Growth monitoring is a critical component of the creche initiative, as it directly supports our primary objective of preventing and reducing malnutrition among children under three years of age. Early childhood is a period of rapid physical and cognitive development, and even small deviations from normal growth can signal underlying nutritional deficiencies, illness, or developmental concerns. Regular monitoring allows us to detect these issues promptly and take timely action.

In our creches, anthropometric measurements, primarily weight and height/length, are systematically recorded to track each child’s growth pattern. Weight is measured every month to identify short-term changes such as weight loss, inadequate weight gain, or episodes of illness. Height/Length is measured quarterly (January, April, July, and October), enabling us to assess long-term growth trends and identify risks such as wasting and stunting.

By observing and analyzing these measurements consistently, we can:

a) Understand each child’s growth trajectory.
b) Identify early signs of growth faltering or malnutrition.
c) Provide special nutrition care and care interventions when needed.
d) Engage parents with meaningful insights about their child’s well-being.
e) Strengthen preventive health and nutrition practices.

Growth Monitoring Process

Setting up a dedicated space for anthropometric measurements in the creche
Procurement of anthropometric equipments
Calibration of anthropometric equipments
Measurement of weight & height/length at the time of enrolment (welcome Anthro)
Weight measurement every month & Height/Length measurement in once in a quarter (Jan, April, July, Oct)
Capturing the measurements on the registers, shishu ghar app, child card and community growth chart
Validating the data to check any outliers or sudden big changes in height/length/weight

Anthropometric Equipments

a) Seca 210 – Infantometer

b) Seca 213 – Stadiometer

c) Samso Bear Baby Weighing Scale with Tray

Anthro Space

A dedicated Anthro space within the creche is essential to ensure that children’s height/length and weight are measured accurately. Having a fixed and well-organized area helps maintain uniformity in measurements, reduces errors, and ensures better tracking of children’s growth over time. The space must be flat, hard, tiled, and level to ensure an equal surface for accurate measurements that can accommodate all 3 anthropometric equipment. Mats, uneven flooring, mud, sand, or soft surfaces must not be used.

Need for a Dedicated Measurement Space

1. Ensure accurate and reliable measurements by avoiding uneven surfaces and disturbances.

2. Helps in maintaining equal ground level using tiles, which is critical for correct height/length and weight readings.

3. Maintains comfort of the child during measurement.

4. Avoids frequent shifting of instruments, reducing damage and misalignment.

5. Strengthens data quality for nutrition monitoring, referrals, and reporting.

Calibration

Calibration is the process of testing or restoring the accuracy of an instrument or measuring equipment by comparing it with an established standard to ensure that it is operating safely and efficiently. In this context, as we are using anthropometric equipment (digital weighing scale, infantometers and stadiometer) in our creches they need to be calibrated on a quarterly basis. This will ensure the quality of the instrument and accuracy in the measurements.

The calibration of anthropometric equipment requires standard weights and lengths which need to be certified by a competent authority.

Procurement of items for standard weights and length:

a) Iron hexagonal weights of one kilogram and half kilogram should be procured from a reliable store dealing in weighing scales and weights.

b) A Chlorinated Polyvinyl Chloride (CPVC) pipe of 35 cm with a 3/4th of an inch diameter with standard dimension ratio (SDR) of 11 or 30 cm stainless steel scale is to be procured from a reliable hardware store. In addition, two sockets of 3/4th of an inch are to be procured to be used as a cap on both the ends of the pipe. It will protect both the ends from any kind of withering.

Weighing scale calibration—

Checking the calibration of the equipment can be done in the creche by the creche supervisor every quarter before the weight and height/length measurement schedule. It can be done by a set of calibrated weights certified by the Legal Metrological Department. A one kg and a ½ kg calibrated weight can be used to check the correctness of the weighing scale by three different weights, i.e., ½ kg, 1 kg and 1 ½ kg. The same scale setup should be used during the calibration process.

If there is a discrepancy between the known calibration weight and the scale reading, change the battery of the equipment and repeat the process once again. If there is a mismatch in the weight used and the readings, it indicates a faulty equipment and should be processed for repair or change. It is always a good practice to keep spare equipment in a cluster of creches so that it can be used without disrupting the anthro process in case of a faulty weighing scale.

