I think we need to be clear about terms. "Infants" means different things in different contexts. In UK schooling (e.g.) the tern usually applies to children aged about 5 - 11 years (the age that children attends an "Infant School". In the airline business an infant is a child aged below two years (this is, I think, derived from the ability to walk). In US law the term "infant" and "minor" are often interchangeable. The Latin term "infans" means "without speech" which is usually taken to be below 2 years. I also think we need to be clear about what we mean by "moderate malnutrition". Is this low W/A, low W/H, low H/A, low MUAC, or some other measure? Anyway ... I'd guess that you means either birth to one year or birth to six months and are interested in "wasting" (low W/H and / or low MUAC). There is much data on prevalence in the six months to one year age-group since this age-group falls within the standard "nutritional anthropometry" survey criteria. In younger children there is recent data on MUAC coming out of Jay Berkley's group in Kilifi, Kenya. Data on W/H is hard to find as many anthropometry guidelines caution against the collection of W/H in this age group since special length boards are required and there is a considerable risk of harming the child. The indicator of choice in this age-group is W/A and data are available from most countries that operate growth monitoring. You may have problems with consistency if case definitions across settings (in the UK, for instance, we use a "thrive line" approach in which tracking of the reference at an level is used whereas other countries use a percentile threshold approach or "fairway" approach). I'd guess that a search on terms such as "growth failure", "growth faltering", and "failure to thrive" might bring way you are after. Related issues are low birth weight and low chest circumference. Best wishes, Mark

Dear Mark, On what do you base your statement that taking length in an infant poses a cosiderable risk of harm. Crown heel lengths are taken routinely in many places in neonates (without any risk) and in >6month old children. Are you basing this statement upon any data at all? If not it is very unfortunate to make this type of sweeping accusation of doing harm.

I don't have the reference to hand but it was, I believe, a WHO / UNICEF joint statement suggesting extreme caution in surveys. I'd be unhappy measuring kids in a field survey unless I had paediatric nurses, special height boards, and 'baby' scales with 10g (rather than 100g as with Salter type spring scales).

you are suggesting that you may get inaccurate data? If so I agree. That is a very different thing from suggesting that you will HARM the children themselves, as you post implies!

I am suggesting both.

Well, I do disagree. I find <6 month old children very easy to measure. There is much less fear/stress for the child - it is quick and atraumatic and does not require a "paediatric nurse". I really think you should either document your statement properly or withdraw it as a pesonal "notion" not founded upon fact. I would be interested to know if any other reader has any experience or knowledge, or has even heard of harm being done to a <6 month old by weighing or measuring? It would be very bad if this idea went unchallenged or into common folk law and was repeated. (The data are not good though on that we can agree.)

In answer to the original question, I don't think there is data on this. Infants <6 months old are an underserved population although at significant risk of mortality. I know that the IFE Core Group is looking at this very question. There are significant challenges associated with assessing this population. For example, digital scales generally don't travel well and in any event need regular recalibration (and I'm not volunteering to be the one with weights in my backpack!). Height/length mats (made from fibreglass I think with perspex right angles at either end,) are less of a problem but this data is pretty useless on it's own. Assessing an infant's age can also be tricky. Then there are the issues around aetiology of growth faltering. Is the baby exclusively breastfed and if not why is the mother giving other foods? Tradition? Separation for work/livelihood activities? She believes it will help the baby sleep? Because she has a breastfeeding problem and noticed the baby's growth faltering? If the baby is exclusively breastfeeding and is undernourished, why? Is there a milk transfer problem? Is it a frequency problem? Is the mother severely malnourished or suffering specific (most often B) vitamin deficiencies? If the baby is totally artificially fed, does the family have access to sufficient supplies (milk; water; fuel; cups)? Is the baby suffering recurrent diarrhoea/LRTI as a result of poor hygiene/sanitation or are bottles being used to deliver milk or other foods? Each of these problems demands a different response. I would also be interested in evidence of harm associated with standard growth monitoring procedures for infants < 6months old. I am aware that there are accuracy issues (both user error and problems with the measurement tools) but haven't seen evidence of harm to the infant associated with the process of measuring. Apart from inaccuracy leading to unecessary intervention, the only evidence of harm coming to infants that I am aware of comes as a result of what is done with the measurements. Lack of awareness of the risks associated with supplementary feeding for this age group and lack of expertise in infant feeding including breastfeeding assessment, management and support (which will include effective communication with care-givers) compound the risks for these beneficiaries. I would be interested to hear what thresholds are being used for intervention (WHZ or WAZ?) and what protocols are in place for assessing and treating these kids.

