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close this book Community Nutrition Action for Child Survival
close this folder Part I - Community nutrition problems and interventions
close this folder Unit 2: Measuring and monitoring growth in young children
View the document Session 1: Measuring growth
View the document Session 2: Arm circumference
View the document Session 3: The road to health chart
View the document Session 4: The thinness chart
View the document Session 6: Counseling, referral and follow-up of malnourished children

Unit 2: Measuring and monitoring growth in young children

SESSION 1: Measuring Growth

SESSION 2: Arm Circumference

SESSION 3: The Road To Health Chart

SESSION 4: The Thinness Chart

SESSION 5: Choosing A Growth Monitoring System

SESSION 6: Counseling Referral and Follow-up of Malnourished Children

Session 1: Measuring growth


Trainees will review the measurements of growth in young children and their usefulness for identifying children at "high risk" of malnutrition.

Time: 1/2 hour


- Flipchart and marking pens

- Handout - "Measuring the Growth of Young Children"


1. Introduce this unit by reminding trainees that:

"Community managers must look for ways to benefit the greatest number of people with their often limited resources. One way we do this in nutrition activities is by clearly identifying and focusing our efforts on children at "high risk" of malnutrition and death. "

2. Ask trainees how they would define and identify "high risk" children.

Responses may include:

- Malnourished children

- Children from poor families

- Children whose mothers or fathers are absent

- Children who have physical signs of malnutrition

- Children who are sick

Summarize trainee responses by saying that there are many conditions and circumstances that may make children nutritionally "high risk." Growth failure is one of the most useful indicators we have for deciding whether children are at high or low risk of malnutrition.

Growth failure is the first sign of malnutrition

3. List and discuss common measurements of growth appropriate for community use. Use the Handout "Measuring the Growth of Young Children" to prepare and guide your presentation.

4. Explain why these measurements are compared with standard measurements for reference populations with normal and sub-normal nutrition status.

5. Explain the difference between single growth measurements and serial (repeated) measurements on the same child. Discuss the advantage of using serial measurements for early detection of growth failure.

6. Close the session by telling trainees that managers must choose which growth measurements and growth monitoring instruments are the best for use in their projects. A manager's choice often depends on the kinds of malnutrition common in an area, the workers' or volunteers' skills and the resources available for training and supervision.

In this module, three instruments for measuring and monitoring growth are presented:

- The three-color arm circumference measuring tape

- The Road to Health Chart

- The Thinness Chart

These instruments have been used successfully in communities worldwide to identify "high risk" children. Besides providing useful measures of growth, they also promote the active involvement of parents and community leaders in the identification of "high risk" children and the causes of malnutrition in their communities.



Measuring a child's growth is one way of detecting malnutrition before the visible signs and symptoms of severe PEM become apparent. Healthy children grow very rapidly, especially in the first few years of life. Failure to grow is the first sign of malnutrition. If we can find children in the community who are not growing normally, we can take action to improve nutrition and prevent serious illness and, in some cases, death.

Growth can be measured and compared in several different ways:

Weight is the most reliable indicator of growth in young children. Changes in the weight of a healthy child can be detected every month from 0-5 years of age. To measure growth, we can (1) compare a child's weight gain over time, (2) classify a child's weight for his age, and (3) compare this measurement to a standard weight for children of the same age.

Height increases more slowly than weight in young children, but comparisons of height-for-age and height-for-weight can be useful measures. Height-for-age tells us about the past nutrition status of a child. Children who are "stunted, " or shorter than normal children their age, have probably been chronically undernourished. Children who are too thin for their height when compared to normal children of the same height are "wasted" or currently malnourished.

Arm Circumference, or the distance around the middle of the upper arm, is another measurement of growth in children from 1-5 years old. In healthy children, arm circumference remains fairly constant between one and five years. When a child is malnourished, the arm circumference is reduced. By measuring arm circumference and comparing it to a standard for normal children, we can detect children who are currently malnourished, or "wasted."

