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Growth charts
UPDate 2014
Jean Cloete
Normal growth
Normal growth is a reflection of
overall health and nutritional status
Understanding
normal growth
Early detection of pathologic deviations
o Poor weight gain due to a metabolic disorder
o Short stature due to inflammatory bowel disease
Prevent the unnecessary evaluation of children with
acceptable normal variations in growth
Which factors influence
growth
Genetics
Environment
Ethnicity
Psycho
social stress
Health
Nutrition
Growth reference
Certain children grew
Particular place and time
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CDC Charts 2000
Smoothed observed centiles from 1978 to 1994
Large cross section of US infants actually grew 1970
to early 1990
Mixed feeding predominantly Formula fed
No exclusion criteria
Revised - CDC charts 2000
CDC Growth reference
Reference curves utilized to
Define the extent and severity of anthropometric
status
Evaluate impact of nutritional interventions
Problem:
Inadequate low frequency of measurements
during infancy
Outdated analytical methods
Growth standards
How children should grow if optimal
Nutrition
Environment
Health
conditions
WHO growth
standards 2006
Goal:
Children born in different regions of the world
Given an optimal start in life
Have the potential to grow and develop within the
same range of height and weight for age
WHO Standards
Primary data collected through population based study
8 446 participants
1997-2003
Longitudinal follow up
Measurements were done 2 weekly
Brazil
Ghana
India
Norway
Oman
USA
Endpoint
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Differences
WHO charts vs CDC charts
Weight for Age
Weight for Age
Differences are particularly important during
infancy.
The divergence in the shape of the curves is likely
due to
issues related to study design (i.e., sample size
and measurement intervals)
characteristics of the sample, mainly differences
in type of feeding.
Weight for Age
CDC curves probably fail to capture the rapid and
changing rate of weight gain in early infancy.
WHO curves to capture the rapidly changing
pattern of growth in early infancy, including the
physiological weight loss that takes place in the first
few days of life.
Weight for Age
Differences in feeding types
WHO standards are based solely on breastfed infants
CDC charts are still based on relatively few infants
who were breast-fed for more than a few months.
The CDC growth charts have proven to be
inadequate for monitoring the growth of breast-fed
infants.
Length for Age
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Length for Age
The shape of the 2 sets of curves is very similar
Average, children in the WHO standard are
somewhat taller than those in the CDC reference.
A notable difference is the tighter variability of the
WHO curves.
For all age groups, stunting rates (i.e., , 22 SD) will
be higher when based on the WHO standard.
Weight for Length/Height
Weight for length/height
CDC charts (U.S. children) are generally heavier
than those included in the WHO sample.
This applies to all the older children, but also to the
upper centiles at younger ages, which likely reflects
greater skew ness in U.S. infant weights.
Weight for length/height
CDC weight-for-height curves are inadequate for
monitoring obesity from 100 cm onward for
example, children measuring 115 cm have a similar
Z-score whether they weigh 30, 40, or 50 kg.
Similarly, the pattern of the lower centiles of the
CDC weight-for-length chart below 53 cm may
reflect peculiarities of the birth registry data used to
anchor the CDC curves.
Weight for length/height
The WHOs weight-for-length curves extend to a
greater length than the CDC curves
110 cm vs. 103 cm to facilitate assessment of tall 2-yolds
and older children who, for whatever reason are unable to
stand
WHO weight-for-height curves start earlier
65 cm than the CDC curves 78 cm to facilitate assessment
of populations with high rates of stunting
Body Mass Index
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BMI
The BMI-for-age curves are dramatically different,
Partly reflecting obesity in the U.S. sample.
The gap at 5 y of age is in line with the gap
observed at 20 y of age in the CDC curves
97th BMI-for-age centile for boys and girls is,
respectively, 32.1 and 33.9, well above the
recommended BMI obesity cut off of 30 for adults
BMI
Estimates of overweight and
obesity will increase
substantially when with
WHO BMI standard
Difference in - 2 SD and -3 SD in the BMI curves
result in lower estimates of under nutrition
Why use WHO growth standards for
infants and children?
