Dear all:

I have to echo Magda on this.  Stunting is a length for age (in a child under two years) that is 
below a certain percentile.  Wasting is a weight for length that is below a certain percentile.  
Weight for age is an almost useless indicator in an infant over three months of age, because 
length makes a huge different in what is appropriate.  Weight should always be compared to 
length, not age. 

And furthermore, these static indicators are almost useless without a full history.  In International 
Nutrition circles, these static measurements were abandoned long ago in favor of growth 
monitoring and promotion and as I've mentioned before, the programs that were sucessful didn't 
leave out the most important of those two --- growth promotion.  Static measures have basically 
been used only in emergency conditions and basically there are problems with screening who gets 
the food for rehab centers.  You get those who are bumped out of the "wasted" category who then 
end up back into the center because you didn't fix the underlying cause.  Hence, nutritional rehab 
has a very low cost-benefit ratio compared to programs that actually fix the underlying problem 
and eliminate the ping pong effect.

If you use growth curves you should not just look at the percentile, z-score or percent of standard 
that is what should be looked at; it is the growth trajectory.  Plateaus in growth or sudden drops 
are of concern.  A plateau might be considered an orange light --- watch closely and investigate 
(but keep in mind that one period of plateau might be due to a mismeasurement).  A sudden drop 
is a red light of "fully investigate this situation" and identify the probable cause. A slow drift 
downward needs to be looked at in light of MANY OTHER clinical as well as emotional and 
behavioral factors.  It may very well be quite normal.  The downward shift should be considered a 
yellow light meaning pay attention investigate and follow up but don't get overly alarmed if 
otherwise the baby seems fine.  

To give two examples of how the downward shift can mean different things:

I had a mom who came to support group for probably six months.  Very relaxed.  She was tall and 
thin.  So was her first.  Her kids were very active.  She came to the group predominantly to hang 
out and chat with other moms.  Her child hovered around the 5th to 1st centile of weight-for-age 
for a long time.  Neither of us were worried - we just kept an eye on it andwatched her babies 
activity levels.

Another mom came to support group with a four month old.  She had been reassured by her 
doctor and at other support groups that her baby was fine.  She was worried because her baby 
wasn't meeting milestones.  THis baby was actually 6 weeks premature, had gained at 1/2 ounce 
per day.  This baby's growth trajectory looked fine and this baby probably weighed as much 
(corrected for gestational age) if not more than the first example.  This baby, however, was most 
decidedly not fine.  THe baby started reaching all the missed milestones very soon after starting 
pumping and supplementation.

While I am quite happy the growth curves have been revised, it does not address the bigger issue 
of how to use anthropometric measurements appropriately and the curves to interpret these 
measurements.

I did not personally attend the clinical session on weighing at the ILCA conference so my 
secondhand information may be biased.  What I was told was that it consisted of strapping a 
weight to a baby doll and weighing this on a digital scale.  If this is how most LCs are trained to 
use a scale without the background into how these scales work, a thorough understanding of 
anthropometric indicators and what they do and do not tell you including the interplay of weight 
and length and how that changes over time, and an intensive and thorough grounding in how to 
interpret the many parameters that influence growth, then I completely understand why so many 
think that the scale is useless.  

Best regards, Susan Burger

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