Child Growth Standards Rr5909

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department of health and human services

Centers for Disease Control and Prevention

Recommendations and Reports September 10, 2010 / Vol. 59 / No. RR-9

Morbidity and Mortality Weekly Reportwww.cdc.gov/mmwr

Use of World Healh Orgaizaioad CDC Growh Chars forChildre Aged 059 Mohs

i he Uied Saes

Please note: An erratum has been published for this issue. To view the erratum, please click here.
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MMWR

Te MMWR series o publications is published by the Oce oSurveillance, Epidemiology, and Laboratory Services, Centers orDisease Control and Prevention (CDC), U.S. Department o Healthand Human Services, Atlanta, GA 30333.

Suggested Citation: Centers or Disease Control and Prevention.[itle]. MMWR 2010;59(No. RR-9):[inclusive page numbers].

Ceers for Disease Corol ad PreveioTomas R. Frieden, MD, MPH

Director

Harold W. Jae, MD, MAAssociate Director or Science

James W. Stephens, PhDOce o the Associate Director or Science

Stephen B. Tacker, MD, MScDeputy Director or

Surveillance, Epidemiology, and Laboratory Services

Ediorial ad Producio SaffChristine G. Casey, MD

(Acting) Editor, MMWRSerieseresa F. Rutledge

Managing Editor, MMWRSeries

David C. JohnsonLead echnical Writer-Editor

Catherine B. Lansdowne, MSProject Editor

Martha F. BoydLead Visual Inormation Specialist

Malbea A. LaPeteStephen R. Spriggserraye M. Starr

Visual Inormation Specialists

Quang M. Doan, MBA

Phyllis H. KingInormation echnology Specialists

Ediorial BoardWilliam L. Roper, MD, MPH, Chapel Hill, NC, Chairman

Virginia A. Caine, MD, Indianapolis, INJonathan E. Fielding, MD, MPH, MBA, Los Angeles, CA

David W. Fleming, MD, Seattle, WAWilliam E. Halperin, MD, DrPH, MPH, Newark, NJ

King K. Holmes, MD, PhD, Seattle, WADeborah Holtzman, PhD, Atlanta, GA

John K. Iglehart, Bethesda, MD

Dennis G. Maki, MD, Madison, WIPatricia Quinlisk, MD, MPH, Des Moines, IAPatrick L. Remington, MD, MPH, Madison, WI

Barbara K. Rimer, DrPH, Chapel Hill, NCJohn V. Rullan, MD, MPH, San Juan, PR

William Schaner, MD, Nashville, NAnne Schuchat, MD, Atlanta, GA

Dixie E. Snider, MD, MPH, Atlanta, GAJohn W. Ward, MD, Atlanta, GA

COntEntS

Introduction .............................................................................. 1

Methods ................................................................................... 1

Creation of the WHO and CDC Growth Curves ........................... 2

Rationale for Recommendations .................................................. 6

Recommendations ..................................................................... 9Use of Recommended Growth Charts in Clinical Settings ............ 11

Recent WHO Growth Chart Policies and Publications ................. 12

Conclusion .............................................................................. 13

References .............................................................................. 13


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Vol. 59 / RR-9 Recommendations and Reports 1

IroducioTe physical growth o inants and children has long been

recognized as an important indicator o health and wellness(1,2). Growth charts have been used or at least a centuryto assess whether a child is receiving adequate nutrition andto screen or potentially inadequate growth that might beindicative o adverse health conditions. raditionally, atten-tion has ocused on undernutrition. However, in the past ewdecades, concerns about excessive weight gain have increased,and growth charts have been used to screen or overweight,including obesity.

In April 2006, the World Health Organization (WHO)released a new international growth standard or children aged059 months (3). Similar to the 2000 CDC growth reerence

Corresponding preparer: Laurence M. Grummer-Strawn, CDC, 4770Buord Highway, MS K-25, Atlanta, GA 30341. elephone: 770-488-5702; Fax: 770-488-5369; E-mail: [email protected]. Te material in thisreport originated in the National Center or Chronic Disease Preventionand Health Promotion, Ursula Bauer, PhD, Director.

Use of World Healh Orgaizaio ad CDC Growh Charsfor Childre Aged 059 Mohs i he Uied Saes

Prepared byLaurence M. Grummer-Strawn, PhD1

Chris Reinold, PhD1

Nancy F. Krebs, MD21Division o Nutrition, Physical Activity, and Obesity, National Center or Chronic Disease Prevention and Health Promotion

2Department o Pediatrics, University o Colorado Denver

Summary

In April 2006, the World Health Organization (WHO) released new international growth charts or children aged 059 months.Similar to the 2000 CDC growth charts, these charts describe weight or age, length (or stature) or age, weight or length (orstature), and body mass index or age. Whereas the WHO charts are growth standards, describing the growth o healthy childrenin optimal conditions, the CDC charts are a growth reerence, describing how certain children grew in a particular place andtime. However, in practice, clinicians use growth charts as standards rather than reerences.