In this module we focus attention on three growth assessment instruments that can be used by the community to identify children who are "in danger" of becoming malnourished and those who are currently malnourished and in need of immediate assistance. These are the:

- Three-color arm circumference tape

- Road to Health Chart

- Thinness Chart

Session 2: Arm circumference


Trainees will be able to make and use a three-color arm circumference measuring tape to identify moderately and severely malnourished children. They will discuss the advantages and disadvantages of arm circumference as an indicator of growth and the use of the three-color tape as a screening tool in the community.

Time: 1/2 hour (1 hour if arm tapes are made during the session)


- Handout - ''Measuring Arm Circumference"

- Materials to make three-color arm circumference tapes(X-ray film; plastic or any other material that will not stretch; scissors; ruler; green, yellow and red marking pens or paint; pencils)

- Flipchart and marking pens


1. Distribute the Handout - "Measuring Arm Circumference" and explain that mid-upper arm circumference is a good indicator of malnutrition in children 1-5 years of age, because the size of the arm in a healthy child changes very little during this period. If the mid-upper arm becomes thin, this is a sign of malnutrition.

2. Distribute three-color arm tapes to the trainees and explain the reasons for the length of the colored areas on the tape. Or, help trainees make their own tapes following the instructions on the handout.

3. Demonstrate the correct method for measuring arm circumference using the tape. It is best to recruit a small cooperative child for the demonstration. Trainees should practice on a number of small children either during or after the session. Observe each trainee and correct any mistakes made using the tape.

4. Ask trainees to list the advantages of using arm circumference and the three-color tape in community nutrition action programs. These include:

- Simple, fast

- Easy for the community to understand and use

- Good where people cannot read or write

- Requires little training

5. Point out that the arm circumference tape:

- is an excellent tool for finding out about the present nutrition status of children 1-5 years;

- can only be used to detect malnutrition in children 1-5 years old;

- does not tell us about past malnutrition;

- while telling us which children are already malnourished, it is not a good tool for finding "high risk" children before they become malnourished.



Mid-upper arm circumference is a useful indicator of the nutritional status of children 1-5 years old

How to Make a Three-Color Arm Circumference Measuring Tape

1) You will need a strip of material that does not stretch (plastic is best).

2) Cut the strip about 20 cm long and 2 cm wide.

3) Mark the strip with fine vertical lines at 12.5 cm and 13.5 cm from one end of the strip.

4) Color the strip red from the end to 12.5 cm (use paint or felt pen that will not come off easily ) .

5) Color the strip yellow from the 12.5 cm mark to the 13.5 cm mark.

6) Color the strip green from the 13.5 cm mark to the other end.

Three-color arm tapes are available in some countries through UNICEF. They can also be ordered from the Voluntary Health Association of India, C-14 Community Center, SDA, Opp. IIT Main Gate, New Delhi 110 016, India. Insertion tapes marked in centimeters, instead of cut-off points, are also available.

Three-Color Arm Circumference Measuring Tape

How to Use the Three-Color Tape to Find "High Risk" Children

1) Only use the three-color strips with children 1-5 years old.

2) Place the strip around the middle part of the child's deft arm. Find the middle of the upper arm by using the top of the arm and the tip of the elbow as the end points.

3) Which color is touched by the red end of the strip? Green, Yellow or Red?

What Do the Colors Mean?

Green - The child is well nourished .

Yellow - The child is " in danger" of becoming severely malnourished.

Red - The child is severely malnourished and in need of immediate attention.

What to Do for "Yellow" and "Red" Children?

Children with yellow and red arm circumference should be fed extra food every day, and they should be treated for any existing illness.

Children with red arm circumference are in danger of death. They need more food in 5-6 small meals a day. In these children, treatment of illnesses that may be causing or complicating malnutrition is extremely important. Families of severely malnourished children may also need temporary assistance to care for and feed their sick children.

Following-Up Malnourished Children

Arm circumference slowly increases as a child's nutrition improves. Use the three-color strip to monitor and evaluate the progress of malnourished children by comparing their monthly arm circumference measures.

Who Can Use the Arm Circumference Tape to Find and Help Malnourished Children?

Health workers, community leaders and parents can be taught to use the tape for screening and monitoring the growth of children in the community.

The three-color arm circumference strip is easy to use and understand. Because it can be used with both literate and non-literate groups, it is a useful tool for involving parents and the community in the health and nutrition of their children.

