Original Articles

PHYSICAL GROWTH IN INDIAN AFFLUENT CHILDREN (BIRTH - 6 YEARS)

D.K. Agarwal K.N. Agarwal

ABSTRACT

Growth characteristics, viz., height, weight and circumferences of head, chest and mid-arm were pleasured on urban affluent children from seven centres (Bangalore, Calcutta, Delhi, Kota, Ludhi-ana and Varanasi—Nutrition Foundation of India study). On each age and sex point there were 200 observations except at 18 and 72 months. The percentiles on pooled data were calculated by smoothed cubic spline least square method. This pooled data showed values lower than European and NCHS (American) standards. Centrewise comparison showed that Ludhiana children ap-proached the latter. The differences in growth seem to be possibly due to lower velocity in Indian children of present study in the first 18 months as compared to American children.

Keywords: Affluent, Growth, Preschool, Percentiles, Velocity.

From the Department of Pediatrics, Institute of Medical Sciences, BHU, Varanasi.

Reprint requests: Prof. (Mrs) D.K Agarwal, New E/10, Jodhpur Colony, BIIU, Varanasi 221 005.

Received for publication: July 21, 1993; Accepted: October 26, 1993

The WHO(l) has recognized the need for a growth chart which could be used internationally particularly by primary health care workers. Reference values for these charts examined by the WHO group were derived from data collected in Mexico, Netherlands, Sweden, Switzerland, UK and USA(2-5), in consultation with experts from various parts of the world and field-tested in 10 centres of different countries in 1974. It was later decided that the WHO chart should be based on data from the United States National Child Health Examination Survey(6) because they better fitted the criteria required. When devising these charts for international use, the WHO group re-cognized that countries or regions might eventually develop local standards, but the reference values presented by WHO(l) should be effective in the interim.

The objective of the present study was to investigate the growth performance of Indian children below six years of age, not subject to any obvious socio-economic con-straints that could be expected to impair growth, only children (below six years) belonging to the affluent population seg-ments (urban) in these cities were selected. The study was carried out in seven different cities of India: Bangalore, Bombay, Calcut-ta, Delhi, Kota, Ludhiana, and Varanasi.

Material and Methods

The study was carried out for two years (1985-1987) as two different cohorts. Co-hort-I consisted of infants from birth to one year and Cohort-II included children from -one to six years of age. The mixed longi-tudinal study design was adopted and the data were analysed on the basis of this format.

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The two cohorts were simultaneously selected. Cohort-I included infants at birth + 15 days up to three months of age and followed at three monthly intervals till their first birthday. Cohort-II was of children from 12 to 72 months of age. Children could enter in the study at any time but the anthropometric readings of each child were recorded at fixed age points, i.e., 12,18, 24, 30, 36, 42, 48, 54, 60, 66 and 72 months. Four hundred eighteen boys and 332 girls were thus included in Cohort-I. while 1011 boys and 874 girls were subjects for Cohort -II. The registration for both cohorts was contained for one full year and those chil-dren who had minimum of three follow ups at three consecutive time points alone were included for data analysis.

In Table I a consolidated statement indicating the number and percentage dis-tribution of children from various centres of both cohorts has been presented. The distribution of registered children and num- ber of observations at different age points is given in Table II.

Affluence in each family was identified by the income level, life style (as directly observed by the investigators), educational status, occupational status and awareness of basic principles of health, personal hy-giene, sanitation and child rearing on the part of parents.

For the selection of subjects of Cohort-I, cooperation from Pediatricians and Obstetricians of leading nursing homes and private hospitals was obtained so that chil-dren born in these hospitals could be re-cruited for the study. Similarly, children for Cohort-II were taken from nurseries and private schools or private clinics.

Date of Birth: The exact date of birth of each subject was confirmed and verified

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from parents and from birth certificates. In case of doubt regarding the exact age, the child was excluded from the study.

Anthropometric Measurements: Weight, height/length, mid-arm circumference, head circumference and chest circumference measurements were taken for each subject (in both the cohorts) in the study(7,8). The investigators were centrally trained and tools used were calibrated periodically.

