1 Growth and nutrition

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Contents

Objectives

When you have completed this chapter you should be able to:

  1. Measure the size of a child
  2. Plot weight for age and height for age on a growth chart
  3. Assess the weight gain and growth of a child
  4. List the different food groups
  5. Describe a balanced diet
  6. Define underweight, wasted and stunted children
  7. Define overweight and obesity
  8. Understand an approach to managing a child with malnutrition.

Growth

1-1 How is the growth of a child determined?

To determine the growth of a child various measurements of body size are measured.

Measurements of body size are used to assess the growth of a child.

1-2 What is growth?

Growth is the increase in size as a child gets older. Older children are bigger than younger children as they have had more time to grow. Some children grow faster than others and therefore are bigger even though they are the same age.

Growth is an increase in size over a period of time.

1-3 What is growth monitoring?

Growth monitoring is documenting the increase in size as a child gets older. To assess growth the size of the child is accurately measured and then this measurement is plotted on a growth chart. Regular growth monitoring of children from birth to 5 years is particularly important because healthy children grow rapidly during this period.

1-4 What measurements of growth are used?

A number of different size measurements are routinely recorded in children of different ages:

1-5 What is a growth chart?

A growth chart shows the size of children at different ages and also indicated whether a child is growing normally. All children of the same age are not the same size as some children grow faster and are bigger than other children. The growth chart shows the normal range for the size of children at different ages. Therefore a growth chart can be used to decide whether a child is growing normally or not. Usually a separate chart is used for boys and girls.

Growth charts of weight for age, height (or length) for age and weight for height (or length) for boys and girls are included in the Road-to-Health booklet.

A growth chart is used to decide whether a child is growing normally.

1-6 How should a child’s weight be measured?

A scale is used to measure a child’s weight. In hospital young infants are usually weighed naked when they lie on the scale. Placing a sheet of paper towel under the infant helps to prevent the spread of infection from other infants. At a clinic the infant may be weighed with a vest and dry nappy provided they are worn every time the infant is weighed. It is important that the scale is zeroed before the weight is measured.

Older children can be weighed wearing pants only while they stand on a digital or bathroom scale. It is important to weigh a child at every clinic visit.

Weight is recorded in kilograms. For example 4.6 kg.

Measure the child’s weight every month in the first year of life, every 2 months in the second year of life and every 6 months after the age of 2 years.

It is important to weigh a child at every clinic visit.

1-7 How should a child’s standing height or lying length and head circumference be measured?

Remove the child’s shoes and let the child stand up against a measuring ruler or a wall. Make sure that the child’s heels, buttocks, back, shoulders and head are up against the ruler or wall. If a measuring ruler is used, pull the lever down until it touches the top of the child’s head and then read the height off the ruler. If measuring against a wall a book can be used. Hold the edge of book against the wall and then slide it down until it touches the top of the child’s head. Mark the positional of the bottom of the book on the wall with a pencil and then measure the distance from this point to the floor. It is important to measure height accurately. This is best done by asking an experienced colleague to show you what to do.

Lying length is measured if the child is too young to stand. Both standing height and lying length are recorded in centimetres. For example 64.3 cm.

Height and length are good measures of growth in a child and are usually measured every 6 months.

Height and length are good measures of growth in a child.

Head circumference is measured with a tape measure. It is important to measure a child’s head circumference at birth, 14 weeks and 12 months and record it on the Road-to-Health booklet.

1-8 How is weight plotted on a growth chart?

There are 4 steps to plotting weight on a growth chart:

1-9 How is height for age and weight for height plotted on a growth chart?

Height for age is plotted on a growth chart in the same way that weight for age is plotted.

Weight is plotted against height (or length) in children up to the age of 5 years. The age of the child is not used when weight for height is plotted as the normal range of weight for height is the same for all children under the age of 5 years.

1-10 Which growth charts are used?

In South Africa the growth charts in the Road-to-Health booklet are used for children from birth to 5 years of age in all communities. Health facilities have growth charts for older children. Separate weight, height and weight for height charts are used for boys and girls as boys are slightly bigger than girls of the same age.

1-11 What is the normal range on a growth chart?

Growth charts have 5 lines (called z lines). The 0 line (green), +2 and -2 lines (orange for warning) and +3 and-3 lines (red for danger). The middle line (0 line) is the average size for children. The +2 and +3 lines are above the middle line while the -2 and -3 lines fall below the middle line. Most healthy, well-fed children (95%) will have a size measurement that falls between the +2 and -2 lines.

