Unit 1: Growth Monitoring + Promotion & Dietary requirements for growth in young children

Question 1

Define ‘growth’

Answer 1

observable changes in skeletal bone and fat and changes in the composition of these elements

Question 2

Growth monitoring and promotion

Answer 2

a preventative and promotional activity that uses growth monitoring (measuring and interpreting of growth) to facilitate communication with caregiver & to generate adequate action to promote child growth through:

1. increasing caregiver awareness about child growth
2. improving caring practices

Question 3

Rationale for amending growth charts (switch from NCHS charts to WHO growth charts)

Answer 3

1. NCHS reference standards are based on a single-country sample of children presumed to be healthy.
2. New WHO standards are based on a sample of children from 6 countries. It is designed to provide how children SHOULD grow by including in study’s selection criteria health behaviour such as beast feeding, standard paediatric care and not smoking.
3. established on breastfed infants as model
4. new standards will help better identify stunted & overweight children
5. charts with expected growth rate over time allow for early identification of children at risk of becoming underweight/ overweight.

Question 4

WHO recommendations on growth monitoring

Answer 4

1. use separate growth charts for boys and girls as the difference in growth is too big
2. use z-score instead of percentile to measure the extremes. Z-scores have the statistical property of being normally distributed thus allow calculation of average value and standard deviation of a population. (more statistically relevant)
3. use more than one indicator to monitor growth, different indicators should measure different outcomes

Question 5

Indicators of growth charts

Answer 5

1. weight-for-age: assess whether child is underweight or severely underweight. NOT used to classify overweight and obesity.
2. length-for-age: identify children who are stunted.
3. weight-for-length: identify those who are wasted or severely wasted but also may used to assess risk of becoming overweight or obese.

Question 6

Interpretation of growth charts - what to look for

Answer 6

1. Normal: not a number but a range of values
2. Always look for trends
3. Look for crossing of z-lines
4. Look for growth lags and catch up with growth

Question 7

MUAC

Answer 7

• mid-upper arm circumference

indication of severe undernutrition and wasting. Refer urgently if MUAC is below 11cm. 11- 12.5cm indicate moderate to severe acute malnutrition

Question 8

Head Circumference

Answer 8

• done at birth, 14 weeks and 12 months

- indicator of brain growth, brain should double its size from birth to 12 months.

Question 9

Growth classification

Answer 9

1. growing well: follows normal growth curve
2. not growing well: loss of weight since previous month; do not gain weight; low weight/height (below -2 line)
3. severe malnutrition: very low weight/height (below -3); clinical signs of malnutrition

Question 10

Causes of growth faltering

Answer 10

1. inadequate/ inappropriate nutrition during antenatal, infancy and childhood periods
2. illness
3. emotional deprivation or stress
4. genetics and hormones (less common)

Question 11

Clinical signs of growth faltering

Answer 11

Marasmus (wasting) & oedema of both feet

Question 12

Consequences of growth faltering (short & long term)

Answer 12

1. affects brain development short term & long term consequences include decline in cognitive and educational performance.
2. short term: changes in growth, muscle mass & body composition. long term: negative impacts on immunity and work capacity.
3. short term: changes in metabolic programming of glucose, lipids, proteins, hormone receptors and genes. long term: diabetes, obesity, heart diseases, hypertension, cancer, stroke and ageing.

Question 13

Define ‘development’

Answer 13

changes in biological, physiological and emotional elements

Question 14

Discuss ‘milestones’

Answer 14

measures of development, achievement of skills gained by developing infant/child. 3 categories:

1. vision and adaptive
2. hearing and communication
3. motor development (reflects muscle and nerve development)

Question 15

When height measurements are unattainable, how would you assess acute malnutrition in a child?

Answer 15

MUAC

Question 16

Limitation of head circumference measurement

Answer 16

it is an indirect indicator of physical brain growth but not the brain’s functional development

Question 17

Necessity of regular developmental screening

Answer 17

allows for early rectification of problems

Question 18

Outline the nutritional context of children in SA: 1 - 3 year olds and 4 - 6 year olds

Answer 18

• 1 - 3 year olds: studies show that incidents of stunting, severe stunting, severe wasting and severe underweight increased during the interval of 2005 - 2012, whilst wasting and underweight decreased.
• 4 - 6 years: studies show that all conditions related to malnutrition (stunting, severe stunting, wasting, severe wasting, underweight and severe underweight) decreased between 2005 and 2012

Question 19

Micronutrient status of children under 5 years of age

Answer 19

• vitamin A deficiency decreased by 20% between 2005 and 2012 (owing to fortification programmes)
• iron deficiency increased by 0.2% between 2005 and 2012

Question 20

How are vit A and iron deficiencies measured?

Answer 20

• vit A: serum retinol of below 0.70µmol/L

- iron: haemoglobin level less than 11gm/dL and ferritin level less than 12ng/mL

Question 21

Immediate causes of malnourishment in the UNICEF conceptual framework

Answer 21

1. inadequate dietary intake
   - may be the result of poor breast feeding, inadequate weaning, inappropriate nutrient density, poor dietary variety/ diversity etc.
2. disease
   - Diarrhoea, TB, HIV/AIDS, pneumonia, measles, parasitic infection, micronutrient deficiency.

