NA Exam 3

Using the WHO Growth Standard Charts

Assessing Growth Using the WHO Growth Charts Use recommended protocols to measure the weight and recumbent length of the child accurately. Record the measurements correctly. Accurately measuring and recording this information is critical for growth charts to be used as an effective screening tool. Calculating age correctly is also critical for accurate growth determinations and interpretations. Plot these measurements on the appropriate WHO growth chart. Use the percentile lines on the chart to assess body size and growth and to monitor growth over time. Percentile Cutoff Values The World Health Organization (WHO) recommends cutoff values of +2 standard deviations, which correspond to the 2.3rd and 97.7th percentiles, to define abnormal growth.1 For the WHO growth charts modified by CDC, these cutoff values are labeled as the 2nd percentile and the 98th percentile. Infants and children with a weight-for-length that is less than the 2nd percentile are classified as low weight-for-length. Infants and children with a length-for-age that is less than the 2nd percentile are classified as having short stature. Infants and children with a weight-for-length that is higher than the 98th percentile are classified as high weight-for-length. WHO Percentile Cutoff Values Differ from Traditional CDC Cutoff Values The cutoff values for the 2nd and 98th percentiles used in the WHO growth standard charts are different from those used in the CDC growth references chart. CDC uses the 5th and 95th percentiles. Different methods are used to create the WHO and CDC charts. Historically, CDC used the 5th percentile to define shortness and low weight-for-length, and the 95th percentile was used to define high weight-for-length. Using the WHO growth chart cutoff values indicates a change in clinical protocol. Theoretically, children in the WHO population would be expected to be healthy. Thus, more extreme cutoff values are more appropriate to define the extremes of growth of children rather than the values used in the CDC growth reference.2 WHO Growth Standards Represent Optimal Growth The WHO growth standard charts are intended to reflect normal child growth under optimal environmental conditions. Although many children in the United States do not experience the optimal environmental, behavioral, or health conditions specified in the WHO Multicenter Growth Reference Study, the WHO growth standard charts are intended for use with children younger than aged 24 months because they represent optimal growth. Interpreting Growth Indicators Using the WHO Growth Charts There are differences in the prevalence of growth indicators when using the WHO growth charts compared to the CDC growth charts. A comparison of low length-for-age, weight-for-age and weight-for-length, and high weight-for-length in US children among infants and children up to 24 months of age using the 2006 WHO growth standard charts and the 2000 CDC growth reference charts (comparing the 2.3rd and 97.7th percentiles for the WHO growth charts and 5th and 95th percentiles for the CDC growth charts) shows that prevalence of nutritional status indicators are as follows. Low length-for-age: The prevalence of low-length-for-age is very similar (within 0.25 percentage points)1 on the WHO and the CDC growth charts. Low weight-for-age: In the first two years of life, the prevalence of low weight-for-age is generally lower on the WHO charts compared to the CDC 2000 charts except in the first 5 months of life when it is similar on both charts.1 This may be beneficial because over-diagnosis of low weight-for-age can result in unnecessary interventions and possibly damage the parent-child interaction.2 Children identified as having low weight-for-age on the WHO growth charts will be more likely to have a true weight deficiency that requires follow up.3 view tableSee WHO Boys Weight-for-age Percentiles Birth to 24 Months compared to CDC Boys Weight-for-age Percentiles Birth to 24 Months). Low and high weight-for-length: The prevalence of low weight-for-length is about 3 percentage points lower on the WHO charts compared to the CDC charts.1 The prevalence of high weight-for-length is generally lower on the WHO charts compared to the CDC charts.1 For a comparison of the WHO and CDC growth chart prevalences of low length-for-age, low weight-for-age, and high weight-for-length among children aged < 24 month---United States, see Use of World Health Organization and CDC Growth Charts for Children Aged 0-59 Months in the United States [PDF-780k] MMWR 2010.3 Infant Growth Patterns on the WHO and CDC Growth Charts Growth patterns differ between breastfed and formula-fed infants. Beginning around 3 months of age weight gain is generally lower for breastfed infants than for that of the formula-fed infant.1-3 Linear growth generally follows a similar pattern for both breast- and formula-fed infants.4 For the first 3 months of age, the WHO growth charts show a somewhat faster rate of weight gain than the CDC growth charts. After about 3 months of age, WHO growth charts show a slower rate of growth than the CDC growth charts. Because formula-fed infants tend to gain weight more rapidly after age 3 months, they may be more likely to cross upward in percentiles on the WHO growth charts, perhaps becoming classified as overweight.5 Early recognition of a tendency toward overweight or obesity might appropriately trigger interventions to slow the rate of weight gain although no evidenced-based guidelines for treating overweight in infancy exist. Studies suggest that higher weight gain during infancy is associated with increased risk of obesity in childhood.6-7 Consequently, lower weight gain during the first two years of life may be beneficial to health in the long term.6-7

