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close this bookGuidelines for Training Community Health Workers in Nutrition (WHO, 1986, 128 p.)
close this folderTraining modules
View the documentMODULE 1 GETTING TO KNOW THE E COMMUNITY AND ITS NEEDS
View the documentMODULE 2 MEASURING AND MONITORING THE GROWTH AND NUTRITION OF CHILDREN
View the documentMODULE 3 PROMOTION OF BREAST-FEEDING
View the documentMODULE 4 NUTRITIONAL ADVICE ON THE FEEDING OF INFANTS AND YOUNG
View the documentMODULE 5 NUTRITIONAL CARE OF MOTHERS
View the documentMODULE 6 IDENTIFICATION, MANAGEMENT, AN D PREVENTION OF COMMON NUTRITIONAL DEFICIENCIES
View the documentMODULE 7 NUTRITIONAL CARE DURING DIARRHOEA AND OTHER COMMON INFECTIONS
View the documentMODULE 8 CONVEYING NUTRITION MESSAGES TO THE COMMUNITY
View the documentMODULE 9 SOLVING NUTRITIONAL PROBLEMS IN THE COMMUNITY

MODULE 2 MEASURING AND MONITORING THE GROWTH AND NUTRITION OF CHILDREN

LEARNING OBJECTIVES

After studying this chapter, taking part in discussions, and doing the exercises, a community health worker should be able to:

· Explain the relationship between growth, development, and nutrition.

· Find out the age of a child by using a local-events calendar if the mother is not sure of the age of her child.

· Weigh a child accurately to within 100 grams.

· Record the weight of a child on a growth chart.

· Explain to the mother the features of the growth chart, and how it will help her decide whether or not the child is doing well.

· Interpret a child's growth pattern from the weight changes recorded.

TRAINING CONTENT

What is the relationship between nutrient intake, growth, and development?

Food is needed for growth, physical activities, and the maintenance of health.

Growth is the gradual increase in size of the body and its organs. Development is the increase in the number of skills performed by the body, including the brain, and in the performance of those skills. Growth and development are fundamental features of children. If a child is growing well he is probably healthy and adequately fed. If a child is not growing well, there must be some reason for this. He may have some illness or he may not be receiving adequate food. Months before a child has obvious signs of malnutrition he will have stopped growing. Measuring a child's growth is one way of measuring his nutritional condition and general health.

Growth is measured in different ways. Body weight is the simplest measurement, and in children change in weight is the most reliable indicator of growth. When a baby is born he weighs about 3 kg. If he grows well he will weigh about 6 kg at 5 months of age and about 9 kg at 1 year of age. This means that healthy babies double their birth-weight in 5 months and treble their birth-weight in 12 months. After that the increase in weight is not so fast-only about 2 kg per year.

Height (or length of the body in the case of infants) is another measure of growth. At birth a baby is about 50 cm long. At 1 year of age he should be about 72 cm long. Height is a particularly useful indicator of growth among older children. If a child is quite tall, but his weight is low, he is thin or wasted. A malnourished child may also be short or stunted.

By measuring weight and growth, we are measuring health.

TRAINING COMMUNITY HEALTH WORKERS IN NUTRITION

Table 3. Milestones of child development


Age

Milestones

Average baby

Nearly all babies

Able to sit without support

6½months

9 months

Able to walk 10 steps without support

12 months

18 months

Able to say single words

15 months

21 months

Able to speak short phrases

23 months

36 months

A baby's head grows very quickly, especially in the first year of life. This is because the brain is growing very rapidly. Development, or the increase of skills, mainly depends on the brain and the nervous system. The growth and development of the brain requires adequate nutrition, just like other parts of the body. When a baby is born it can do very little for itself. Gradually he develops and is able to move his body in the way he wants and can do simple things. Special skills like talking develop later. It is useful to know the ages when most children can do some simple things. These are used as markers of development and are sometimes called "milestones of development" (see Table 3).

