Pilot Testing of WHO Child Growth Standards: India Perspectives

  • Jarnail Singh Thakur
  • Shankar Prinja


More than 80% of undernourished children are located in 20 countries of the world, with India being home to more than half of the world’s underweight children. Nutritional programs and growth monitoring are justified on various arguments emerging from economics, social welfare and human rights approach. India’s Integrated Child Development Services (ICDS) program is a holistic program directed at overall child development including nutritional status by monitoring growth of children through active involvement of mothers. ICDS program uses an Indian Association of Pediatrics (IAP) classification based on Harvard standards to monitor growth of children under 5 years age.

Recently, in 2006, World Health Organization introduced new growth standards based on the Multicentre Growth Reference Study (MGRS). Government of India endorsed the new WHO growth standards for a phased introduction in India’s health and nutritional programs for monitoring child growth. We piloted the use of WHO growth standards in ICDS program in Chandigarh, India. The present chapter discusses the drawbacks of the old growth standards and provides justification for introduction of new WHO growth standards. We present the results of a study where we compared underweight prevalence among children under 5 years using the WHO growth standards and the IAP classification (using Harvard growth charts).

Our study shows that the prevalence of underweight (Z score less than –2) in the first 6 months of life was nearly 1.6 times higher when calculated in accordance with the new WHO standards rather than IAP growth curves. For all ages combined, the estimated prevalence of underweight was 1.4 times higher when IAP standards instead of the new WHO standards were used. Similarly, the prevalence of underweight in both sexes combined was 14.5% higher when IAP standards rather than the new WHO growth standards were applied (P < 0.001). In contrast, severe malnutrition estimated for both sexes was 3.8 times higher when the new WHO standards were used in place of IAP standards (P < 0.001).

The new WHO growth standards will project a lower prevalence of overall underweight children and provide superior growth tracking than do IAP standards, especially in the first 6 months of life and among severely malnourished children. This chapter concludes by highlighting that the use of growth monitoring can be successful only with concurrent active participation of the mothers of children. Programmatic efforts should focus on building the capacity of mothers in monitoring growth of children for improvement in health and nutritional status.


World Health Organization Growth Standard Urban Slum Growth Monitoring National Family Health Survey 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