Data Analysis: After combining the data for two cohorts from seven centres, we have analysed for percentiles (3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th and 97th) at different age points according to sex for five para-meters, viz., weight, height and circumfer-ences of head, chest and midarm using cubic spline method(9).

Estimation of Norms at Specified Ages: The estimate of norms or population mean values and their standard errors at specified ages for growth parameters were obtained from the mixed longitudinal series of observations(10,ll).

Velocity: Since the percentile curves show only growth from one age point to another, therefore to estimate the rate of growth velocities were calculated. It was calculated by simply taking increment between birth to six months, 3 months to 9 months and so on. This was done for each child sepa-rately and for all the 5 parameters. After calculating the velocity at two age intervals, the velocity percentiles were also calculated for each age interval.

Pooling of Data

Height: Before pooling data from six centres, Bangalore, Calcutta, Delhi, Kota, Ludhiana and Varanasi, the variation was calculated from the 50th percentile of pooled data which is under 3% for all the study

AGARWAL & AGARWAL GROWTH IN AFFLUENT PRESCHOOLERS

The observed velocity percentile for boys and girls at different ages for 6 monthly intervals are presented in Tables VIII and IX. It appears that increments are higher in the early age period (first 12 months) and progressive deceleration was observed upto 6 years of age. The boys had marginally better gains than the girls. The total gain (50th percentile) in length/height (cm) from birth to 72 months was 63.2 and 62.8 cm for boys and girls, respectively.

Weight

The weight percentile data are presented in Table X and XL Boys have marginally

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higher weight by around 0.3 kg at all age points except for birth weight.

The weight means with standard error (SE) for age and sex for different centres are given in Tables XII and XIII. The means were similar for Bangalore, Calcutta, Delhi and Varanasi for girls as well as boys. The Ludhiana means were significantly higher for girls as compared to other centres.

The weight velocity at 6 monthly interval in percentiles is given in Table XIV and XV for boys and girls, respectively. The total gain (50th percentile) in weight (kg) from birth to 72 months of age for boys and girls

centres are also given in Tables XXII and XXIII. Ludhiana children show more gain and remain higher as compared to other centres. Chest overtook head circumference by 11.4 and 12.0 months in boys and girls, respectively. The earliest take over was observed in Delhi children by 9.24 and 9.85 months for boys and girls, respectively (Table XXII). At all age points upto 66 months the 50th percentile values for chest circumference were higher in boys as com-pared to girls, except for the value at 72 months where both boys and girls had sim-ilar 50th percentile value. The increments for chest circumference in case of boys were higher, upto 36 months of age; thereafter, the girls had marginally higher increments.

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The total gain (median) in chest circumfer-ence from birth to 72 months of age for boys and girls was 23.3 and 23.0 cm, respec-tively.

Midarm Circumference

The percentiles are presented in Tables XXV and XXVI for boys and girls. The 50th centile values for boys and girls were sim-ilar; only marginal difference was noted at 3rd and 97th centiles. The means with SE for various centres are presented in Tables XXVII and XXVIII. The means were higher for Ludhiana as compared to other centres.

In velocity, the maximum increment appeared to be in the first 9 months of life which was marginally higher for boys than

girls. Thereafter, the increments were small and similar upto 66 months of age (Tables XXIX and XXX).

Discussion

Habicht et al. (12) stated that there are small differences 3% for height and 6% for weight in different ethnic groups with similar socio-economic status. In contrast, the varying socio-economic status can have higher difference (12% for height and 30% for weight). Therefore, these workers re-commended that both genetic and ecologic background as well as their mutual inter-action be taken into account in the con-struction of growth references. Similarly,

Goldstein and Tanner(13), Tanner(14) have argued for local standards, which need to be updated from time to time to account for changing socio-economic level. The use of western standards set unattainable goal and overestimate degree of under nutrition among children. The same could be avoid-. ed by using local attainable as standards(15-19). Vanloon et al.(20) working in 4 different geographical areas showed that growth curves had heterogeneity as well as the values had varying differences as compared to the NCHS standard for individual age points. Presently in India, growth charts/ road to health cards/child health card/ weight for age charts in practice are

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basically derived from the growth charts designed showing upper line NCHS 50th centile of weight for boys, the lower line being 3rd centile for girls.