In 2006, CDC, the National Institutes o Health, and the American Academy o Pediatrics convened an expert panel to reviewscientifc evidence and discuss the potential use o the new WHO growth charts in clinical settings in the United States. On the

basis o input rom this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO internationalgrowth charts, rather than the CDC growth charts, or children aged


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2 MMWR September 10, 2010

tic evidence and obtain opinions regarding the use o the newWHO growth charts in clinical settings in the United States.Te participants at the meeting were selected on the basis otheir expertise in child growth, statistical methodology, clini-cal application, and maternal and child health policy. CDC,NIH, and AAP each had numerous representatives; additional

experts rom academia, clinical proessional groups, and othergovernment agencies were invited.

Participants were provided background documents describ-ing the development o both sets o curves. At the meeting,CDC made presentations on the methods used to create theCDC growth charts, and a principal investigator or the WHOMulticentre Growth Reerence Study (MGRS), which gener-ated the data used or the WHO growth curves, made a presen-tation on the methods used to create the WHO charts. CDCconducted a statistical comparison o the charts and presentedthe results to participants. Meeting discussions ocused on thenumerous actors involved in the selection o a chart, includ-ing the assessment o child growth using reerences (i.e., howcertain groups o children have grown in the past) comparedwith standards (i.e., how healthy children should grow in idealconditions), dierences between the growth o breasted andormula-ed inants, the methods used to create the CDC andWHO charts, and implications o using the charts in clinicalpractice. At the time o the meeting, WHO was developingbut had not released growth charts or head circumerence orage; thereore, these charts were not discussed. Te charts havesince been released and are available at http://www.who.int/childgrowth/standards/hc_or_age/en/index.html.

Te panel was not asked to arrive at a consensus. At the endo the meeting, CDC asked all participants to provide writtenopinions on which curves should be recommended, at whichages, and or which children. Ater the meeting ended, CDCworked with NIH and AAP to develop these CDC recom-mendations based on the meeting proceedings.

Creaio of he WHO ad CDCGrowh Curves

Hisory

Until the late 1970s, clinicians used various growth chartsto assess child growth (69). In 1977, the National Center orHealth Statistics (NCHS), which became a part o CDC in1987, published a new set o growth charts or children aged


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TABLE 1. Comparison of sample populations used to create the CDC and WHO growth curves for children aged


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surements were used. A total o 18,973 distinct measurementso weight and length were included in the data set. Data onparticipants who were not included in the data set were not

available to meeting participants.A primary study hypothesis o MGRS based on previous

research (13,14) was that all young children have the potentialto grow similarly, regardless o their ethnic group or place obirth, i they are in a healthy environment and receive adequatenutrition. Tis hypothesis was conrmed; the mean lengthmeasurements o children aged


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are selected through a complex, multistage probability design.All NHANES surveys include a household interview and adetailed physical examination that includes anthropometricmeasurements. Data rom NHANES III (19881994) wereused to create the curves or children aged 25 months;NHANES II (19761980) and III or ages 611 months;and NHANES I (19711974), II, and III or ages 1259months. In addition, supplementary length data rom clinicsthat participated in the CDC Pediatric Nutrition SurveillanceSystem (PedNSS) (19751995) and had data or older inants

and children that were similar to the NHANES nationalsurveillance data were used or the length-or-age charts orages 0.1 to


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study, anthropometrists took two measurements independentlyand repeated measurements that exceeded preset maximumallowable dierences. NHANES anthropometrists took mea-surements once. In general, both WHO and CDC assessedlength (measured lying down) or children aged


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Te expert panel universally agreed that breasteeding is theoptimal orm o inant eeding and recognized that the growtho breasted inants diers rom that o ormula-ed inants.Te panel also recognized that AAP has stated the breastedinant is the reerence or normative model against which allalternative eeding methods must be measured with regard to

growth, health, development, and all other short- and long-term outcomes (24).

Some U.S. clinicians who are currently using the CDC chartsmight be unaware o or not understand the growth pattern oexclusively breasted inants, which diers rom that o ormula-ed inants. Tese clinicians might inappropriately recommendthat mothers supplement breasteeding with ormula or advisethem to wean their inants rom breasteeding completely.

