Table of Contents Summary 86  1. Background 88  1.1 History and development of growth monitoring programmes 88  1.2 Objectives of growth monitoring 89  2. Expected benefits of growth monitoring and growth promotion 90  3. Objectives of this review 91  4. Methodology 91  5. Evidence of effectiveness of growth monitoring programmes 91  5.1 Nutritional status and mortality of young children 91   5.1.1 Studies before 1990 91   5.1.2 Studies since 1990 96  5.2 Utilization of primary health services 103  6. Quality of implementation 104  7. Caregivers' knowledge and understanding of growth charts 105  8. Empowerment and community mobilization 106  9. Coverage and attendance 107 10. Potential consequences if withdrawn 108 11. Feasibility and conditions under which growth monitoring and promotion can be expected to work 108 12. Cost‐effectiveness 109 13. Potential adverse consequences 109 14. Policy considerations and recommendations 110 References 113

The rationale for growth monitoring and promotion is persuasive but even in the 1980s the appropriateness of growth monitoring programmes was being questioned. The concerns centred largely around low participation rates, poor health worker performance and inadequacies in health system infrastructure that constrained effective growth‐promoting action. More recently there has been a call for a general review of the impact of large‐scale growth monitoring and promotion programmes to determine if the investments are justified. The launch of the new World Health Organization growth standard and charts has been a timely reminder of this debate. It is within this context that this review has been undertaken: the main purpose is to analyse the evidence that growth monitoring programmes are effective in conferring measurable benefits to the children for whom growth charts are kept. The benefits considered here are improved nutritional status, increased utilization of health services and reductions in mortality.

There is evidence from small‐scale studies in Nigeria, Jamaica, India (Narangwal and Jamkhed), and from large programmes in Tanzania (Iringa), India (Tamil Nadu Integrated Nutrition Project), Madagascar and Senegal that children whose growth is monitored and whose mothers receive nutrition and health education and have access to basic child health services have a better nutritional status and/or survival than children who do not. There is tentative evidence from a large‐scale programme in Brazil (Ceara) that participation in growth monitoring confers a significant benefit on nutritional status independent of immunization and socio‐economic status. There is evidence from India (Integrated Child Development Services) and Bangladesh (Bangladesh Rural Advancement Committee and Bangladesh Integrated Nutrition Project) that growth monitoring has little or no effect on nutritional status in large‐scale programmes with weak nutrition counselling. There is evidence from Tamil Nadu in a randomized trial that when mothers are visited fortnightly at home and have unhurried counselling, no additional benefit accrues from the visual depiction of growth on a chart. There is some evidence that growth monitoring can improve utilization of health services.

Although there is no unequivocal evidence that growth monitoring is beneficial per se, it was perceived to be beneficial by the investigators of several of the studies described in this review. Growth monitoring can provide an entry point to preventive and curative health care and was an integral part of programmes that were associated with …