Growth monitoring and promotion: review of evidence of impact.

Table of Contents Summary 86 1. Background 88 1.1 History and development of growth monitoring programmes 88 1.2 Objectives of growth monitoring 89 2. Expected benefits of growth monitoring and growth promotion 90 3. Objectives of this review 91 4. Methodology 91 5. Evidence of effectiveness of growth monitoring programmes 91 5.1 Nutritional status and mortality of young children 91 5.1.1 Studies before 1990 91 5.1.2 Studies since 1990 96 5.2 Utilization of primary health services 103 6. Quality of implementation 104 7. Caregivers' knowledge and understanding of growth charts 105 8. Empowerment and community mobilization 106 9. Coverage and attendance 107 10. Potential consequences if withdrawn 108 11. Feasibility and conditions under which growth monitoring and promotion can be expected to work 108 12. Cost-effectiveness 109 13. Potential adverse consequences 109 14. Policy considerations and recommendations 110 References 113 Summary The rationale for growth monitoring and promotion is persuasive but even in the 1980s the appropriateness of growth monitoring programmes was being questioned. The concerns centred largely around low participation rates, poor health worker performance and inadequacies in health system infrastructure that constrained effective growth-promoting action. More recently there has been a call for a general review of the impact of large-scale growth monitoring and promotion programmes to determine if the investments are justified. The launch of the new World Health Organization growth standard and charts has been a timely reminder of this debate. It is within this context that this review has been undertaken: the main purpose is to analyse the evidence that growth monitoring programmes are effective in conferring measurable benefits to the children for whom growth charts are kept. The benefits considered here are improved nutritional status, increased utilization of health services and reductions in mortality. There is evidence from small-scale studies in Nigeria, Jamaica, India (Narangwal and Jamkhed), and from large programmes in Tanzania (Iringa), India (Tamil Nadu Integrated Nutrition Project), Madagascar and Senegal that children whose growth is monitored and whose mothers receive nutrition and health education and have access to basic child health services have a better nutritional status and/or survival than children who do not. There is tentative evidence from a large-scale programme in Brazil (Ceara) that participation in growth monitoring confers a significant benefit on nutritional status independent of immunization and socio-economic status. There is evidence from India (Integrated Child Development Services) and Bangladesh (Bangladesh Rural Advancement Committee and Bangladesh Integrated Nutrition Project) that growth monitoring has little or no effect on nutritional status in large-scale programmes with weak nutrition counselling. There is evidence from Tamil Nadu in a randomized trial that when mothers are visited fortnightly at home and have unhurried counselling, no additional benefit accrues from the visual depiction of growth on a chart. There is some evidence that growth monitoring can improve utilization of health services. Although there is no unequivocal evidence that growth monitoring is beneficial per se, it was perceived to be beneficial by the investigators of several of the studies described in this review. Growth monitoring can provide an entry point to preventive and curative health care and was an integral part of programmes that were associated with significant reductions in malnutrition and mortality. Good nutrition counselling is paramount for growth promotion and is often done badly. Effort must be made to improve this and provide age-appropriate advice to achieve exclusive breastfeeding and appropriate complementary feeding, irrespective of decisions about growth monitoring. This review highlights the paucity of rigorous trials to determine the impact of growth monitoring separately from the impact of growth promotion. There is no controversy about the need for growth-promotion activities, and weighing children is desirable to assess health and nutrition status. The debatable question is whether weights need to be monitored monthly and plotted on a chart. Even if there is a policy for growth monitoring, if a child has grown well in the first year of life then it would appear that little is gained by monitoring weight beyond the age of 12 months, and that the time spent monitoring older children might be better spent improving the counselling given to caregivers of infants. Growth monitoring may not be the best use of limited resources in countries with weak economies and inadequate health budgets: a limited package of health and nutrition interventions including good nutrition counselling may be preferable, aiming for good coverage and effective health worker performance, and prioritizing infants and children <18 months of age. Two of the potential strengths of growth monitoring are that it provides frequent contact with health workers and a conduit to child health interventions. Taking into account the evidence from recent nutrition education interventions in India and Peru that used multiple delivery channels within routine health services, possible options to consider for the future are: • If growth monitoring is not in place, then focus efforts on growth-promotion activities and consider counselling caregivers intensively at all child health contacts and through home visits by community health workers or volunteers. Where possible chart weights at birth, immunization (6, 10, 14 weeks and 9 months), vitamin A distribution and sick-child visits. Follow up and counsel any whose weight is faltering and those with a weight-for-age <−2 SD. • Where growth monitoring exists but the coverage is low or there is little potential for improvement, then consider abandoning it and re-focus efforts on growth-promotion activities as described above. • Where growth monitoring and promotion programmes currently exist and there is potential for improvement, then maximize their potential, strengthen the nutrition counselling elements, combine growth monitoring with other health intervention channels such as immunization for the convenience of caregivers, and ensure consistent message delivery. Target younger children and use the time gained to improve services. Monitor weight until 12 months of age. If there are episodes of growth faltering, continue to monitor until 18 months. Where cultural traditions and conditions are favourable, use growth monitoring additionally for community mobilization to address underlying socio-economic and other causes of poor nutrition and health. Scaling up from successful small-scale growth monitoring and promotion programmes to effective national programmes will require political commitment, investment, extensive capacity building and strengthening of health systems. Training, supervision and support will need to be improved if health workers are to be equipped with the necessary knowledge and communication skills to promote healthy growth. Impact will be related to coverage, intensity of contact, health worker performance, adequacy of resources and the ability and motivation of families to follow advice.