The present study meets the WHO cri-teria of selecting well nourished popula-tion, based on well defined sampling crite-ria in seven centres to cover various parts of the country. The anthropometric scales were similar and the staff was trained at Varanasi (coordinating centre). The differ-ence has come up in the sample design, the present study is on cross linked design based on the method suggested by Rao and Rao(21). Thus, a well-nourished selected child nearing its birthday or its portion (3rd

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or 6th months) has been measured three times in a period of two years of study. This is an contrast to the selection of 200 children cross-sectionally for each age and sex point. However, as far as possible only one child has been selected from a family unit. In the present study, comparison of height data for individual centre and for combined pooled data of all the centres, the 50th centile at any age point showed a maximum of 3% variation. Thus, one is justified in presenting the growth percentiles for the data by pooling the observations from different regions of the country.

In view of the variation as compared to the NGHS and Europeans but proximity to

Asians, it would be more appropriate to use the Indian growth data as reference instead of the NCHS standard(22). This suggestion is further strengthened by the data collected for 6 monthly increments (the height velocity). As the velocity (increment) rate was lower during the study age period as compared to the increments reported-for American children by Baumgartner(23). In contrast, it can be argued that the differences observed particularly in case of Ludhi-ana (approaching close to the NCHS and other centres having significantly lower values) may indicate: (a) regional differences, (b) population having secular trend; and (c) changing social inputs.

The recent data from European coun-tries show that boys in Netherlands, Den-

mark and Norway are taller than NCHS by around 2!7 cm at 72 months of age. The present Indian data remain lower by 2.5 cm at this age point as compared to NCHS. The height means for Indian, Hongkong and Thailand children are very similar but lower than the means observed for Chinese by 1.0 cm. The Japanese boy is shorter by 0.7 cm as compared to Indian and other Asians (Table XXXI).

The girls in Netherlands and Denmark are taller by 3.7 and 2.6 cm, respectively as compared to those from Spain and NCHS data. Indian girls are short by 1.0 cm at 72 mo of age; however remained close to NCHS during birth to 9 mo and 30 to 36 mo. The Chinese girls are taller by 1.0-1.5 cm but Japanese are short by 1.0 cm as compared

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to the Indians (Table XXXI).

The 50th weight centiie for boys upto 6 mo approached around 30-40th centiie and between 20-30th centiie for age 9-72 mo as compared to NCHS standards. For girls, the 50th centiie of the present study is near 40-50th centiie upto 6 mo and thereafter between 30-40th centiie of NCHS standards. The European boys and girls from Norway, Poland, Netherland, Denmark and Italy weigh significantly higher than those in NCHS data. Similar weight means are observed for Asian boys and girls. Indians are lighter by 1.5 kg and 0.6-0.9 kg for boys and girls, respectively as compared to the NCHS data (Table XXXII).

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The comparative data for head and chest circumferences in Table XXXIII show that both parameters are smaller, in Indian children.

The velocity for weight and head cir-cumference as in case of height in early years was lower in Indian children of the present study as compared to the American counterparts(23). The mid-arm circumference values are lower than those for European counterparts (Table XXXIV). The height and weight data from Ludhi-ana, Delhi, Calcutta and Varanasi show that growth potential level observed in the present study continues in later life (6-18

yr of age)(36). Thus, it could be said that growth level attainable in India be used on pooled data or on regional basis to avoid overestimates of undernutrition. The need for continuous efforts to collect data for growth parameters on longitudinal (in adolescence) or cross sectional basis in a nation wide approach will ultimately pro-vide an assessment measure for optimal growth potential.

Acknowledgements

We are grateful to Dr. C. Gopalan, Chairman Nutrition Foundation of India, New Delhi, for valuable guidance and finan-cial support.

We are also indebted to Sv. Shri Raj Seth, Laxmi Kant, U.D. Sharma, and Ms Preeta Agarwal from the Computer Sci-ence Section and NNMB Unit for help.

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* Means estimated at the specified ages using observations made at that age as well as all previous ages and at the immediately succeeding age.

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