>I notice on the site the charts require training to use?  Will  that be 
an issue?< 

I am glad that the message from WHO that the new charts require training has 
come across. 

In my opinion this is easily one of the most important aspects of the way 
the charts have been developed and launched.  In 7 years of reading the 
literature about the new chart (that's the time I have been reading, they 
started writing before that), I have noticed the members of the WHO working 
group have shifted their ground from concentrating just on the chart itself, 
and onto the necessity of training. 

When the impetus for the chart was recorded it was very much stated that 
poor recommendations were being given to women about supplementing 
breastfeeding becasue the baby's weight appeared to be poor due to the 
design features of the chart.  In recent papers I see an increased emphasis 
on the poor training health professionals have received in conducting and 
interpreting weights. From the results of my own study, I would go further 
and point to an almost complete lack (certainly here in the UK) of any 
training in how to explain weight gain and expectations to parents 
proactively, how to give information about a weight just conducted and also 
a nearly criminal lack of information on issues which make the weights 
conducted more technically accurate (eg routine weighing never more frequent 
that 14 days, same time of day, same scale.  Even where professionals 'know' 
some of this, I have almost never heard a mother get the message). 

I am doubtful if using a different chart / standard alone will make much 
difference to improving breastfeeding messages to women in developed (at 
least) countries, as long as the poor understanding of how to interpret 
infant growth (which is what I found in my phd study in the UK, and which is 
echoed in everything I have read on the subject) and sloppy practice in 
weighing continues.   The chart has been hailed as 'the answer'.  I am 
enthusiastic about the charts -- don't get me wrong -- but they are just the 
beginning of a process which has to happen in practice to change weight 
monitoring if it is to support not only women's confidence in breastfeeding, 
but appropriate breastfeeding and other interventions in cases where babies 
are experiencing some hindrance to growth in their individual circumstances. 

Crucially, there is hardly any evidence and certainly no clear guidance as 
to when a relative amount of under-nutrition through breastfeeding (which 
many babies can easily make up when they move on to timely, appropriate etc. 
complementary foods) is acceptable and when it crosses the line to something 
that requires action and what that action should be.  Most importantly, 
perhaps, when should that action be the use of foods or milks other than 
breast milk? 

Without addressing the whole series of issues implied in growth monitoring 
(summarised in the Cochrane review by Panpanich et al) changing the chart 
may not be much help in practice.  WHO is clearly committed to the chart 
making the difference, but the task includes training and re-training of 
health professionals world-wide to move growth monitoring on to a different 
level of activity. 

I should stress that here is almost no (research) evidence on how the chart 
influences women's feeding decisions.  Behague's paper pointed to some 
really negative influences of the chart, but her data is difficult to apply 
to all women as the women she investigated were those already feeling they 
had 'weak milk'.  In my own ethnographic study, I found that the way both 
professionals and women perceived the chart as a 'true' document and that 
babies 'must' grow on one particular centile (the nearer the 50th the 
better) impeded any useful suppor the chart could give to breastfeeding 
support.  Indeed, since the UK introduced our own national chart into 
parent-held records in the 1990's, I actually think there has been a 
negative influence of giving women their baby's growth chart and the use of 
a chart rather than previous system of giving weight change in numbers of 
ounces may itself have had a negative impact. 

I have not seen the WHO training materials, but if their mere existence 
sparks practitioners to question current practice, that will be brilliant.
While poor weighing practice continues, the impact of changing the chart 
will be minimal.  After all, a poor workman easily blames her tools. 

Magda Sachs, PhD. 

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