Session 3: The road to health chart

Many different types of growth charts are available for screening young children. The one presented in this session is the WHO Road to Health Chart which has been adapted for use in many parts of the world. The Road to Health Chart is an effective tool for monitoring a child's weight gain over time where regular weighing (monthly or bi-monthly) is possible. The purpose of the chart is early identification of growth failure so that action can be taken to prevent severe malnutrition. *

* The WHO chart does not allow classification of nutrition status (i.e., normal, moderate and severe malnutrition). Charts using the Gomez or Harvard standards of weight for age are available for this purpose.


Trainees will practice completing and using the Road to Health growth chart to identify children with growth failure. They will also discuss probable causes of growth failure for different age groups.

Time: 2-3 hours


- One sample Road to Health Chart for each trainee

- Wall-sized flannel graph or drawing of the Road to Health Chart (TALC)

- Road to Health Workbook for each trainee

- Weighing scale (a portable hanging scale with 100 or 500 gram divisions is best for community use)

- Several cooperative young children


1. Introduce this session by telling trainees that changes in weight are the most sensitive indicators of growth and nutrition status in young children. Distribute a Road to Health Chart to each trainee. Explain that the Road to Health Chart is a screening tool that allows us to monitor a child's weight gain in order to find children who are becoming malnourished before they develop severe malnutrition.

2. Describe the features of the Road to Health Chart pointing them out on the wall-sized chart. (See Workbook, page 2)

3. Distribute a Road to Health Workbook to each participant. Use the workbook to complete the following steps:

a. Regular Weighing: In order to use the Road to Health Chart for growth monitoring, we must weigh and record the weight of a child regularly (monthly, bi-monthly). Demonstrate how to weigh a young child using a portable scale that can be purchased or obtained locally. Review the points on page 5 of the Road to Health Workbook "Accurate Weighing is Important."

b. Calculating Age: Weight is plotted together with age on the Road to Health Chart. It is only necessary to find out the child's age once, when the chart and the calendar are first filled out. In some areas, mothers do not know the ages or the birth dates of their children. Where this is true, a local-events calendar can be made relating events that people are likely to remember (i.e., festivals, holidays, political events, disasters, etc.) and seasons (summer, winter, rainy, maize, harvest, etc.) to specific months and years. Workbook Exercise 1 - "A Local-Events Calendar" should be completed by trainees during or after the session.

c. Recording Weight for Age on the Road to Health Chart: Using the wall-sized chart, demonstrate each step in completing a Road to Health Chart for the first time and for repeat weighings. Use page 9 of the workbook to guide the demonstration.

Ask trainees to practice recording weights on the Road to Health Chart by completing Exercise 2 in the workbook. When they finish, help them correct their charts by drawing the growth curves as they should appear on the wall-sized chart. Watch for and correct the following common errors:

- The calendar is not filled in completely or it is filled in incorrectly

- The first month written on the calendar is not the month of birth. The most common mistake is to write January (or the first month of the local year) or the month the child is first weighed instead of the birth month in the first box of the calendar

- The dot for weight is on the wrong weight or in the column for the wrong month

Practice plotting different weights and ages until most trainees can successfully record weights and ages on the chart.

d. Interpreting the Growth Curve: Record one weight on the wall- sized chart under the lower reference line. Record another weight for a child of the same age between the lines. Explain why we cannot say that one is healthy and the other "high risk" without more information.

Draw growth curves for the six months prior to the weights given for each child as in the following example.

Growth Curve

* 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.

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.






Follow these steps

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)


Marking on the spring scale

Spring Scale

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

London, UK.

Spring Scale

Dial-Shaped Spring Scale

Source: Teaching Aids & Low Cost

Dial-Shaped Spring Scale

A Single Beam Scale for Clinic Use

Source: CMS Weighing Equipment, Ltd.,

London, UK

Single Beam Scale

Philippine Bar Scale

Source: Nutrition Center of the Philippines,

Manila, Philippines

Philippine Bar Scale

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.


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.



Festivals and Events







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).