I haven't heard of harm from measuring infants under six months, but I think it comes down to having the right equipment (scales that they can lie in with no danger of tipping out) and confidence in handling this age-group (e.g. measuring length, they tend to curl their legs and so you need to handle this) that comes from some exposure/experience. So perhaps there is a fear of doing harm. A little while back, ENN reported on an evaluation of anthropmetric training of emergency nutrition staff which found that there was a lack of practical training on anthropometric measurement, plus handling infants under six months was a gap area. While 88% of national nursing and nutritional staff said they felt very competent at undertaking weight measurement for children aged between 6 months and 5 years, this fell to 29% for infants less than 6 months. A survey of scales used for infants under six months is reported in FEX 29 at http://fex.ennonline.net/29/weighingscales.aspx The work on assessing training in anthropometry is in FEX 32 at: http://fex.ennonline.net/32/investigation.aspx

The question "I would be interested to hear what thresholds are being used for intervention (WHZ or WAZ?) and what protocols are in place for assessing and treating these kids." is important. It is not easy to answer! See IFE group publications. Height is just too difficult to measure accurately - a very small error makes a big difference in the WHZ (see early FEx). A single weight is not very much use either - low birth wt infant may be suckling well, gaining weight and healthy - but will be low W/A and should not be admitted. Larger kids may be actively loosing weight. In this age group things can happen very quickly - and they need intervention before they become severe. The ideal is to have longitudinal data on the child. I know there have been a lot of critics of growth monitoring, but it seems that this is because there is usually no effective intervention and the charts simply document the infants deterioration. So where there is a growth monitoring program (does it really do physical harm to weigh babies?) these are the data that should be used to confirm that breast feeding is inadequate - and we should have an intervention that works and skilled staff to run the program! To me, if a child is faultering it is nearly always because of a failure of breast feeding in one form or another (many causes). The objective then becomes to return the child to exclusive breast feeding. We should abandon all anthropometric cut-offs for these infants. The single admission criterion then becomes confirmed failure of breast feeding (no matter the anthropometry), and the treatment protocol is different from the older child - it is only directed at return the child to exclusive breast feeding. The discharge crierion then becomes, gaining weight on exclusive breast feeding (no matter the anthropometry). The same principles apply where there is no growth monitoring program - failure of adequate breast feeding - it is this that we have to establish criteria to recognise - not a cross-sectional anthro measurement. And a considerabe proportion of infants are in this category (this is when growth faultering starts) and the infant needs intervention and the mother practical help (often with admission for a few days) and a good diet. Many infants are weak and do not cry or suckle sufficiently to stimulate the mother's milk flow (they do not supply what is not demanded). For these we have tried admission and breast feeding support only to watch the child continue to deteriorate and loose wt - if they are then put on artifical feeds (standard protocol) they end up weaned - anther loosing option. The SS technique is the only way to go for these weak infants and it really does work - but is much more staff intensive and needs skill. I advocate for special units to be established for <6month infants - which are physically separate and separately staffed - for the skills needed are different. Posters are put up, mothers cajoled to breast feed and advocacy with fanfare - but in reality there is very little in the way of practical hands-on support given in most countries, insufficient trained staff, no special units "breast feeding corners" etc.and no National program or National protocol that is implemented! So growth monitoring continues to document deterioration without effective intervention. Who will set up a modle unit, capeable of finding and managing relatively large numbers of patients, that is exclusively for <6 month old infanct and demonstate what can be done?

Michael asked, "Who will set up a modle unit, capeable of finding and managing relatively large numbers of patients, that is exclusively for <6 month old infanct and demonstate what can be done? " Find me a funding source for such a project and I will be on the next plane to just about anywhere. Also "if a child is faultering it is nearly always because of a failure of breast feeding in one form or another (many causes). The objective then becomes to return the child to exclusive breast feeding" Yes (although I prefer describing this as 'inadequate milk transfer' because I try to avoid inferring that mothers or their bodies have, in yet another way, failed) - and I am sure you have found that it is also important to help the mother to indentify and address the cause of the poor intake, lest the problem simply recur following discharge. And "in reality there is very little in the way of practical hands-on support given in most countries, insufficient trained staff, no special units "breast feeding corners" etc.and no National program or National protocol that is implemented!" I would include donor countries in this description, too. I don't think that a paucity of staff possessing the skillset necessary to adequately assess and enable mothers to manage their breastfeeding relationships is a problem specific to recipient countries. (Perhaps this is why it has proven so difficult to get a model programme off the ground.)

Marie jogged my memory ... It is that "they [infants] tend to curl their legs and so you need to handle this". This is usually handled, with children > 6 months, by firm pressure at the knees to straighten the legs. It is not possible to straigthen the legs of the youngest children without damaging their knees. The WHO publication that I had in mind was, I believe, the WGS Module B training manual on anthropometric assessment but you'll probably find the same advice elsewhere. The WGS manual counsels cautious handling. I've seen some pretty rough handing of wriggling children during length measurements taken in surveys. I suppose that I put "two and two together" and decided to avoid doing length measurements of < 6 month old children in my own surveys (unless I could be sure of safe handling) and to advise against others doing so. Note that I am talking about field surveys (where supervision can be lax and measurements hurried) rather than surveys in clinical contexts or routine clinical measurements.