The WHO growth charts represent growth standards that describe how healthy infants and young children should grow under optimal environmental and health conditions. To achieve this purpose, infants were excluded from the study sample used to create the growth curves if they were

Born to mothers who smoked during pregnancy or lactation. Breastfed <12 months. Introduced to complementary foods before 4 months of age.

CDC Growth Reference (2000)

Data sources: National vital statistics (birthweight) Missouri and Wisconsin vital statistics (birth length) Pediatric Nutrition Surveillance System (length, 0.1 to <5 mos) NHANES I (1971-74): 12-23 mos NHANES II (1976-80): 6-23 mos NHANES III (1988-94): 2-23 mo Type and frequency of data collection: Cross-sectional data on weight and length starting at age 2 mos, with mathematical models used to connect birth weights and lengths to survey data Sample size: 4,697 observations for 4,697 distinct children Exclusion criteria: Very low birth weight (<1,500 g [<3 lbs, 4 oz]) Infant feeding: 50% ever breastfed 33% breastfed at 3 mos

WHO Growth Standard (2006)

Data sources: Multicenter Growth Reference Study (longitudinal component) Type and frequency of data collection: Longitudinal data with measurements of weight and length at birth; 1, 2, 4, 6, and 8 weeks; and 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16, 18, 20, 22, and 24 mos Sample size: 18,973 observations for 903 distinct children Exclusion criteria: Low socioeconomic status Born at altitude >1,550 m/4,921 f Birth at <37 wks or >42 wks Multiple births Perinatal morbidities Child health conditions known to affect growth Mother smoked during pregnancy or lactation Breastfeeding <12 mos Introduction of complementary foods before age 4 mos or after 6 mos Weight-for-length measurements >3 standard deviations above or below study median for sex Infant feeding: 100% ever breastfed 100% predominantly breastfed at 4 mos 100% breastfed at 12 mos Complementary foods introduced at mean age of 5.4 mos

Comparing Methodologies Used to Develop WHO and CDC Growth Charts for Children Birth to Aged 2 Years

Differences in Methodology Different approaches were used to construct the 2000 CDC and 2006 WHO growth charts for children from birth up to 2 years and include differences in the Data sources. Type and frequency of data collection. Sample sizes. Exclusion criteria. Breastfeeding rates among infants in the sample. Use of cross-sectional data to construct the CDC charts versus longitudinal data to construct the WHO growth charts.

The United States was not included as one of the study countries in which data were collected to construct the WHO growth standard charts.

False

Development of the U.S. Recommendations to Use the WHO Growth Standards with Children Younger Than 2 Years of Age

Following the release of the WHO Standards in 2006, the Centers for Disease Control and Prevention, (CDC), the National Institutes of Health (NIH), and the American Academy of Pediatrics (AAP) convened a meeting of experts to consider the potential use of the WHO growth standards in clinical settings to monitor growth among children in the United States. Experts considered the rationale for developing an international standard, the methods, statistical comparisons, differences in growth between breast and formula fed infants and practical implications. Based on the comparison between the CDC growth reference and the WHO growth standards and input from the expert panel, CDC and AAP developed the following recommendations: The WHO growth standard charts should be used for children younger than 2 years of age. The CDC 2000 growth reference charts should be used for children aged 2 to 19 years. The CDC growth reference charts are more suited for children 2 years and older because these charts can be used continuously up to age 20 years. The WHO released the international growth standards for young children ages birth to 5 years of age. However, for children ages 2 to 5 years, the WHO BMI-for-age charts offer little advantage over the CDC BMI-for-age charts for the assessment of child growth from 2 to 5 years of age as the data collection methodology was similar for the two charts. For example, the data used to construct the curves are cross-sectional and sample selection was similar.

