David Bratton mentioned that growth charts are simply screening devices.
Having been exposed to the use of growth charts in developing countries for
the last 18 years, I would like to point out that this is not the only use,
nor the best use of growth charts.

If anyone is interested in a good critical review of the evidence in using
growth charts for growth monitoring, Marie T. Ruel wrote a Chatper
on "Growth monitoring as an educational tool, an integrating strategy, and
a source of information:  A review of experience" in Child Growht and
Nutrition in Developing Countries:  Priorities for Action, ed. Pinstrup-
Andersen, Pelletier, and Alderman.  Published by Cornell University Press,
1993.  She basically concludes that:

1) Growth monitoring is potentially useful in primary health care programs
for education, motivation and promotion of other health services/

2) The usefulness of growth monitoring and promotion data for screening at
the individual level (and population level for monitoring evaluation, and
surveillance) looks less promising becuase the data often has a high rate
of measurement errors.

While one might argue that developed countries should have less measurement
error, I have to say that my observations of the accuracy of weighing and
measuring techniques in pediatric offices in New York City are that it is
actually is somewhat worse than I have seen in most primary health care
services in developing countries.

More specifically regarding its use in a lactation consultant practice, I
see significant problems with using growth monitoring as anything other
than a very very very rough guide that should ALWAYS BE USED CONJUNCTION
WITH other clinical and behavioral observations of both mother and infant.
Just a few of the problems I see are:

1) While the data in the growth curves are measured on a set of infants
over time, the percentiles are calculated as static measurements at
particular points in time, not as velocity curves.  That is to say, the
percentiles (or more frequently used in public health, the standard
deviations) are only calculated for a set of infants at a particular age.
Velocity curves would calculate the percentiles (or standard deviations)
for a period of growth (e.g. the expected growth from birth to two weeks of
life).  The NORMAL variation in weight gain over a period of time is much
much greater than the variation in a static measurement of weight at a
particular point in time.

2) The data used to develop the growth charts did not measure infants with
the same frequency that may be the case when working with newborns. So, the
curves are extrapolated across the early time intervals when mothers most
frequently present with breastfeeding problems.

3) The growth charts are not well designed to capture the normal range of
catch-up growth for premies, nor for small for gestational age infants.

While I have seen some successful uses of growth monitoring and promotion
in developing countries whereby women and families were empowered to make
their own decisions about how to improve their infant's health, these
programs were extremely expensive and its not clear to me that other
educational efforts that were not so concentrated on measurement might not
have had the same result.  This was one point that Marie Ruel made fairly
strongly in her review.

Susan Burger, PhD, MHS

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