 Hello everyone, so in this part I will be explaining about standard normal distribution okay Z score charts, but I want you to understand what is the standard normal deviation, because you know although as pediatrician we used to using percentile growth chart you know with our patient, but when you work in the programs or you know when you look at this data you know NFH is 4, NFH is 5 data, they look at how many percentage of children are basically you know below minus 2 standard deviation, how many children are below minus 2 standard deviation, because those are the children who are basically they are underweight, they are stunted, they are wasted you know. So we need to understand this growth chart, Z score growth charts also because it is not taught as part of the curriculum in pediatrics okay. So here it is and it is also important for healthcare workers because obviously you know they want to see in the program that how many children are under-weight, how many children are you know all those wasted and stunted. So again let us discuss this chart okay, so this is a bell curve okay, this is your basically a mean okay. Now this is your minus 1 standard deviation, this is a minus 2 standard deviation, this is a minus 3 standard deviation okay, then you want most of your children to fall between minus 2 to plus 2 standard deviation, so this is your normal basically curve, most of your children they fall in this from plus 2 to minus 2 standard deviation okay, how many percent fall in this, so look at the southern numbers, so from minus 1 or say I would say from means to 1 you have 34.1 percent children fall between 0 to plus 1 and from plus 1 to plus 2 you have 13.6 percent children fall into this a positive that means they are taller than or they are bigger than your mean average you know, then this are some children they are below average right, so below average would be your 34.1 percent children they fall up to like from mean to minus 1, 34.1 percent children will fall in that and then you have some children are even smaller than that, so you have what between minus 1 to minus 2 standard deviation, so about 13.6 percent children they fall in this okay from minus 1 to minus 2 okay, but once they start falling below minus 2 standard deviation these are the children that means they are they are counted as under nourished you know like moderate malnourished, severe malnourished, so who are moderate malnourished? The moderate malnourished are the children who are between minus 2 and minus 3 standard deviation okay, these are moderately malnourished and who are the children who are severely malnourished, these are the children who are falling below minus 3 standard deviation okay, so these children are basically we have to immediately work on the children to get them up you know at least towards them being, we want to bring them not just not just over here you know you don't want to just bring them over here and leave them, you know you want to make sure that they get the full potential, so our goal is to bring them as close to the mean as possible, so there is a long way to go for the child to go from here from minus 2 to mean right and look at this they should be only under minus 2 you need you can have just like maybe 2.1 and maybe 0.1, so not not much maybe 2.1 you know we will figure out that how many children should like you know normally you see in a standard deviation, how many children do you see below minus 2 standard deviation unfortunately in India these numbers are too high okay, these numbers they are much higher than what it is shown over here okay, so we will talk about that but remember that half of your children are half of your children are above average okay, half of your children are above average, half of your children are probably below average okay, so you want to make sure that you know you don't just stop over here, you try to bring child in the positive growth, this is the positive growth okay, so try to bring your children more towards plus 1 to plus 2 because those children will if you try to bring them early on say from 0 to 6 months of age this as the weight goes up the length will go up okay and that I will show you some of the growth chart, so okay this is another one here we have shown all the different standard deviation and we have shown the basically percentile okay, so look at this your 50% children, so your 50% children would be on here like you know just below mean and your 50% children will be above mean right okay, now look at your minus 2 standard deviation okay, so minus 2 standard deviation basically coincides with 2.3 percent, so normally only 2.3% children should be below minus 2 standard deviation, only 2.3% children in the world but in India if you look at the weight 32% children are below minus 2 standard deviation, 32% look at the difference between 2.3 to 32, do you understand what I am saying okay, now this is below minus 2 standard deviation, so you can imagine mostly mostly our children are probably between minus 2 to minus 1 you know and if some of some of this will maybe go up to 0.5, very seldom you know breast-fed babies I see it over here in a positive growth, I do not see too many children who are between 0 to plus 2 standard deviation okay but yes we just started seeing once we started using a cross-caddle hole, we started seeing children basically more in this average you know your 50% 50% and this this side of the mean rather than this side okay, what is happening right now when they find children who are below minus 2 standard deviation or even minus 3 standard