Preventing growth faltering among Australian Indigenous children: implications for policy and practice

Elizabeth L McDonald, Ross S Bailie, Alice R Rumbold, Peter S Morris and Barbara A Paterson
Med J Aust 2008; 188 (8): S84. || doi: 10.5694/j.1326-5377.2008.tb01753.x
Published online: 21 April 2008


Objective: To determine what preventive models or programs are most likely to improve patterns of growth faltering in children aged under 5 years in remote Australian Indigenous communities.

Methods: Nine electronic databases and the websites of key stakeholder, government and non-government agencies were searched. Two reviewers independently assessed articles for inclusion and for study quality. All types of study design were eligible.

Results: 140 studies assessing a diverse range of interventions were identified. Of these, 51 articles referring to 44 individual programs and 7 review articles met the review criteria. The evidence for the effectiveness of many interventions to prevent growth faltering is not strong, and any observed effects are modest. Community-based nutrition education/counselling and multifaceted interventions involving carers, community health workers and community representatives, designed to meet program best-practice requirements and address the underlying causes of growth faltering, may be effective in preventing growth faltering. Other interventions, such as food distribution programs, growth monitoring, micronutrient supplementation and deworming should only be considered in the context of broader primary health care programs and/or when there is an identified local need.

Conclusion: For remote Indigenous communities, development and implementation of programs should involve a consideration of the evidence for potential impact, strength of community support and local feasibility. Given the lack of strong evidence supporting programs, any new or existing programs require ongoing evaluation and refinement.

Our review was commissioned as a result of an international trend to encourage public policy and management to be better informed by the results of relevant and reliable research.1 The need for this comes from research showing that some health and social interventions believed to be beneficial were in fact harmful; some interventions, although expensive, were largely ineffective; and some effective inventions have been adopted only slowly or ignored.2

Frequently, the incorporation of interventions into policy is influenced more by different perceptions of the seriousness and cause of problems (held by politicians, the general public, and influential individuals or organisations) rather than the evidence available.3 This is very much the case in developing policies and programs to address the health and other problems confronting Indigenous Australians. The subject of our review is the problem of growth faltering, and subsequent failure to thrive, among Australian Indigenous children. The causes of this problem are multiple and complex. There are no simple or quick solutions to achieve sustainable reductions in prevalence.

The normal growth curve of children is represented as gradual, incremental increases in weight from birth based on regular recordings of bodyweight.4 Growth faltering is a reduction in the expected rate of growth along an infant’s previously defined growth curve. In contexts of poverty, growth faltering typically occurs at about 6 months of age with children’s transition to foods that are often inadequate in quantity and quality. In addition, the children experience greater exposure to the environment and the increased likelihood of illness.5 Preventing growth faltering is important, as early childhood growth and development set a base for subsequent learning, behaviour and health over the life cycle.6

In the Northern Territory, rates of underweight among Indigenous children are slowly declining. However, Indigenous children under 5 years in remote NT communities still experience high levels of underweight (14.5%), stunting (11.3%) and wasting (9.0%).7 In a healthy population profile, the expected prevalence of underweight is ≤ 2.3%.7 A complex mix of factors, including poor nutrition, acute and chronic infections and parasitic diseases, combines to hinder the healthy growth of Indigenous children in remote communities.8 Addressing the problems that underlie these conditions and the level of disadvantage experienced by Australian Indigenous people presents a significant challenge to policymakers. We undertook a systematic literature review to determine what preventive models or programs are most likely to improve patterns of growth faltering in children aged under 5 years in remote Indigenous communities.


A key implication of our findings is reflected in a recent report on policies of Australian governments in the broad area of child health and wellbeing.12 The report identifies better coordination of existing policies as the priority issue for child health. The report also highlights the need to identify any gaps in existing policy. These actions are necessary because child health policies are being developed in several sectors and implemented across several portfolios (for example health, welfare and education), as well as through several levels of government.

This results in a fragmented approach to program development and service delivery, which in turn makes it difficult for those working at community level to take a strategic approach to addressing Indigenous child health problems. This is particularly evident when these problems arise from a mix of complex issues such as poor living conditions, overcrowding, low socioeconomic status, family and community dysfunction, and poor access to early intervention and social support services.

The implications for policy and practice from the research evidence arising from this review are:

These potential interventions rely on some understanding of the factors that underlie growth faltering in a particular community. The relative significance of individual factors is likely to vary between communities. Box 2 provides a framework to guide policy for improving the growth and development of young Indigenous children and preventing disease. Policy and programs have tended to “medicalise” the problem of growth faltering, the causes of which are now recognised as being largely social and economic in origin.14

Several important implications for policy and practice were drawn from the general literature, including the following:

Hence, while the underlying causes of growth faltering in a remote community should inform the choice of intervention(s), the approach taken to implementing interventions needs to be acceptable to community members.

The complex nature of growth faltering (and the importance of the problem) is reflected in the diversity of interventions identified and assessed in our review. It is clear that the serious consequences of growth faltering require immediate measures to limit its impact, as well as longer term measures to address the underlying causes of the problem. It is critical that interventions to prevent growth faltering among Australian Indigenous children living in remote communities address the complex mix of social, cultural, economic and environmental factors that underlies the problem.

There is a clear need for high-quality evidence to support specific preventive interventions, in addition to better evidence on approaches to implementing interventions. This is especially relevant to remote Indigenous communities, where the primary cause of disadvantage is largely related to social exclusion and poverty. International experience indicates that coordinating interventions between the health sector and other sectors will do more to improve children’s health in contexts of poverty than a series of single interventions, or than one sector trying to address the problem alone.15 Strengthening resources and capacity at the community level to plan and implement preventive programs that are culturally appropriate, participatory, and focus on the family, appears to be the key to success and sustainability of interventions.

1 Review findings

The nature of the interventions to prevent growth faltering that have been the subject of research is diverse. Interventions, used singly or in combination, have included food supplements (for children and pregnant or lactating women), growth monitoring, education/counselling (for carers of children, community workers or health workers), deworming, vitamin and mineral supplements, multiple micronutrient supplements, and studies that simultaneously address more than one underlying factor.

Approaches used to implement interventions have included centre-based programs and home visiting. The quality of research evidence for interventions is variable and generally poor. Many reports focus on specific interventions rather than program models, and the reporting of information on intervention design and implementation is generally inadequate. The major findings of our review were as follows:

1. While the evidence is not strong and the effects are modest, the interventions for which there is some evidence of benefit in general populations include:

2. Interventions for which there is some evidence of benefit in specific populations include:

3. Interventions for which the research evidence clearly supports neither implementation of new programs nor withdrawal of existing programs* include:

4. Interventions where the research showed no clear evidence of benefit include:

* Interventions for which there is no evidence of benefit or harm (in some studies, there were methodological concerns).

  • Elizabeth L McDonald1
  • Ross S Bailie1
  • Alice R Rumbold1
  • Peter S Morris1,2,3
  • Barbara A Paterson4

  • 1 Menzies School of Health Research, Charles Darwin University, Darwin, NT.
  • 2 NT Clinical School, Flinders University, Darwin, NT.
  • 3 Royal Darwin Hospital, Darwin, NT.
  • 4 Maternal and Child Health Division, Northern Territory Department of Health and Community Services, Darwin, NT.


Competing interests:

None identified.

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