Stadiometer/Infantometer calibration—

Checking the calibration of equipment can be done in the creche by the creche supervisor every quarter with the help of a calibrated 30 cm stainless steel scale and 35 cm plastic pipes (these pipes have been cut with the help of a calibrated stainless steel scale).

a) Ensure that the infantometer is placed on an even, perfectly flat surface. There must be enough light that the display is easily readable.

b) First, ensure that the mat of the infantometer is clear of any small objects, then move the footboard of the infantometer to the minimum length position.

c) For the infantometer, use the 30 cm stainless steel scale provided. Place the scale between the headboard and the footboard of the infantometer and take the reading. Check that the display reads 30 cm and note it down. Repeat the procedure again for verification.

d) Review the calculations. If there are consistent deviations of more than 5 mm, repeat the measurement to check for errors.

e) For stadiometer, use the calibrated plastic pipes of 35 cm each and place them in the standing position on footboard of stadiometer. Bring down the headboard towards the pipe so that the reading shows 35 cm. Make sure the pipes are not bending when the headboard touches the pipe.

General Instructions

a) Ensure that the stadiometer/infantometer and weighing scale are clean, in working condition, and properly calibrated before use.

b) Always place the measuring equipment on a hard, flat, and even surface. As far as possible, use a dedicated anthropometry space within the creche.

c) Inform mothers/caregivers at least one week in advance about the anthropometric measurement day so they can plan their household or agricultural work and be present.

d) Measuring can make some children feel scared or uncomfortable. The mother or caregiver should help in holding, positioning, and calming the child to ensure accurate measurement and reduce stress.

e) If the mother or family member is not available, the creche caregiver should support the child and help in making the process comfortable.

f) Some children may cry, kick, or resist during measurement. Supervisors and caregivers should stay calm, explain the process clearly to parents, and handle the child gently and confidently.

g) Ensure that toys, play materials, stories, or songs are used during the measurement to keep the child engaged and relaxed. The mother should stand in front of the child to provide comfort.

h) If a child is very anxious, allow a calm child or sibling to be measured first so the child understands that the process is safe and painless.

i) Supervisors and caregivers must wash their hands before touching or positioning the child. Remove bulky items like watches or bangles that may affect the measurement.

j) Do not measure the child immediately after a meal. Ensure there is a gap of at least one hour after eating before height or weight is taken.

k) Measuring immediately after food may show incorrectly higher weight and can cause discomfort or vomiting in some children during height or length measurement.

l) Before starting the measurement process, ensure that all children have passed urine, as anxiety may cause them to urinate during measurement and damage the equipment.

Weight Measurement

The weights of children are taken to help determine their weight-for-age z-scores which are their weights relative to their age and therefore to determine the prevalence of moderately underweight or severely underweight.

Age Group	Weight
Below 2 years ie., Till 729 days	With Tray sitting or lying
Above 2 years ie., 730 days and above	Without Tray standing

Set up scales Follow the steps below to put the scales into operation:

Step 1: Ensure that the battery is rightly placed in the weighing scale.

Step 2: Put the scale on a firm, flat surface/Anthro Space.

Step 3: Turn on the scale and wait until the display shows 0.00. The weighing scale has the option to measure the weight in kg and lb. If the display does not show 0.00, that indicates that the weighing scale is currently set to take the weight in lb. Press the button with the caption ‘kg/lb’ once to set the weighing scale in ‘kg’ mode.

Procedures

Follow the steps below to measure the weight of children in creches:

Step 1: Ask the caregiver to remove footwear (shoes, slippers, sandals, etc.) and socks of children. They should also remove any heavy belts and empty the children's pockets. Ensure that the children are not holding any toys or objects while taking the weight.

Step 2: Ask the caregiver to place the child onto the scale with one foot on each side of the scale. Smaller children who cannot stand would be placed at the toddler’s tray.

Step 3: Ask the creche caregiver to facilitate that the child:

a) stand still or stay still on the tray

b) face forward/upward

c) place arms on the side and

d) wait until asked to step off

Step 4: Immediately record the reading in kg into the designated register ensuring accuracy.

Step 5: Reset the reading of the weighing scale to 0.00 for next measurement.

Demonstration of Weight measurement without Tray - Video credits (PHRS)

Demonstration of Weight measurement with Tray - Video credits (Harsha Trust)

Length Measurement

Age Group	Length
Below 2 years ie., Till 729 days	Infantometer

Keep the measuring board flat on a hard and level surface such as the floor or the Anthro space. Make sure it does not move during measurement.
One supervisor will take the measurement, and one caregiver will assist in holding and positioning the child.
Correct sitting/kneeling positions: *The supervisor should sit or kneel on the right side near the child’s feet (foot end of the board). *The caregiver should sit or kneel near the child’s head at the top end of the board.
The caregiver should slowly lay the child on the board while supporting the head. The supervisor may support the body if needed.
The child’s head should touch the top end of the board and face straight upward. The caregiver should hold the head in this position gently and firmly.
Make sure the child’s body is straight, shoulders and hips are in line, and the child is lying in the centre of the board.
The supervisor should gently press the child’s knees downward to straighten both legs. Do not use force, especially for very small, weak, or crying children.