Te WHO and CDC charts show dierent growth pat-terns that might lead clinicians to dierent conclusions aboutvariations in growth. Healthy breasted inants typically gainweight aster than ormula-ed inants in the rst ew months

o lie but then gain weight more slowly or the remaindero inancy (25,26). Tereore, in the rst ew months o lie,WHO curves show a aster rate o weight gain than the CDCcharts or boys and girls (Figures 2 and 3). Use o the WHOcharts in the United States might lead to an increase in themisperception o poor growth at this age.

Beginning at approximately age 3 months, WHO curvesshow a slower rate o weight gain than the CDC charts, bothin weight or age and weight or length. Because WHO curvesare derived rom inants who breasteed through 12 months,inants who are still breasteeding at approximately age 3months are more likely to maintain their percentages on theWHO growth charts but to decrease in percentages on theCDC charts. In contrast, i WHO charts are used to assessthe growth o ormula-ed inants, these inants might beidentied as growing too slowly during the rst ew months olie but then be identied as gaining weight too quickly aterapproximately 3 months.

Childre Aged 2459 MohsCDC curves allow or a transition period rom 2435

months when children can be assessed using either the chartsor children aged 036 months or or persons aged 219 years.

Children in this age range can have their measurements plot-ted on the chart or younger children to show continuity withprevious growth and on the chart or older children to showcontinuity with subsequent growth. For weight or length (orstature) and length (or stature) or age, assessing children usingboth curves requires measuring the child both recumbent andsupine and thereore is not a common practice.

Te meeting participants raised concerns that weights >2standard deviations above the median should not have been

deleted in creation o the WHO curves because they were paro the ull weight distribution o the study population. Teyalso noted that the methods or selecting the study participantor this age range was not substantively dierent between theWHO and CDC charts. CDC and WHO growth charts orages 2459 months were both based on cross-sectional data

and compared with the methods used to create the growthcurves or children aged


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and overweight that is similar to the prevalence rom the CDCcurves using the 5th and 95th percentiles (27). Tereore, inpediatric practice, the number o children identied or addi-

tional ollow-up because o short stature and overweight wouldbe similar to current numbers. In contrast, use o the 5th and95th percentiles with the WHO weight charts would result in10% o the WHO growth curve population being categorizedas underweight or overweight, even though the populationcomprises healthy children who were ed according to inter-national recommendations. Te population used to create theCDC charts includes children with various health problemsand children who were not ed according to international rec-

ommendations. Use o the 5th and 95th percentiles with theWHO curves to assess the U.S. population might overestimatethe prevalence o short stature, underweight, and overweight in

the United States. For example, the mean stature included in theWHO and CDC charts is similar, but the WHO charts haveless variability than the CDC charts among children aged


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or the WHO charts (using the 2.3rd and 97.7th percentiles)are used (Figure 6). A substantial dierence exists in theprevalence o low weight or age, with the WHO standard

showing a lower prevalence beginning at age 6 months. TeCDC reerence identies 7%11% o children aged 623months as having low weight or age, whereas the WHO stan-dard identies


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are recommended or identication o children whose growthmight be indicative o adverse health conditions. Te rationaleor use o the WHO growth charts or this age group includes

the ollowing: 1) the recognition that breasteeding is the rec-ommended standard or inant eeding and, unlike the CDCcharts, the WHO charts refect growth patterns among childrenwho were predominantly breasted or at least 4 months andstill breasteeding at age 12 months; 2) clinicians already usegrowth charts as a standard or normal growth; and 3) theWHO charts are based on a high-quality study, the MGRS.

Coiued Use of CDC Growh Charsfor Childre Aged 2459 Mohs

Use o the CDC growth charts or children aged 2459months is recommended. Te CDC charts also should beused or older children because the charts extend up to age 20years, whereas the WHO standards described in this reportapply only to children aged 059 months. Te rationale orcontinuing to use CDC growth charts includes the ollowing1) the methods used to create the WHO and CDC charts aresimilar ater age 24 months, 2) the CDC charts can be usedcontinuously through age 19 years, and 3) transitioning at age

FIGURE 4. Comparison of World Health Organization (WHO) and CDC growth chart length/stature-for-age measurements for girls aged


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24 months is most easible because measurements switch romrecumbent length to standing height at the this age, necessitat-ing use o new printed charts.

Use of Recommeded GrowhChars i Cliical Seigs

CDC recommends the use o modied versions o theWHO curves or children aged


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thereore cross upward in percentiles, perhaps becoming clas-sied as overweight. Although no evidence-based guidelines

or treating overweight in inancy exist, early recognition o atendency toward obesity might appropriately trigger interven-tions to slow the rate o weight gain.