Recording the weight on a growth chart



Example of a growth line

Exercise 2: Recording Weights

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:




- 5 kg


- 7.5 kg


- 5.5 kg


- 7 kg


- 6 kg


- 7.5 kg


- not weighed


- 8 kg


- 6.5 kg


- not weighed


- not weighed


- 8.5 kg


- 7 kg


- 8.5 kg


- 7.5 kg


- 9 kg



- not weighed



- not weighed



- 10 kg



- 10 kg

Exercise 2: Recording Weights

Recording Weights


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:


- 7 kg


- 7.5 kg


- 7.5 kg


- 8 kg


- 8 kg


- 8.5 kg


- not weighed


- 9 kg


- 8.5 kg


- 8 kg


- 8.5 kg


- 9 kg


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.

In the first 6 months of life a levelling off or a downward movement of the growth line is a serious matter. After 2 years a small variation over one or two months is not so serious.

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.


Direction of the growth curve

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

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?

Analyze the growth of the children (A)

Analyze the growth of the children (B)

Analyze the growth of the children (C)

Session 4: The thinness chart

The Thinness Chart was developed for use in maternal child health clinics in Nepal by Save the Children (UK). The Thinness Chart uses two measures, weight and height, to assess the nutrition status of young children. A large multi-colored wall chart is first attached to the wall. Children are weighed and then placed standing in front of their weights on the chart. Height is then measured by placing a flat hand on the head and marking the point where the hand touches the chart. Nutrition status can be measured either in terms of percentages of standard weight for height or by using color-coded cutoff points indicating high, potential and low risk. Age is not required for this method. Graphing of weight is accomplished simultaneously with the measurement of height on the chart.


In this session, trainees practice using the Thinness Chart to classify the nutrition status of young children. The advantages of the Thinness Chart for community action projects are discussed.

Time: 1 hour without practice


- The Thinness Chart, available from TALC - Teaching Aids at Low Cost

- One copy of the booklet, "The Thinness Chart - How You Use It" for each trainee

- Chalkboard and chalk

- Several willing young children


1. Introduce the session by telling trainees that one way to identify children who are presently malnourished or at high risk of malnutrition is by comparing their current weight to their current height. By comparing a child's weight and height to standards for well-nourished and malnourished children, we can identify those children who are growing well as well as those who are malnourished and in need of additional counseling and medical attention.

2. Display the Thinness Chart. Explain that weights are shown on the vertical lines of the chart and heights on the horizontal lines. The colored bands across the chart tell the health or nutrition workers whether a child is healthy (green), in danger of malnutrition (yellow), malnourished (lower red) or severely malnourished (upper red). In contrast to the Road to Health Chart, the higher a child falls on the chart's curve, the more malnourished he or she is.

3. Distribute copies of the booklet "The Thinness Chart, How You Use It." Demonstrate steps for using the chart as presented in the booklet.

4. Practice: Arrange a practice session in which trainees weigh and assess several children using the Thinness Chart. Observe trainees and correct problems to improve their skills where necessary.

5. Ask trainees to brainstorm the advantages and disadvantages of the Thinness Chart as a tool for nutrition assessment at the community level. These might include:


- Does not require calculation of age. Can be used by people with minimal literacy skills.


- Mothers can participate.


- Colored bands make assessment easy and understandable


- Requires special chart and weighing equipment.


- Wall and adjoining floor must be flat.


- Difficult to make children stand still in front of chart.


- For children under one year, a measuring board is also required.


6. Summarize by reviewing the purpose and steps in using the Thinness Chart for nutrition assessment.

Note: The Thinness Chart is being used in two of the countries where CEDPA's training workshops have been held, Nepal and Senegal. The chart is generally easier to use and interpret than the WHO Road to Health Chart because it does not require graphing numerical measurements and assessing their position on the graph. Instead, the wall chart combines the measurement of height with the assessment of normal or abnormal growth. The Ministry of Health of Senegal is currently attempting to adapt the chart for use by non-literate village workers, who would use color coded weighing scales and wall charts to assess nutritional status of young children.


How you use it

Thinness chart

Developed by the Save the Children Fund with the London School of Hygiene and Tropical Medicine. The Thinness Chart is available from: TALC, P.O. Box 49, St. Albans, Herts, ALl 4AX, UNITED KINGDOM.

- Put the chart near your scales.

- The chart goes on the wall. The wall must be even.