The growth patterns between breastfed and formula fed infants differ. Which statement accurately describes these differences:

Formula fed infants typically gain weight more slowly after 3 months of age compared to breastfed infants.

Breastfeeding as the Norm for Infant Feeding

Growth Patterns of Breastfed and Formula-Fed Infants The growth patterns of breastfed and formula-fed infants are different. For example, Healthy breastfed infants typically put on weight more slowly than formula-fed infants in the first year of life.1-2 Formula-fed infants typically gain weight more quickly after about 3 months of age. Differences in weight patterns continue even after complimentary foods are introduced.1 Linear growth generally follows a similar pattern for both breastfed and formula-fed infants. WHO Growth Standards The WHO growth standard charts consider the effect of infant feeding on growth by using breastfeeding as the norm. When the WHO growth curves were created, the differences in growth patterns of breastfed and formula-fed infants were considered.3 A healthy breastfed infant is the standard against which all other infants are compared. All infants in the WHO sample were breastfed at least until aged 12 months and predominantly breastfed for at least 4 months. Complementary foods were introduced at the mean age of 5.4 months. The breastfed infant is the reference or normative model against which alternative feeding methods are measured with regard to growth, healthy development, and all other short-term and long-term outcomes.4 This is consistent with U.S. dietary reference intakes, in which norms for infant intakes of most nutrients are determined on the basis of the composition of human milk and the average volume of human milk intake.5 CDC Growth Reference CDC growth reference charts were developed to represent all infants in the United States. Feeding criteria were not identified.

Creating the WHO Growth Standard for Infants and Young Children

In 1993, WHO established a working group on infant growth to conduct a comprehensive review of the uses and interpretation of the 1977 National Center for Health Statistics (NCHS)/WHO growth reference, which had been recommended for international use since the late 1970s.1 The experts on the working group concluded that New growth curves were needed to replace the existing international reference, which had numerous limitations making it inappropriate for assessing the growth pattern of individual children and populations.2 A standard rather than a reference was needed to describe how children grow in all countries rather than how they grew in a specific place and time.3 A standard was needed to emphasize the importance of ensuring that the new growth charts were consistent with the growth of infants under the "best" health conditions such as being exclusively breastfed for at least 4 months and born to a mother who does not smoke during pregnancy and lactation. The outcome of the recommendations was the WHO Multicenter Growth Reference Study (MGRS) on which the WHO growth standards are based. WHO Multicenter Growth Reference Study (MGRS) The MGRS was conducted from 1997 to 2003 in six sites (Pelotas, Brazil; Accra, Ghana; Delhi, India; Oslo, Norway; Muscat, Oman; and Davis, California) to generate new growth curves to assess growth of infants and young children throughout the world. A primary study hypothesis was that infants and young children have the potential to grow similarly, regardless of their race/ethnicity and place of birth, if they are breastfed, living in a healthy environment, and have adequate nutrition. This hypothesis of similar growth was confirmed as the mean length measurements from birth up to 24 months in the 6 country sites were virtually identical.

Breastfeeding Advocacy

In 2006, the Centers for Disease Control and Prevention, the National Institutes of Health, and the American Academy of Pediatrics (AAP) convened an expert panel to review the scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. The expert panel agreed that breastfeeding is the optimal form of infant feeding. They also agreed that using the WHO growth charts for children aged birth to younger than 2 years, which are based on breastfed infants as the standard, helps to support current infant-feeding recommendations in the United States. The AAP recommends breastfeeding for at least 12 months, with exclusive breastfeeding for about 6 months.1 Other major health professional organizations agree with this recommendation for most infants in the United States. Examples of these organizations include the American Academy of Family Physicians,2 the American Dietetic Association,3 and the American Public Health Association.4 AAP supports the position that breastfeeding ensures the best possible health, as well as the best developmental and psychosocial outcomes for the infant. Exclusive breastfeeding is sufficient to support optimal growth and development for about the first 6 months of life.