With normal growth the size measurements will slowly increase and follow the lines.

Most children will fall between the +2 and the -2 lines on a growth chart.

1-12 What can the lines on a growth chart tell us about a child’s weight?

A child with a weight between the -2 and-3 lines weighs less than expected for their age while children with a weight below the -3 line weighs much less than expected for their age.

Children with a weight falling between the +2 and +3 lines weighs more than expected for their age while children falling above the +3 line weighs much more than is expected for their age.

Weight for age is used to identify children who weigh more or less than expected for their age.

1-13 What can the lines on a growth chart tell us about height and length?

As with weight for age, most healthy, well-fed children have a height (or length) between the +2 and -2 lines. Children with a height or length falling between the -2 and -3 lines are shorter than expected for their age while children with a height falling below the -3 line much shorter than expected for their age. Children with a height or length below the -3 line are called stunted and have been growing slowly for a long time.

Children with a height above the +2 line are taller than average for their age.

Children with a height between the -2 and -3 lines are shorter than expected for their age while those below the -3 line are much shorter than expected for their age.

1-14 What can the lines on a growth chart tell us about weight for height?

Instead of comparing weight and age, weight can be compared to height (or length) on a weight for height chart in children up to 5 years of age. Most healthy well-fed children have a weight for height between the +2 and -2 lines. The same weight for height chart is used for boys and girls.

A child with a weight for height falling between the +2 and +3 lines weighs more than expected for their height and therefore are overweight while a child with a weight for height above the +3 line weighs much more than expected for their height. Children with a weight for height above the +3 line are obese.

A child with a weight for height falling between the -2 and -3 lines weighs less than expected for their height. They are called wasted or thin. A child with a weight for height below the -3 line weighs much less than expected for their height and are called very wasted. These findings help to confirm which children weigh more or less than they should be.

The weight for height charts are used to detect young children who weigh more or weight less than expected for their height.

In children older than 5 years and adults body mass index (BMI) charts are used rather than weight for height charts.

1-15 How can growth charts be used to assess growth over a period of time?

Healthy, well-nourished children usually gain weight and height along or parallel to the lines on the growth chart. This shows that their rate of growth is normal. A sudden increase in both weight and height suggests a normal “growth spurt”.

If a child’s weight remains the same, suddenly drops or crosses down over a line on a growth chart the child is not gaining weight normally. This suggests that the child is not getting enough food or is ill. Not gaining weight normally is always a worry and must be investigated. With improved nutrition the child’s weight should “catch up” by suddenly increasing.

Similarly it is worrying if a child’s height is not increasing normally over time. This suggests that the child is not growing normally.

1-16 Why are growth charts important?

Growth charts are important as they are used to identify children who are not growing and gaining weight normally. These children must be carefully examined and a diet history taken to assess whether they have a problem with nutrition. It is best if all the child’s growth charts are reviewed. Growth charts therefore are useful in assessing a child’s nutritional status (whether the child is receiving enough food).

Growth charts help to assess the growth and nutritional status of a child.

If weight, and if possible height, are measured and plotted on a growth chart every time a child visits a clinic it will be possible to identify children who are not thriving. It is important to find out if the child is not growing well so that appropriate action should be taken to correct it.

Good nutrition

1-17 What is nutrition?

Nutrition is the food a person eats and drinks. This is also known as diet. Nutrition determines whether someone is well-nourished or malnourished (their nutritional status).

1-18 What is good nutrition?

Good nutrition is a well-balanced diet which contains the correct amount of all the important foods groups. Therefore all food groups in the correct amount are needed in a healthy diet. It is also important to avoid too much or too little food even if the diet is balanced. Good nutrition is needed for normal growth and development, good health and a strong immune system to prevent infections.

Good nutrition is a well-balanced diet which contains the correct amount of all the important foods groups.

1-19 What are the important food groups?

The 5 important food groups are:

1-20 What are energy foods?

The important energy foods are carbohydrates, fats and oils. Too much energy food leads to excessive weight gain and possible obesity while too little energy food leads to poor growth, weight loss and possible wasting.

Measuring a child’s weight for age or mid-upper arm circumference helps to screen children who are not getting the correct amount of energy food. Weight for length or BMI helps screen for children who are getting too much energy food.

Carbohydrates, fats and oils are energy foods.

1-21 What foods contain carbohydrates?