- The bottom of the chart must touch the ground.

Scale and chart

- Weigh the child.

Weigh the child

- Note the weight to the nearest half kilo (kg).

Note the weight

- Find the weight on the chart with your finger.

Find the weight

- Ask the mother to put her child under your finger.

- The child must be in the correct place.

The child must be in the correct place

CHECK THAT: 1 the middle of the child's head is under his weight on the chart.

The middle of the child's head

CHECK THAT: 2 the child's shoulders and feet are against the chart.

The child's shoulders and feet

CHECK THAT: 3 the child's heels are against his weight at the bottom of the chart.

The child's heels

THEN: Put the palm of your hand on the child's head.

Touch the chart with your finger.

Which colour does your finger touch?

Your hand on the child's head

Is the child in the:





Where is the child?

You can darken the upper red section yourself. This will show you if the child is extremely thin.

This child is in the UPPER RED.

He is extremely thin (wasted).

You must help him urgently.

Child in upper red.

This child is in the LOWER RED.

He is very thin (wasted).

You should help him quickly.

Child in lower red.

This child is in the YELLOW.

He is thin.

You must watch him regularly.

Child in yellow.

This child is in the GREEN.

He is well nourished.

Child in green.

Session 5: Choosing a growth monitoring system


To compare the advantages and disadvantages of three growth monitoring tools: the three-color arm circumference tape, the Road to Health Chart and the Thinness Chart.

For use in training managers who will choose their own systems for measuring and monitoring the growth of young children.

Time: 20 minutes


- Handout - "Choosing a Growth Monitoring Systems"

- Wall-sized version of the handout


1. Distribute the Handout - "Choosing a Growth Monitoring System." Ask participants to use information from Sessions 2-4 to answer the questions on the chart.

Note: A copy of the completed handout is provided with this session for the trainer's reference.

2. Complete the wall-sized handout as a group activity. Use this as a time to review important points about each growth monitoring system.

3. Remind participants that the following criteria determine which growth monitoring system is appropriate in a given situation:

- Characteristics of malnutrition in the area

- Number of workers and their skills

- Resources available for training and supervision

- Resources available for assistance to "high risk" children










Mid-upper Arm

- Distance Around Mid-upper Left Arm

-Severe Malnutrition in Children 1-5 Yrs.

- Tape Marked either with Three Colors or in CM Divisions

- Minimal Training Required to Teach Health Workers, Mothers and Other Community Members How to use

- Only Useful with Children
- Measures Malnutrition that is already Severe

- Quick, Easy to Use
- Portable, Can Be Used Anywhere
- Easy to Understand
- Detects Improvements in Nutrition Status

Road to Health Chart

- Monthly Weights
Age at First Weighing

- Past and Present Malnutrition
- Most sensitive with Children Under 2 Yrs.

- Weighing Scale
- Road to Health Chart

- Extensive Training And Supervision Required

- Age is Often Difficult to Determine
- Workers Must Be Literate
- Equipment Expensive

- Sensitive to Early Changes in Nutrition Status
- Weighing Activity is Popular in the Village

Thinness Chart

- Weight
- Height

- Present Malnutrition
- Wasting

- Thinness Chart
- Weighing Scale
- Measuring Board

- Training and Supervision Required

- Requires Flat Wall and Floor
- Difficult to Make Children Stand
- Chart must be Purchased or Produced Locally
- Equipment Expensive

- Easier to use Than the Road to Health Chart
- Can Be Used by Semi-literate Workers
- Colors Make it Easy to Understand and Use
- Weighing Activity is Popular

Session 6: Counseling, referral and follow-up of malnourished children


In this session, trainees practice explaining the significance of children's growth measurements to their parents. Actions that should be taken in cases of severe malnutrition and early growth failure are discussed.

Time: 2 hours


- Role Plays - containing growth charts and mother's instructions for three situations (In this exercise, trainees use the Road to Health Chart as the tool for assessing the nutrition status of several children. Arm circumference measures or measures from the Thinness Chart can be substituted.)

- Handout - "Community Action with Malnourished Children" (This should be developed locally. An example is included.)


1. Introduce the session with a discussion of the critical role parents play in monitoring and taking action to improve the growth of their children.