Factors other than nutrition can also influence development. Children only develop skills if they are given the opportunity. The presence of people who take an interest and talk to them, helps children to develop. Children left alone and given nothing to play with will develop slowly. There are only small differences in the rate of growth and development in different races. Race does not have an important influence on growth and development compared with adequate nutrition and stimulation.

In children normal growth and development are signs of good health and nutrition. One of the best ways to measure a child's health is to measure growth, and one of the easiest ways of measuring growth is to weigh a child regularly and to note how his body weight is increasing with age in comparison to the weights of healthy children of the same age.

How to find out the age of a child if the mother does not know-use of a local-events calendar

There are two important factors in measuring growth-weight and age. It is very important, therefore, to know the age of a child correctly. Often mothers do not remember the dates of birth of their children. In such cases the community health worker can estimate the age of a child by asking the mother certain questions and by using a local-events calendar.

The first and the simplest way of finding out the age of a child is to look up the local official register of births, baptismal certificate book, or similar record. Often mothers forget or are not aware of the existence of such records.

If the child is not registered or if no such records exist, the community health worker should first try to find out the year of birth of the child. This can be done by asking the mother if her child was born a few months before or after the birth of another child in the neighbourhood. The community health worker should then find out if the date of birth of that child is known. If the mother of the second child knows the date of birth of her child, the year of birth of the first child can be easily estimated. The year of birth can be easily determined in this way for children up to 4 years of age. In the case of older children the year of birth becomes difficult to estimate correctly; however, with older children it is not so important to be absolutely accurate.

The next step is to determine the month of birth. This can be done by the use of a local-events calendar. A local-events calendar shows all the dates on which important events took place during a past 3-5 year period. It may show the different seasons, months, phases of the moon, local festivals and events in the agricultural cycle (Fig. 1). National and local occurrences of importance are also marked on it; these include storms and cyclones, political elections, the opening of nearby roads, cinemas, shops, etc. Each community health worker should make his own local-events calendar.

Using a local-events calendar, the community health worker tries to remind the mother of events that will help her to remember the birth of her child. She should start with the seasons-"Was it the hot, the wet, or the cold season when your baby was born?" She then asks her about the months, the festivals, and events in that part of the year, for example, "Was your baby born before or after such-and-such a festival?" Gradually she narrows down the period until she can tell with some confidence in what month the child was born. This is possible for most small children, and it can be done quite quickly.


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How to weigh a child accurately

A child's weight is a valuable measure of its health and nutrition. Weighing a child requires reliable equipment and a standard method to achieve accurate results.
There are two main types of weighing scale-beam balance scales and spring scales. A beam balance scale is usually accurate and reliable, but it is often heavy and expensive (Fig. 2). Scales of this kind are used in markets and shops in many countries and are therefore familiar. A spring scale on the other hand is quite cheap, fairly reliable, light, and easily carried. Such a scale has one hook above, to hang the scale from a beam or a branch of a tree, and one hook below from which hangs a sling or basket (for infants) a small chair, or pair of pants (for older children) (Fig. 3). The child is placed in the sling or basket, seated on the chair, or slipped into the pants as the case may be. It is important that the child feels secure and the mother does not mind her child being suspended in that way.

The most common spring scale (often called a Salter scale, although many other brands exist) has a face or dial which looks like a clock. The weights are marked in kilograms around the dial. Some dials also show 100-gram divisions between kilograms, but the simplest scales only have kilograms marked by bold lines and 500 grams marked by thin lines. Such scales are convenient for workers with limited education because these lines are similar to those which are drawn on the most widely used growth charts (Fig. 4).


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Accurate weighing is important.


Fig. 4. The markings on the face of the spring scale should correspond to those on the growth chart. This helps the health workers in completing the chart, particularly if they are not familiar with the decimal system

Accurate weighing is important. A community health worker can learn how to weigh a child quite easily by following the instructions given below:

1. Hang up the scale securely, keeping the dial at eye-level so that the weight can be read easily.

2. Adjust the pointer to zero before placing the child in the sling or basket. Most scales have a knob or screw to make this adjustment.

