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WHO Child Growth Standards: Evolution, Concepts, Overview Challenges, Issues and Options

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Growth charts ... grow and develop within the same range of height and weight for ... of new WHO standards for weight for age, height for age and BMI for age ... – PowerPoint PPT presentation

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Title: WHO Child Growth Standards: Evolution, Concepts, Overview Challenges, Issues and Options


1
WHO Child Growth Standards Evolution, Concepts,
OverviewChallenges, Issues and Options
  • Dr Arvind Mathur
  • MD,DHA,DNB
  • Cluster Focal Point
  • Family Community Health
  • WHO-India

2
INDICATORS OF NUTRITIONAL STATUS
  • Direct Indicators
  • -- Nutritional Anthropometry
  • -- Clinical Assessment
  • -- Bio-chemical Estimations
  • -- Biophysical Tests

Indirect Indicators -- Dietary assessment
-- Prevalence of Morbidities -- Vital
Statistics
In addition, Secondary Data -- Socio-economic
-- Demographic -- Environmental
3
NUTRITIONAL ANTHROPOMETRY
4
Nutritional Anthropometry
Weight - Total Body mass
- Simple, widely used -
Sensitive to small changes in nutrition Height
- Genetically Determined
- Environmentally influenced
- Stunting Reflects long duration undernutrition
MUAC - Reflects
muscle/fat - Easy to measure,
used for quick screening -
Independent of age (1-5 years) Fat Fold
Thickness- Measures body fat
-Correlates well with total body fat

5
REQUIREMENTS FOR NUTRITIONAL ANTHROPOMETRY
Standard equipment - Accuracy /
Consistency, Appropriate techniques
- Training Standardization Correct assessment
of age - Wrong age vitiates the results
Reference values - For comparison and
computation of indices Classification
- For grading nutritional status
6
Reference Values
Anthropometric measurements obtained on
statistically adequate number of individuals who
are well nourished, representing cross section of
community living in an environment free from
constraints of any sort and have capacity to
reach maximum growth potential at each age
group/Gender. - National E.g. Well-to-do
Hyderabad pre-school children - International
E.g. NCHS, Harvard, MGRS
7
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

8
Growth monitoring
  • By using growth charts-screening tool for
    diagnosis of nutritional, chronic systemic and
    endocrine diseases

9
Need for growth charts
  • Individual level
  • Community level
  • National level
  • Scientists
  • 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

10
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

11
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

12
WHO Child Growth Standards
  • Why?

13
Why Children Should Grow Healthy?
  • Child undernutrition or failure of children to
    grow properly in early childhood , results in
    greatly increased child mortality.
  • At more than 3000 infants a day, the death toll
    from undernutrition by far exceeds even the
    Tsunami or Bhuj.
  • Those children that survive do so with a greatly
    reduced capacity to lead productive and healthy
    lives.

14
Rationale for the development of the WHO child
growth standards
  • The recommended NCHS/WHO international
    reference is inappropriate for assessing
    nutritional status
  • Individual infants
  • interferes with sound nutritional management
    of breastfed infants, increasing their risk of
    morbidity and mortality
  • Populations
  • provides inaccurate estimates of
    undernutrition and overweight

15
New WHO growth standards
  • The international growth standards established by
    the WHO in April 2006 directly confront the
    notion that ethnicity is a major factor in how
    children grow. The new standards demonstrate that
    children born in different regions of the world
    , when given an optimum start in life , have the
    potential to grow and develop within the same
    range of height and weight for age.
  • (ECHUI 2006 Global Framework for Action)

16
Why should we adopt new charts?
  • The new Child Growth Standards is a crucial
    development in improving infant and young child
    nutrition globally. Unlike the old growth charts,
    the new standards (1) describe how children
    "should grow," (2) establish breastfeeding as the
    biological "norm," and (3) provide international
    standards for all healthy children, as human milk
    supports not only healthy growth, but also
    optimal cognitive development and long-term
    health. 