WHO Growth Standards Are Recommended for Use with Children Younger Than Aged 2 Years in the United States

In April 2006, the World Health Organization (WHO) released a new international growth standard for young children aged birth to 5 years. This standard describes the growth of healthy children living in well-supported environments in six countries, including the United States. The standard shows how infants and children should grow rather than simply how they do grow in a certain time and place. The WHO growth standards are recommended for use with children younger than aged 2 years in the United States The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend that health care providers in primary care settings Use the WHO growth standard charts for children aged birth to younger than 2 years regardless of type of feeding, to monitor growth in the United States.1 Use the 2000 CDC growth reference charts for children aged 2 until aged 20 years to monitor growth in the United States.1 Similar to the 2000 CDC growth reference charts, the WHO growth standard charts describe weight-for-age, length (or stature)-for-age, weight-for-length, and BMI-for-age. The WHO standards are relevant to infants and young children in the United States because they were included in the WHO study sample, and their growth tracks along the median of the pooled international sample. The WHO standard charts use growth of the breastfed infant as the norm for growth. The WHO standards bring the tools used to assess growth and national guidelines that recommend breastfeeding as the optimal infant feeding method into agreement.1 The WHO standards are based on high-quality data collected for children younger than aged 2 years . The WHO growth standard charts were created with longitudinal length and weight data measured at frequent intervals.2-3 The CDC growth reference charts were based on cross-sectional length and weight data. However, weight data were not available for infants aged birth to 2 months, and the sample sizes were small for sex and age groups during the first 6 months of age.4

CDC & WHO Similarirties

Similarities in Methodology While there were many differences in the design and methodology between the WHO and CDC chart development, similarities exist. Growth curves for both charts were developed using an LMS methodology1-2 to describe both percentiles and z-scores (standard deviation units) although there were some differences in the smoothing techniques used to create the growth curves. Data quality was tightly controlled in both studies with precise procedures for training and standardization of measurements using high quality anthropometry equipment. Optimal data entry and cleaning techniques were used

Features of the WHO Multicenter Growth Reference Study (MGRS)1

Specific communities in the study were selected on the basis of High socioeconomic status. Low altitude (<1,500 m/<4,921 f). Low population mobility, allowing for a 2-year follow-up. A minimum of 20% of mothers in the community were already following the international feeding recommendations. Study sites had to have a research institution capable of conducting the study. Feeding criteria specified that infants had to follow international infant feeding recommendations, including Predominantly breastfeeding for at least 4 months. Introducing complementary foods by at least 6 months but not before 4 months. Continued breastfeeding for at least 12 months (no upper limit on breastfeeding duration). Study sites had to have a breastfeeding support system that included lactation consultants to provide support and counseling to all mothers to ensure that any problems with breastfeeding were addressed quickly and that mothers received appropriate counseling on complementary feeding. Exclusion criteria included Maternal smoking during pregnancy or lactation. Prematurity (<37 weeks gestation). High gestational age (≥42 weeks). Multiple births. Substantial morbidity. Low socioeconomic status. Unwillingness of the mother to follow feeding criteria. WHO collaborated with the United Nations University Food and Nutrition Program, United Nations Children's Fund, CDC, several governments, and others to develop the WHO growth standards to replace the 1977 NCHS/WHO growth reference that had been used in the international community.2

When Brady's weight and length are plotted on the WHO weight-for-length growth chart, his weight-for-length is between the 25th and the 50th percentiles for the first month of life. Brady's health care provider can assure his caretakers that he is growing at an appropriate weight and discourage any increase in formula intake. At 12 months of age, plotting Brady's weight-for-length on the WHO growth chart indicates that:

That Brady's weight is high for his length.