3. Undress the child with the help of the mother. It is better to weigh the child naked if it is not too cold and if local customs permit.

4. Place the child in the sling or basket with the help of the mother. Ask the mother to stand nearby and to talk to the child. The mother should not hold the child and the child's feet should not touch the ground when the weight is being read.

5. Read the weight on the scale. If the child is struggling try to calm him with the help of the mother and when he stops moving read the weight quickly.

6. Write down the weight in figures, for instance, 3.5 kg.

The growth chart

A growth chart is basically a graph on which a child's weight is shown at different ages. There are many types of growth chart in common use in different countries, but all of them have the same basic features. It is up to the health administration of each country to select or develop a chart suitable for the country. Figs. 5 and 6 show the two sides of a growth-chart developed by WHO. Figs. 7, 8, and 9 show examples of growth charts used in India, Indonesia, and Zaire, respectively

Across the prototype chart developed by WHO are printed two growth reference lines. The area between these lines gives the general direction of growth in healthy children. They are not the target of growth for all children. If a child's weight on the first weighing is much below the lower line, there is some reason for concern, and the community health worker should look for the reason. However, the direction of the child's own growth line, based on weighings at regular intervals, is of much more significance than any weight recorded below the lower reference line.

Not all growth charts have two reference lines. As can be seen from the Indian, Indonesian, and Zairian charts, there are additional lines. The purpose of these lines is to indicate the degree of malnutrition, i.e., how much the child is malnourished.

There are three degrees of malnutrition: mild, moderate, and severe. It is important to stress here that it is not important to know how much the child is undernourished by weighing him on the first visit. Rather, it is essential to note how he is growing (i.e., how his weight is increasing) on successive visits (weighings). In other words, the community health worker should be more concerned with the direction of the child's growth line rather than his actual weight. As long as a child's growth line continues to move upwards there is nothing to worry about, even if his weight remains in the area showing moderate malnutrition. On the other hand, if a child's weight is in the healthy path, but the direction of the line, based on successive weighings, is downwards, the community health worker should pay extra attention to that child. This point will be explained further in the section on how to interpret a growth chart.

All growth charts should be printed on card or paper sufficiently strong to be used for some years. The trainer should select the particular type of growth chart used in his country and should use it for training community health workers.


Fig. 5. A prototype growth chart developed by WHO


Fig. 6. The back of the growth chart may be used to collect information on the child and the family

On all growth charts, the vertical lines represent the age of the child in months. The horizontal lines represent weight in kilograms, and these weights are marked on the left-hand side of the card. The vertical lines form 12 columns for each year, corresponding to 12 months of the year. The month names can be written in the 12 boxes below the columns. The first box on the left-hand side of the chart is for the month of birth. In the prototype growth chart developed by WHO this box has thick lines around it. The first column for each year also has a box with thick lines around it. This is to identify the beginning of each year of age. The year of birth is marked by the side of the first box indicating the month of birth.


Fig. 7. A growth chart used in India


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Some other important features of the growth chart are given below:

· Information about the child and family. This is written on the back of the graph. The family address and name, the number of children, and their state of health are all recorded (Fig. 6).

· Immunizations. There is a space for recording the different dates of immunizations. This also serves as a reminder of when the next immunizations are due.

· Medical history. It is convenient to indicate any illnesses suffered by the child on the side of the chart that shows the weight graph. The name of any disease can be written vertically in the month in which it occurs. This makes it easy to see how a disease such as measles seriously affects growth.

· Additional information. The same chart can also be used for recording additional information. For example, if a nutrition supplementation programme is being carried out and vitamin A is given every 6 months, a large A can be written at the bottom of the column of the month in which it was given. If food supplements or antimalarial drugs are given monthly a tick can be marked in the column for the appropriate month. Parents are advised to space their children as this permits each child to have a maximum of care and nourishment; if they have been advised, or have accepted some form of contraception, it is good to record this on the chart as well.

