The Road to Health Chart

Guidelines for Health Workers.

These guidelines are issued with each pack (100) of the Road to Health Chart (RtHC). The aims of this chart are to have an accurate home-based record of a childís health and development, to promote the relationship between health workers and the parent(s)/caregiver of the child and to improve the identification of children needing extra care. The chart is based on the Teaching Aids at Low Cost (TALC) chart and other charts previously developed and used in many parts of South Africa. The chart has been updated and improved, and the layout was developed by the national Directorates for Nutrition, Child & Youth Health and provincial contributions. It is generally agreed that the format of the chart should be uniform throughout the country to accommodate children moving from one area to another and to make training and ongoing support easier. The chart can also be used for evaluating community nutritional status over time and the monitoring of immunisation coverage.

Background.

The Road to Health Chart (RtHC) is often the only ongoing link between health workers (including doctors) and a childís parent(s)/caregivers. If used properly, it promotes these relationships, improves decisions and helps to focus on those children needing extra care.

Growth monitoring and promotion are of the most useful tools available in child health. Routine and regular growth monitoring and promotion is the easiest and quickest method available for the early detection of disease, developmental and nutritional problems, and for the positive reinforcement of behaviours that promote growth in children. The most sensitive indicator of a childís growth is weight.

Experts have made the following recommendations to the national Department of Health on the use of the chart:.

Material and protection

The chart is made of Tyvek® paper that is tear- and waterproof to ensure that the chart will not be easily damaged or soiled. Since this chart should be kept throughout the life of a child, durability of the chart is important.

Colour

The print is predominantly green on a white background for the sections that must be completed by health workers to make black/blue ink more legible. Headings/examples are printed in black on white. A pen with a fine point should be used, with ink that does not run when wet, e.g. fine ballpoint.

Size

The chart is an A3 size to allow adequate space for proper record keeping. The chart is designed to fold into an A4 size along its length and then into a flyer format along three further folds. The flyer format makes it easy to handle and store.

1. Use of the Road to Health Chart

1.1 Issue, ownership and responsibility

This chart must be issued at birth by the health service concerned. Some sections on the chart may be discussed and completed on admission to the labour ward. If birth takes place at home, the first opportunity after delivery should be used to issue the chart. The RtHC is the property of the childís parent(s) or legal guardian. The chart should be presented to the health worker at every visit to a health facility. Filling the childís details and progress in on the chart, shows respect for the parent(s)/caregiver and will improve both effective decision making and health facility management..

1.2 Frequency of use

Health workers who examine young children should request to check the information recorded on the chart at every visit; this provides useful rapid background information, and reinforces its value to the parent(s)/caregiver. Routine weighing, plotting, interpretation and feedback are recommended monthly during the first two years of life, and regularly after that at three month intervals. This amounts to 36 times within the first five years, providing reasonable opportunity to promote a good relationship between health workers with the parent(s)/caregiver and child, to detect problems early and to initiate intervention.

2. Layout of information.

2.1 Growth monitoring chart

This is a graph that records the childís growth progress..

2.1.1 Identification

The top left corner on the growth monitoring chart provides space to record the childís name. This should be checked every time that the childís weight is recorded.

2.1.2 Growth monitoring. (Make sure the scale weighs accurately)

(i) Vertical axis

This is the weight axis. It is represented in kilograms both on the left and right margin of each year, starting at 0kg with the 2,5kg line highlighted. The vertical axis is marked at 0,5kg intervals (dotted lines) with the 1kg intervals (solid lines) exactly one centimetre apart. The child should be weighed naked or with minimal clothing (example: vest and nappy). The accuracy of weighing and plotting on the growth graphs should always be double checked by a second health worker for every 10th to 20th child. The weighing scale used, should be zeroed daily and calibrated weekly with standard 5kg and 10kg weights.

(ii) Horizontal axis

This is the age axis. The age scale has one space (column) per month for the entire period. This prevents confusion in labelling the axis and plotting weight in later years. Each month is represented by a block in which the health worker has to write the appropriate month. The first block of each year is outlined in bold and represents the space for the birth month to be recorded. It also provides enough space for the year of birth to be inserted (see example). The first year and the birth month of each year should be filled in at birth, in neat block letters, by the health worker who issues the chart. The completion of each month of life is numbered on the age-axis. The childís age can be read immediately from the age scale at any time, provided the months have been correctly labelled.

(iii) Standards and reference curves

The National Centre for Health Statistics (NCHS) standards were used as it is currently the most frequently used standard values on available cards. The four solid lines plotted on the growth monitoring graph are called centiles.

A centile represents an average weight of most children in the same age group. If the weights of 100 healthy children, according to age groups, are plotted on the graph and the average weight within each age group is calculated, plotted and linked, it will represent the 50th centile reference curve (bold curve on graph). The weights of the 100 healthy children will be scattered around the 50th centile, with more weights near to it rather than far above or below it. To obtain a normal range of weights, an upper and lower reference curve is also plotted. On the graph it is represented by the 97th and 3rd centile reference curves (the 2 curves above and below the 50th centile). This means that of the weights plotted of a 100 healthy children, the weight of 3 healthy children will fall above the 97th centile and the weight of 3 healthy children will fall below the 3rd centile. If a childís weight does fall above the 97th or below the 3rd centile it does not necessarily mean that the child is overweight/underweight or sick, but rather the direction of the childís growth that is important. However, if a childís weight is near or below the 4th line or 60% of average weight, the child is likely to be seriously malnourished.