The supervisor should move the footboard until it touches both heels. The child’s feet should be flat against the footboard with toes pointing upward.
Check the head, body, legs, and feet once again. If the child moves, calm the child and reposition.
Once everything is in the correct position, read the length clearly and write it immediately in the register.
Gently lift or help the child off the board and hand the child back to the caregiver.

Note - If a child under 2 years of age will not lie down, measure standing height and add 0.7 cm to convert it to length. If a child 2 years of age or older cannot stand, measure recumbent length and subtract 0.7 cm to convert it to height.

Demonstration Video credits (PHRS)

Height Measurement

Age Group	Height
Above 2 years ie., 730 days and above	Stadiometer

Place the stadiometer on a hard, flat surface in the Anthro space, vertically against a wall or a table so that it does not move.
The supervisor should kneel or squat in front of the child on the left side, and the caregiver should kneel on the child’s right side to assist.
The supervisor should gently lift the child’s chin so the child looks straight ahead. The child’s eyes should be parallel with the ground. The supervisor may squat at the child’s eye level and gently hold the head in this position.
The caregiver should make sure the back of both feet touches the board. Any one of the following positions is acceptable:

With help from the caregiver, the supervisor should ensure that:

• The child’s arms hang freely at the sides • Shoulders are level • Weight is equally balanced on both feet • Buttocks touch the measuring board

For most children, the back of the head, shoulders, calves, and heels will touch the board. For obese children, the shoulders and calves may not touch the board properly. For some children, the back of the head may not touch the board. These differences are normal, but the body must be straight.
The supervisor should check the child’s full position and re-adjust if needed to make sure the body is straight and not bent.
If the child has difficulty standing straight, the caregiver may gently push the stomach backward to help the child stand straight. Do not force.
The supervisor should slide the movable headpiece down gently until it just touches the top of the child’s head and lightly presses the hair.

The supervisor should read and record or plot the height immediately and clearly in the correct register. The recorded height should be checked again for clarity and accuracy.
The supervisor should remove the headpiece and gently help the child step away from the board and return the child to the caregiver. A toy may be given to comfort the child.

Note - If a child under 2 years of age will not lie down, measure standing height and add 0.7 cm to convert it to length. If a child 2 years of age or older cannot stand, measure recumbent length and subtract 0.7 cm to convert it to height.

Demonstration Video credits (PHRS)

Data Entry and Validation

a) Immediate Recording of Measurements

To ensure accuracy and prevent memory-based errors, all anthropometric measurements (weight, height /length) must be recorded immediately at the time of measurement in the notebook by the supervisor or cluster coordinator.

i) Measurements should never be noted later from memory. ii) If there is any doubt regarding the reading, 2–3 repeated measurements must be taken, and the most consistent value should be recorded. iii) This practice helps minimize variation errors caused by child movement, instrument position, or reading mistakes.

b) Multiple-Level Data Entry

The same measurement data must be entered in all four official records to maintain consistency and enable cross-verification:

i) Notebook – Primary field-level raw record

ii) Child Card – Individual child’s growth tracking record

iii) Community Growth Chart–Visual monitoring of growth trends at creche level

iv) Shishu Ghar App – Digital database for reporting and monitoring

All entries across these four sources must match exactly. Any mismatch should be corrected on the same day.

c) Review for Outliers and Sudden Changes

After recording the measurements, the data must be reviewed carefully to identify outliers or sudden, unrealistic changes, by comparing with the child’s previous records (especially using the Child Card).

i. Sudden Weight Changes

Any child showing a weight change of more than ±0.5 kg compared to the previous month should be flagged for verification. Such changes are uncommon under normal conditions and may indicate:

• Improper scale calibration

• Measurement error (e.g., child holding an object, moving during weighing)

• Recording error (e.g., wrong digit or decimal placement)

ii. Repeat Verification

• If a value looks implausible or shows a sudden large change, the child must be re-measured immediately.

• If the discrepancy still remains after repeat measurement, it should be clearly noted in the register.

d) Digital Entry and Validation through Shishu Ghar App

Once the data is entered into the Shishu Ghar App, it must be validated by the Cluster Coordinator or MIS Coordinator using system-generated reports. If outliers or abnormal values are found during digital validation:

o The data must be cross-verified with the physical records at the creche.

o Re-measurement of the child must be initiated, wherever required.

o Only validated and corrected data should be finalized for reporting.