New Delhi: Last month, the Indian Council of Medical Research (ICMR) — India’s apex medical research body — called for expressions of interest to carry out a multi-centric research project to devise India’s first country-specific child growth reference standard.
Routinely used by paediatricians to evaluate a child’s growth vis-a-vis their age, growth reference standards include weight, height, weight for height, and body mass index. These measurements are also taken into account in surveys and medical studies — including the ones conducted by governments — to gauge the parameters associated with child malnutrition, such as stunting and wasting.
The ICMR’s exercise is being conducted amid concerns that the standards India uses currently — from the World Health Organization-Multicentre Growth Reference Study (WHO-MGRS) — are inaccurate in the Indian context. Used in India since 2006, the WHO-MGRS was based on a detailed analysis conducted between 1997 and 2003 and was arrived at by pooling growth data from six countries — the US, Oman, Ghana, Brazil, Norway, and India.
Last year, following directions from the Union health ministry, the ICMR had formed a panel to prepare India-specific growth standards.
In its call for expressions of interest, ICMR has said that while India was one of the six participating sites for the WHO-MGRS study, the students enrolled in that study were from South Delhi.
“However, considering likely regional variations in growth potential, a growth reference representing urban and rural children from different regions of the country is desirable,” the ICMR has said in its invitation for expression of interest.
ThePrint tried to reach ICMR director-general Dr Rajiv Bahl for his comments through phone calls. This report will be updated if and when a response is received.
But Dr. H.P.S.Sachdev, a senior pediatrician and researcher who is a member of the committee constituted last year, said that the panel felt that carrying out a prospective study would be “the best way forward”.
Here’s everything you need to know about this exercise — what the ICMR intends to do with this study and why it’s necessary in the Indian context.
Need to develop Indian growth charts
It has been increasingly felt that the infants’ birth weight and length at birth, caloric intake, and parents’ heights are important determinants of their growth patterns, an ICMR scientist who did not wish to be named told ThePrint.
“But there is also an understanding that under the WHO-MGRS, genetic factors may not have been accounted for sufficiently in developing universal growth standards,” the scientist said.
Paediatricians like Dr. Gurleen Sikka, who is associated with Delhi’s C.K.Birla Hospital, believe that ethnicity plays a role in how children grow. As a result, India’s diverse population and factors like socio-economic disparities necessitate exploring India-specific growth references, she said.
“Applying global standards might misjudge child health, leading to inaccurate diagnoses and interventions,” Sikka said, adding that tailoring references to local contexts could improve child health monitoring and interventions, ensuring optimal growth for all Indian children.
According to the ICMR’s call for proposals, the Indian children enrolled in the WHO-MGRS study were from urban areas of South Delhi. “This cohort of children from well-off socio-economic backgrounds definitely cannot be representative for the whole of India,” the ICMR scientist quoted above said.
In a paper published in The Lancet last year, researchers from India and the US analysed the fifth round of the National Family Health Survey (2019–21) for measurements of age, height, and weight for 211,164 children between ages 0 and 59 months. They then estimated the prevalence of stunting, wasting, and being underweight in India using a published country-specific growth chart.
Called Indian Urban Middle Class (IUMC), this chart was based on a sample of children from urban middle and upper-middle class households from the five geographically dispersed zones (North, South, East, West, Central),
Using the IUMC reference, The Lancet paper found that stunting prevalence for India was 24 percent and wasting was 9 percent. This was against 33 percent and 19 percent prevalence according to the MGRS-based reference.
However, the paper also found the prevalence of underweight children to be 29 percent, whether using the IUMC or MGRS reference.
“India should engage in an informed and transparent discussion on whether to solely rely on MGRS-based prevalence or consider an India-specific reference, especially for setting national targets for reducing stunting and wasting,” the paper had said.
Another paper published by Sachdeva in 2018 said that only 5-10 percent of Indian children fulfil the WHO-MGRS parameters on nutrition.
What will the ICMR study entail
According to the ICMR, the study will be a multi-centre research initiative consisting of two observational studies conducted in rural and urban areas from six regions in the country.
The first will be a longitudinal one — one that follows particular individuals over a prolonged period. This will be initiated from early pregnancy until delivery and will also include periodic follow-ups of the newborn up to two-three years of age, the ICMR’s call for interest document shows.
As part of this, pregnant women before 20 weeks of gestation will be enrolled, the document says. “These will be ‘healthy’ women, according to predefined criteria, to be finalised during protocol development, with accurate pregnancy dating done by ultrasonography and willing to comply with study requirements needed to ensure ‘no constraints to growth’ environment,” the document says.
The second one will be a cross-sectional study — where data is collected from many different individuals at a single point in time — for all age brackets starting at 2-3 years of age up to 19 years.
Under this, participants will be selected “based on predefined criteria to ensure that they had ‘no constraints’ to their growth and functional or development outcomes and are not at risk of any discernible metabolic disorders”, the document says.
The setting for the research project will include households or schools in urban and rural areas “where the children and adolescents are likely to experience an environment conducive to growth and development without known social, educational, and economic constraints”, it adds.
Sources in the ICMR told ThePrint that some panel members had proposed using growth standards with criteria broadly similar to the WHO reference in the interim until the prospective study results become available.
However, an ICMR official said that the project of devising a new standard could take at least four years and that in the meantime, the WHO-MGRS reference will continue to be used.
(Edited by Uttara Ramaswamy)