deviation, healthcare worker try to bring them up little bit you know and then they leave them, they try to bring them children up little bit and then they leave them, so our children are just falling into this 4.4% children who are between minus 2 to 1.5 standard deviation, they are just leaving all these children over here, our goal is not to keep the children in this section, we want to bring our children at least average children should be over here in mean okay, the earliest you start better it is okay, let's see at the chart, now this is your weight for age Z score, so in Z score see here this is in the form of growth chart, you have mean okay, you have minus 2 standard deviation, you have minus 3 standard deviation, similarly you have plus 2 standard and plus 3 standard deviation, so average all your children should fall between 2 to minus 2, 2 to minus 2 okay, if your child fall below minus 2 and it falls between minus 2 to minus 3 that means your children are moderately malnourished okay, now this is because of weight it's weight for age, it will be underweight, so if your child falls between minus 2 to minus 3, those are moderately underweight and if child falls below minus 3, those are severely underweight, so those are called SUW and MUW okay, remember this, so I want you now to bring your children not just over here okay but I want you to bring your children up to mean and maybe above mean okay, try to bring the children up but with mother's milk and earlier you start better it is okay, similarly this is for length, so again this is your standard deviation growth chart, you have you know five lines in this okay, so your 0 to minus 2 and a 0 to plus 2, these are basic children should fall in this from plus 2 to minus 2 and moderately standard children will fall between minus 2 to minus 3, remember only 2 point through almost 2 percent children should fall below minus 2 but we have in India we have almost I would say 36 percent children are falling below minus 2 standard deviation, instead of only 2 percent we have 36 percent okay and minus 3, below minus 3 is your severe stunting, so length for ages for stunting okay, this is your weight for length chart, again here in length for weight for length means over here you have a length and over here you have a weight okay, so when you look at the length and weight chart basically look at this, this is your Sam and Ma'am okay, acute malnutrition Sam and Ma'am, so between minus 2 and minus 3 standard deviation those are called Ma'am moderately acute malnutrition and below minus 3 is your Sam severe acute malnutrition okay, so this is your Sam and Ma'am and that's for that's called wasting also we use it weight for length chart okay, we have very high number of high percent of children who fall below minus 2 standard deviation and that's a kind of I would say it's an emergency because children when they are malnourished or cutely malnourished that's when they have a high risk of mortality okay, alright now this is I want to show you what kind of chart we use in ICDS okay, so this is ICDS chart this is for boy child, this is for a girl child okay, so in ICDS they have this standard deviation chart but the way they have painted it they have painted this green color from mean to minus 2 and my question is that where is the green color from 0 to 2 because that also children I mean I want 50% children to be over here between 0 to 2% 0 to 2 standard deviation so we don't have this green zone at all so for healthcare workers if they bring the child in this particular little bit of green zone they are extremely happy I want all the students to be above green zone in a white zone okay, so what we can do I'm requesting government to kind of fix this growth chart and have green zone from plus 2 to minus 2 standard deviation not we don't want our children to be negative below 0 or below mean okay, so that's what again our growth charts what we have in ICDS they have only used green zone from minus 2 to 0 this part is completely missing so please talk to your local administration and tell them that this is what is missing and we need to fix it okay alright now last two slides and I'm done so this is a girl child I had shown in one of my presentation earlier this is a child who is only six months old girl child and this is length for age okay this is a percentile growth chart because this child had beautiful milk transfer in first six months look at whether child's length is she is 97 percentile this is 97 percentile only 3% children of her age are this tall and she's a tribal child okay so you want to look at the weight that's a 9.42 so as child was growing beautifully on mother's milk catching up on growth and with full potential the length was growing so you this child is definitely going to be very very tall when she grows up okay because genetic kicks in after five years of age so if you can really focus on mother's milk and complementary food which is high in protein and good fat the children will grow tall similarly this is a boy child even this child look at the length plotted at 97 percentile very tall child okay so he's only six months old look at the weight six months old child weight is 10 kg remember the average weight for a boy child I had mentioned about I would say I would say I think 8 kg this child is 10 kg so as the weight was high you know you can see the length is high too okay so this is the this is what I want to explain to you thank you so much and you know I will I will basically ask you to see two of her tutorials and let me know if you have any questions okay thank you so much