WHO Growth Grids/
2012 Risk Changes
Diane Traver
Joyce Bryant
Overview
 CDC
vs WHO Growth ChartsWhy Change?
 Transition from <24 mo to 24-59 mo charts
 Risks


Definition
Justifications/Implications
Shift in Population Growth
 Concern
for underweight has been
replaced with concerns of
overweight and obesity
 Re-examination of methodologies
used in establishing CDC charts
reveal improvements needed
 USDA requiring implementation by
Oct ’12 (will be in Aug release)
CDC Charts
 Based
on only on US data from 1960’s-90’s
 No exclusion criteria
 Composition of formula has changed in last 35
years since first data collected
 Growth of formula fed infants may not be same
now as those used in creation of charts, as a result
 Little data available for infants < 2 months old
 Several data sets combined to generate the charts
 Reference- description of how certain children
grew in a particular place and time
WHO Premise
All young children have the potential to grow
similarly, regardless of ethnic group or place of
birth, if they are in a healthy environment and
have adequate nutrition
In order to identify abnormal growth, healthy
growth must be defined and adopting a
standard would identify and address
environmental conditions negatively affecting
growth
WHO Charts
 International study Participants willing to follow international
feeding guidelines
 100% BF for 12 months
 Adherence to many exclusion criteria
 Longitudinal data collected over 2 year
period
 Premise confirmed
 Standard- how healthy children should
grow under optimal conditions
Differences in Growth
Breast-fed infants- gain weight more
quickly in first few months of life but then
weight gain slows the remainder of
infancy
Formula-fed infants gain weight more
slowly in first few months of life but then
weight gain increases quickly after 3
months
Case Examples
Case Example #1: Low Weight-forLength
Maya is a healthy 9-month-old girl who was
exclusively breastfed for 6 months and
continues to breastfeed. Maya's mother
began feeding her solid foods at 6 months
of age. Maya's mother reports that Maya “is
a good eater”.
Example #1: Low Weightfor-Length
Case Example #2: Excess
Weight Gain
Brady is an 18-month-old boy. Brady is cared
for by his grandmother during the day when
his mother is working. Brady has been
formula-fed since birth, and he was around
5 months of age when he began eating
solid foods.
Case Example #2: Excess Weight Gain
WHO Weight-for-age
98th%
CDC Weight-for-age
95th%
What’s the difference?
Connecting WHO to CDC
charts
 WHO-
0 through 23 months
 CDC- 24 through 59 months- knowing
there would be a discrepancy
24-36 month olds measured both
recumbently and standing to assess the
discrepancy between the 2 methods and
allow for the connection of growth curves
before and after age 24 months
Transitioning from WHO to CDC
WHO
Growth Grids- 0 through 23 monthsrecumbent
CDC Growth Grids- 24-59 months - stature
 MI-WIC- Will no longer have ‘R/S’ option
If C-2 cannot be measured standing, click
‘Unknown’ and add measurement in
‘Comment’
Percentile Cutoffs
 WHO- uses cutoffs at
2.3 and 97.7
percentiles
WHO is a standard for
growth and based on
optimal conditions for
growth, therefore, any
plot outside is considered
abnormal
 CDC- continues to
use cutoffs at 5th and
95th percentiles
With new WHO curves and cutoffs, what
differences can be expected from CDC
chart assessments?
 Somewhat
similar prevalence of low
length-for-age (possibly a little higher
prevalence)
 Lower prevalence of low weight-for-age
 Lower prevalence of low weight-forlength
 Lower prevalence of high weight-for-age
In transitioning between
WHO and CDC charts



Remember that a series of measurements
establishes a growth pattern
Use measurements in conjunction with
medical and family history
Caution should be used in interpreting
any changes
Summary

WHO Growth Charts depict standard of growth

CDC and AAP Recommend:

Birth- <24 months: WHO Growth Charts

2-20 years: CDC Growth Charts

WHO Growth Chart Cutoffs: 2.3rd and 97.7th

CDC Growth Chart Cutoffs: 5th and 95th

More infants will “fall off” WHO weight-for-age
charts up to age 3 months but fewer will “fall off”
from 3-18 months

