New Delhi: India’s plan to introduce country-specific growth standards for children in order to gauge their nutritional status is likely to take several more years to become a reality, ThePrint has learnt.
Last year, following directions from the Union health ministry, the Indian Council of Medical Research (ICMR) had formed a panel to prepare India-specific growth standards amid concerns that the World Health Organisation’s (WHO’s) weight and height references, which are currently used, are not suitable in the Indian context.
But now, the Centre has decided that this committee will instead commission a local study of children aged 0-2 years to assess their growth patterns, government sources told ThePrint.
For kids older than two years, a cross-sectional study that will analyse population level data from communities is being planned.
The protocol and details for the study, however, are yet to be finalised, it is learnt. This could push the plan to introduce the local standards in the country by several years, at least two government officials familiar with the matter told ThePrint.
At an individual level, weight and height for children 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, these measurements which also include weight for height and body mass index (BMI) — apart from weight and height — form crucial parameters to gauge the nutritional status of children in surveys such as the National Family Health Survey (NFHS) and Comprehensive National Nutrition Survey (CNNS).
ThePrint reached ICMR Director General Dr Rajiv Bahl and NITI Aayog Member (Health) Dr V K Paul — who have led many meetings of the government-formed committee over the last several months — via calls. This report will be updated as and when they respond.
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What sparked debate to have India-specific standards
“The debate around using the WHO references started as evidence started emerging that genetic factors may not have been accounted for sufficiently in these universal growth standards,” said a member of the government-formed committee, who did not wish to be named.
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 be giving the actual scenario of the Indian situation, he further said.
“The need, therefore, was felt to determine the growth patterns of Indian children and develop our own standards. However, a consensus is now building to carry out a prospective study on examining the growth pattern of Indian children in the 0-2 age group,” the member added.
Another member of the panel, who requested anonymity, said that details related to the study — for instance, inclusion and exclusion criteria, determination of social, demographic and economic status for selecting children to be followed — are yet to be fleshed out.
“Since it’s going to be a prospective study, meaning a certain number of children to be born on a cut-off date will be followed up and the data will later be analysed, it might take a few years since the standards may be ready,” he added.
Issues with WHO references
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.
Substantial deviation from this growth standard is used to define three important indicators — stunting (low height for age), wasting (low weight for height), and underweight (low weight). These three indicators are most often used to assess the prevalence of different forms of undernutrition in a population.
They are used in international targets such as Sustainable Development Goals. India too uses these reference points in its POSHAN Abhiyaan and several other public health programmes since 2008, apart from calculating figures related to stunting, wasting and malnutrition.
But opponents of WHO MGRS standards, such as paediatrician and medical researcher Dr H. P. S. Sachdeva, who is also part of the ICMR committee, argue 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 did not take 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 told ThePrint.
Pune-based paediatrician and child growth researcher Dr Anuradha Khadilkar welcomed the decision to plan an Indian study for assessing the growth of children, especially for charting the growth of an individual child.
“Comparing Indian babies with WHO references puts an unnecessary burden on mothers and families, and in older children it raises the risk of unnecessary investigations which increases the cost of healthcare,” she told ThePrint.
Khadilkar, 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 last year.
Opposing viewpoint
But not all are in favour of the proposed exercise.
Dr Ramesh Kumar, a senior member of the Indian Academy of Paediatrics (IAP) — the largest network of child health specialists in the country — cautioned that a prospective study could be a laborious task that would need multiple layers of data validation over the next several years.
A ‘Review of WHO growth standards and their relevance for India’, commissioned by WHO India and only submitted last week, has also recommended that the “WHO-MGRS Child Growth Standards for height-for-age are appropriate for use in the Indian context”.
This MGRS study, the report has said, purposefully selected a very privileged population in India with no biological or environmental constraints on growth for the purpose of setting “growth standards”.
“There should be clarity that WHO-MGRS Growth Standards are only relevant at the population level,” the 71-page report, reviewed by ThePrint, further said.
It however adds that the WHO growth standards, when used for clinical purposes, may be supplemented with other references as recommended by professional medical associations.
(Edited by Gitanjali Das)
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