CDC Growth Reference

The CDC growth charts are a growth reference. They describe the growth of children in the United States. The CDC growth charts Are descriptive because they indicate how children grew in a particular place and time. Indicate how children grew in the United States during approximately 30 years (1963 -1994). Do not imply that the pattern of growth they represent is healthy.

Summary

The Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) recommend that health care providers in primary care settings Use the WHO growth standard charts for children younger than aged 2 years regardless of type of feeding, to monitor growth in the United States. Use the 2000 CDC growth reference charts for children aged 2 to 20 years to monitor growth in the United States. Using the WHO growth standard for infants and children birth to aged 2 years has several advantages over the CDC growth reference for children of the same age including: The WHO growth standard charts utilize growth of the breastfed infant as the norm for growth. The WHO standards are based on high quality data collected for children younger than aged 2 years. CDC's adapted versions of the WHO growth charts for children younger than aged 2 years are available with English units of measurement and percentiles at www.cdc.gov/growthcharts. The 4 available growth charts include: Girls and boys, birth to 24 months: length-for-age and weight-for-age Girls and boys, birth to 24 months: weight-for-length and head circumference-for-age. The WHO growth charts as modified by CDC use the 2nd percentile and the 98th percentile as the outer most percentile cutoff values. Using the WHO growth chart percentile cutoff values indicates a change in clinical protocol. Using the WHO growth charts, infants and young children with a Weight-for-length less than the 2nd percentile are classified as low weight-for-length. Length-for-age less than the 2nd percentile are classified as having short stature. Weight-for-length greater than the 98th percentile are classified as high weight-for-length. The use of BMI-for-age is not recommended for children younger than aged 2 years at this time. When transitioning from the WHO growth standard charts to the CDC growth reference charts at aged 2 years, a change in growth classification may occur. During this transition, caution should be used in interpreting any changes in classification. For the growth assessment to be an effective screening tool, accurate measurements are critical. A series of measurements will assist in appropriate interpretation of growth patterns

Carmen's length is plotted on the WHO growth chart and her length-for-age tracks between the 2nd and 5th percentiles from birth to 6 months of age.

The WHO growth chart indicates that Carmen is following a healthy growth centile curve.

The WHO growth charts are considered a standard against which all infants and young children should be compared because

The WHO growth charts describe how healthy infants and young children should grow.

Accessing the WHO Growth Charts Online

The WHO growth charts for children younger than 2 years have been adapted for use in the United States and are available with English units of measurement and percentiles at www.cdc.gov/growthcharts. These growth charts are recommended for clinical use with all infants and young children. The 4 available growth charts are scaled for both English and metric measurements and include the following: (birth to 24 mo) Use of the BMI-for-age growth chart is not recommended for children younger than age two years at this time. While the WHO growth standards include a BMI chart beginning at birth, the expert panel generally agreed that many questions about BMI during infancy remain unanswered so use of the BMI chart is not recommended for clinical use before age two years. The BMI in infancy is based on recumbent length rather than stature and, to date, there has been little research on what BMI calculated from length means in infancy and on the consequences of high or low BMI in infancy.

WHO Growth Standards

The WHO growth charts represent growth standards that describe how healthy infants and young children should grow under optimal environmental and health conditions. The WHO growth charts Are prescriptive because they describe growth under optimal environmental conditions and included healthy infants who were well-fed according to international recommendations. Were designed to be an international standard for infants and young children. Provide a standard against which all infants should be compared. Create an opportunity for clinicians to identify and address environmental conditions that might be negatively affecting growth.

Which of the following statements are true:

The prevalence of low weight-for-length will be lower when using the WHO growth charts compared to the CDC growth charts.

