Strategic option for updating child growth Standards

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Strategic option for updating child growth
Standards

• Dr AKDutta
• Director Professor HOD
• Dept. of Pediatrics
• Lady Hardinge Medical College Kalawati Saran
  Childrens Hospital
• New Delhi

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Sub Headings

• Uses of growth charts
• Evolution
• Currently available growth charts
• Comparison of their features
• Recommendation for use in our country

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Growth charts

• Consist of a series of percentile curves that
  illustrate the distribution of selected body
  measurements in the study population
• Used to track the growth of children from infancy
  thru adolescence
• Indicates the state of the child's health,
  nutrition and well being

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Growth monitoring

• By using growth charts-screening tool for
  diagnosis of nutritional, chronic systemic and
  endocrine diseases
• Individual growth monitoring in children in
  India-Is it possible to achieve?
• Who shall use the growth charts?
• Pediatricians? Family Physicians? Anganwadi
  workers? ASHA?

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Need for growth charts

• Monitoring documenting growth
• Comparison with references
  std
• To detect growth faltering
• Monitoring health status
• Performance of programs
• Comparison over time
• Identification of problem areas
• National/international comparisons
• Research tool

• Individual level
• Community level
• National level
• Scientists

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Community level

• Early identification of childrens growth failure
  for detection of malnutrition and taking
  appropriate interventions
• Early identification-overweight/obesity
• Sensitize health workers
• Educate parents and allay their anxiety by
  showing normal growth in chart

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Community level

• Measurements required
• Weight
• Length/Height
• Head circumference lt 2 years

• Anthropometric indices
• Length / stature for age
• Weight for age
• Weight for length /stature
• BMI for age
• Head circumference for age
• Length, wt, BMI in relation to pubertal stage

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What needs to be monitored at community level

• Length/age
• Weight/age
• Weight /height or BMI
• Head circumference/age
• Height/age
• Weight/age
• BMI/age
• Above in relation to pubertal development

• First 2 years
• 2 10 years
• gt10 years

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Earlier available growth charts Harvard standards

• Reference data from Boston childrens hospital
• Hospital based
• Longitudinal study
• Small sample size
• Top fed babies
• Still served the purpose of creating an awareness
  re need for monitoring growth assessment
• Used in Indian growth charts for classification
  of malnutrition since mid 1970s (50th centile
  taken as 100)

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Earlier available growth chartsICMR Standards

• Banik Dutta et al ICMR Technical report series
  no. 18, 1972 Growth Physical development of
  Indian infants children
• Not affluent population, but mixed group
• Community based
• Criticised for method of sample selection data
  collection

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Charts/Standards currently available

• Indian Dr KN Agarwal
• CDC 2000
• WHO

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Dr KN Agarwal growth standards 0 - 6 years
(Indian Pediatrics,1994)

• Study years 1985-1987
• Design Mixed-longitudinal study/ cross-linked
  data collection
• Minimum of three readings for each child
• Cohort
• a)Birth to first year of age 418 boys, 332
  girls
• b)12 - 60 months 1011 boys and 874 girls
• Sample zones Bangalore, Calcutta, Delhi,
  Ludhiana, Kota Varanasi

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Dr KN Agarwal growth standards 5 - 18 years
(Indian Pediatrics-1992 2001)

• Study years 1988-1991
• Design cross-sectional study minimum of 200
  children at each age and sex point.
• Sample size 12,893 male 10,941 female (23
  schools)
• Sample Zones (9 states)
• North - Delhi, Shimla, Dehradun, Nainital
• West-south - Bombay,Madras, Udaipur
• Central - Lucknow Allahabad, Varanasi
• East Calcutta, Dhanbad

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Dr KN Agarwal ref. standards available

• birth 66 months
• 6-18 years

• Height, weight both sexes
• 3 monthly interval till 1 year, then 6 monthly
• 3rd - 97th centile
• -3SD - 3 SD
• Height, weight both sexes
• 6 monthly interval
• 3-97th centile
• Mean SE

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Dr KN Agarwal ref. standards available