· Reasons for special care. In Module 1 it was stated that certain social, economic, and health factors are associated with a high risk of malnutrition. The chart has a space to record these factors; it is headed "Reasons for special care". This makes it easy to identify quickly the priority children.

If parents are made to understand the significance of the information on the chart, and then allowed to keep the chart themselves, they will feel more involved and responsible for the child's health care. It saves the time and space needed for storing the charts in a health centre. Also, the charts can be taken with a child during visits outside the community (e.g., to the grandparents' home), or to any health centre. The charts should be put in plastic (polyethylene) covers to help parents keep them clean and dry. Another advantage of asking the parents to keep the cards is that the community health worker does not have to carry them when making home visits. In the case of children who are at special risk, however, the community health worker should keep duplicate growth charts at the health centre.


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Completing the growth chart

Details about the child and his or her weight should be recorded on the chart according to the instructions given below.

1. Write the name, address, and other information about the child and the family on the back of the chart. It is important to do this at once to show whose record this is and to avoid recording one child's weight on another child's chart.

2. Write the month of birth in the box below the first vertical column (the first box which has thick lines around it). Near the box write the year of birth. This is September 1978 in the example shown in Fig. 10.

3. Note that there are five sets of 12 columns. Each set is for one year of the child's life. Beginning with the month of birth (see instruction 2), write out the following months of the year in the following boxes. When you reach January, write the year near that box exactly as you wrote the year of birth (see instruction 2) near the box for the month of birth.

4. Record the weight by putting a big dot on the line corresponding to that weight in kilograms. For example, if the weight of a child is 6 kg in a given month, find the horizontal line representing 6 kg and put a dot at the point on that line where it meets the column for the month in which the weight is being taken. This is January 1979 in the example shown in Fig. 10.

5. The position of the dot within a column can be adjusted. The purpose of this is to indicate when (early in the month, in the middle of the month, or late in the month) the child is being weighed. If the child is being weighed early in the month, put the dot towards the left side of the column. Put the dot in the middle of the column if the weight is being taken in the middle of the month. If the weight is being taken late in the month, put the dot towards the right side of the column.

The above instructions should be followed each time you record the weight on a chart. An example of a growth chart showing the weight of a child taken on three different occasions is shown in Fig. 11. Notice that the three weight dots are joined by a line. This is the line of growth. It is very important.

Notice too, that the chart in Fig. 11 is for a different child from the one in Fig. 10. The child in Fig. 11 was first seen and weighed in September 1977 by the community health worker, who questioned the mother as to when the child was born. The month of birth (June 1977) was written in the first box on the chart and the first weight record was placed in the fourth column (September).

How to interpret the growth line

Look carefully at the growth line in Fig. 11. Note that the line is going upwards from left to right, from 5.5 kg in September to 6.5 kg in November and then to 7 kg in January 1978. Remember that when the line is going up, the child is growing; this is good. If the line is horizontal or going down the child is not growing well, and this is not good. Some charts have examples of the direction of the growth line printed below the chart. This is to remind health workers that the direction of the growth line, upwards, horizontally, or downwards, is very important.

In the first 6 months of life a levelling off or a downward movement of the growth line is a serious matter

The importance of the direction of the growth line is illustrated in Fig. 12. Arrows A, B, C, and D have been drawn on the growth line parallel to the growth line for different periods. The growth line parallel to arrow A is good. The growth line parallel to arrow B is not satisfactory and action should have been taken. When the growth line fell, parallel to Arrow C, the child was in a dangerous condition and urgent action was needed. Any child who does not gain weight for 3 months should
be referred to the supervisor or health centre. When the growth line returned to the direction of arrow D, the child's growth became normal again.

Increase in weight with age is more important than weight on any one occasion.