17
Rationale for change to new WHO standards
Corrects the historical fallacy of using
formula fed children from single ethnic group
in one country as global standard for
assessment of nutritional status of preschool
children and consequent problems in
interpretation of data .
18
WHO Child Growth Standards
  • HOW?

19
Milestones in the development of theWHO child
growth standards
  • 1991-1993 WHO Working Group on Infant growth
  • Comprehensive review shows growth patterns of
    healthy breastfed infants differ from the current
    NCHS/WHO international reference
  • A new growth reference is needed to improve
    infant health management
  • The reference population should reflect health
    recommendations in view of the frequent use of
    references as standards

20
Milestones in the development of the WHO child
growth standards
  • 1993 WHO Expert Committee
  • Recommends development of a new international
    growth reference
  • Based on an international sample of healthy
    infants
  • 1994 WHA resolution (WHA 47.5)
  • Endorses need for new reference
  • Requests it to be based on breastfed infants

21
A Growth Curve for the 21st Century
The WHO Multicentre Growth Reference Study
22
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23
Approaches for developing growth references
  • Descriptive approach
  • defines growth on the basis of representative
    samples of healthy groups, i.e., without
    identifiable disease
  • Prescriptive approach
  • defines growth on the basis of health and feeding
    practices known to promote optimal growth and
    selects the sample accordingly

24
WHO Growth Reference StudyPrescriptive Approach
  • Optimal Nutrition
  • Breastfed infants
  • Appropriate complementary feeding
  • Optimal Environment
  • No microbiological contamination
  • No smoking
  • Optimal Health Care
  • Immunization
  • Pediatric routines

Optimal Growth
25
MGRS study design
Longitudinal (0-24 months)
year 1
year 2
year 3
Cross-sectional (18-71 mo)
26
WHO Child Growth Standards
  • Construction
  • growth
  • standards

27
Mean length from birth to 24 months for the six
MGRS sites
28
Length at selected centiles for the pooled sample
and the sample following the exclusion of Norway
29
Length at selected centiles for the pooled sample
and the sample following the exclusion of India
30
Construction of growth curves
  • The rigorous methods of data collection yielded
    very high-quality dataset
  • State-of-art statistical methods applied in a
    methodical way
  • Detailed examination of 30 existing methods,
    including types of distributions and smoothing
    techniques
  • Selection of a software package flexible enough
    to allow comparative testing of alternative
    methods and the actual generation of the curves
  • Systematic application of the selected approach
    to the data to generate models that resulted in
    the best fit
  • Ongoing statistical review by external expert
    panel

31
WHO Child Growth Standards
  • Attained growth
  • Weight-for-age
  • Length/height-for-age
  • Weight-for-length/height
  • Body mass index-for-age
  • Mid-upper arm circumference-for-age
  • Triceps skinfold-for-age
  • Subscapular skinfold-for- age
  • Head circumference-for-age
  • Growth velocity
  • Weight
  • Length/height
  • Head circumference
  • Arm circumference

32
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33
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34
Prevalence of stunting (below -2 SD
length/height-for-age) by age based on the WHO
standards and the NCHS reference in Bangladesh
Source de Onis M, Onyango AW, Borghi E, Garza C,
Yang H, for the WHO Multicentre Growth Reference
Study Group. Comparison of the WHO Child Growth
Standards and the NCHS growth reference
implications for child health programs. Public
Health Nutrition 20069942-947.
35
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36
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37
Prevalence of underweight (below -2 SD
weight-for-age) by age based on the WHO standards
and the NCHS reference in Bangladesh
Source de Onis M, Onyango AW, Borghi E, Garza C,
Yang H, for the WHO Multicentre Growth Reference
Study Group. Comparison of the WHO Child Growth
Standards and the NCHS growth reference
implications for child health programs. Public
Health Nutrition 20069942-947.
38
Mean weight-for-age z-scores of healthy breastfed
infants relative to the NCHS, CDC and WHO curves
39
Breastfeeding
No gift is more precious
  • provides perfect nutrition
  • provides initial immunization
  • prevents diarrhoea
  • maximizes a childs physical
  • and intellectual potential
  • supports food security
  • bonds mother and child
  • helps birth spacing
  • benefits maternal health
  • saves money
  • is environment-friendly

