Once the mainstay of child health clinics in low- and middle-income countries (LMICs), a new Cochrane Review of growth monitoring and promotion (GMP) shows the evidence to support its use is limited and uncertain. The authors looked at GMP from all angles: to identify and address growth faltering, inadequate infant and child feeding practices, and to promote contact with and use of health services among children under 5 years of age in LMICs.
GMP is a complex intervention routinely used in LMIC settings, which involves measuring a child's growth at regular intervals, plotting the measurements on a chart, combined with different nutrition promotion activities. Liverpool School of Tropical Medicine (LSTM) lead and senior authors Melissa Taylor and Dr Helen Nabwera partnered with Janet Tapkigen, Tampere University (Finland), Isra Ali, Liverpool Heart and Chest Hospital (UK), Qin Liu, Chongqing Medical University (China), and Qian Long, Duke Kunshan University (China) to synthesise the evidence of the effectiveness of this intervention in LMICs for the promotion of key child health indicators.
Undernutrition remains a problem among children under five years of age who live in LMICs. The causes are multiple, but poverty and disempowerment of women are important underlying factors. This can lead to frequent illnesses, impaired brain development, and death. GMP seeks to identify those children with faltering growth and provide caregivers with support and nutrition counselling to address this early. However, there are no standard guidelines explaining how to implement GMP and the purpose and effectiveness of GMP as an approach to prevent undernutrition remains a subject of debate.
This new Cochrane Review aligns with the findings of the original Cochrane Review by Panpanich 1999, which concluded that there was insufficient evidence to support the use of growth monitoring. This new review searched the available evidence up to 3 November 2022, and included six studies conducted in resource‐poor rural settings with high levels of undernutrition in children. The studies varied in how they defined GMP, implemented GMP, and measured its impact. Due to this heterogeneity, it was not possible to assess the evidence in a pooled analysis, that is the gold standard. The authors therefore presented findings as a narrative review.
Three studies assessed the impact of a GMP programme delivered in community health centres and meeting spaces compared to standard care. Due to very low-certainty evidence, it is unclear whether GMP had any impact on infant and child feeding practices, or on health service usage (such as presenting for vaccinations or deworming medications). No studies in this group reported on child growth.
Two studies assessed the impact of a GMP programme delivered in community health centres and meeting spaces, providing extra food to children, compared to standard care. Based on very low- to low-certainty evidence, it is unclear if GMP made any difference to child weight for age and may make no difference to child height for age. It is also unclear if GMP makes any difference to infant and child feeding practices. No studies in this group reported on health service usage.
The review authors had serious concerns about the reliability of the reported results. All studies were judged as high risk of bias, mostly because participants were often aware to which study arm they had been assigned.
Senior author Dr Helen Nabwera added, “The lack of standardization in the reporting of the outcomes was particularly challenging. Ideally, if a framework for reporting could be developed and adopted, this would help to streamline the reporting process. To think that a lot of health care investment goes into GMP, in the context of limited evidence of whether it works or how best to implement it, is astonishing.”
This Cochrane Review shows that despite continued investment in GMP programmes globally, there is currently limited and uncertain evidence of their effectiveness. Further robust evaluation of this intervention is required.
- Taylor M, Tapkigen J, Ali I, Liu Q, Long Q, Nabwera H. The impact of growth monitoring and promotion on health indicators in children under five years of age in low‐ and middle‐income countries. Cochrane Database of Systematic Reviews 2023, Issue 10. Art. No.: CD014785. DOI: 10.1002/14651858.CD014785.pub2.
The editorial base of the Cochrane Infectious Diseases Group is funded by UK aid from the UK government for the benefit of low- and middle-income countries (project number 300342-104). The views expressed do not necessarily reflect the UK government’s official policies.