Common carbohydrate foods include:

Many cheap foods contain carbohydrates. They can be divided into sweet (simple) carbohydrates and not-sweet (starchy) carbohydrates. Small amounts of sweet carbohydrates such as sugar, sweets, jam, fruit juices and cools drinks contain a lot of energy and are important causes of overweight and obesity.

1-22 What foods contain fats and oils?

Food from animals such as meat, milk, cream and butter contain fat while many plant foods contain oils such as cooking oil (olive oil and sunflower seed oil), margarine and peanut butter. Fish also contains some oil. Animal fats and plant oils contain a lot of energy and too much of these foods can lead to overweight and obesity.

1-23 What foods contain proteins?

Proteins are present in animal and plant foods and are essential for normal growth. Common foods include:

Animal protein

Vegetable protein

Maize only contains a little protein. Protein foods also provide some energy. Unfortunately most foods that are rich in protein are expensive, especially animal foods and fish. Vegetable proteins are cheaper and very good.

Some foods contain more than one food group. For example peanut butter contains both protein and oil.

1-24 Which foods contain vitamins?

There are many different vitamins and therefore they are found in many types of food:

You will notice that fruit and vegetables in the diet are important as they provide most of the important vitamins. Children on a well-balanced diet do not need daily vitamin supplements but young children between 6 months and 5 years of age are given vitamin A every 6 months as part of national protocol. While vitamin deficiency is common with a poor diet it is rare for a child to have too many vitamins in their diet. Maize and wheat flour have added folic acid to prevent some birth defects.

Fruit and vegetables are a good source of vitamins.

1-25 Which foods contain minerals?

Important minerals include iron, zinc, iodine and fluoride:

1-26 How should one plan a well-balanced diet?

A well-balanced diet is made up of meals that contain some foods from all food groups. Expensive foods are not needed for a well-balanced diet. Important steps to a well-balanced diet are:

Malnutrition

1-27 What is malnutrition?

Malnutrition is a condition caused by too little food to meet the body’s needs. This is usually due to a poor diet especially in a poor community. However some children who are sick (with TB for example) may be malnourished even though their diet is good.

Sometimes malnutrition is also called undernutrition.

1-28 What are the 3 common types of malnutrition?

There are 3 common types of malnutrition:

When assessing a child for malnutrition it is important to look at all the growth charts (weight for age, height for age, weight for height) in order to decide which type of malnutrition is present. It is also important to clinically examine the child for other signs of malnutrition such as obvious wasting or oedema (swelling) of both ankles.

Other types of malnutrition are caused by a lack of vitamins (such as rickets due to low vitamin D) or lack of minerals (such as anaemia due to too few iron-rich foods).

1-29 How can you tell if a child is underweight?

You need to plot weight for age on a growth chart to diagnose underweight. A child with a weight for age between the -2 and-3 lines is underweight while a child with a weight for age below the -3 line is severely underweight. All these children weigh less than expected for their age.

Children with a weight for age between the -2 and -3 lines are underweight while those below the -3 line are severely underweight.

Plotting weight for age is more important in identifying children who are underweight than identifying children who are overweight. About 15% of South African children are underweight.

1-30 Why is it important to identify children who are underweight?

Because these children may be underfed or have an infection (such as TB) or bowel parasites. Children who are underweight are at an increased risk of not having an adequate diet while children who are severely underweight are almost certainly not getting an adequate diet. It is important to take a careful history and make a complete clinical examination in these children to look for the cause of being underweight. It is important to ask about their diet and whether they have loose stools.

Children may be underweight or severely underweight because they are wasted, stunted or both. Therefore it is important to decide whether these children are wasted, stunted or both.

1-31 How can you tell if a child is wasted?

You need to plot a child’s weight for height (or length) on a growth chart. Most healthy, well-fed children will have a weight for height (or length) between the +2 and -2 lines. A child with a weight for height (or length) between the -2 and-3 lines is wasted while a child with a weight for height (or length) below the -3 line is severely wasted.

Usually you can suspect wasting by looking at a child. Wasted children are thin while severe wasted children look very thin and often starving.

Children with a weight for height or length between the -2 and -3 lines are wasted while those below the -3 line are severely wasted.

1-32 Can mid-upper arm circumference be used to screen children for wasting?

Yes. The circumference of the left arm midway between the shoulder and elbow can be used to assess nutrition, especially in a child between 6 months and 5 years of age. Most healthy young children have an upper arm circumference above 13.5 cm. Mid-upper arm circumference (MUAC) is a useful and easy way of screening children every 3 months for malnutrition. A tape measure or a special MUAC measuring tape can be used. The special tape has a green (normal), orange (warning) and red (danger) zone.