Small differences in the length-for-age WHO and
CDC charts
Risk Criteria Changes 2012
WHO Growth Chart (Birth<24 mo.)
 103.01+
High-risk underweight
 103.02
At-risk of underweight
 115
High Weight-for-Length- NEW
 121.01
Short stature
 121.02
At Risk of Short Stature
 152
Low head circumference
Terminology Changes
 113+
High risk overweight (Obese)
 114
Overweight or At-risk of overweight
Expanded, Updated Information
 344+
Thyroid disorders
 351+
Inborn errors of metabolism
103.01+ High-risk underweight
Definition:
• Birth to less than 24 months (I, C1):
– At or below < 2.3rd percentile weight-for-
length on WHO gender specific growth charts
•
Children at or above 24 months (C2-C4):
–
–
At or below < 5th percentile BMI-for-age
CDC gender specific growth charts
Note: If manually plotting, round down percentiles
103.01+ High-risk underweight
Justification/Implications
• Sensitive to acute under-nutrition
• Can reflect long-term status
•
•
•
Goal: Promote adequate weight gain
Intervention: Counsel families in making
nutritionally balanced food choices
Monitor regularly
103.02 At-risk of underweight
Definition:
• Birth to less than 24 months:
–
–
•
Above the 2.3rd percentile for weight-for-length
and at or below the 5h percentile for weight-forlength
WHO gender specific growth charts
Children at or above 24 months:
–
–
Above the 5th percentile and at or below the
10th percentile BMI-for-age
CDC gender specific growth charts
103.02 At-risk of underweight
Justification/Implications:
• Sensitive to acute under-nutrition
• Also can reflect long-term status
•
•
•
Goal: Promote adequate weight gain
Intervention: Counsel families in making
nutritionally balanced food choices
Monitor regularly
113+ High risk overweight/obese
Definition (C2-C4)
• At or above > 95th percentile BMI-for-age
OR >95th percentile weight-for-stature
CDC gender specific growth charts
Problematic feeding practices
– Excessive energy intake
– Decreased energy expenditure, lifestyle
– Impaired regulation of energy metabolism
LANGUAGE: Provide sensitivity, compassion, and a
conviction that this is an important, treatable
chronic medical problem. Focus on future benefit
shown to be effective.
AMA recommends use of ‘obese & overweight’ in
assessment & documentation only.
–
113+ High risk overweight/obese
Justification/Implications
• Goals: Achieve normal growth and development
• Reduce risk of adolescent and adult obesity and
obesity-related chronic disease
• Intervention:
– Choose food high in nutritional quality
– Avoid unnecessary or excessive amounts of
calorie rich foods and beverages
– Increase age-appropriate physical activity/
Reduce inactivity
Remember: Overweight is a chronic medical
problem that can be treated.
114 Overweight or At-risk of overweight
Definition:
Overweight - Children ≥ 24 months of age, at or above the
85th and below the 95th percentile BMI-for-age (CDC)
At Risk of Overweight: Have 1+ risk factors for at-risk of overweight
Infants˂ 12 months Biological mother BMI ≥ 30 at
conception or 1st trimester, Self-reported or HCP
measurement
•
Children ≥ 12 months Biological mother BMI ≥ 30 at
certification, Self-reported pre-pregnancy BMI or staff measures
taken at certification (not PG or delivered in past 6 mo.)
•
Infants or Children, Biological father with BMI ≥ 30 at
certification, Self-reported BMI or staff measurements taken at
certification
114 Overweight or At-risk of overweight
Justification/Implications
 Parental obesity +/or genetic
predisposition

increases risk of overweight in preschoolers,
even in the absence of other overt signs of
increasing body mass
–
–

BUT is Not inevitable
Environmental and other factors mediate the
relationship
Intervention:
–
–
–
Positive Encouragement
Food choices, family fun activities
Appropriate referrals for entire family
115 High Weight-for-Length-New
Definition:
Infants and children less than 24 months of
age, ≥ 97.7th percentile weight-for-length

