New Delhi: A mega exercise to develop India’s first growth and development standards for infants and toddlers has now been rolled out across six cities, representing all regions of the country. Part of the initiative Unnati, or Upgrading Norms for Growth and Development Assessment of Indian Children, the move is aimed at developing country-specific growth references to be used as parameters for healthy growth of kids aged 0-2 years.
The Union health ministry had asked the Indian Council of Medical Research (ICMR) in 2023 to conduct a country-specific study following recommendations by a government-constituted committee amid concerns that the World Health Organisation’s (WHO) weight and height references, which are currently used, are not suitable in the Indian context.
Government officials also tell ThePrint that some experts were of the opinion that using WHO standards may have led to an exaggeration of undernutrition and malnutrition status in Indian kids while also showing higher than actual numbers of wasted and stunted children.
The latest project by ICMR has been started in Delhi, Pune, Bengaluru, Indore, Shillong and Purulia as part of which 3,000 children—from reasonably affluent socio-economic backgrounds—will be enrolled and tracked over the next two years. “The idea is to assess the growth pattern of Indian babies under optimal biological, socioeconomic, and behavioral conditions,” a senior ICMR scientist associated with the project tells ThePrint, adding that sites for the exercise had been carefully chosen to represent various ethnicities and regions of the country.
As part of the project, adds the scientist, analysts will measure childhood growth and development, develop normative growth curves and neurodevelopmental charts for children born in an environment without major biological, socio-behavioral, and economic constraints to growth among Indian children 0-24 months of age.
“Given India’s distinct ‘thin-fat’ phenotype and regional growth variations, a nationally representative Indian growth reference study is essential for accurate growth assessment and informed health policies,” says another scientist attached with the project. Experts say that for individual kids, growth references that include weight and height are charted from birth by paediatricians and then expressed in percentiles to assess whether a child is growing well and achieving growth milestones in a timely manner.
At the population level on the other hand, these measurements which also include weight for height and body mass index (BMI)—apart from weight and height—that form crucial parameters to gauge the nutritional status of children in national surveys, explains Dr Manoj Kumar Das, principal investigator of the project in Shillong.
These surveys include the National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS).
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Tracking babies through infancy
Dr Samiran Bisai, principal investigator of the project in Purulia, says the survey has a strict inclusion criteria in the longitudinal study—that there is no constraint to growth and possibility to reflect the genetic potential.
As part of the exercise, a total of 3,000 pregnant women are being recruited following evaluation of sociodemographic data, maternal and paternal education levels and their height and weight, occupation, and family income, history of chronic illness and haemoglobin level in mothers.
Pregnancy complications, say analysts working on the project, were also a criterion for exclusion.
The next part of the study will track babies born to women selected for their weight, height, mid-upper arm circumference, head circumference and developmental assessments while also recording their morbidity, hospitalisation and immunization status, apart from breastfeeding and complementary feeding practices. The babies will also be measured for their body composition or fat mass and fat-free mass or muscle and bones.
“The idea is to analyse this comprehensive data from 3,000 kids in the country and use them to develop the first national growth and body composition reference charts for kids up to 2 years of age while also preparing growth velocity charts for specific age bands,” says Dr Das.
Later, the project can be extended to also develop such charts for boys and girls up to 18 years of age.
Controversy around international standards
According to those who have been part of the government-constituted panel on growth standards, the WHO references came under scanner after evidence started emerging that genetic factors may not have been accounted for sufficiently in these universal growth standards.
Based on WHO’s Child Growth Standards, the prevalence of stunting—impaired growth in children—in India at 35.5 percent according to NFHS-5 (2019-2021), for instance, is very high, which may not give the actual scenario of the Indian situation, pointed out a paediatrician-researcher who was a member of the committee.
In the late 1970s, the United States’ National Center for Health Statistics (NCHS) growth reference was adopted by the WHO for international comparisons of nutritional status across populations as well as for monitoring the growth of individual children.
However, over time, its adequacy as an international reference was challenged on the grounds that the sample of children were predominantly bottle-fed, contrary to breastfeeding recommendations of international agencies, and that they were of a restricted socio-economic and genetic background.
Following this, the WHO launched a Multicentre Growth Reference Study (MGRS) in 1997 which drew samples from six diverse sites: Brazil, Ghana, India, Norway, Oman and the US. The standards were finally drawn in 2006, following the population level study between 1997 and 2003, and have since been considered a universal standard for healthy height and weight in children.
But, points out Dr Das, these standards are now over two decades old and the country felt the need to develop a reference point that can be true to its circumstances. But those who criticise WHO MGRS standards, such as paediatrician and medical researcher Dr H.P.S. Sachdeva, who was also part of the government-appointed panel, have been arguing that the study sample for India included children from affluent families in South Delhi and cannot be seen as a representative sample for the whole country.
“This study also had not taken into account the fact that haemoglobin levels, gestational restrictions and zinc serum in Indian women also play a key role in determining the height and weight of kids,” he had underlined while talking to ThePrint earlier.
Some Indian pediatricians, along with researchers from Harvard University, had co-authored a paper titled ‘Should India adopt a country-specific growth reference to measure undernutrition among its children?’, which was published in The Lancet in 2023. This paper argued that one advantage of having a universal standard is the ability to compare populations and to establish the maximum growth potential of children.
However, when developing policy and program interventions on undernutrition, it is necessary to consider the specific context of the population, especially for height-based measures, which have a substantial intergenerational component, researchers had underlined.
They also insisted that it is not uncommon for countries to use their own growth reference. For example, the US uses the Centers for Disease Control and Prevention (CDC) 2000 growth reference chart for charting growth of children in the country.
(Edited by Amrtansh Arora)