1-33 What is moderate acute malnutrition?

This is a classification used by the World Health Organisation (WHO) for children who are wasted. They have:

Children with acute moderate malnutrition are wasted (thin).

These children usually are not getting enough food or are ill.

1-34 What is severe acute malnutrition?

This is a classification used by the World Health Organisation (WHO) for children who are severely wasted. They have either:

Underweight children with swelling of both legs (nutritional oedema) are also classified as severe acute malnutrition. This condition used to be called kwashiorkor. These children are irritable and often have thin hair and skin rashes.

Children with severe acute malnutrition are very wasted or have swollen legs.

1-35 Are children who are underweight always wasted?

No. Some children who are underweight are not wasted but are stunted. Therefore they are underweight but are not thin. Both their weight and height will be less than expected for their age.

1-36 When is a child stunted?

Most healthy children have a height between the +2 and –2 lines. A child with a height between the -2 and-3 lines is shorter than average and is called stunted while a child with a height below the -3 line is much shorter than average and is called severely stunted.

There are many causes of stunting but the most important is chronic malnutrition where a child has been on a poor diet for many months or years. Children with repeated illnesses or a chronic illness like TB can also be stunted. About 20% of children in South Africa are stunted.

Children with a height for age between the -2 and -3 lines are stunted while those below the -3 line are severely stunted.

Children with a height for age between the +2 and +3 lines are tall for their age and usually have tall family members. Being taller than expected is rarely a clinical problem.

Some children can be stunted and yet be overweight. Many adults are stunted due to a poor diet in childhood and overweight due to excess energy foods as adults.

1-37 Why is it important to know whether an underweight child is also stunted?

Because there are 2 main reasons for a child being underweight or severely underweight:

It is very helpful if the child’s weight and height have been measured at every clinic visit as this will show whether weight and height gain have been normal or not and whether weight for height has dropped recently.

Plotting height as well as weight for height helps to tell whether an underweight child has an acute or chronic problem.

Overweight

1-38 When is a child overweight for their age?

When their weight for age plots between the +2 and +3 lines. It is important to decide whether these children are heavier than expected for their age due being fat or whether they are simply a big child. To diagnose that a child is overweight or obese a weight for length chart is used.

A weight for height chart should be used to assess whether a child is overweight or obese.

Children with a weight for length between the +2 and +3 lines are called overweight while children with a weight for height above the 3+ line are obese.

In children older than 5 years and adults the body mass index (BMI) is used in a similar way to define overweight or obese individuals.

Children with a weight for height between the +2 and +3 lines are overweight while those above the +3 line are obese.

1-39 Can weight for age be used to diagnose overweight and obesity?

No. Weight for age can be used to screen children for malnutrition but weight for age is not used to identify children who are overweight or obese, as a child with both a weight and height falling equally high on the charts is simply a fast growing child. Instead a weight for height chart is used to diagnose overweight or obesity. A weight for age chart is also useful to document weight loss if an obese child is started on a low energy diet.

1-40 How often are children overweight?

Being overweight or obese is common in industrialised countries but is also becoming common in developing countries and poor communities. In South Africa 15% of children are overweight. This increases to 30% for girls living in urban areas.

1-41 What are the health risks if a child is overweight or obese?

There are many risks to being overweight and these risks are highest if the child is obese:

1-42 What is the cause of being overweight or obese?

Eating too much. More energy (calories) is taken in compared to the energy used and this leads to weight gain. The cause is complicated and the management is difficult:

Managing a child with malnutrition

1-43 How is malnutrition managed?

The 3 steps in managing malnutrition are:

Community health workers can play an active role in all 3 stages of managing malnutrition.

1-44 How can malnutrition be prevented?

Everyone should be education about a healthy diet and getting enough exercise. A well-balanced diet should contain enough protein, carbohydrates, animal fat and vegetable oils, vitamins and minerals and not have too much carbohydrate, fat and oils. Schools, church groups, social and sport clubs and the media are all places where communities can be taught about healthy eating. It is easier to change the eating habits of a community or family than that of a single person.

In poor communities school feeding schemes, social grants and food parcels can help families that cannot afford an adequate, well-balanced diet.

1-45 How can an early diagnosis of malnutrition be made?

1-46 How should children with malnutrition be managed?

1-47 How should children who are overweight or obese be managed?

