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Year : 2019  |  Volume : 10  |  Issue : 3  |  Page : 137-142

Assessment of growth and development in toddlers: A mixed method approach for developmental surveillance and screening by a healthy baby contest in an urban resettlement colony of Delhi, India

1 Department of Community Medicine, Lady Hardinge Medical College, Delhi, India
2 John Snow India Pvt. Ltd., Delhi, India

Date of Submission16-Apr-2019
Date of Decision29-May-2019
Date of Acceptance29-Jun-2019
Date of Web Publication22-Jul-2019

Correspondence Address:
Dr. Anita Shankar Acharya
Department of Community Medicine, Lady Hardinge Medical College, Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/INJMS.INJMS_40_19

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Introduction: Under-five mortality is still a major concern in India, and we are very far from reaching Millennium Development Goal 4, i.e., reducing child mortality. Various key interventions have been developed to reduce child mortality which needs to be implemented in an integrated manner by our health-care workers. Sole focus of our physicians at primary health-care centers is either clinical management of the child or immunization. In this study, for the overall assessment of the child, a comprehensive healthy baby scorecard has been designed to objectively assess the overall health status of the child and factors affecting it. Methodology: The study was a pilot study designed as healthy baby show contest at an urban health center (UHC) in a resettlement colony of east Delhi. A total of 36 mother–child pairs (children were in the age group of 0–3 years) were enrolled at the UHC for the comprehensive assessment of the child using healthy baby scorecard. Weightage was given to growth which was assessed by three criteria: weight for age, length/height for age, and weight for length/height. In-depth interviews of mothers were conducted to assess their understanding about child development. Results: Overall, 61.1% (n = 22) of participants showed satisfactory nutritional status. Of 14 children with poor nutritional status, 50% of mothers perceived their child to be healthy. Exclusive breastfeeding was present in only 10% of the participants. Correct knowledge about child's normal development was present in 17%–30% of the mothers for various aspects of child rearing. Conclusion: Healthy baby show conducted revealed that child-rearing practices were not conducive for the child's normal development and growth. The main factors are poor knowledge of mother in the concept of child development and child-rearing practices besides other factors such as social and cultural.

Keywords: Development, growth, healthy baby contest, screening, toddlers

How to cite this article:
Acharya AS, Tiwari N, Thakur A, Rasania SK, Bachani D, Khandekar J. Assessment of growth and development in toddlers: A mixed method approach for developmental surveillance and screening by a healthy baby contest in an urban resettlement colony of Delhi, India. Indian J Med Spec 2019;10:137-42

How to cite this URL:
Acharya AS, Tiwari N, Thakur A, Rasania SK, Bachani D, Khandekar J. Assessment of growth and development in toddlers: A mixed method approach for developmental surveillance and screening by a healthy baby contest in an urban resettlement colony of Delhi, India. Indian J Med Spec [serial online] 2019 [cited 2023 Jun 7];10:137-42. Available from: http://www.ijms.in/text.asp?2019/10/3/137/264531

  Introduction Top

Children represent the future and ensuring their healthy growth and development ought to be a prime concern of all societies.[1] However, currently, world is facing a grim situation as around 13,000 under-five children are dying daily, and 50% of these deaths occur in the first month of life.

The situation of child health has been more adverse in India because of its high child mortality rate, higher than its neighboring countries such as Bangladesh and Nepal which are poorer than India. India is among 50 countries with the highest under-five mortality rate and has failed to achieve its targets for Millennium Development Goals. Most of these deaths can be avoided by simple and affordable interventions.

This age group is highly vulnerable to malnutrition and infections such as diarrhea, pneumonia, and measles, which can be easily prevented. Key strategies for promoting, protecting, and maintaining child health are immunization, appropriate child feeding, integrated management of childhood illness, and early intervention for newborn complications. Overall growth and development of the child depend on various child rearing and feeding practices and measures taken by family for social and intellectual development of a growing child.[1] In a health facility, our physicians and health workers mainly focus on anthropometric measurement, which only tells about growth. It is not a comprehensive indicator to categorize the health status of the child, as there are various other factors that determine health and development of the baby. There should be an overall assessment of the child in the facility before choosing appropriate line of management. Overall assessment includes assessing the baby for any diseases, disability, development delays and deficiency, anthropometric measurements, feeding practices (breastfeeding and complementary feeding practices), immunization status of the child, and hygiene practices (such as hand washing). It is very crucial to know the social support for the mother in rearing her child and the role of family members in the intellectual development of the child.