Body mass index


Confidence interval


District Level Household Survey


Indian Association of Pediatrics


Indian Association of Preventive and Social Medicine


Integrated Child Development Services


International Institute of Population Sciences


Indian Public Health Association


Multicentre Growth Reference Study


National Center for Health Statistics


Standard deviation


World Health Organization


  1. Agarwal K, Agarwal D, Agarwal A, Rai S, Prasad R, Agarwal S. Impact of Integrated Child Development Services (ICDS) on maternal nutrition & birth weight in rural Varanasi. Indian J Pediatr. 2000;37:1321–27.Google Scholar
  2. Arnold F, Choe M, Roy T. Working papers, population series no. 85. Son preference, the family-building process and child mortality in India. Hawaii: East-West Center; 1996.Google Scholar
  3. Bhagwati J, Fogel R, Frey B, Yifu-Lin J, North D, Schelling T. Ranking the opportunities. In: Lomborg B, editor. Global crises, global solutions. Cambridge, UK: Cambridge University Press; 2004.Google Scholar
  4. Bhasin S, Bhatia V, Kumar P, Aggarwal O. Long term nutritional effects of ICDS. Ind J Pediatr. 2001;63:211–6.CrossRefGoogle Scholar
  5. Bhutta ZA, Ahmed T, Black RE, Cousens S, Dewey K, Giugliani E, Haider BA, Kirkwood B, Morris SS, Sachdev HP, Shekar M. What works? Interventions for maternal and child undernutrition and survival. Lancet. 2008;371:417–40.PubMedCrossRefGoogle Scholar
  6. Bryce J, Coitinho D, Darnton-Hill I, Pelletier D, Pinstrup-Andersen P. Maternal and child undernutrition: effective action at national level. Lancet. 2008;371:510–26.PubMedCrossRefGoogle Scholar
  7. de Onis M, Blossner M, Borghi E, Frongillo EA, Morris R. Estimates of global prevalence of childhood underweight in 1990 and 2015. JAMA. 2004a;291:2600–6.PubMedCrossRefGoogle Scholar
  8. de Onis M, Blossner M, Borghi E, Morris R, Frongillo EA. Methodology for estimating regional and global trends of child malnutrition. Int J Epidemiol. 2004b;33:1260–70.PubMedCrossRefGoogle Scholar
  9. de Onis M, Garza C, Onyango A, Martorell R. WHO child growth standards. Acta Paediatr Suppl. 2006a;450:1–101.Google Scholar
  10. de Onis M, Onyango A, Borghi E, Garza C, Yang H. Comparision of WHO child growth standards and National Centre for Health Statistics/WHO international growth standards: implication for child health programs. Public Health Nutr. 2006b;9:942–7.PubMedGoogle Scholar
  11. Garza C, de Onis M. Group for the Multicentre Growth Reference Study. Rationale for developing a new international growth reference. Food Nutr Bull. 2004;25:S5–14.PubMedGoogle Scholar
  12. Ghosh S. Integrated child development services programme – need for reappraisal. Indian J Pediatr. 1997;34:911–8.Google Scholar
  13. Gopalan C. “Small is healthy?” For the poor, not for the rich! NFI Bull. 1983;4.Google Scholar
  14. Gopalan C. Growth standards for Indian Children. In: Gopalan C, Kaur H, editors. Towards better nutrition: problems and policies. New Delhi: Nutrition Foundation of India; 1993.Google Scholar
  15. Horton R. Maternal and child undernutrition: an urgent opportunity. Lancet. 2008;371:179.PubMedCrossRefGoogle Scholar
  16. IIPS. Mumbai: National Family Health Survey 1, International Institute of Population Sciences and ORC Macro Mumbai; 1993.Google Scholar
  17. IIPS. Mumbai: National Family Health Survey 2, International Institute of Population Sciences and ORC Macro Mumbai; 1998.Google Scholar
  18. IIPS. Mumbai: National Family Health Survey 3, International Institute of Population Studies and ORC Macro Mumbai; 2006.Google Scholar
  19. Kapil U, Pradhan R. Integrated Child Development Services Scheme (ICDS) and its impact on nutritional status of children in India and recent initiatics. Indian J Public Health. 1999;43:21–5.PubMedGoogle Scholar
  20. Lal S. Towards universalization of Integrated Child Development Services (ICDS). Indian J Community Med. 2003;28:147–52.Google Scholar
  21. Ministry of Health & Family Welfare, G. o. I. National workshop on adoption of new WHO child growth standards. New Delhi: MOH&FW, UNICEF, WHO; February 8–9, 2007.Google Scholar
  22. Pacey A, Payne P. (1985). Agricultural Development and Nutrition. London: Hutchinson, 255p.Google Scholar
  23. Prinja S, Verma R, Lal S. Role of ICDS program in delivery of nutritional services and functional integration between anganwadi and health worker in north India. Internet J Nutr Wellness. 2008;5.Google Scholar
  24. Prinja S, Thakur JS, Bhatia SS. Pilot testing of WHO child growth standards in Chandigarh: implications for India’s child health programmes. Bull World Health Organ. 2009;87:116–22.PubMedCrossRefGoogle Scholar
  25. Ramachandran P. Adoption of WHO Child Growth Standards (2006) – issues and implications. NFI Bulletin. 2007;28:1–6.Google Scholar
  26. Saiyed F, Seshadri S. Impact of the integrated package nutrition & health services. Indian J Pediatr. 2000;67:322–8.PubMedCrossRefGoogle Scholar
  27. Seckler D. Small is healthy: a basic hypothesis in the theory, measurement and policies of malnutrition. In: Sukhatme P, editor. Newer concepts in nutrition and their implications for economic policy. Pune: Maharashtra Association for Cultivation of Science; 1985;127–37.Google Scholar
  28. Swami H, Thakur J, Bhatia S, Singh K, Bhan V, Bhatia V. National immunization day to assess nutritional status of underfives in Chandigarh. Indian J Pediatr. 2000;67:15–7.PubMedCrossRefGoogle Scholar
  29. Swami H, Thakur J, Bhatia S, Bhatia V. Nutritional status of preschool children in an integrated child development services (ICDS) block in Chandigarh. JIMA. 2001;99:554–6.PubMedGoogle Scholar
  30. Trivedi S, Chhaparwal B, Thore S. Utilization of ICDS scheme in children of one to six years of age in a rural block of central India. Indian J Pediatr. 1995;32:47–50.Google Scholar
  31. WHO. Global database on iodine deficiency disorders: India. (2004). Accessed 12 Apr 2008.

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  1. 1.School of Public HealthPost Graduate Institute of Medical Education and ResearchChandigarhIndia

Personalised recommendations