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

Using the World Health Organization (WHO) Growth Charts to Assess Children

from Birth to 2 Years

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 chartsfor infants and children 0 to 2 years of age

• Use the CDC growth chartsfor children ages 2 to 20 years

CHDP requires transition to theWHO growth charts by October 2013

• 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 arethe standard toolfor interpreting growth

WHO Growth Chartsfor Infants and Children Birth to 24 Months

Compare the WHO Growth Standards and the CDC Growth Reference

Comparison WHO Growth Chart CDC Growth Chart

Studied population Breastfedinfants and toddlers

Breastfed and formula fed infants and toddlers

Growth pattern How healthy children SHOULD GROW in ideal conditions

How certain groups of children HAVE GROWN in the past

Concept of growth A STANDARD by which all children should be compared

A REFERENCE does not imply that pattern of 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

Mode of feedingGrowth in thefirst 3 months

Growthafter 3 months

Breastfeeding Faster Slower

Formula Slower Faster

Impact of WHO Growth Charts on the Interpretation of Growth

Mode of feeding can influence infant growth rate

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

Breastfed infantsgrow fasterin the first 3 months

Breastfed infants grow slower from3 to 12 months

Girls: Birth to 24 monthsWeight-for-age curves

Growth Rate for Breastfed Infant

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 5th percentile on Length-for-age charts

Compare the WHO and CDC Growth Prevalence Rates by Age

Low weight-for-age*

Low length-for-age*

High weight-for-length†

Recommended Cutoffs WHO Growth Charts - Birth to 24 months

2 - 98 %Healthy weight

> 98 %High weight-for-length

< 2 %Low weight-for-length

9850 959075251052

5 - < 85 %Healthy Weight

≥ 95 %Obese

< 5 %Underweight

50 95857525105

85 - < 95 %Overweight

Recommended BMI-for-Age Cutoffs CDC Growth Charts - 2 to 20 Years

Use terms “overweight” and “obese” only for children and teens between 2 and 20that fall in the corresponding %ile ranges

WHO Growth StandardsBirth 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 monthsHead circumference-for-

age Weight-for-lengthLength-for-ageWeight-for-age

Girls: Birth to 24 monthsHead circumference-for-

age Weight-for-lengthLength-for-ageWeight-for-age

Incorporating the WHO Growth Charts Into Your Practice

• CHDP requires that enrolled providers transitionto 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 Deviatesfrom 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 ExampleGraph 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 CDCCDC Weight-for-Age Growth Chart WHOWHO Weight-for-Age Growth Chart

George George

Comparing Weight-for-LengthCDCCDC Weight-for-Length Growth Chart WHOWHO Weight-for-Length Growth Chart

George George

Moving from WHO to CDC Chartsat 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 Changesfor 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

• 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

How to Get Started

References

• WHO Growth Chart Trainingshttp://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 Reportshttp://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm

• WHO Growth Chartshttp://www.cdc.gov/growthcharts/who_charts.htm

• AAP Policy Statement:Breastfeeding and the Use of Human Milkhttp://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 materialshttp://www.nal.usda.gov/wicworks/Sharing_Center/gallery/family.html http://wicworks.nal.usda.gov/breastfeedinghttp://www.cdph.ca.gov/programs/wicworks/Pages/WICBreastfeeding.aspx

• Women, Infants and Children Program (WIC)http://www.cdph.ca.gov/programs/wicworks/Pages/default.aspxSlides 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