Case study 1

A poor, unemployed woman is visited at home by a community health worker. Her 4-year-old son looks thin and has a weight which falls between the -2 and -3 lines on a weight for age growth chart. The child’s mid-upper arm circumference is 12 cm. The mother says she has little money for food and feeds her child white bread and jam for most meals. The CHW takes the mother and child to the local clinic.

1. Do you think this child is malnourished?

Yes. The weight for age falling between the -2 and -3 lines is below the normal range which is -2 to +2. This indicates that the child has moderate acute malnutrition. The child is probably malnourished due to a poor diet. However the child may also be ill causing weight loss.

2. How can you tell whether this child has recently lost weight or has been underweight for a long time?

If the child had been weighed at every clinic visit and his weight for age plotted on a growth chart you would be able to tell.

3. How can you decide whether the child is thin?

By plotting the child’s weight for height on a growth chart. If this falls between the -2 and -3 lines the child is thin (wasted). If it falls below the -3 line the child is very thin (very wasted). This is called acute severe malnutrition.

4. What other method can be used to screen children to detect those that are malnourished?

Measuring the mid-upper arm circumference in children between 6 months and 5 years of age. If the arm circumference is between 11.5 and 12.5 cm the child is thin (wasted). This child has a mid-upper arm circumference of 12 cm which indicates that he is thin.

5. Why is it important to decide whether an underweight child is thin or not?

Because the child may not be thin but underweight because of stunting. These children have been growing slowly for a long time rather than suddenly losing weight. This suggests a chronic rather than a recent problem.

6. What should be the management of this child?

The child should be clinically examined and a full dietary history taken at the clinic to decide why the child is underweight. The community health worker can help advise the mother on how to access a social grant or food parcels. Further information can be given is making a well-balanced meal.

Case study 2

A 6-year-old child is brought to the clinic by a community health worker because he is shorter than other children of his age. When his height is measured and then plotted on a growth chart it falls below the -3 line. He does not look thin and his weight for age falls between the -2 and +2 lines.

1. Is this child shorter than expected for his age?

Yes. His height falls below the -3 line which means that he is very stunted.

2. Do you think he is stunted because he is starving?

No. He is unlikely to be starving as his weight for height is normal. Therefore he is not wasted (thin).

3. What does it mean if he is stunted but not thin?

This suggests that he has been growing slowly for a long time. He needs to be fully examined to assess whether he has a chronic medical problem. It would also be important to take a careful diet history. A lack of protein but enough energy foods in the diet can result in stunting without the child being thin.

4. Does it matter if a child is taller than average?

Usually not. Tall children often have tall parents. Therefore measuring height is important to detect stunted but not tall children.

Case study 3

A woman on a social grant asks a community health worker to advise her on what food to buy for her 3-year-old daughter. She wants her daughter to remain well and grow normally.

1. What food does this child need?

She needs a well-balanced diet and enough food to grow and develop normally.

2. What is a well-balanced diet?

A well-balanced diet is made up of all the food groups. Protein, energy foods like carbohydrates, fat and oil, vitamins and minerals.

3. How can you tell that she is getting enough food?

By plotting her weight on a growth chart. Children that are getting enough food from a well-balanced diet will grow normally and gain weight and height between the -2 and +2 lines.

4. Which foods contain protein?

Foods rich in protein include meat, fish, eggs, milk, cheese, beans, peas, lentils, peanut butter and sorghum.

5. Are all carbohydrate foods good for a child?

It is better to avoid cool drinks, sweets and sugar. Rather vegetables, fruit, wholewheat bread, rice, maize and cereals are advised.

6. What foods are rich in vitamins?

Fruit, yellow and green leafy vegetables, milk and meat.

Case study 4

A school teacher refers a 12-year-old boy who is overwight and being teased by his class mates. She asks that the child can be given a diet to lose weight.

1. How can you decide whether this child is overweight or obese?

Plot him on a body mass index (BMI) for age chart. If he falls between the +2 and +3 lines he is overweight and if he is over the +3 line he is obese.

2. What foods should he have to lose weight?

He needs a well-balanced diet which does not have too much energy food. Cutting out sweet carbohydrates like sugar and cool drinks are important.

3. Is it easy for obese children to lose weight?

No. It helps if the whole family can have a well-balanced diet. He will need a lot of support and encouragement.

4. Why is it important to manage obesity in childhood?

Because obese children usually grow into obese adults who have a high risk of diabetes, hypertension, heart attack and stroke. An obese child is often an unhappy child due to teasing.