New International Growth Curves for Breastfed children

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New International Growth Curves for Breastfed
children Dr. Chessa Lutter Regional
Advisor Child and Adolescent Health
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New international standard for child growth

• Why?
• How?
• Future Plans

World Health Organization
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New international standard for child growth

• Why?

World Health Organization
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Justification for the new international standard
for child growth

• WHO Working Group (1991-93) in a review of the
  growth patterns of breastfed children showed
  that
• The growth of healthy breastfed children is
  different than the current WHO/NCHS international
  standard.
• The reference population should reflect health
  and feeding recommendations, given their use as
  standards to assess normal growth.
• A new standard for child growth would improve
  clinical care among breastfed children.

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Growth of healthy breastfed children in relation
to the NCHS/WHO growth curves, median Z scores
Source Evaluation of the growth of breastfed
children, WHO 1994
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Weight for age of healthy breastfed children in
relation to the CDC revised NCHS data , Z scores
Source de Onis Onyango. Acta Paediatrica
200392413-419
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Justification for the elaboration of a new growth
standard
Increased weight of the reference population
Childhood overweight/obesity



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A new child growth curve for the 21st Century

• How?
• WHO Multi-center Growth Reference Study
• Department of Nutrition, WHO

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WHO Multi-center Growth Reference Study Focus on
prescriptive growth

• Optimal nutrition
• Breastfeeding, EBF 4-6 months and BF for one
  year or more
• Appropriate complementary feeding
• Optimal environment
• absence of environmental contamination
• Absence of tobacco smoke
• Optimal health care
• complete immunization schedule
• normal scheduled pediatric care

Optimal growth
WHO Multi-center Growth Reference Study
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Selection criteria for participants

• Absence of health, environment, or economic
  conditions that could limit optimal growth
• Mother willing to follow recommendation on
  breastfeeding and complementary feeding
• Term birth
• Singleton birth
• Absence of perinatal morbidity
• Mother doesnt smoke (neither before nor after
  giving birth)

WHO Multi-center Growth Reference Study
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Study design
Longitudinal (0-24 months)
Year 1
Year 3
Year 2
Transversal (18-71 months)
WHO Multi-center Growth Reference Study
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Calendar of anthropometric measurements in
children
WHO Multi-center Growth Reference Study
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Motor development

• Six motor milestones measured from 4 to 18 months
  of age

WHO Multi-center Growth Reference Study
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Evaluation of motor development
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Sample size

• Total sample 8,440, sexes and countries combined
• cohorts de ? 300 newborns per country
• 1400 children from 18 to 71 months per country
• Minimum sample size calculated to develop the
  standard 400 per sex

WHO Multi-center Growth Reference Study
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Compliance with infant feeding and smoking
recommendations
WHO Multi-center Growth Reference Study
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Protocols for measuement and standardization

• Rigorous scientific norms were applied and
  monitored in this complex study that conducted in
  6 different cultural settings

WHO Multi-center Growth Reference Study
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The WHO Multicentre Growth Reference Study
Rationale, Planning Implementation
Food and Nutrition Bulletin vol 25, no.1
(supplement) March 2004 Background summary
articles in information packet
WHO Multicentre Growth Reference Study
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WHO Multi-center Growth Reference Study
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New WHO Child Growth Standard

• Present
• and
• Future

WHO Multi-center Growth Reference Study
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Calendar for the new growth standard
WHA Resolution (May 1994)
Growth Curves 2nd group
Growth Curves 1st group
Elaboration and evaluation of curves
Expert Committee Recommendation (Nov 1993)
Multi-center Growth Reference Study
July 97
Dec 03
Implementation in the field
WHO Work Group on Child Growth
Protocol preparation
1st Group Weight or age, length/height for
age, weight for length/height), BMI for age,
indicadors of motor development 2nd Group Arm
circumference, head circumference, sub-scapular
and triceps skin folds
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New WHO Growth Standards

• Attained growth
• Weight for age
• Length/height for age
• Weight for length/height
• Head circumference for age
• Arm circumference for age
• Skinfold triceps for age
• Subscapular triceps for age
• Body mass index (BMI) for age

WHO Multi-center Growth Reference Study
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New WHO Growth Standards

• Velocity
• Weight
• Length
• Head circumference
• Arm circumference
• Body mass index (BMI)

WHO Multi-center Growth Reference Study
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New WHO Child Growth StandardsInnovative aspects

• Prescriptive focus that recognizes the need for
  norms (rather than descriptive of how a group of
  children grow)
• Breastfeeding as the model and norm for optimal
  growth
• International sample
• Reference data to evaluate
• Child obesity
• Growth velocity
• Links physical growth with motor development

WHO Multi-center Growth Reference Study
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New WHO Child Growth Standard 2005 - 2010

• Elaboration of curves
• Evaluation of first draft of curves in the field
• Development of software to facilitate the use of
  the standards in the clinic and for national
  growth monitoring
• Development of modules for training to ensure
  their appropriate use

WHO Multi-center Growth Reference Study
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New WHO Child Growth Standard 2005 - 2010

• Revision of interventions to prevent and treat
  alternations in child growth (because of deficit
  or excess)
• Elaboration of a strategy for the application of
  the new standards at the global and national
  level
• Adaptation of the global system for monitoring
  the achievement of the Millennium Development
  Goals

WHO Multi-center Growth Reference Study
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Global practices in child growth
monitoring Reference population
Source de Onis et al. Journal of Pediatrics
2004144461-5.
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Global practices in child growth monitoring
Problems with the use of growth curves
Source de Onis et al. Journal of Pediatrics
2004,144461-5.
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Strategy to promote healthy growth
Elaboration of an international and ideal
standard for child growth
Training in its appropriate use and the
interpretation of growth data
Clinical and public health interventions
WHO Multi-center Growth Reference Study
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• Child survival
• Physical growth
• Child development
• Breastfed child

WHO Multi-center Growth Reference Study