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Date: | Sun, 23 Jul 2006 11:13:35 -0400 |
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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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