Chart comparison & transition at 2 yrs

Transitioning from WHO to CDC Growth Charts at 2 Years of Age When a child reaches age 24 months, health care providers need to switch from using the WHO growth standards charts to using the CDC growth reference charts for children ages 2 years up through 19 years. During the transition from one chart to another, children may experience a difference in classification because of a change from: Recumbent length to standing height measurements. Note that the difference between recumbent length and stature in national survey data is approximately a 0.8 cm (¼ inch) difference. Standing height measures less than recumbent length. Breastfed reference population to a primarily formula-fed reference population. Weight-for-length chart to BMI-for-age chart. One set of cutoff values to another. WHO Weight-for-Length Chart to the CDC BMI-for-Age Chart Moving from the WHO weight-for-length chart to the CDC BMI-for-age chart may result in a change in a child's percentile classification because of Changes from one indicator to another indicator. Changes from a recumbent length measurement to a standing height measurement. Changes to a different cutoff value and a different reference population. A child who is identified as being at a specific percentile when plotted on the WHO weight-for-length chart may "drop" to a lower percentile on the CDC BMI-for-age chart. For example, a 24-month-old boy weighing 24 pounds and 4 ounces with a length of 23.25 inches is plotted between the 25th and 50th percentiles on the WHO weight-for-length chart. When plotted on the CDC BMI-for-age chart, the same boy is plotted just above the 10th percentile. Both percentile classifications are within the healthy range. WHO Length-for-Age Chart Compared to the CDC Length-for-Age Chart In general, the WHO and the CDC length-for-age growth charts are somewhat similar. WHO Weight-for-Age Chart Compared to the CDC Weight-for-Age Chart The WHO weight-for-age charts show a pattern of slower weight gain after about 3 months of age since they are based on the weights of breastfed infants. When changing from the WHO-weight-for-age chart to the CDC weight-for-age chart at 2 years of age, the weight-for-age percentiles may change downward to a lower percentile. For example, a weight of 26 ¾ pounds for a 24-month old boy is at about the 50th percentile on the WHO weight-for-age chart. The same weight on the CDC weight-for-age chart is between the 25th and the 50th percentile. Both percentile classifications are within the healthy range. During this transition, caution should be used in interpreting any changes. Growth measurements need to be used in conjunction with medical and family history if aberrant growth is identified. Growth monitoring is based on a series of measurements. When assessing physical growth, it is critical to have a series of accurate measurements to establish an observed growth pattern. A series of accurate measurements takes into consideration short- and long-term conditions and provides a context for individual measurements in interpretation. Thus, misinterpretation can be avoided based on a single plot on a different chart.

After about 3 months of age, WHO growth charts show a slower rate of weight gain than the CDC growth charts.

True

For children over 2 years of age, continued use of the 2000 CDC BMI-for-age charts is recommended.

True

The WHO growth standard charts were developed to describe optimal growth among infants and children.

True

When Maya's weight-for-length measurements are plotted on the WHO weight-for-length growth chart, her measurements fall above the 2nd percentile curve for the first 4 months of age and fall above the 5th percentile at 6 and 9 months of age. Given her current measurements, Maya's weight-for-length is considered to be within the healthy range.

True

The CDC growth charts do not reflect a growth pattern typically seen in breastfed infants.

True - primarily formula fed

When transitioning from the WHO weight-for-length growth chart to the CDC BMI-for-age growth chart at age two years, Gustavo's growth indicators moved from between the 25th and 50th percentile to the 15th percentile. All percentiles represent a healthy weight. When moving from the WHO weight-for-length chart to the CDC BMI-for-age chart a change in percentile classification may occur. This may be due, in part, to changing from recumbent length to standing height measurements.

True- Changing from recumbent length to standing height measurements is a reason that may explain, in part, a change in percentile classification when moving from the WHO weight-for-length chart to the CDC BMI-for-age chart.

An advantage of using the WHO growth standard charts with all infants and children from birth up to aged 2 years is that

U.S. children were included in the WHO study sample and their growth is similar to other children in the sample.

Basic Information About Clinical Use Graphics

WHO growth charts look similar to the CDC growth charts. On the WHO growth charts, the length-for-age percentiles are published on the same page as the weight-for-age percentiles. On the WHO growth charts, the weight-for-length percentiles are published on the same page as the head circumference-for-age percentiles. Portions of the annotated WHO growth charts have been lettered to call attention to features of the WHO growth charts.