Remember that it is the direction of the growth line that is more important than the position of the dots on the line. The dots parallel to arrow B are above the lower reference line, but the growth line is levelling off and this is a matter for concern. The dots parallel to arrow D are below the reference lines, but the direction of the growth line is once again upwards and therefore the mother should be congratulated for her good care.

The direction of the growth line is more important than the position of the dots.


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How to measure the nutritional status of children

There is no easy and satisfactory way to measure the nutritional status of a child at a single examination. Two methods that are widely used are described below, but neither of them is ideal, and it is better to use the growth chart just described to see what direction the growth line takes.

Weight-for-age (Gomez-type) nutrition classification

In this classification, the average weights of a series of children (up to 5 years of age) of different ages are used as standard. A curve representing this standard is drawn across a growth chart. Below it are drawn parallel curves representing 90%, 75%, and 60% of the standard weights (Fig. 13). Sometimes 80%, 70%, and 60% lines are also drawn. According to this system, if a child's weight dot at any age is between the 90% and 75% line, he is considered to have first-degree malnutrition. If the weight dot is between the 75% and 60% lines, he has second-degree malnutrition. If the weight dot is below the 60% line, he is said to have third-degree malnutrition.

Although this classification is widely used, it should be borne in mind that a full diagnosis of the nutritional status of the child should not be made on this basis alone. A child may be heavy for his age, but if he is not growing (i.e., if his growth curve is not moving upwards) he can be in danger. Similarly, a child may be light for his age (the weight dot being below the 75% line) but he will not be in serious danger as long as his growth curve is moving upwards.

Assessing nutritional status by measuring mid-upper-arm circumference

A child's upper arm grows very slowly between the ages of 1 and 5 years. The distance around the middle of the upper arm (mid-upper-arm circumference) of all well nourished healthy children is more or less the same. If a child is undernourished and is not growing well, the arm becomes thin and the mid-upper-arm circumference reduces. The more severe and prolonged the malnutrition, the thinner will be the upper arm (Fig. 14). By measuring the middle of the upper arm of children, using a tape or a special three-colour measuring strip (Fig. 15), one can find out whether a child is malnourished or not. Note that you cannot use the measuring strip to find out how a child is growing month by month. For that you have to use a growth chart.

A special three-colour measuring strip is easier to use than a measuring tape. It can be easily made from string or a strip of material that does not stretch. But be careful that the markings are accurate.


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To use the three-colour measuring strip.

Put the strip around the child's upper arm (half-way between the elbow and the shoulder) and see which colour on the strip meets the marker line (see Fig. 14).

· If the marker line is over the green part, the child is healthy and well nourished.

· If the marker line is over the yellow part, the child is moderately undernourished. In such cases, the mother should be warned about it. The community health worker should find out why the child is undernourished, and should then give proper advice to the mother.

· If the marker line is over the red part, the child is severely undernourished and is in danger. Such a child can fall ill easily and may even die if he is not helped quickly. He should be given more foods of the right type. If there is any special feeding programme for malnourished children in the area, the child should be included in it immediately so that he can get supplementary foods. It is always advisable to get such children examined by the supervisor or by a doctor in the health centre.

· The three-colour measuring strip is good for identifying children in danger.

· This strip is not suitable for measuring growth.

Weight-for-height method of assessing nutritional status

Another method of assessing the growth of a child is to measure his height and compare it with the desirable height for his age. This method is not commonly used because it is not easy to measure the height of a child accurately. For infants who cannot stand, the length of the body is measured. This can be difficult and requires the use of a special instrument. In some countries, the weight of a child in relation to his height is compared to a desirable standard. In this method, the big advantage is that there is no need to determine the age, which is also not an easy task in many situations.


Fig. 14. Identifying malnourished children by using a three-colour measuring strip


Fig. 15. A three-colour measuring strip

In most developing countries, watching the growth of children by weighing them at regular intervals and recording the weight on a growth chart is the most common method of assessing nutritional status. In some other countries, the weight-for-height method is used. In yet others, where weighing scales are not easily available in all places, the three-colour strip for measuring mid-arm circumference is commonly used.

