 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 the how many 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 underweight, 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 this 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 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 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 undernourished you know like moderate malnourished, severe malnourished. So, who are moderate malnourished? The moderately malnourished are the children who are between minus 2 and minus 3 standard deviation okay this 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, this children are basically we have to immediately work on the children to get them up you know at least towards the mean 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 2.0 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 this numbers are too high okay this number is 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 percent children so your 50 percent children would be on here like you know just below mean and your 50 percent 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 percent children should be below minus 2 standard deviation only 2.3 percent children in the world but in India if you look at the weight 32 percent children are below minus 2 standard deviation 32 percent 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 our children are probably between minus 2 to minus 1 you know and if some of the children maybe go up to 0.5 very seldom you know breastfed 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 did started seeing once we started using a cross cuttle hole we started seeing children basically more in this average you know your 50 percent 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 percent 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 this 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 okay let us 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 in 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 falls 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 is weight for age so it will be under weight so if your child falls between minus 2 to minus 3 those are moderately under weight and if child falls below minus 3 those are severely under weight so those are called SUW and MUW okay so 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 those 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 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 age is 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 MAM okay acute malnutrition SAM and MAM so between minus 2 and minus 3 standard deviation those are called MAM moderately acute malnutrition and below minus 3 is your SAM severe acute malnutrition okay so this is your SAM and MAM 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 acutely malnourished that's when they have a high risk of mortality okay all right now this is I want to show you what kind of chart we use in ICDS okay so this is the 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 percent children to be over here between 0 to 2 percent 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 children 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 all right 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 percent 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