WHO gender specific growth charts
115 High Weight-for-Length
Justification/Implication
•
Client-Centered Counseling
–
–
Supportive, empathetic, nonjudgmental, and
culturally appropriate
Suggested language (AMA Expert Committee
Report):
•
•
–
High weight-for-length
?Weight disproportional to height, Excess weight
Evaluate & assist:
•
•
•
Recognition of satiety cues
Non-Food Ways to comfort a child
Behavior modeling
121.01 Short stature
Definition
• Birth to less than 24 months, at or below 2.3rd
percentile length-for-age
–
•
WHO gender specific growth charts
Children 2-4 years of age, at or below the 5th
percentile length or stature-for-age
–
CDC gender specific growth charts
Note: Use adjusted gestational age with
prematurity
121.01 Short stature
Justification/Implications
–
Abnormally low
–
–
–
–
Prolonged undernutrition or repeated illness
Inadequate protein, with poor diet quality
Metabolic conditions, FAS
NOTE per WHO study: Ethnic & racial differences
<environmental factors
Intervention:
• Thorough dietary assessment
• Possible HCP referral
• Monitor growth with frequent follow-up
121.02 At Risk of Short Stature
(Infants and Children)
Definition
• Infants and children up to 2 years of age, above
the 2.3rd percentile AND at or below 5th percentile
length-for-age
–
•
WHO gender specific growth charts
Children 2 to 4 years of age, above the 5th
percentile AND at or below the 10th percentile
stature-for-age
–
CDC gender specific growth charts
Note: Use adjusted gestational age with prematurity
121.02 At Risk of Short
Stature (Infants and Children)
Justification/Implications (same as 121.01
•
Related to:
–
–
Lack of total dietary energy
Inadequate protein, due to poor diet quality
Intervention:
• Thorough dietary assessment
• Possible HCP referral
• Monitor growth with frequent F/U
152 Low head circumference
Definition
• Birth to less than 24 months, at or below
the 2.3rd percentile head circumferencefor-age
–
WHO gender specific growth charts
152 Low head circumference
Justification/Implications
•
Associated with:
– Pre-term birth or Very low birth weight
– Potential risk for neurocognitive abilities in light
of other factors
–
–
Genetic, nutrition, health, Socioeconomic status
factors
LHC not necessarily Abnormal head size
 Intervention:
Consider medical referral when improvement is
slow to respond to dietary interventions
–
344+ Thyroid disorders
Definition
• Diagnosed hyperthyroidism (↑ levels)
• Diagnosed hypothyroidism (↓ levels)
• Diagnosed postpartum thyroiditis in 1st
year post-delivery (thyroid dysfunction)
344+ Thyroid disorders

Justification/Implications
-Hyperthyroidism: ↓ weight despite ↑ appetite
-Hypothyroidism: ↑ weight
For both : Monitor weight and diet

Intervention: Reinforce & Support medical dietary
therapy
-Maternal needs for iodine increase
PG hyperthyroidism relatively uncommon
 Encourage iodine sufficiency, Iodine-rich foods
 150 mcg in prenatal supplements


Promote breastfeeding, Discourage smoking
Use soy with caution
351+ Inborn errors of metabolism
Definition:
Gene mutations or deletions that alter metabolism of proteins,
carbs, or fats
• IEMS include, but are not limited to:








Fructoaldolase deficiency
Galactokinas deficiency
Galactosemia
Glutaric aciduria
Glycogen storage disease
Histidinemia
Homocystinuria
Hyperlipoproteinemia
–
–
–
–
–
–
–
–
Hypermethioninemia
Maple syrup urine disease
Medium-chain acyl-CoA
dehydrogenase (MCAD),
Methylmalonic academia,
Phenylketonuria (PKU),
Propionic academia
Tyrosinemia
Urea cycle disorders
Additional information may be found at http://rarediseases.onfo.nih.gov/GARD
351+ Inborn errors of metabolism
Justification/Implications
• Can manifest at any stage of life
• Early identification important
Goal: Achieve normal growth and development
Intervention: Reinforce & Support medical dietary
therapy
–
–
•
Correct metabolic imbalance
Ensure adequate energy, protein, and nutrients
Continual monitoring
–
–
–
Nutrient intake – Need to follow prescribed dietary
regime!
Laboratory values
Growth
Release Webcast
July 26,2012
Questions?
THANK YOU!