Growth Chart

Dr. Irum Gilani

Associate Professor
Health Services Academy, Islamabad
Learning outcomes
At the end of this session, learners will be able to:-
– Distinguish between standards and reference for growth
monitoring.
– Understand method utilized by the WHO to calculate
growth standards of 2006.
– Differentiate between methods of growth assessment
based on standard/ z-scores and percentiles.
– Apply knowledge to identify malnutrition-related
conditions from examples (plotted growth chart).

2
 Types of Growth Assessment

• Longitudinal growth assessment entails measuring the

same child at regular intervals
• Cross sectional comparisons of growth involve a large
number of children of the same age.
 Growth Chart
• A growth or “road-to-health” chart is a tool that visually depicts the
growth of a child from birth to 5 years. Growth chart is designed
primarily for the longitudinal growth monitoring.
• Each baby should have its own growth chart containing repeated
measurements at intervals; ideally monthly from birth to 1 year, every
two months during the second year and every 3 months thereafter up
to 5 years of age.
• Growth measurements are compared with reference standards of the
children of the same age. There are separate growth charts for boys
(blue) and girls (pink).
 WHO child growth standards, 2006
▪ For developing the WHO growth standards 2006, a Multicenter
Growth Reference Study (MGRS) was undertaken between 1997 and
2003 in Brazil, Ghana, India, Norway, Oman and the USA.
▪ Primary data was gathered from 9,440 healthy breast-fed infants and
young children (0 to 60 months boys and girls) from widely diverse
backgrounds and cultural settings of six countries selected for the
MGRS. A sample which is utilized to set standards (or reference values)
for a specific population is known as standardization sample.
▪ Characteristics (e.g., age, gender, education, income) of the
standardization sample are the same as those of the larger population
on which the standards (or reference values) are intended to be
applied.
 WHO child growth standards, 2006
▪ During analysis of the scores of the standardization sample, their
average performance level and the relative frequency of each deviation
from the mean are ascertained and tabulated.
▪The standardization sample of the Multicenter Growth Reference
Study (MGRS) was based on privileged and healthy children living
under conditions likely to favour achievement of their full genetic
growth potential and to reduce the impact of environmental variations.
▪ Furthermore, mothers of children in the MGRS were engaged in
fundamental health-promoting practices, namely breastfeeding and
not smoking. Hence, the WHO growth standards 2006 can be used to
assess children regardless of ethnicity, socioeconomic status and type
of feeding.
 Standard Vs Reference values
• The WHO Multicenter Growth Reference Study (MGRS) was
designed to produce ‘standard’ rather than ‘reference.’

• In practice references often are mistakenly used as standards of

growth owing to the fact that both serve as basis for comparison.
However, a growth ‘standard’ defines how children should grow
and deviations from it are evidence of abnormal growth while a
growth ‘reference’ does not provide sound basis for such value
judgments.
 Methods of Growth Assessment
By utilizing the WHO growth standards 2006, measurement and
comparison of children’s growth can be carried out:-
• Based on standard or Z-scores: A variation of 2 standard
deviations (SD) from either side of the mean (or median) is
considered as within normal limits.
• Based on percentiles: Range of normal is between 3rd and 97th
percentiles.
 1. Standard or Z-score based growth assessment
• Any normal distribution can be converted into the standard normal distribution for
the purpose of converting variables measured in different units into a standard
score to be displayed on the same axes.
• A standard normal distribution with a mean of zero and the standard deviation of 1
is known as the Z-distribution whose values are called standard or a Z-scores.
 Standardizing a dataset to Z-scores
To convert a value to a standard or "z-score”:-
first subtract the value from the mean,
then divide by the Standard Deviation
Converting a measurement to a Z-score indicates how far from the mean the
observation lies in units of standard deviations.
 Standardizing Anthropometry Scores of boys to Z-scores

Abdullah’s measured weight at birth (0 week)= 2.7 kg

Median/average weight-for-age standard for boys at birth (0 week)= =3.3 kg
Standardizing Abdullah’s weight= 2.7(measured weight)- 3.3(standard value of
median)/0.14602 (Standard Deviation)=-4.1 which falls at +2 SD (normal range is
between -2 SD and +2 SD of the average).
 Z-score Growth Charts

Normal range is between +2 SD and -2 SD of the average.