CASUAL EFFECTS BETWEEN THE TWO FACTORS
- undernutrition leads to infection (ineffective immunity) which leads to exacerbated undernutrition and this vicious cycle leads to long term morbidity & death.

• Infectious disease leads to undernutrition which increases the needs for nutrients & energy. This uses up body stores. Disease also leads to decreased intake of nutrients though dropped appetite, irritability and vomiting and increased losses of nutrients from diarrhoea and vomiting.
• cultural beliefs may exacerbate these effects through inappropriate treatment of the sick.

Question 22

Underlying cause of malnourishment in the UNICEF conceptual framework

Answer 22

1. inadequate access to food
   - the physical and economic access to food. Quality and quantity of food and whether supply is sustainable.
2. inadequate care for women and children
   - cultural taboos and practices, birth spacing and adequate diet during pregnancy and lactation. Multiple roles of women may be overwhelming)
3. insufficient health services and unhealthy environment
   - basic facilities such as piped water, toilet, roads and infrastructure.
   - health system: primary health care delivery, education, family planning, curative and preventative health services.

Question 23

Basic cause of malnourishment in the UNICEF conceptual framework

Answer 23

1. Resources and control - human, economic & organisational resources.
   - economic recession, inequitable distribution of wealth, weak Rands.

Question 24

Dietary requirements for the first year of life

Answer 24

1. first 6 months of life: exclusive breastfeeding or an appropriate breast milk substitute.
2. second 6 months of life:
   - complementary feeding
   - 6 to 8 months: milk followed by solids
   - 9 months to 6 years: solids first
   NB: meal frequency, texture, variety
   - 1 to 5 years of life: 5 small meals a day.

Question 25

Macronutrients in diet

Answer 25

1. Carbohydrates: source of energy for the brain. constitute 45% - 65% of diet. (diet consumption must be sufficient to ensure growth and spare protein)
2. Protein: growth
3. Fat: insulation and absorption of fat-soluble protein

Question 26

Iron: function, sources and why iron deficiency is so prevalent in SA

Answer 26

• production of Hb, electron and enzyme transport
• NB for growth
• sources: liver, meat, green leafy vegetable

*however dietary consumed Fe have low bioavailability due to dietary inhibitors of Fe.

Question 27

Vitamin A: two types of Vit A and their sources

Answer 27

1. Preformed Vitamin A (retinol)
   - food sources are of animal origin: egg yolk, organ meats, diary products
2. Pro-vitamin A (carotenoids)
   - plant origin: orange coloured fruits and vegetables such as pawpaw, sweet potato, spinach and carrots

Question 28

How did SA government tackle the problem of Vitamin A deficiency?

Answer 28

fortification of maize and supplementation programme

Question 29

Problems with infant feeding practice in SA

Answer 29

1. Breastfeeding initiation rate is 88% but by 6 months EBF rate is dropped to 8 - 25%
2. More than 70% of infants are introduced to solids before 6 months of life

Question 30

Outline the PFBDGs

Answer 30

1. give only breast milk and no other foods or liquids to your baby for the first 6 months of life
2. from 6 months of age start giving your baby small amounts of complimentary foods while continuing breast feeding up to 2 years and beyond
3. responsive feeding: foster healthy dietary habits early in life
4. oral health and hygiene for children under 5 years of age
5. food hygiene and sanitation for children under 5 years of age

Question 31

Define a well nourished child

Answer 31

1. exclusively breastfed and intro ducted to solids at 6 months of age
2. parents ensure diet variety
3. taught portion control
4. reminded to eat (responsive feeding - 5 small meals)
5. food treats are kept for weekends
6. food is not used as a reward
7. adopted healthy habit of primary caregiver

Question 32

Commonly used methods to assess growth of infants and young children: discuss their advantages, limitations and methodologies

Answer 32

1. Weight
   - Advantages: most sensitive index of acute episodes of ill-health and malnutrition.
   - Limitations: non-specific, reflects composition of all body components.
   - Methodology: scales are regularly checked to ensure accuracy. Weight w/o nappy. Weekly until 2 months of age; monthly until 1 year of age and; and 2 monthly until school going age.
2. Length/height
   - Advantages: measures skeletal growth
   - Disadvantage: low sensitivity to acute nutritional insult
   - Methodology: supine position for children under 3 years, length taken at 3, 6, and 12 months, and 6 monthly thereafter. Standing assessment above 3 years of age.
3. Head circumference
   - Advantages: assessment of severe growth disorders and intracerebral pathology, indicates degree of obesity.
   - Limitations: no simple relationship between head growth and brain growth
   - Methodology: measure largest part of child’s head just above the ear. Around occipital prominence at back of head.

Question 33

Most dramatic period of growth in infants

Answer 33

from birth to 4 months of age