reminiscences from indian pediatrics: A
tale of 50 years |
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Indian Pediatr 2016;53: 905-906 |
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Growth, Nutritional
status and Anemia in Indian Adolescents
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Sharmila B Mukherjee
Department of Pediatrics, Lady Hardinge Medical
College & Associated Hospitals, New Delhi, India.
Email: [email protected]
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T he
35-paged October issue of Indian Pediatrics comprised of three
research papers current literature and news. The research paper being
discussed in this section was based on a study of the sociological,
anthropometric, hemato-logical and biochemical parameters of school-aged
children [1]. This visionary school-based study may have paved the way
for many a landmark research on Indian school children that followed in
the next fifty years.
The Past
This cross-sectional observational study to evaluate
the aforementioned parameters of 9- to 18-year-old school children (n=475)
of Calcutta was conducted by Chaudhari, et al. [1] in 1962.
Children born to Bengali Hindu (n=251) or Punjabi Sikh (n=224)
parents who during partition had migrated from East Bengal and West
Punjab, respectively, were recruited from schools. Their work-up
included measurement of weight and height, and estimation of hemoglobin
(Hb), packed cell volume (PCV), serum iron, iron binding capacity,
coefficient of iron saturation, serum proteins and serum copper.
Most Bengali Hindu fathers were salaried office
workers with a monthly per capita income of below Rs. 50 in 67% and
above Rs. 101 in 6%. Most (69.5%) Punjabi Sikh fathers were businessmen
with monthly per capita income of above Rs. 101 in 40% and below Rs. 50
in 28 %. The weight and height of Punjabi Sikh boys was significantly
higher than Bengali Hindu boys, but for girls it was not statistically
significant. The average Hb, PCV, total proteins and serum albumin were
significantly lower in Bengali Hindu boys and girls compared to their
Punjabi Sikh counterparts. Indicators of iron status and serum copper
levels were below normal in all children, especially in girls. The
authors concluded that these results were attributable to the more
nutritive diet of Punjabi Sikh children due to better socio-economic
circumstances.
Historical Background and past knowledge: Once it
was realized that growth monitoring could identify deviation from normal
and thus ill-health, the search for the ideal ‘reference’ of the same
age and sex started intensively. Various researchers started to develop
normative data worldwide. It was recognized that growth patterns changed
with time thus necessitating periodic updating of the data. The Iowa
charts were used in America in the forty’s and the Tanners charts in the
United Kingdom in the fifties. Harvard data (1930 – 56) became popular
globally in the sixties after being adapted by World Health Organization
(WHO) [2]. In 1977, National Centre for Health Statistics (NCHS) and
Centers for Disease Control (CDC) integrated data of three
cross-sectional NCHS surveys of 2-18 year olds (1960- 1975) with
longitudinal data of 0 -23 month olds from the Fels Research Institute
(1929 -75) [3]. The result was the creation of percentile-based graphs
(weight, height and head circumference) of children from birth till 18
years. In 2007, the WHO reconstructed the NCHS original reference data
of 5-19 year old children by applying state-of-art statistical methods
and merged it with the WHO MGRS under-five data [4].
On the national front, many Indian growth charts were
also being developed. The earliest charts were created by Indian Council
of Medical Research (ICMR) based on a nationwide cross sectional study
from 1956 to 1965 [5]. Agarwal, et al. [6] in collaboration with
Nutrition Foundation of India developed growth charts for children from
birth to 5 years based on data of affluent urban children from seven
Indian states between 1989 and 91 (N=2,664, 54.2% boys). During
the same period (1988-91), ICMR conducted a cross -sectional growth
study of affluent Indian children between 5 years to 17/ 18 years
(girls/ boys) from eight states (N=22,850) [7]. In 2007, the
Indian Academy of Pediatrics (IAP) published the first Growth Monitoring
Consensus Guidelines which recommended annual assessment of height,
weight and body mass index (BMI) in children between 9 to 18 years and
use of Agarwal charts.
In 2007, Khadilkar, et al [8] collected data
related to weight, height and BMI from children (age 5-18 y) of 11
schools in 5 geographical zones (N=18,666). At the same time
(2006-2009), Marwaha, et al. [9] were also conducting a cross
sectional study of 5-18 year old school going children of 19 cities in 4
zones. They used the data of the affluent children (N=64,629) to
create the growth curves. An increase in obesity was noted in both these
data sets.
