Using the World Health Organization

(WHO) Growth Charts to Assess Children

from Birth to 2 Years

Adapted by the State of California CHDP Nutrition Subcommittee

from the online training module:
Using the WHO Growth Charts to Assess Growth in the United States
Among Children Ages Birth to 2 Years
Centers for Disease Control and Prevention, 2012
November 2012
 Objectives

By the end of this presentation, you will be able to:

• Describe the new WHO growth chart
• Understand differences between WHO and CDC
growth charts for infants and children 0-2 years
• Plot on the appropriate growth chart
• Interpret results and make referrals when
appropriate
Growth Chart Recommendations for
Health Care Providers
CDC recommends that health care providers:
• Use the WHO growth charts
for infants and children 0 to 2 years of age
• Use the CDC growth charts
for children ages 2 to 20 years
CHDP requires transition to the
WHO growth charts by October 2013
 WHO Growth Charts
for Infants and Children Birth to 24 Months
• Child growth is monitored to:
– Assess adequacy of nutrition
– Identify weight status and potential for obesity
– Screen for disease related to abnormal growth

• Growth charts are

the standard tool
for interpreting growth
Compare the WHO Growth Standards
and the CDC Growth Reference

Comparison WHO Growth Chart CDC Growth Chart

Studied population Breastfed Breastfed and formula
infants and toddlers fed infants and toddlers
Growth pattern How healthy children How certain groups of
SHOULD GROW in children HAVE GROWN
ideal conditions in the past
Concept of growth A STANDARD by which A REFERENCE does not
all children should be imply that pattern of
compared growth is optimal
 Benefits of Using WHO Growth Charts

• Based on high quality population data

• Growth charts align with AAP and WIC growth
assessment tools and feeding
recommendations
• Supports breastfeeding as optimal nourishment
• Allows provider to address feeding practices
and family environment
Impact of WHO Growth Charts on the
Interpretation of Growth

Mode of feeding can influence infant growth rate

Growth in the Growth

Mode of feeding first 3 months after 3 months
Breastfeeding Faster Slower
Formula Slower Faster
 Growth Rate for Breastfed Infant
Breastfed infants
grow faster
in the first 3 months

Girls: Birth to 24 months

Breastfed infants Weight-for-age curves
grow slower from
3 to 12 months
Adapted from Figure 2. Use of World Health Organization and CDC Growth Charts for Children Aged 0--59 Months in the United States. CDC
Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2010; 59(rr09):1-15.
Available online at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm
 WHO Growth Charts Are Different

• Fewer infants are below 5th percentile on Weight-for-age

charts
• Fewer infants are above 95th percentile on Weight-for-
length charts
• Fewer infants are below 5th percentile on Weight-for-
length charts
• A similar number of infants are below 5 th percentile on
Length-for-age charts
Compare the WHO and CDC Growth Prevalence Rates by Age

Low length-for-age* Low weight-for-age* High weight-for-length†

 Recommended Cutoffs
WHO Growth Charts - Birth to 24 months
<2% 2 - 98 % > 98 %
Low weight-for-length Healthy weight High weight-for-length

2 5 10 25 50 75 90 95 98
 Recommended BMI-for-Age Cutoffs
CDC Growth Charts - 2 to 20 Years
<5% 5 - < 85 % 85 - < 95 % ≥ 95 %
Underweight Healthy Weight Overweight Obese

5 10 25 50 75 85 95

Use terms “overweight” and “obese” only

for children and teens between 2 and 20
that fall in the corresponding %ile ranges
 WHO Growth Standards
Birth to 24 Months
• Growth Parameters
– Weight-for-age
– Length-for-age
– Weight-for-length
– Head circumference-for-age

• No BMI percentile because this is not a

measure used for children younger than 2
 Boys: Birth to 24 months
Length-for-age Head circumference-for-age
Weight-for-age Weight-for-length
 Girls: Birth to 24 months
Length-for-age Head circumference-for-age
Weight-for-age Weight-for-length
 Incorporating the WHO Growth Charts
Into Your Practice
• CHDP requires that enrolled providers transition
to WHO growth charts by October 2013
• Review growth at each health assessment and
interpret carefully
• Understand that an infant will plot differently on the
WHO growth chart than on the CDC chart

• Encourage breastfeeding
• Review feeding with each health assessment and
determine if foods are developmentally appropriate
 When Growth Deviates
from the Norm
• Check accuracy of your measurements
• Note that individual growth may not follow a
smooth curve
• Recognize limitations of a single growth
percentile value
• Obtain serial measurements over time
• If weight-for-length is < 2nd % or > 98 %,
assess fully, follow closely and refer, if needed
 Case Example
Graph George’s Growth
George is an 18-month-old boy. George's mother,
Rae, works outside the home. George is cared for by
his grandmother during the day when Rae is
working. George has been formula-fed since birth,
and he was around 5 months of age when he began
eating solid foods. George has been seen by his
health care provider regularly since birth, and his
weight and length have been recorded and plotted
on the growth chart at each visit.
 Graph George’s Growth
CDC Weight-for-Age Growth Chart WHO Weight-for-Age Growth Chart
George George
 Comparing Weight-for-Length
CDC Weight-for-Length Growth Chart WHO Weight-for-Length Growth Chart
George
George
 Moving from WHO to CDC Charts
at 2 Years

• Recumbent length to standing height measurements

(difference is approximately 0.8 cm or ¼ inch)
• Optimally fed study population to a reference
population using the general pediatric population
• WHO weight-for-length to CDC BMI-for-age percentile

• 5th - 95th cutoff values to 2nd - 98th cutoff values

 Possible Changes
for an Individual Child at Age 2

• Length-for-age percentile may be

similar
• CDC weight-for-age may be lower

• CDC BMI-for-age percentile may be

lower than WHO weight-for-length
 How to Get Started

• Develop protocol for weighing and measuring

• Select appropriate charts for age and gender

• Record and plot on growth charts

• Interpret growth indicators

• Counsel on growth and feeding

• Support breastfeeding
 References
• WHO Growth Chart Trainings
http://www.cdc.gov/nccdphp/dnpao/growthcharts/who/index.htm
http://www.who.int/childgrowth/training/en/
• CDC Morbidity and Mortality Weekly Report (MMWR)
Recommendations and Reports
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm
• WHO Growth Charts
http://www.cdc.gov/growthcharts/who_charts.htm
• AAP Policy Statement:
Breastfeeding and the Use of Human Milk
http://www2.aap.org/breastfeeding/files/pdf/Breastfeeding2012ExecSum.pdf
 Training and Education Tools
• CHDP Training Modules
– How to Accurately Weight and Measure Children
– Using Body Mass Index-for-Age Growth Charts
– Counseling the Overweight Child
– Promoting Physical Activity
– Glucose and Cholesterol Screening
http://www.dhcs.ca.gov/services/chdp/Pages/Training.aspx

• Breastfeeding materials
http://www.nal.usda.gov/wicworks/Sharing_Center/gallery/family.html
http://wicworks.nal.usda.gov/breastfeeding

http://www.cdph.ca.gov/programs/wicworks/Pages/WICBreastfeeding.asp
x
• Women, Infants and Children Program (WIC)
http://www.cdph.ca.gov/programs/wicworks/Pages/default.aspx
Slides 11 and 12 of this presentation were adapted from the WIC WHO Growth Charts In-Service Training:
http://www.cdph.ca.gov/programs/wicworks/Pages/WorldHealthOrganization(WHO)GrowthCharts.aspx