The WHO standards establish growth of the
breastfed infant as the norm for growth.
The WHO standards provide a better description of
physiological growth in infancy.
Clinicians often use the CDC growth charts as
standards on how young children should grow
The WHO standards are based on a high-quality
study designed explicitly for creating growth charts.
5 19 year old
WHO Growth reference for children 5-19 years
The WHO Reference 2007 is a reconstruction of the
1977 National Centre for Health Statistics
(NCHS)/WHO reference
It uses the original NCHS data set supplemented
with data from the WHO child growth standards
sample for under-fives
Same statistical methodology was used as in the
construction of the WHO standards.
5 19 year old
Merged data sets resulted in a smooth transition at
5 years for height-for-age, weight-for-age and BMI-
for-age
For BMI-for-age across all centiles the magnitude of
the difference between the two curves at age 5
years is mostly 0.0 kg/m to 0.1 kg/m.
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5 19 year old
At 19 years, the new BMI values at +1 Z score
25.4 kg/m for boys
25.0 kg/m for girls
These values are equivalent to the overweight cut-off for
adults (> 25.0 kg/m)
The +2 Z score value
29.7 kg/m for both sexes
compares closely with the cut-off for obesity > 30.0 kg/m
5 19 year old
Population serving good socio economic
background and essentially healthy
Consider using WHO charts
Diagnose possible obesity earlier Opportunity to
intervene earlier
Chronically ill patients
WHO charts under nutrition under diagnosed
Stunting more prevelant with WHO charts
CDC charts 2 years to 19 years
As both are references consider using the one most
appopriate to your needs
Growth reference 5-19 years
depends on patient
population
Most countries have
adopted WHO growth
standards
Other charts
Premature charts
Downs Syndrome charts
Turner Syndrome charts
Cerebral palsy charts
Examined
patient
Plotted the
patient
Interpret
charts
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WHO Standards Interpretation
Z ZZ Z- -- -
score score score score
Length/height Length/height Length/height Length/height
for age for age for age for age
Weight Weight Weight Weight for Age for Age for Age for Age
Weight Weight Weight Weight for for for for
length/height length/height length/height length/height
BMI BMI BMI BMI f ff for or or or A AA Age ge ge ge
> 3 > 3 > 3 > 3 Very tall Very tall Very tall Very tall Obese Obese Obese Obese Obese Obese Obese Obese
> 2 > 2 > 2 > 2
Possible growth Possible growth Possible growth Possible growth
problem problem problem problem
Overweight Overweight Overweight Overweight Overweight Overweight Overweight Overweight
> 1 > 1 > 1 > 1
Possible growth Possible growth Possible growth Possible growth
problem problem problem problem
Possible risk of Possible risk of Possible risk of Possible risk of
overweight overweight overweight overweight
Possible risk of Possible risk of Possible risk of Possible risk of
overweight overweight overweight overweight
0 0 0 0
< < < < - -- -1 11 1
< < < < - -- -2 22 2 Stunted Stunted Stunted Stunted Underweight Underweight Underweight Underweight Wasted Wasted Wasted Wasted Wasted Wasted Wasted Wasted
< < < < - -- -3 33 3
Severely Severely Severely Severely
stunted stunted stunted stunted
Severely Severely Severely Severely
underweight underweight underweight underweight
Severely wasted Severely wasted Severely wasted Severely wasted Severely wasted Severely wasted Severely wasted Severely wasted
Malnutrition
Malnutrition
Weight for height assist
Deciding between chronic malnutrition and acute
malnutrition
Acute on chronic malnutrition
Mid upper arm
circumference
Mid upper arm
circumference
Mid upper arm circumference
6 months to 5 years
Standardized with charts
Easy to do
Assessment of nutritional state
Just as predictive of death as Weight for height Z
scores
Severe Acute Malnutrition
