-point between
the two bony points.
Measurement to be taken by firmly placing
non-stretchable tape around the arm at the
mid-point.

How to interpret the result?

1 to 5 years of age: Normal value is 16-17 cm.
6. UPPER SEGMENT (US), LOWER SEGMENT (LS) & US: LS RATIO
Lower segment: It is the measurement of length between upper border of
symphysis pubis and the heel.
Upper segment: It is the measurement of length between vertex and upper
border of symphysis pubis; and actually measured by subtracting the lower
segment from height.
US: LS ratio:
At birth: 1.7:1.0
At 1 year: 1.5:1.0
At 10 years: 1.0:1.0
At 18 years: 0.9:1.0

7. ARM SPAN:

It is the distance between the

tips of the middle fingers of
two upper limbs when they
are outstretched at right angle
to the trunk.

How to measure?
The child should be asked to
stand with both upper limbs
out-stretched and the back of
the trunk, the dorsal aspects
of arms, forearms and hands
against the wall (to keep
steady).
Now the points at the tip of
middle fingers are marked on the wall.
• Distance between these two points are measured after removing the child
away from the wall.
How to interpret?
Arm span< Height by 1-2 cm (up to 5 years of age)
Arm span = Height (at 10-12 years of age)
Arm span > height by 1-3 cm (above 12 years of age)

8. BODY MASS INDEX (BMI):

It is calculated as
Weight in kg / (Height in m)2
BMI is mainly used in adults. It is also useful in assessing physical growth in
adolescents. It can be used in children.
Age based BMI nomograms are used mainly for diagnosis of obesity and
overweight.
Interpretation – BMI
≥ 95th percentile = Obesity
94th-85th percentile = Overweight
84th-5th percentile = Normal
< 5th percentile = Underweight
[For adults normal BMI is 18.5-25.
Adult overweight is with BMI 25-30.
Adult obesity is with BMI 30.]
WHO Growth Charts
•Normal –Green zone (upper line is the median)
•Moderately underweight –Yellow zone (-2 SD to -3 SD)
•Severely underweight –Red zone (below -3 SD)
Growth Curve Plotting of Points:

2. Indicators of Malnutrition

 Single best parameter for assessment of physical growth: Weight

 Single most sensitive measure of growth: Weight
 Single most reliable criterion of assessment of health and nutrition:
Weight
 Weight: Reflects only present health status
 Height: Indicates events in the past also

Acute and Chronic Malnutrition:

 Low weight for age: Is known as ‘Underweight’ (Acute ON Chronic

Malnutrition)
 Low weight for height: Is known as ‘Nutritional wasting’ or ‘Emaciation’
(Acute Malnutrition)
 Low height for age: Is known as ‘Stunting’ or ‘Dwarfing’ (Chronic
malnutrition)

Age-independent parameters for growth assessment:

 Weight for height

 Mid-arm circumference (MAC)
 Thickness of subcutaneous fat
  Body ratios:
o Weight: Height
o MAC: Head circumference

Gomez Classification of malnutrition: Is based on ‘weight for age’

Weight for age [Underweight / Acute ON Grade of malnutrition

Chronic]
>90% Grade 0 (Normal)
75-89% Grade I (Mild PEM)
60-74% Grade II (Moderate PEM)
<60% Grade III (Severe PEM)

Waterlow Classification of malnutrition: Is based on ‘Wasting and

Stunting’

Weight for height Height for age Grade of malnutrition

[Wasting / Emaciation / [Stunting / Dwarfing /
Acute] Chronic]
>90% >95% Grade 0 (Normal)
80-90% 87.5-95% Grade I (Mild PEM)
70-80% 80-87.5% Grade II (Moderate PEM)
<70% <80% Grade III (Severe PEM)

Welcome Trust Classification:

Weight for age With edema Without edema

60-80% Kwashiorkor Undernutrition
<60% Marasmic-kwashiorkor Marasmus

5. Mid (Upper) Arm Circumference [MUAC]:

 MAC is measured for 6 months-5 years age (as it remains practically
constant during this age)

Shakir’s Tape: A useful field instrument for measurement of

nourishment status of a child, through measurement of MAC.

Interpretation of Shakir’s tape findings:

MUAC Color Interpretation Management

(cms) Zone
>13.5 Green Satisfactory nutritional -
status
12.5-13.5 Yellow Mild-moderate malnutrition At home; through
diet
<12.5 Red Severe malnutrition Refer; Institutional
6. Nutrition Rehabilitation Centres (NRCs)

• Description:
Facility-based units: To provide medical and nutritional care to Severe
Acute Malnutrition (SAM) children under 5 years of age who have
medical complications
Special focus: Skill improvement of mothers on child care and feeding
practices

• Services provided at NRCs:

i. 24-hour care and monitoring of the child
ii. Treatment of medical complications
iii. Therapeutic feeding
iv. Sensory stimulation and emotional care
v. Counselling on appropriate feed, care, and hygiene
 vi. Demonstration and practice by doing of energy-dense foods
vii. Identification of contributory factors (Social assessment or family)
viii. Follow-up of discharged children

SAM Management:
i. Stabilization phase (1-2 days): ‘Starter diet’ for nutritional and
electrolyte balance
ii. Transition phase (2-3 days): Transition to ‘Catch up diet’ when
there is the beginning of loss of edema, return of appetite, no
nasogastric tube/infusion/severe medical problems, and the child
is alert and active; purpose to ensure that child tolerates
increased energy/protein intake
iii. Rehabilitation phase: Initiated when reasonable appetite (finishes
>90% feed given), major loss of edema, and no other medical
problem; purpose is promotion of rapid weight gain, stimulation
of emotional/physical development, and preparation for feeding
at home
iv. Micronutrient supplementation: Vitamin A to all children on Day
0, 1, 14 (50,000 IU <6 months age/100,000 IU 6-12 months age or
weight <8 kg/200,000 IU >12 months age)
Daily basis supplementation for 2 weeks: Multivitamin (A, C, D, E,
B12), Folic acid, Zinc, Copper, Iron
v. Follow-up of children discharged: Home visits (by AWWs, ASHAs)
and NRC visits.