Using the World Health Organization (WHO) Growth Charts to Assess Children from Birth to 2 Years

1
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
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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

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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

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WHO Growth Chartsfor 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 arethe standard toolfor
  interpreting growth

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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
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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

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Impact of WHO Growth Charts on the Interpretation
of Growth
Mode of feeding can influence infant growth rate

Mode of feeding Growth in thefirst 3 months Growthafter 3 months
Breastfeeding Faster Slower
Formula Slower Faster
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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
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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

10
Compare the WHO and CDC Growth Prevalence Rates
by Age
Low weight-for-age
Low length-for-age
High weight-for-length
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Recommended Cutoffs WHO Growth Charts - Birth to
24 months
12
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 20 that fall in
the corresponding ile ranges
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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

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Boys Birth to 24 months

• Head circumference-for-age Weight-for-length

• Length-for-age
• Weight-for-age

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Girls Birth to 24 months

• Head circumference-for-age Weight-for-length

• Length-for-age
• Weight-for-age

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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

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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 lt 2nd or gt 98 ,assess
  fully, follow closely and refer, if needed

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Case ExampleGraph Georges 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.

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Graph Georges Growth
CDC Weight-for-Age Growth Chart
WHO Weight-for-Age Growth Chart
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Comparing Weight-for-Length

• CDC Weight-for-Length Growth Chart

• WHO Weight-for-Length Growth Chart

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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

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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

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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

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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 StatementBreastfeeding and the Use
  of Human Milk
• http//www2.aap.org/breastfeeding/files/pdf/Breas
  tfeeding2012ExecSum.pdf

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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/Traini
  ng.aspx
• Breastfeeding materials
• http//www.nal.usda.gov/wicworks/Sharing_Center/g
  allery/family.html
• http//wicworks.nal.usda.gov/breastfeeding
• http//www.cdph.ca.gov/programs/wicworks/Pages/WI
  CBreastfeeding.aspx
• Women, Infants and Children Program
  (WIC)http//www.cdph.ca.gov/programs/wicworks/Pag
  es/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(W
  HO)GrowthCharts.aspx