Abstract

Growth monitoring has been identified as an important component of the ‘Child Survival and
Development Revolution’—an initaitive advocated by UNICEF and supported by several other
development agencies.

In this initiative, improvements in the survival of children are attained through the widespread
promotion, distribution and utilisation of selected health maintaining technologies by family
members. Health workers, community institutions and welfare services help the family by
providing encouragement, support and assistance. Growth monitoring has been identified as one
of the key technologies—not only because it helps to promote the satisfactory nutrition of
children, but also because it provides an opportunity for uniting other low-cost child health
interventions.

This paper re-examines the importance of widespread growth monitoring as a part of child care
in developing countries. In the early sections, reasons for monitoring the growth of children are
examined and the role of growth monitoring in primary health care is considered. The rationale
for including growth monitoring in the child survival revolution is explored and the potential
benefits of growth monitoring are reviewed. The authors then examine the results that have been
achieved, to date, in a variety of programmes where child growth is being monitored. They
conclude with a re-assessment of the importance of growth monitoring in child care. If the
widespread promotion of growth monitoring is being considered as a means to improve the
health of a community's children, three key questions must be answered. What are the risks
associated with growth faltering or weight loss? To what extent can different health, educational
or welfare interventions reduce these risks? How much will these interventions cost; could the
resources (including mothers' time and enthusiasm) be put to better use? Such questions are not
often asked in national programmes; they are rarely debated, and the decision to include growth
monitoring in child care activities is usually made as a result of international pressure rather than
consideration of local realities.

In practice effective growth monitoring activities are not easily implemented: perhaps their
widespread advocacy is not a result of a careful review of policy and programme research, more
a reflection of changes in the needs and concerns of international aid agencies.
Abstract

Growth monitoring has become a major component of many child health

programmes in developing countries over the past two decades. Little research
has been carried out on the separate contribution of growth monitoring to the
effectiveness of child health programmes, and discussion on the subject
frequently take on an exhortative rather than a scientific character. This paper
reports some of the results of an evaluation of three child health programmes in
rural Zaire which used growth monitoring as a screening tool for targeting health
and nutrition interventions. The monthly sessions to which mothers brought their
children were observed, the health workers interviewed, and information
obtained on the supervision system in the programmes, in order to determine
wether the health workers accurately identified at-risk children and provided
appropriate interventions through the use of growth monitoring information.

Health staff were observed weighing and consulting a total of 506 mothers and
children. Whilst they measured and recorded weights accurately, they did not
carry out any further investigation in one-third of children who had experienced
growth faltering. Similarly, no counselling was given to one-third of mothers
whose children were ill and/or had growth faltering, called collectively ‘at-risk
children’. Generally, the quality of advice and referral for illness was more
satisfactory than the nutritional advice given to mothers, which consisted of brief,
standard directives. The value of individual screening by weighing is questioned,
since attendance was infrequent and non-representative, many mothers
identified their children as ill and therefore at-risk even before they were
weighed, and since nearly two-thirds of children attending the sessions were
classified as at-risk. The theoretical gain in health service efficiency by targeting
was largely lost by the staff-time required to weigh and record the weights of
individual children, and the fact that the information that a child had growth
faltering was frequently not acted upon. The programmes did not exploit the
potential of growth monitoring as an educational and motivational tool to
promote action by mothers and communities to improve their children's health.
The use of growth monitoring did not appear to be an important factor in the
overall quality of care within these three programmes.

The disappointing results of this evaluation, which have been mirrored in other
recent reports, and a review of the theoretical grounds for growth monitoring,
have led the authors to conclude that the case for including growth monitoring in
child health programmes remains unproven either on theoretical grounds or in
practice. There is a critical need for further research into the cost-effectiveness of
growth monitoring, but the introduction of growth monitoring into future child
health programmes appears difficult to justify at present.