 Growth chart of a girl named Noor Bibi from birth till 10 months of age at monthly
interval. Trend in her growth chart shows that Noor Bibi’s weight remained within normal
limit (between average and -2SD) but towards the lower side. This concludes that Noor
Bibi is a smaller than average girl.
 Growth chart of a girl named Mussarat from birth till 10 months of age at monthly interval.
Trend in her growth chart shows that Mussarat’s weight remained low beyond -3SD which is
not within the normal limits, thus, she is a low-birth-weight girl.
Growth chart of a girl named Eisha from birth till 10 months of age at monthly interval. Trend
in her growth chart shows that Eisha’s weight remained within normal limits till the age of 6
months. Afterwards, she gained weight faster than usual and her weight was beyond +2SD
concluding her overweight status.
 2. Percentile based growth assessment
Percentile: A statistical measure in which a
population is divided into 100 equal parts,
with each part representing 1% of the total.
Percentile versus percentage- percentiles
are relative measures, while percentages are
absolute measures.
Example: A student appears for two tests,
one uses percentiles to determine who
passed while the other uses percentages for
the same purpose. Both have the same
numerical value- 50th percentile or 50% as
the cutoff value. The student scored 60/100
but she failed the first test that uses
percentiles while passed the second using
percentages.
This happened because the test was very easy, and most students scored 70 to 90 out of 100. The cutoff was
set at the 50th percentile (50% of scores fall below the median). Since the exam median was around 70, she
did not pass. On the other hand, the relative performance of other candidates did not matter in the second
test using percentages, hence, all that she needed to pass was a score equal to or above 50%.
 Percentile Vs Standard or Z-score

Most standardized tests have mean Z-score of 100 and SD of 15 points.

Standard/Z-scores between 85 and 115 are within average range. Standard
score below 85 is considered below the average range.
Percentile ranks on a standardized test compare a child with other children
of his/her age. For example, if a child has percentile rank of 16, he/she scored
higher than 16% of children of the same age who took the test.
 Revision of Standardization Sample
• A standardized test like the USMLE (United States Medical Licensing Examination ) requires
all test-takers to answer the same questions and is scored in a “standard” or consistent
manner, which makes it possible to compare the relative performance of the test-takers.
• Reliable reference values for a specific population are generated with the help of a
standardization sample. For example, the standardization sample for a new test of
computer literacy in older adults might comprise of a large set of test takers above age 60
whose characteristics (e.g., sex, education, place of residence) are the same as those of the
larger population on which the test is intended to be administered.
• The arrangement of scores obtained by analyzing the results of the computer literacy test
administered on the standardization group (of over age 60 years) subsequently provides
reference values against which the scores of other old test-takers will be compared on the
same computer literacy test.
• During analysis of the scores of the standardization sample, their average performance
level and the relative frequency of each deviation from the mean are ascertained.
 Standardizing Anthropometry Scores of boys to Percentiles

Abdullah’s measured weight at birth (0 week)= 2.7 kg

Median/50th percentile weight-for-age standard for boys at birth (0 week)= =3.3 kg
Standardizing Abdullah’s weight= 2.7(measured weight)- 3.3(standard value )/0.14602 (Standard
Deviation)=-4.1 which falls at 95th percentile which is within the normal range from 3rd to 97th
percentile.
Standardizing Anthropometry Scores of girls to Percentiles
 Percentile-based Growth Chart

Normal range is between 3rd to 97th percentiles.

 Percentile Vs Z-score Growth Charts

A Z-score of +2 corresponds to 97th percentile while Z-scores of +3 and -

3 corresponding to above 97 percentile and below 3 percentile are
taken as abnormal.
Percentile growth chart of a girl named Hina maintained at every 2 months till 12 months of
age. Her weight was normal (50th percentile) when she was 2 and 4 months old. However,
Hina gradually lost weight at 6, 8,10 and 12 months of age. Trend in her growth chart shows
dropping on the percentile lines from 50th to 15th which is a cause for concern.