This study aimed to determine the growth and development of toddlers residing in an urban resettlement colony of east Delhi, and study the knowledge, attitude, and practices of mothers in child-rearing.

As a pilot, a comprehensive healthy baby scorecard has been designed to objectively assess the overall health status of the child and factors affecting it.

  Methodology Top

The study is a descriptive cross-sectional study conducted in an urban Resettlement colony, Kalyan Puri, east Delhi. The study unit was mother–child pair in which child belonged to the age group of 0–3 years. This pilot study was planned under a project of Indian Council of Medical Research (ICMR), Ministry of Heath and Family Welfare (MoHFW), Government of India, named “Health Accounting Scheme-Empowering people for health care through multi-sectoral coordination – An Operational Evaluation” which is being carried out in two blocks (intervention blocks 18 and 12 and control block 20), which were selected by simple random sampling. These two blocks comprised 504 households with a total population of 2495 including 147 children of age 0–3 years. The families of these children were screened and invited to participate in the healthy baby contest at the urban health Center (UHC) of Kalyan Puri. Hence, a total of 40 mothers and 41 children visited the UHC on the scheduled day and thus enrolled for the study. The inclusion criterion was the age of the child between 0 and 3 years. Four toddlers and four mothers were excluded from the study as they did not fulfill the inclusion criteria of the study. The sample selected for the study was not representative but purposively chosen to include mothers from poor neighborhoods but not extremely high-risk ones. The mother and child pair was identified with the help of health accounting scheme staff.

The contest was assessed using a specified scoring system, in which due weightage was given to growth, development, immunization status, personal hygiene, systemic illness, congenital malformation, deficiency status, mother's knowledge about the child-rearing practices and nutrition, and the role of family members in intellectual overall holistic development of the child. The screening of children for growth and development was done at UHC by qualified medical personnels using pretested scorecard as a screening tool.[2] Usage of pretested scorecard also helped to enhance the precision of the developmental surveillance process.

A predesigned, pretested questionnaire [3],[4] (scorecard) was developed and given individually to all mothers participating, and in-depth interview of all the participating mothers was also conducted to assess the child-rearing practices and objectively the “health” of the baby. The children aged between 0 and 3 years were divided into three groups: (1) 0–12 months, (2) 13–24 months, and (3) 25–36 months as the growth and development varied in these groups as well as the child-rearing practices are different, and different set of questionnaire was used in these groups. The World Health Organization (WHO) growth charts were used to assess the anthropometric measurement of the child. Total scores were assigned to each mother–child unit. At the end of the contest, the first, second, and third winners in each age group were given prizes, certificates, and token gift. Furthermore, every child was given an appreciation certificate and a token gift, so as to encourage all mothers and appreciate their efforts in child rearing practices and to motivate them to do even better.

Institutional ethical clearance had been taken for the Health Account Scheme study. Informed consent was also taken from the mother of the child. Privacy and confidentiality were taken into account, and appropriated referrals were made to higher centers if required.

Data were entered into the Microsoft Excel and analyzed after data cleaning in SPSS version 16, (IBM Inc., Chicago, Illinois, USA). Continuous data were expressed in terms of mean and standard deviation, and 95% confidence interval was used. The categorical data were expressed as percentage/proportions, and difference in proportions was compared using Chi-square test. P <0.05 was considered to be statistically significant.

  Results Top

A total of 36 mother–child pairs participated in the study. There was one pair of twins in the study. Hence, total respondents (mothers) were 35, and total numbers of children were 36 in the study. Out of a total of 36 children, 21 (58.3%) were boys, and 15 (41.7%) were girls. The children were in the age group of 0–3 years with total 9 in 0–1 year, 16 in 1–2 years, and 11 in 2–3 year's age groups. More than half (58.3%) were boys.