• Head circumference
• BMI

• Each sex
• birth to 6 years
• 3 monthly interval for 1yr, then 6 mthly
• 3rd-97th centile
• - 3SD to 3 SD
• 2-18 years
• Yearly
• 5th 95th centile
• Mean And SD
• Each sex

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Useful upto
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CDC growth charts

• NCHS growth charts based on growth of American
  children developed in 1977
• Adopted by WHO for international use
• CDC 2000 growth charts a revised version of
  earlier NCHS chart Revision of previous existing
  14 charts with introduction of 2 new BMI charts
• No new primary data collected
• Used national studies conducted at various times
  places and improved statistical tools

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CDC 2000 growth charts new features

• Addition of BMI for age charts 2 20 years
• Addition of 85th centile on BMI for age wt for
  stature charts
• Addition of 3rd 97th centiles
• Limits of length stature extended on wt for
  length wt for stature charts
• Smoothened percentile curves Z scores
• Correction of disjunction that occurred between
  24 36 months when switching from length to
  stature in NCHS charts

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CDC charts available

• Birth 36 months
• 2 - 20 years
• 2-5 years

• Length weight for age
• Head circumference for age
• Weight for length
• Stature weight for age
• BMI for age
• Weight for stature

2 sets 3rd-97th centile, 5th 95th centile for
each sex 85th centile for BMI for age wt for
stature
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WHO charts

• Review of child growth references by WHO expert
  committee in 1993 NCHS stds do not describe
  physiologic growth adequately single country
  based with many technical /biological drawbacks
• WHO multi-centric growth reference study
  undertaken between 1997 2003
• Primary data collected from 8500 children from
  Brazil, Ghana, India, Norway, Oman USA
• Growth data available for children 0 - 5 years of
  age

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MGRS Study Design and Sample

• Eligibility Criteria for Individuals
• No health, environmental or economic constraints
  on growth
• Mother willing to follow feeding recommendations
  Exclusive/ predominant breast feeding for 1st 4
  mths, introduction of complementary feeding by 6
  mths
• Term, single birth
• Lack of significant perinatal morbidity
• Non smoking mothers before and after delivery

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MGRS Study Design and Sample

• Longitudinal study (birth-24 months)
• Mothers newborns screened enrolled at birth
• Weight, length, head circumference 21 times over
  24 months
• Arm circumference 10 times between 3 and 12
  months
• Skin fold thickness 6 times between 14 and 24
  months

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MGRS Study Design and Sample

• Cross-sectional survey (18-71 mo)
• Weight, length, head circumference, arm
  circumference, skin fold thickness
• Total sample 8440 children from 6 countries
• 300 newborns per site (1743 total) followed up
  till 24 mo from the longitudinal study
• 1400 children per site (6647 total) aged 18-71
  mo through the cross sectional surveys

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WHO charts

• Available 0 5 years
• Length (birth-2yrs)/height (2-5 yrs) for age
• Weight for age
• Weight for length/height
• BMI for age

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Mean length from birth to 24 months for the six
MGRS sites
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Comparison of existing growth charts
WHO Primary data 1997-2003 6 Countries pooled
data. healthy children practices Birth-5yrs
KNA Primary data 1988-1991 Affluent Indian
population, multicentric Birth-18 yrs
Data charact Source Study period Population
Age-group
CDC Multiple different studies 1963-1994 US,
mixed feeding, no racial/ethnic diff Birth-20 yrs
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KNA study vs European NCHS std
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KNA study vs other Asian studies
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Which growth chart to use?

• Depends upon for what purpose it is used
• Who will be monitoring the growth?
• It should be represented by National data
• The growth charts should be for the entire period
  of growth from Infancy till full growth potential
  is achieved
• Scientifically collected analyzed multi-centric
  data
• Their use should prevent unnecessary referrals

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Summary

• WHO growth charts are excellent ,recent, up- to-
  date, multicentric, multinational reference
  charts
• Ideal growth chart to be used for children up to
  5 yrs of age
• Drawback is after that age Which chart to use?
• Can we use two different charts-one up to 5 yrs
  and the other for the 6-18 yrs age?

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THANK YOU