Weight for Height Z score < -3 SD
or
Height for Age < -3 SD
or
Bilateral pitting oedema of nutritional origin nutritional origin nutritional origin nutritional origin
or
Mid-upper-arm circumference < 11.5 cm
(children 1-5 years)
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Moderate Acute
Malnutrition
-3 SD < Weight for Height Z score < -2 SD
or
-3 SD < Height for age < -2 SD
or
No No No No Bilateral pitting oedema of nutritional origin nutritional origin nutritional origin nutritional origin
or
11.5 cm < Mid-upper-arm circumference < 12.5 cm
(children 1-5 years)
Online resources
WHO Anthro -
http://www.who.int/nutgrowthdb/software/en/
WHO Anthro Plus -
http://www.who.int/growthref/tools/en/
Nutristat http://nutristat.codeplex.com/
References
1. Comparison of the WHO child Growth standards and the national centre for health statistics/WHO
international growth reference: implications for child health programmes. De Onis M et al, Public Health
Nutrition 9(7), 942 - 947
2. Use of WHO Health organization and CDC growth charts for children aged 0-59 months in the United
States Mortality and Morbidity Weekly report September 2010 Accessed www.cdc.gov/mmwr
3. Comparison of the prevalence of shortness, underweight and overweight among US children aged 0 to
59 months by using the CDC 2000 and the WHO 2006 Growth charts Mei Z et al, Journal of Pediatrics
2008
4. Is the 2000 CDC growth reference appropriate for developing countries ? Roberfoid D et al, Public
Health Nutrition: 9(2), 266-268
5. Development of normailzed curves for the international growth reference: historical and technical
considerations Dibley M et al, Am J Clin Nutr 1987;46:736 48
6. Standard deviations of anthropometric Z-scores as a data quality assessment tool using the 2006 WHO
growth standards: a cross country analysis Mei Z et al, Bulletin of the WHO June 2007, 85 (6)
7. Assessing the impact of the introduction of the WHO growth standards and the weight for height Z
scores criterion on the response to treatment os severe acute malnutrition in children: Secondary Data
Analysis Isanaka S, Pediatrics 2009;123;e54
8. Are universal standards for optimal infant growth appropriate ? Evidence from Hong Kong Chinese
birth cohort. Hui L et al, Arch Dis Child 2008 93:561-565
9. Field testing the WHO child growth standards in four countries. Onyango A et al, Journal of Nutrition
2007 137:149-152
10. Comparison of the WHO child growth standards and the CDC 2000 growth charts. Onis M Journal of
Nutrition 137:144-148, 2007
11. CDC Growth Charts: United States NCHS Number 314 May 30, 2000
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References
12. SCN Endorses the New WHO Growth Standards for Infants and Young Children UNITED NATIONS
SYSTEM Standing Committee on Nutrition http://www.unsystem.org/scn
13. Child growth standards and the identification of severe acute malnutrition in infants and
children - A Joint Statement by the World Health Organization and the United Nations
Childrens Fund http://www.who.org
14. Guidelines for the inpatient treatment of severely malnourished children - Ann Ashworth
Sultana Khanum,Alan Jackson, Claire Schofield. http://www.who.org
15. Short Stature in Childhood Challenges and Choices - David B. Allen, Leona Cuttler-
N Engl J Med 2013;368:1220-8
16. Using the New World Health Organisation Growth Standards: Differences From 3
Countries -Bridget Fenn and Mary E. Penny - Journal of Pediatric Gastroenterology and
Nutrition 46:316321
17. WHO guidelines for management of severe malnutrition in rural South African hospitals: effect on case
fatality and the influence of operational factors - Ann Ashworth Lancet 2004; 363: 1110115
18. Use of Mid-upper Arm Circumference for Evaluation of Nutritional Status of Children and for
Identification of High-risk Groups for Malnutrition in Rural Bangladesh - Nikhil Chandra Roy J Health
Popul Nutr Dec 2000
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