* This example shows that unless a child's weight falls far below the bottom line we cannot be sure he is malnourished. Some children will be smaller than others for genetic reasons or because of past malnutrition. The important thing is that a child is gaining weight every month.

+ Likewise, it is not always safe to assume that a child is well nourished if his weight is between the two reference lines. He could be at "high risk. because of recent weight loss.

Draw the arrows below on the flipchart and explain the significance of the directions of different growth curves.

Use the example on page 13 of the workbook to further explain the directions of the curve.

e. Looking for the Causes of Growth Failure: When growth failure occurs, the first thing to do is to find out what is causing it. Explain that illness, a change in feeding habits, separation of mother and child, etc., will cause sudden weight loss.

Trainees should complete Workbook Exercise 3, Interpreting the Growth Curve. This can be done in small work groups or individually. When they finish, discuss each of the five growth curves mentioning the common causes of growth failure for each age group.

4. Write on the flipchart:

"Interpreting the growth curve and taking action to correct growth failure are the most important steps when using the Road to Health Chart."

5. Summarize this session by reviewing with trainees:

- Purpose of the Road to Health Chart - early identification of malnourished children

- Resources Required - Road to Health Charts, weighing scale set, trained literate workers, space, time

- Frequency of Weighing - monthly or every other month Location - community, clinic, homes.

Road to health workbook

A. The Growth Chart

B. Accurate Weighing is Important

C. How to Find the Age of a Child if the Mother Does Not Know

D. Recording Weights on the Growth Chart

E. How to Interpret the Growth Line

Adapted and excerpted from World Health Organization. Guidelines for Training Community Health Workers in Nutrition. Geneva, 1981.

(Trainers should select growth charts available in their regions. These growth charts should be substituted for the growth charts used in figures and exercises in this workbook. If charts with more than two reference lines are used, the description and instructions for recording and interpreting weight will also require modification.)

A. The Growth Chart

A Growth Chart is basically a graph on which a child' weight is shown at different ages. There are many types of growth charts, but most of them have the same basic features. Fig. 5 shows a typical growth chart. It should be printed on card or paper sufficiently strong to be used to some years. The horizontal lines in this chart represent weight in kilograms. The vertical lines represent age in months. The weights are marked against each horizontal fin' on the left-hand side of the chart. The vertical lines for 12 columns for each year, corresponding to the 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. This box has thick line 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 box for the month of birth (i.e., the first box with thick lines around it).

Across the graph are printed two growth reference lines These lines give the general direction of growth in health children. They are not the target for the growth of all children. If a child's weight is much below these grows! reference lines there is some reason for concern, but it is the direction or angle of a child's own growth line that is much more significant than any weight recorded below the lower reference line.

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 write the illness suffered by the child on the side of the chart that shows the weight graph. The name of the disease can be written vertically in the month in which it occurs. This makes it easy to see ho, a disease such as measles seriously affect. growth.

- Additional information. The same chart can also be used for recording additional information. For example, if a nutritional supplement 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. 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. This encourages community participation. It saves the time and space needed for storing 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 keeping cards with the parents is that the community health worker does not have to carry them when making home visits. In the case of children who are at a special risk. however the community health worker should keep duplicate growth charts at the health centre.

B.

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 the scale up 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 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. Record the weight in figures, for instance 3.5 kg.

The most common spring scale (often called a Salter scale, although many other brand names exist) has a face 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)

Fig. 4 THE MARKINGS ON THE FACE OF THE SPRING SCALE CORRESPOND TO THOSE ON THE GROWTH-CHART. THIS HELPS THE HEALTH WORKERS IN COMPLETING THE CHART, PARTICULARLY IF THEY ARE NOT USED TO THE DECIMAL SYSTEM.

Spring Scale

Source: Appropriate Health Resources and Technologies Action Group, (AHRTAG),

London, UK.

Dial-Shaped Spring Scale

Source: Teaching Aids & Low Cost

A Single Beam Scale for Clinic Use

Source: CMS Weighing Equipment, Ltd.,

London, UK

Philippine Bar Scale

Source: Nutrition Center of the Philippines,

Manila, Philippines

C. How to find out the age of a child if the mother does not know

There are two important factors in measuring growth weight and age. It is very important, therefore, to know the correct age of a child. Often mothers do not remember the dates of births 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 simplest way to find 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 the child wee born a few months before or after another child in the neighborhood. 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.

FIG. 1 AN EXAMPLE OF A LOCAL-EVENTS CALENDAR USED IN INDIA

EXERCISE 1: A Local Events Calendar

Develop a calendar of key events in your area during the past four years, to help parents recall the approximate birth months of their children.

D. Recording weights on the growth chart

The weight of a child should be recorded on the chart according to the instructions given below.

1. Write the name, address and 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 it 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 in Fig. 7.

3. Note that there are 5 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. 7.

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 was 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 weight chart showing 3 weights of a child taken on 3 different occasions is shown in Fig. 8. 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. 8 is for a different child from the one in Fig. 7. The child in Fig. 8 was first seen and weighed in September 1977 by a community health worker, who questioned the mother about when the child was born. The month of birth (June 1977) was written in the first box on the chart and the weight record was placed in the fourth column (September).

FIG. 7 RECORDING THE WEIGHT ON A GROWTH CHART

FIG. 8 AN EXAMPLE OF A GROWTH LINE

PLOTTED ON THREE WEIGHT MEASUREMENTS

Exercise 2: Recording Weights

Complete the growth chart for this child:

1) John was born in March 1982. His mother brought him to the clinic in May 1982 when he was weighed for the first time. His weights during 1982 and 1983 were:

Exercise 2: Recording Weights

MORE PRACTICE!

Guillermo Gomez was born 20 December 1982. He was first weighed at a community weighing day in June 1983. His weights during the next 12 months were:

E. How to interpret the growth line

Look carefully at the growth line in Fig. 8. Note that the line is going upwards 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 growth curve printed below the chart. This is to remind health workers that the direction of growth, upwards, horizontally or downward, is very important.

The importance of the direction of the growth curve is illustrated in Fig. 9. Arrows A, B. C, and D have been drawn on the growth chart parallel to the growth curve for different periods. The growth curve parallel to Arrow A is good. The growth curve parallel to Arrow B is not satisfactory and action should have been taken. When the growth curve 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 three months should be referred to the supervisor or health centre. When the growth curve returned to the direction of Arrow D, the child's growth became normal again.

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

FIG. 9 THE DIRECTION OF THE GROWTH CURVE IS MOST IMPORTANT

Exercise 3: Interpreting the Growth Curve

When a child begins to lose weight or does not gain weight for several months, it is a sign of problems. Analyze the growth of the children in the next five charts:

1. Describe the growth of each child.

2. What questions would you ask to find out the possible causes of growth failure in each case?

3. What advice would you give each mother at the most recent weighing session?