40
WHO Child Growth Standards
The new standards will play a key role in the
prevention and early recognition of childhood
obesity
41
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42
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43
Prevalence of overweight (above 2 SD
weight-for-length/height) by age based on the WHO
standards and the NCHS reference in the Dominican
Republic
Source de Onis M, Onyango AW, Borghi E, Garza C,
Yang H, for the WHO Multicentre Growth Reference
Study Group. Comparison of the WHO Child Growth
Standards and the NCHS growth reference
implications for child health programs. Public
Health Nutrition 20069942-947.
44
WHO standards versus NCHS reference
  • Important differences that vary by age group,
    sex, growth indicator, specific percentile or
    z-score curve, and the nutritional status of
    index populations.
  • Differences are particularly important during
    infancy due to type of feeding and issues related
    to study design (eg, measurement interval)
  • Difference in shapes of the weight-based curves
    in early infancy makes interpretation of growth
    performance strikingly different depending on
    whether the WHO standard or the NCHS reference is
    used
  • Healthy breastfed infants track along the WHO
    weight-for-age mean z-score while appearing to
    falter in NCHS from 2 months onwards
    implications assessment of lactation performance
    and adequacy of infant feeding

45
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46
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47
Comparison of existing growth charts
Data charact Source Study period Population
Age-group
CDC Multiple different studies 1963-1994 US,
mixed feeding, no racial/ethnic diff Birth-20 yrs
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
48
  • Use of new WHO growth standards
  • Corrects the historical fallacy of using
    formula fed children from single ethnic group
    in one country as global standard and
    consequent problems in interpretation of data .
  • Computed under-nutrition rates in the critical
    0-6 month age group with new WHO standard are
    higher as compared to under -nutrition rates
    derived from NCHS/WHO standards this should
    not be viewed with alarm
  • Computed under-nutrition rates in 1-5 year age
    with new WHO standard are lower as compared
    to under -nutrition rates derived from NCHS/WHO
    standards this should not lead to complacency

49
  • Use of new WHO growth standards can make an
    important contribution in clearly bringing into
    focus the importance of nutrition and health
    education in improving infant and young child
    feeding and caring practices and reducing the
    under-nutrition in preschool children

50
  • Low birth-weight rate in India is 30
  • Prevalence of under-weight in first three
    months is 30 suggesting that breast feeding in
    the first three months prevents deterioration in
    nutritional status
  • After 3 months underweight rate rises ? due to
    early introduction of milk supplements
  • Between 6 and 11 months underweight rate further
    rises to 45 -?due to inadequate complementary
    feeding
  • Analysis of data using new WHO norms clearly
    brings out importance of wrong infant feeding
    habits as determinants of underweight in infancy
    and emphasises importance of nutrition
    education to correct them.

51
  • Progressive increase in the underweight rates in
    12 to 24 months of age ?attributable to
    inadequate intake of family food due to poor
    child feeding practices. Need for nutrition
    education to correct these faulty habits .
  • With the availability of new WHO standards for
    weight for age, height for age and BMI for age
    clinicians and research workers can assess which
    of the three indices is the most a appropriate
    index for assessment of functional
    de-compensation in the era when both under and
    overnutrition are public health problems

52
Some Questions?
  • Individual growth monitoring in children in
    India-Is it possible to achieve?
  • Who shall use the growth charts?
  • Pediatricians? Family Physicians? Anganwadi
    workers? ASHA? Mothers?
  • Capacity Building
  • Training of different level of workers/volunteers
  • Systematic Changes/strengthening
  • How do we introduce the new charts in the
    existing program?
  • Are there actions that the CoP members can take?
  • More questions!!

53
Thank You!
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