The Present
In 2015, IAP decided to update the growth charts for
5–18 year olds [10]. This included children from 14 cities in 5
geographical zones (N=33991). Height, weight and BMI curves were
constructed with the same strategy used for the 2007 WHO curves. There
was a significant increase in all parameters for both genders when
compared with the previous IAP charts. The latest IAP guidelines
recommend the use of the 2006 WHO charts for children under the age of
five years, and revised 2015 IAP growth chart for older children [11].
Unfortunately, neither the National Family Health
Survey (NFHS) nor the ‘Children of India’ survey conducted by the
Ministry of Statistics and Program Implementation collects data related
to adolescent malnutrition; though the prevalence of anemia is
determined. Irrespective of the reference norm or classification system
used, one truth is starkly apparent. Anemia and malnutrition in children
above five years of age is highly and widely prevalent throughout India.
Thinness, underweight and stunting is more common in the lower
socioeconomic strata, overweight and obesity in the higher, and anemia
in both. The WHO and the Global Nutrition Report use country profile
indicators which signify when malnutrition is a significant public
health problem based on prevalence in under-five children and women
[12]. The only parameters that are used for older children are anemia,
overweight and obesity. Surprisingly the parameters of undernutrition
which is so prevalent in developing countries are not included.
Even today, many issues remain unresolved pertaining
to the growth and nutritional status of children between 5 to 18 years.
The ideal growth chart is yet to be developed. International policy
makers are yet to incorporate public health indicators specific for
undernutrition of this group. The NFHS data does not include assessment
of BMI in their national and state-wise surveys.
It cannot be disputed that several national and state
schemes are currently operational to reduce malnutrition in school- aged
children. However these have been functional since years and the
situation remains status quo. In any case, we as individuals can
definitely make a tangible difference by pledging to monitor the growth
of all children irrespective of age and however busy we may be, so that
those at risk can be identified early and appropriate intervention can
be started.
References
1. Chaudhuri S, Ghosh J, Tapaswi P. Anthropometric,
hematological and biochemical study of Indian school children of two
communities in Calcutta. Indian Pediatr. 1966;10:349-66.
2. Jelliffe DB. The assessment of the nutritional
status of the community. World Health Organization Monogr Se 53. Geneva,
WHO, 1966.
3. National Centre for Health Statistics. Growth
curves for children birth – 18 years. United States Vital and Health
statistics Ser 11 No 165, DHEW publ 78-1650. National Centre for Health
Statistics. Washington: Government Printing Office, 1977.
4. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida
C, Siekmann J. Development of a WHO growth reference for school-aged
children and adolescents. Bull World Health Organ. 2007;85:660-7.
5. Khadilkar VV, Khadilkar AV, Choudhury P, Agarwal
KN, Ugra D, Shah NK. IAP Growth Monitoring Guidelines for children from
birth to 18 years. Indian Pediatr. 2007;44: 187-97.
6. Agarwal DK, Agarwal KN. Physical growth in Indian
affluent children (Birth–6 years). Indian Pediatr. 1994;31:377-413.
7. Agarwal DK, Agarwal KN, Upadhyay SK, Mittal R,
Prakash R, Rai S. Physical and sexual growth pattern of affluent Indian
children from 5-18 years of age. Indian Pediatr. 1992;29:1203-82.
8. Khadilkar VV, Khadilkar AV, Cole TJ, Sayyad MG.
Cross-sectional growth curves for height, weight and body mass index for
affluent Indian children. Indian Pediatr. 2009;46:477-89.
9. Marwaha RK, Tandon N, Ganie MA, Kanwar R,
Shivaprasad C, Sabharwal A, et al. Nationwide reference data for
height, weight and body mass index of Indian school children. Natl Med J
India. 2011;24:269-77.
10. Khadilkar V, Yadav S, Agrawal KK, Tamboli S,
Banerjee M, Cherian A, et al. Revised IAP Growth Charts for
height, weight and body mass index for 5- to 18-year-old Indian
children. Indian Pediatr. 2015;52:47-55.
11. Khadilkar VV, Khadilkar AV. Revised Indian
Academy of Pediatrics 2015 Growth Charts for height, weight and body
mass index for 5–18-year-old Indian children. Indian J Endocr Metab.
2015;19:470-6.
12. World Health Organization. Nutrition Landscape
Information System Country Profile Indicators Interpretation guide.
Geneva:WHO, 2010.
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