The weight-for-height method of assessing nutritional status is useful in two situations:

· For screening malnourished children in the community, weight-for-height is the best method. In most developing countries, an added advantage of this method is that it is not necessary to know the age of the child, which is sometimes difficult to ascertain in rural areas.

· For monitoring growth of children over a limited period, weight-for-age is the simplest method.

An example of a growth chart based on weight-for-body length of female children is shown in Fig. 16.


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TRAINING METHODS

1. Lecture: Training content.

2. Demonstration: Weighing a child, recording weights on a growth chart, and assessing nutritional status of children by different methods.

3. Group discussion: Interpretation of prerecorded growth charts.

4. Practical exercises in a clinic or health centre: Weighing children and recording weights on growth charts and interpreting the recorded weights.

5. Pole-playing: Filling in a growth chart for a new baby (see exercise 4) or other similar exercises.

EXERCISES

Exercise 1. Making your own local-events calendar

In this exercise the trainees make their own local-events calendar. They should make it on the basis of the description of a local-events calendar on page 00, borrowing calendars that give information such as the phases of the moon in the past few years and adding important local events; especially religious festivals celebrated in the area, fairs, visits from circuses, serious storms, and similar happenings that people in the community are likely to remember easily.

Exercise 2. Making and interpreting a growth chart

In this exercise the trainees practice how to make a weight chart and how to interpret a growth line. A blank weight chart is provided for each trainee.

1. Using the information given below fill in the blank weight chart provided to you.

A girl was born in May 1976. Her name is Laxmi. She was weighed on different months following her birth. The weights in each of the months are given below.

2. Put the dots in the right columns for the weights given above.

3. Join these dots by a line and draw a growth line.

4. Turning the chart sideways, write out important information (e.g., diarrhoea and special nutrition care) in the appropriate columns.

5. Now answer the following questions.

(a) How old was Laxmi in:

December 1976?
April 1978?

(b) Why do you think Laxmi did not gain weight between January and April 1978, and between December 1978 and February 1979?

(c) What special help and advice would you give Laxmi's mother in:

February 1977?
January 1978?

Exercise 3. Practising weighing a baby and filling in a growth chart

Hang up a spring scale and ask the trainees to gather around it and sit comfortably. Give each trainee a growth chart. Tie a doll to the handle of a bucket and hang the bucket on the scale. From a second bucket pour some water into the first bucket until the weight on the scale reads 3 kg. This is the birth weight of the imaginary baby. Ask the trainees to write the present month in the appropriate box and put a weight dot in the correct column. Then ask them to write the subsequent months in the appropriate boxes. Next ask one trainee to come up to the scale and pour some more water in the hanging bucket and read out the new weight on the scale. This will be the weight for the next month. Again ask the trainees to put the weight dot in the appropriate column. Repeat the procedure by asking the other trainees to come up to the scale one by one and add water to the hanging bucket. From time to time, ask a trainee to remove some water from the bucket, to represent loss of weight. This might be caused by an illness or by stopping breast-feeding; the trainees should also enter these events on the chart.

This type of exercise is sometimes called a "simulation exercise" because it simulates (it is like) the real-life situation. You can also use a flannel graph to demonstrate how to fill in a growth chart.

Exercise 4. Role-play about filling in a growth chart for a new baby

In role-play the trainees act out typical real-life situations they are likely to encounter when they become community health workers. By playing different roles they learn about the attitudes of different types of people they will meet in the community.

An example is given below. In this play a mother comes for the first time with her new baby to the community health worker. The community health worker takes this opportunity to fill in a growth chart for the new baby and to give the mother some advice on immunization. The name of the mother in this story is Mrs Kartini.

Community health worker

Good morning Mrs Kartini. How are you and your new baby?

Mrs Kartini

Good morning. I am very well, thank you, and my baby is also doing well.

