Weighing of young children is an activity that goes on in clinics throughout the developed world and less privileged countries. In the latter, it is considered important as a step to prevent or identify early under nutrition which in some areas is almost universal and plays a major part in infant and child mortality. In the 60's, the author designed a home-based weight chart which with some variation was adopted by WHO, UNICEF and governments worldwide. Weighing and the plotting of weight for the age curve became known as Growth Monitoring (GM). In using these weight charts the health worker is expected to read off a weight, usually from a dial scale, and insert this as the next entry on the weight for age growth chart.
Almost all doctors and politicians assume that this graphic representation of the child's weight, increasing with age can be created by health workers and be understood and interpreted by them and the mothers. This is not so. For years, just like the ‘Emperor's Clothes’, failure has been accepted as due to a lack of instruction in the use of charts. Weight for age graphs are rarely created and even where created their meaning is not understood nor are decisions taken from variations in the growth curve. To discover the reason for this, we must have discussions with colleagues responsible for primary and secondary education. Piaget (1896-1980) suggested that the graphic representation of number is difficult and is best taught at the primary school age. Few primary schools in less privileged countries teach the graphic representation of number. A colleague teaching in a secondary school told me it took a term to teach her students to grasp the concept of graphs.
Should growth monitoring then be abandoned? Certainly it cannot be justified unless decisions on the health of the child are taken from a source other than the weight for age growth curve. The Alma Ata conference in 1978 defined primary health care as: “Essential health care made universally accessible to individuals and acceptable to them through their full participation at a cost that the community and country can afford”.
Research suggests that if the weighing of children is undertaken by their own mothers using a simple, low cost, easily understood Direct Recording Scale1 things can change. This scale has no needle moving against numbers but a large spring which the mother sees stretching up her child's chart as she, in her own home, lowers her child into the trousers below the scale. She then inserts the next point on the weight for age curve. Such an indestructible scale used in their home by a group mothers leads them to an understanding of the meaning of the growth curve and enable them to take action when faltering occurs2. If resources are limited, the scale can be made locally in wood using an imported spring. Its cost is low3 and leaves the health workers time required for other activities by saving them the time spent weighing babies at the clinic.
This is not to suggest that the Direct Recording Scale is the only answer. It needs much more research, but it may be the direction in which research in GM should move. This weighing scale will enable the family and community health worker to recognise changes in the child's growth and if their resources allow take appropriate action.
1. Morley D, Nickson P, Brown R. TALC Direct Recording Scale Lancet. 1991;338:1600
2. Meegan M, Morley D. Growth monitoring family participation: effective community development Tropical Doctor. 1999;29:23–27
3. . Teaching Aids at Low Cost (TALC) will provide more information and is a source for the Direct Recording Scale. POB.49. St. Albans. AL1 5TX. UK [email protected]http://wwwtalcuk.org
*Professor David Morley is a world figure and authority on tropical child health. He devoted himself to promoting health of children in the ‘developing world’. His famous book ‘Paediatric Priorities in the Developing World’ was described in one of the British Paediatric Association meetings as the “most important book ever written in medicine in the 20th century.” Professor Morley was the winner of the first King Faisal International Prize in Medicine in the early 80's. His students – many of them now decision makers and university teachers – are found all over the developing world. The Editor of this journal is one such.
Professor Morley has had a lifelong interest and concern for the growth of children in the ‘third world’. He designed the growth chart (Road-to-Health chart) in the 60's. He is indeed the ‘father of growth monitoring’. He continually researched and tried to improve growth monitoring. He has always been keen on the use of appropriate, affordable and cost-effective technology. This led him to invent the Direct Recording Scale for growth monitoring. Professor Morley has always preached the bridging of the current gap between available life saving technology and its use where it is desperately needed. He has always called for a social breakthrough to institute the scientific breakthroughs in health institutions and homes of the people.
Over the past few years, he, and upon assessing results of collaborative research, he seems to be convinced that growth monitoring is proving cost-ineffective. The reasons for this he summarized in this special communication. However, on answering whether growth monitoring should be abandoned, Prof. Morley is suggesting restricting its use to situations where decisions on the child's health are taken from the weight-for-age growth curve. Hopefully this communication would stimulate further research and discussion of the subject.
Professor Hassan Bella