Majority were Hindus (69.44%). All the mothers except one were homemakers. Nearly, 3/4th (26) children lived in joint families. Around one-fifth of the study participants were illiterate or just literate [Table 1].
Table 1: Sociodemographic profile of respondents of study participants (n=35)*

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Majority (32 [88.9%]) of the children had an institutional delivery. Thirty-two children (88.9%) were immunized as per their age, and rest were partially immunized.

[Table 2] shows anthropometric assessment of the study participants. Majority (80.5%) of the children in the age group of 0–3 years were normal as per height for age (80.5%), weight for age (80.96%), and weight for length (77.78%). Overall, 22 (61.1%) participants showed satisfactory nutritional status by all three criteria.
Table 2: Anthropometric assessment of children (n=36)

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Early initiation of breastfeeding was practiced by 51.4%, and colostrum was given by 80% mothers. Exclusive breast feeding was practiced by 8.5%, whereas 62.9% of mothers offered bottle feeding to their child. Timely initiation of complementary feeding was present among 45.7% [Table 3].
Table 3: Feeding practices among mothers (n=35)

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[Table 4] shows knowledge of mother regarding appropriate age for some developmental milestones. Nearly, one-third of mothers knew the correct age of social smile and age at walking.
Table 4: Knowledge of mothers about child's development (n=35)

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The analysis of the in-depth interviews and discussion with mother showed that 77% of the mothers did not understand the concept of child development. They were not aware about the milestones as per the age. According to them, increase in age from infanthood to childhood means development.

[Table 5] shows the role of family members in intellectual development of the child. Except playing with child, family members played no role in other intellectual development activities in majority of the family. Approximately in half of the family, mothers were involved in intellectual development activities. On in-depth analysis, it was found that child-rearing was considered only mother's responsibility (68.5%), and there was no role of father and family in child-rearing practices. Father's responsibility was only to fulfill the basic needs, so they do not find time in child-rearing.
Table 5: Role of family members in intellectual development activities of the baby (n=36)

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Mothers did not perceive (66%) that playing with child and showing figures, colors, rhymes, and music play any important role in the development of child, they think that these activities are only to engage their child to avoid boredom, so they give the least importance to these activities.

[Table 6] shows mothers' perception about the nutritional status of their child. Of 14 children who had unsatisfactory nutritional status, 50% of mothers assumed their child's nutritional status as normal.
Table 6: Mother's perception of health of her child (n=36)

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  Discussion Top

The baby show was organized to assess the comprehensive growth and development of the child and to identify the growth and developmental disability among the toddlers in the community settings.

The screening tool, scorecard, and questionnaire employing a mixed methods model, demonstrated satisfactory predictive ability to detect developmental disability and growth in toddlers. The objective criterion of screening was developed by strategically choosing easily assessable variables for analysis. “The Score Card” was designed to assess the participants of the healthy baby contest. The results obtained in the pilot phase of the current study revealed that the objective information relating to weight, length/height, and age were the strongest determinants of nutritional risk, and this was expected as anthropometry was commonly used as defining criteria for growth and developmental disability.[5],[6] These conventional indicators reflect different aspects of anthropometric failure. Stunting (low height for age) which reflects retarded skeletal growth is used as an indicator of chronic malnutrition. Wasting (low weight for height) which means loss of fat which gives a picture of acute malnutrition. Underweight (low weight for age) reflects stunting or wasting or combinations.[7],[8] These indicators were used in scorecard as they provide valuable information about quite distinct biological response.[8] However, anthropometric measurements alone do not give complete picture of the growth and disability. In addition, assessment of dietary intake, underlying clinical conditions and its management is also required.[9]

In this study, developmental delays in the achievement of motor milestone were present in 2.7% of children. According to the WHO, around 5% of children below the age of 14 years have some type of developmental delay or childhood disability [10] in India. The prevalence of developmental delay under the age of 2 years is approximately 2%.[10],[11] The early identification of delays in achieving milestones is critical for child development.[10] Children who do not achieve the developmental milestone at expected age fall in the category of developmental delay.