2. Divide into work groups of three people. Work groups will conduct three role plays each. The characters in the role plays are a "community nutrition worker," the "mother" of a malnourished child and an "observer." Work group members will rotate the roles so that each member plays all three roles.

3. Give group members different situation sheets and instruct them to remove the " Instructions to the Mother" for their own reference. In each situation, the "mothers brings her child's Road to Health Chart to the Community nutrition worker." The "worker's" job is to:

- explain the Road to Health Chart and the child's growth curve to the "mother";

- discover the causes of growth failure by asking the questions about the health, eating habits, etc., of the child;

- help the "mother" plan what to do to improve the growth of her child.

The "observer" should note how the "worker" uses the Road to Health Chart to explain the child's situation and the need for action.

Allow about five minutes per role play situation.

4. Discuss the role plays by asking trainees to answer the following questions based on their experience in the roles of "mother," and "community nutrition worker" and


- How did the "community nutrition worker" use the Road to Health Chart to explain a child's nutrition status? - What questions did you ask to find out why the child had stopped growing?

- Did the "community nutrition workers" tell the "mothers" what they should do, or did they plan together how to improve the child's growth? Which do you think is more effective?

5. Counseling and education of parents are two community interventions to improve the nutrition of children identified during growth monitoring activities. Ask participants: "What other actions can/should be taken in the community with "high risk" children?" Write their responses on the flipchart.

6. Distribute the Handout - "What to Do When Children are Malnourished." Explain that each community nutrition program must decide what the community/clinic or agency will do for the malnourished children identified in growth monitoring activities. This handout gives a basic list of appropriate community interventions. Review them with the trainees and encourage them to add others that they feel would be necessary and feasible.

7. Review the basic steps in measuring growth and taking action to improve the nutrition of "high risk" children:

- Measure and assess the growth of all children under five regularly.

- Counsel the parents of "high risk" children. Visit them at home if possible.

- Refer or treat malnourished and sick children for illness.

- Follow up and evaluate the progress of each child.


Situation #1

Situation #1

Instruction to the Mother:

You brought the baby to the weighing activity because she is sick and has gotten thin.

You stopped breastfeeding her in September, at 4 months, because she "didn't like" your milk.


Situation #2

Situation #2

Instruction to the Mother:

You work on a tea plantation all day and leave this child with your 8-year-old daughter. Your husband left in August to find a job in the city. You are breastfeeding in the morning and at night. During the day the baby eats rice from the morning meal.


Situation #3

Situation #3

Instruction to the Mother:

You stopped breastfeeding this child in August when he was 16 months old because you became pregnant again. He refused to eat much for the next few weeks. Then he got the measles in November. Since then he has had frequent diarrhea.



To the Trainer:

This handout should be developed by each program based on the nutrition assessment instruments they use, their resources and established guidelines for intervention.


In a CEDPA-supported nutrition program, Community Nutrition Volunteers use arm circumference and weight gain to identify "high risk" children.

If a child has:

The Community Nutrition Volunteer:

Yellow Arm Circumference
(>12.5 cm <13.5 cm)
No weight gain for two months

- Counsels the parent(s)
- Teaches the mother to make improved foods for child feeding
- Refers the child to the nearest clinic if he is sick
- Follows up after one month

Red Arm Circumference
(<12.5 cm)
No weight gain for three months

- Counsels the parent(s)
- Refers for immediate medical treatment
- Gives food supplement
- Visits home one week later to teach mother how to make improved foods and how to treat diarrhea with ORS
- Follows up monthly until arm circumference is green

All children

- Teaches the mother to prepare improved weaning foods
- Teaches the mother how to make and give ORS to treat diarrhea
- Discusses the importance of and methods for child spacing



American Public Health Association. Growth Monitoring. 1981.

Morley, D. and Woodland, M. See How They Grow Monitoring Child Growth for Appropriate Health Care in Developing Countries. Oxford University Press, New York, 1979.

Nabarro, D., Verney, J. and Wijga, A. The Weight-for-Height Chart Project. Evaluation Report. 1982-1984.

World Health Organization. Guidelines for Training Community

Health Workers in Nutrition. WHO Offset Publication No. 59. Geneva, 1981.