(iv) Growth direction

2.2 Health and demographic information.

This information is shown on two-thirds of an A4 sheet, next to the growth monitoring chart for children aged three to five years. The chart attempts to present the minimum data needed as clearly as possible. The name Road to Health Chart (RtHC) is a message of the chartís value. A statement, placed at the heading of this section, reminds the parent(s) /caregiver of the need for the chart to accompany the child at every visit to a health facility.

.2.2.1 Child identification

The name and identification number of the child to be stated in full. Tick boy or girl.

2.2.2 Perinatal/Antenatal information

The date of the childís birth is important, as is the place of birth. If a child is born at a maternity home, clinic, health centre or hospital it must be noted as such in the space provided. If a child is born at home, it should be clearly stated (home delivery). Birth weight, birth length, head circumference and gestational age are recorded as baseline data upon which to evaluate future changes. Relevant serology results should also be recorded. Complications during pregnancy and child delivery may influence the health and development of a child. Key words must be used to record this under the heading Problems during pregnancy /birth/neonatally. For example:

during pregnancy:  never attended ANC, WR positive,
  TT not given, high BP.
during labour:  prolonged 2nd stage, forceps.
neonatal:  premature, incubator for 2 weeks.

.The number of sisters/brothers born, and the number alive, must be indicated. The reason(s) for the death of any of the childís sisters/brothers, must be recorded under the heading Reason(s) for death(s):

2.2.3 Parents/caregiver identification

The motherís and fatherís names must be stated in full. If the child lives with someone else, for instance a family member or guardian, this personís name must also be stated. A space is also provided to record the name of the health worker who provided the parent(s)/caregiver with the chart and laid the foundation for the road to health.

2.2.4 Visual/hearing screening

Visual test: From 6 weeks onwards a baby should be able to follow horizontally with both eyes a moving object (pencil/pen), held about 20-30cm from the face, from full left gaze to full right gaze. From 3 years onwards simple eye charts can be used.

Voice test: Stand at armís length behind a young child (>12 months) and say something in a soft whisper. If the child accurately repeats what was said, the child has normal hearing in at least one ear. If the child cannot understand what was said, repeat something else in a normal conversational voice. If the child cannot hear your whispered voice, but can hear your conversational voice, the child has a moderate hearing impairment. If the child still cannot hear, say something in a loud voice. If the child cannot hear your conversational voice, but can hear your load voice, then the child has a severe hearing impairment.

2.2.5 Vitamin A supplementation

When vitamin A supplementation is given to a child, it must be noted on the Vitamin a supplementation chart by date given and signature of the health worker, who administered it.

2.2.6 In need of special care

This information must be recorded so that extra time can be given to discuss problems, provide encouragement and special advice, and early follow-up or referral as necessary. If the child is at risk, record the relevant information under In need of special care.

2.2.7 Immunisation record

A primary schedule (with boosters) for immunisations is given, citing vaccine and prescribed injection site details. Space is provided for other vaccinations. Immunisations must be recorded by date given together with the signature of the health worker who administered it.

IMMUNISATIONS

 

IMMUNISATIONS

Age of child

Vaccine

 

Age of child

Vaccine

At birth

BCG1
Polio vaccine

 

14 weeks old

Polio vaccine
DTP vaccine
Hib vaccine
Hepatitis vaccine

6 weeks old

Polio vaccine
DTP2 vaccine
Hib3 vaccine
Hepatitis vaccine

 

9 months old

Measles vaccine

10 weeks old

Polio vaccine
DTP vaccine
Hib vaccine
Hepatitis vaccine

 

18 months old

Polio vaccine
DTP vaccine
Measles vaccine
 

5 years old

Polio vaccine
DT4 vaccine

1 vaccine against tuberculosis
2
vaccine against diphtheria, whooping cough and tetanus (lock-jaw)
3
vaccine against Haemophilus influenzae type b
4
vaccine against diphtheria and tetanus only

2.3 Health worker consultation sheet..

2.3.1 Health worker consultation.

The space for clinical notes covers two A4 sheets on the inside fold of the RtHC. It should be used for making short keyword notes, including assessment of growth and actions taken, so that all health workers seeing a child, know what has previously been decided/noted of that child. Each entry should take no more than 2-8 lines per visit. For example:. 

02/02/2000:  Cough, fever for two days.
Rapid breathing, T38BC
Pneumonia, Rx amoxycillin 125mg tds x 5 days.

2.3.2 Hospital admissions

At the bottom right of the health workersí consultation sheet is a table to record hospital admissions. On discharge from a hospital, record the discharge diagnosis and any key points for follow-up.

2.3.3 Clinic address

The address of the clinic regularly visited by the parent(s)/caregiver must be completed in full by the health worker. If the babyís family moves to another town/city/rural area, the address of the new clinic visited, must be completed.

3. Future of the Road to Health Chart

The concept and general layout of the chart are very similar to the previous RtHC versions. Research on improving the RtHCís use in the field is encouraged. Comments or enquiries can be forwarded to the following address:

Road to Health Chart
Directorate Nutrition
Department of Health
Private Bag X828
PRETORIA 0001
Fax: (012) 312-3112
Tel: (012) 312-0065