Optimal infant and young child feeding (IYCF) and United Nations Children's Fund (UNICEF) global strategy for IYCF (2003) are as follows: “as a global public health recommendation, the infant should be exclusively breastfed for the first 6 months of life to achieve optimal growth, development, and health. Thereafter to meet their evolving nutritional needs, infants should receive safe and nutritional adequate complementary foods while breastfeeding continues for up to 2 years of age or beyond. Exclusive breastfeeding from birth is possible except for a few rare medical conditions as specified by the WHO and UNICEF.[12],[13]

Early initiation of breastfeeding is recommended by the WHO and UNICEF, putting newborns to the breast within the 1st h of life are critical to newborn survival and to establishing breastfeeding over the long term.[14] Early initiation of breastfeeding decreases the neonatal mortality and morbidity.[15]

Half of the children under 3 years (50%) were breastfeed within 1 h after delivery. This rate was higher as compared with the national rate of India [16] (41.6%) and Delhi (28%). This rate (50%) is recognized by the WHO as good (between 50% and 89%). Low rates of early initiation of breastfeeding have been reported in Uttar Pradesh 25.2%, Uttarakhand 27.8%, Rajasthan 28.4%, and Punjab 30.7%.[16]

Colostrum is the first milk produced by mothers in late pregnancy just prior to giving birth and continues to the early days of breastfeeding, This thick yellowish-orange sticky milk is rich in protein, carbohydrates, Vitamin A, and sodium chloride, and immunoglobulins but contains lower amount of lipids, fat, and potassium compared to normal milk.[17] About 77.8% of mothers fed colostrum to their newborns, which is a good practice.

Exclusive breastfeeding defined by the WHO as practice of feeding only breast milk (including expressed breast milk) and allows the baby to receive vitamins, minerals, or medicines and water, breast milk substitutes, other liquids, and solid foods are excluded from the study. The prevalence rate of exclusive breastfeeding by 6 months was 36.1% lower than national level 55.9% as reported by the National Family Health Survey 4.[16]

Complementary feeding is the food which is given to the baby during the transition period from exclusive breastfeeding to family feeding.[18] This is the most vulnerable period in any child's life, typically it covers 6 to 18–24 months. It is the time where malnutrition starts in any child's life.[18] In this study, 44% mothers had the knowledge that complementary feeding should be started by 6 months, which is almost similar to the study conducted in Delhi (46%).[19]

Parenting plays an important role in child growth and development. Mental growth, social, and cognitive development have direct relationship with the parenting practices.[20]

The small sample size in the pilot phase might be considered as a limitation of the present study. As a result of unique nature of the present study, calculations to estimate the sample size before conducting the study could not be made because of lack of published data on which to base such estimates. The other limitation of this study was that the history of development was assessed based on the report from the mothers (respondents); therefore, some degree of recall bias cannot be ruled out.

  Conclusion Top

This study shows that child-rearing practices in the study area are not providing conducive environment for child growth and holistic development. The main factor is the lack of information of mother in the concept of child development and child-rearing practices besides other factors such as social and cultural, but the ignorance of mother is the main factor which can be removed by sensitizing the mothers about growth and development of the child.

The healthy baby shows are one of the best methods, where screening and surveillance can be done side by side. This also gives a platform to sensitize the mothers regarding the best practices of child rearing for the overall holistic development and growth of the child.

The Centers for Disease Control and Prevention estimates that about one in six children has a developmental disability. Children with developmental problems are at increased risk for poor outcomes in many areas important to health, well-being, and success in life. Developmental disorders increase a child's risk for poor school performance, frequent absences from school, and repeating a grade, as well as for having more health problems.

Periodic preventive surveillance of growth and development and screening of children in the community can be evaluated through healthy baby shows conducted regularly. Mother and child both should be screened The most important reason for monitoring each child's development is to find out if a child's development is on track. It is important to act early if there are signs of potential development delay because early treatment is so important for improving a child's skills and abilities.[21]


We are grateful for valuable guidance from late Prof. (Dr.) Deoki Nandan, Dr. Saumya Swaminathan, Dr. Balram Bhargava, Dr. V. M. Katoch, Dr. R. S. Sharma, and Dr. Neeta Kumar.

Financial support and sponsorship

This study was financially supported by the Indian Council of Medical Research, Task Force Grant number No. 5/7/1/208-RHN, IRIS number 2008-0826, A to C.

Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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