Community health worker

The first thing we will do is make a growth chart for your baby. This will be a record of his health. I will explain this later. Do you mind if I ask you some questions about the baby?

Mrs Kartini

No, I don't mind.

Community health worker

First, what is Your baby's name?

Mrs Kartini

His name is Peter.

Community health worker

Your full name is Lika Kartini, is that right?

Mrs Kartini

Yes.

Community health worker

What's Your husband's full name?

Mrs Kartini

He's called David Kartini.

Community health worker

On what date was Peter born?

Mrs Kartini

I don't remember exactly. It was in the first week of July, the day after the village school closed for the holidays.

Community health worker

Thank you. That will have been Friday, the sixth of July. I will now write the months in the chant What is your home address?

Mrs Kartini

I live in Madang Street. There is no house number, but we live near the village well.

Community health worker

How many brothers and sisters does Peter have?

Mrs Kartini

Only one. A brother.

Community health worker

What's his name?

Mrs Kartini

John.

Community health worker

Do you have a growth chart for John?

Mrs Kartini

No.

Community health worker

Do you know John's date of birth?

Mrs Kartini

No, but he has always been quite healthy!

Community health worker

He should have some immunization, to stop him becoming ill. If you agree, I will give him an immunization against tuberculosis today. First of all, I want to weigh Peter. (After weighing). Peter's weight is six and a half kilograms. I will now put a large dot on the chart, opposite 6.5 kg above this month, which is September. You can see that I have written the names of the months in the boxes at the bottom of the chart. I started with July, in the first box on the left. This is because Peter was born in July.

Mrs Kartini

Is that a good weight?

Community health worker

Yes, that is a good weight for a two-month old baby, but we must weigh Peter each month in order to be sure that he is gaining weight regularly. That will mean he is growing well and is healthy. Now I want to ask you some more questions. First of all, what are you giving Peter to eat?

Mrs Kartini

I only breast-feed him.

Community health worker

That's good. It is best if you keep breast-feeding him as long as possible, until he is two years old, or even older. When he is 5 6 months old, you can start to teach him to taste other foods, in addition to breast-milk, and gradually increase the amount of food.

Exercise 5. Interpretation of growth charts

Look carefully at the weight charts of Tola, Raman, Jose, and Sara (Figs. 17, 18, 19, and 20). Trainees should be able to make several comments about each chart and about the risks to and the progress of each child. Ask one trainee to explain each chart and then discuss the chart together.

Compare the growth and the general situation of Tola and Jose in the first 9 months of their lives. In what ways were they similar, and in what ways did they differ?

Look at the growth charts of Raman and Jose. When they were both 1 year old, what advice on nutrition would you have given to their mothers?

Exercise 6. Identifying mistakes on growth charts

Look carefully at the growth charts of Leela and Tanete (Figs. 21 and 22). Can you see any mistakes or unexpected results on the charts?

Discuss how to avoid mistakes of the type shown on these charts.

Exercise 7. Field evaluation of use of weight charts

1. Visit a village, and systematically call at each house where there are children under 5 years of age. What proportion of children have growth charts? How many children had charts but their parents have lost them?

(This indicates how effectively the service covers the whole community).

2. At a clinic or during home visits check a number of charts to see if the items given below have been correctly filled in:

-Child's name and address
-Family members and state of health
-The months and years in the calendar
-Weight dots and lines
-Risk factors. Have these been written in when appropriate?
-Illnesses. Have these been written in?
-Family planning advice given to parents and the attitude and action of the parents
-Immunizations. How many immunizations have been given to children over 1 year of age?

(This indicates how well trained and how careful the health personnel are in using weight charts).

Exercise 8. Frequency of weight measurement

At a clinic or during home visits note how many times children have been weighed in the 1 st, 2nd, and 3rd year after birth. This is done by adding the number of dots on the growth chart for each year.

(This indicates how often there is contact between the children and the health services).



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