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Using the WHO Growth Charts to Assess Children from Birth to 2 Years

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Using the World Health Organization
(WHO) Growth Charts to Assess Children
from Birth to 2 Years
Adapted by the State of California CHDP Nutrition Subcommittee
from the online training module:
Using the WHO Growth Charts to Assess Growth in the United States
Among Children Ages Birth to 2 Years
Centers for Disease Control and Prevention, 2012
November 2012
By the end of this presentation, you will be able to:
• Describe the new WHO growth chart
• Understand differences between WHO and CDC
growth charts for infants and children 0-2 years
• Plot on the appropriate growth chart
• Interpret results and make referrals when
Growth Chart Recommendations for
Health Care Providers
CDC recommends that health care providers:
• Use the WHO growth charts
for infants and children 0 to 2 years of age
• Use the CDC growth charts
for children ages 2 to 20 years
CHDP requires transition to the
WHO growth charts by October 2013
WHO Growth Charts
for Infants and Children Birth to 24 Months
• Child growth is monitored to:
– Assess adequacy of nutrition
– Identify weight status and potential for obesity
– Screen for disease related to abnormal growth
• Growth charts are
the standard tool
for interpreting growth
Compare the WHO Growth Standards
and the CDC Growth Reference
WHO Growth Chart
CDC Growth Chart
Studied population
infants and toddlers
Breastfed and formula
fed infants and toddlers
Growth pattern
How healthy children
ideal conditions
How certain groups of
children HAVE GROWN
in the past
Concept of growth
A STANDARD by which
all children should be
A REFERENCE does not
imply that pattern of
growth is optimal
Benefits of Using WHO Growth Charts
• Based on high quality population data
• Growth charts align with AAP and WIC growth
assessment tools and feeding recommendations
• Supports breastfeeding as optimal nourishment
• Allows provider to address feeding practices
and family environment
Impact of WHO Growth Charts on the
Interpretation of Growth
Mode of feeding can influence infant growth rate
Growth in the
Mode of feeding first 3 months
after 3 months
Growth Rate for Breastfed Infant
Breastfed infants
grow faster
in the first 3 months
Breastfed infants
grow slower from
3 to 12 months
Girls: Birth to 24 months
Weight-for-age curves
Adapted from Figure 2. Use of World Health Organization and CDC Growth Charts for Children Aged 0--59 Months in the United States.
CDC Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2010; 59(rr09):1-15.
Available online at:
WHO Growth Charts Are Different
• Fewer infants are below 5th percentile on
Weight-for-age charts
• Fewer infants are above 95th percentile on
Weight-for-length charts
• Fewer infants are below 5th percentile on
Weight-for-length charts
• A similar number of infants are below 5th
percentile on Length-for-age charts
Compare the WHO and CDC Growth Prevalence Rates by Age
Low length-for-age*
Low weight-for-age*
High weight-for-length†Recommended Cutoffs
WHO Growth Charts - Birth to 24 months
2 - 98 %
> 98 %
Low weight-for-length
Healthy weight
High weight-for-length
2 5 10
90 95 98
Recommended BMI-for-Age Cutoffs
CDC Growth Charts - 2 to 20 Years
5 - < 85 %
85 - < 95 %
≥ 95 %
Healthy Weight
5 10
Use terms “overweight” and “obese” only
for children and teens between 2 and 20
that fall in the corresponding %ile ranges
WHO Growth Standards
Birth to 24 Months
• Growth Parameters
Head circumference-for-age
• No BMI percentile because this is not a
measure used for children younger than 2
Boys: Birth to 24 months
Head circumference-for-age
Girls: Birth to 24 months
Head circumference-for-age
Incorporating the WHO Growth Charts
Into Your Practice
• CHDP requires that enrolled providers transition
to WHO growth charts by October 2013
• Review growth at each health assessment and
interpret carefully
• Understand that an infant will plot differently on the
WHO growth chart than on the CDC chart
• Encourage breastfeeding
• Review feeding with each health assessment and
determine if foods are developmentally appropriate
When Growth Deviates
from the Norm
• Check accuracy of your measurements
• Note that individual growth may not follow a
smooth curve
• Recognize limitations of a single growth
percentile value
• Obtain serial measurements over time
• If weight-for-length is < 2nd % or > 98 %,
assess fully, follow closely and refer, if needed
Case Example
Graph George’s Growth
George is an 18-month-old boy. George's mother,
Rae, works outside the home. George is cared for by
his grandmother during the day when Rae is
working. George has been formula-fed since birth,
and he was around 5 months of age when he began
eating solid foods. George has been seen by his
health care provider regularly since birth, and his
weight and length have been recorded and plotted
on the growth chart at each visit.
Graph George’s Growth
CDC Weight-for-Age Growth Chart
WHO Weight-for-Age Growth Chart
Comparing Weight-for-Length
CDC Weight-for-Length Growth Chart
WHO Weight-for-Length Growth Chart
Moving from WHO to CDC Charts
at 2 Years
• Recumbent length to standing height measurements
(difference is approximately 0.8 cm or Вј inch)
• Optimally fed study population to a reference
population using the general pediatric population
• WHO weight-for-length to CDC BMI-for-age percentile
• 5th - 95th cutoff values to 2nd - 98th cutoff values
Possible Changes
for an Individual Child at Age 2
• Length-for-age percentile may be similar
• CDC weight-for-age may be lower
• CDC BMI-for-age percentile may be
lower than WHO weight-for-length
How to Get Started
• Develop protocol for weighing and measuring
• Select appropriate charts for age and gender
• Record and plot on growth charts
• Interpret growth indicators
• Counsel on growth and feeding
• Support breastfeeding
• WHO Growth Chart Trainings
• CDC Morbidity and Mortality Weekly Report (MMWR)
Recommendations and Reports
• WHO Growth Charts
• AAP Policy Statement:
Breastfeeding and the Use of Human Milk
Training and Education Tools
• CHDP Training Modules
How to Accurately Weight and Measure Children
Using Body Mass Index-for-Age Growth Charts
Counseling the Overweight Child
Promoting Physical Activity
Glucose and Cholesterol Screening
• Breastfeeding materials
• Women, Infants and Children Program (WIC)
Slides 11 and 12 of this presentation were adapted from the WIC WHO Growth Charts In-Service Training:
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