Anthropometry of the child

8.6. Much has been written about the assessment of nutritional status in infants and young children by anthropometry. The usual cross-sectional approach is, however, relatively insensitive to change unless it is dramatic.

More precise information can be obtained by measurements of growth velocity. This naturally requires longitudinal measures, but the advantage is that quite small samples can give meaningful results. Figure 22 (see

FIG. 22. Weight Gain in Children Aged 5-32 Months in Nepal during Two Monthly Periods (Mean ± SE) (Source: D. Nabarro, unpublished data)) shows seasonal difference in growth from the village of Dhankuta in Nepal; the sensitivity of growth velocity is obvious.

As already emphasized in relation to mortality and morbidity, it is important to look separately at children in different age-ranges and not to group them all together. There is an additional reason for this in anthropometric assessment. In most populations the prevalence of wasting decreases after the first two years, while that of stunting increases (9); it is thus not possible to interpret the response of three-year-old children in the same way as one-year-olds.

8.7. More information is needed about the significance of growth deficits. An important indicator is increased risk of death. Figure 23 (see

FIG. 23. Mortality Rate in Relation to Weight for Age in the Punjab, India (Redrawn from Kielman and McCord) (Source: ref. 11)), from studies in the Punjab (10), shows the relationship between risk and degree of deficit in weight for age. The risk increases steeply with increasing deficit. A point, however, which has not been sufficiently emphasized is that for a given deficit the risk is much greater for younger children. Consequently the threshold or cut-off point at which the extra risk is appreciable varies with age. Below one year the threshold is at about 80 per cent of standard, between one and three years at about 70 per cent.

A very important study in Bangladesh (11) has traced the relationship between risk of death and degrees of wasting and stunting. Children who were severely wasted and stunted had very high mortality rates, but moderate degrees of stunting did not carry any extra risk.

8.8. Mortality is a very crude and extreme indicator of functional impairment. Since in some countries up to 50 per cent of pre-school children may be classified as stunted by the usual criteria (height-for-age less than 90 per cent of reference), it becomes extremely important to know more about the cause and significance of stunting. Does being small matter?

Some workers look upon stunting as a successful adaptation to a shortage of food, although not successful enough for the child to overcome completely the changes in his environment. This issue is of more than intellectual interest. There is no use in having an indicator unless it is useful for making decisions. The usefulness will depend on the type of decision to be made. If the decision is about the need for a feeding programme, then our ignorance about the causes and physiological significance of stunting is embarrassing.