For the rst 3 months o age, the WHO charts show asomewhat aster rate o weight gain than the CDC charts,leading to the identication o more inants who appear to begrowing slowly. Clinicians should recognize that this slower rateo weight gain is typical or ormula ed inants. For breastedinants identied as growing slowly, clinicians need to careullyassess general health issues and ensure appropriate managemento lactation. Only i there is evidence o lactation inadequacyshould they consider supplementation with ormula.

Dierences in the length-or-age WHO and CDC charts aresmall, and clinical dierences based on these charts are expectedto be insignicant. In contrast, when the WHO charts are usedto assess the growth o U.S. children, ewer children aged 623months will be identied as having inadequate weight or age.Some assert that this might be benecial because overdiagnosiso underweight might damage the parent-child interaction,subjecting amilies to unnecessary interventions and possibly

unintentionally creating an eating disorder (28). Howeverchildren who are identied as having low weight or age on

the WHO charts will be more likely to have a substantial de-ciency. Clinicians need to seek out the causes or poor growthand propose changes accordingly. For example, poor weighgain might result rom neglect, substantial morbidities, or othermedical problems that require immediate attention (29).

Rece WHO Growh Char Policiesad Publicaios

According to WHO, 111 countries had adopted the WHOgrowth standards as o July 1, 2010 (A. Onyango, WHO

personal communication, July 26, 2010.). Canada has recom-mended the use o the WHO growth charts (30), includingthe more recently published charts or children aged 517years (31). Te United Kingdom Department o Health hasrecommended use o the WHO growth standards or childrenaged 2 weeks to 5 years in combination with United Kingdombirth weight charts (3242 weeks gestation) (32,33).

In 2007, the AAP board o directors voted to support theuse o the WHO growth charts or children aged


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(D. Burrowes, American Academy o Pediatrics, personal com-munication, November 7, 2007), with the recognition thatsubstantial educational measures are needed to assist with inter-pretation o the charts. AAP has waited or the availability oclinically useable charts to publicize this recommendation.

Various studies have compared the WHO growth standards

with other growth reerences (3437). Researchers also haveanalyzed ways in which use o the WHO standards might aectprevalences o wasting, stunting, and underweight worldwide(38), as well as the distribution o z scores, a commonly usedindicator o data quality in international surveys (39). WHOhas developed an algorithm to convert population prevalencesthat were computed using the previous NCHS, CDC, andWHO growth curves (10,11) to those expected using the newcharts (38). Several studies have conducted eld testing o theWHO charts in clinical settings worldwide, showing dier-ences in prevalence compared with existing charts but alsodocumenting that the WHO standards generally correspondwith clinical assessment o malnutrition (36,40,41).

CoclusioBecause the CDC charts are currently in use in clinical set-

tings to assess growth o children, use o the WHO charts orchildren aged


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23. Heird WC. Progress in promoting breast-eeding, combating malnutri-tion, and composition and use o inant ormula, 19812006. J Nutr2007;137:499S502.

24. American Academy o Pediatrics, Section on Breasteeding. Breasteedingand the use o human milk. Pediatrics 2005;115:496506

25. Dewey KG. Growth characteristics o breast-ed compared to ormula-ed inants. Biol Neonate 1998;74:94105.

26. Dewey KG. Growth patterns o breasted inants and the current statuso growth charts or inants. J Hum Lact 1998;14:8992.

27. Mei Z, Ogden CL, Flegal KM, Grummer-Strawn LM. Comparison othe prevalence o shortness, underweight, and overweight among USchildren aged 0 to 59 months by using the CDC 2000 and the WHO2006 growth charts. J Pediatr 2008;153:6228.

28. Wright JA, Ashenburg CA, Whitaker RC. Comparison o methods tocategorize undernutrition in children. J Pediat 1994;124:9446.

29. Sherry BL. Epidemiology o inadequate growth. In Kessler DB, DawsonP, eds. Failure to thrive and pediatric undernutrition: a transdisciplinaryapproach. Baltimore: Paul H. Brookes, pp. 1936.

30. Dietitians o Canada, Canadian Paediatric Society; Te College OFamily Physicians O Canada; Community Health Nurses o Canada.Promoting optimal monitoring o child growth in Canada: using thenew WHO growth charts. Collaborative Statement o the Dietitianso Canada, Canadian Paediatric Society, Te College O Family

Physicians O Canada, and Community Health Nurses o Canada.2010. Available at http://www.cps.ca/english/publications/cps10-01.htm. Accessed June 1, 2010.

31. de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, SiekmannJ. Development o a WHO growth reerence or school-aged childrenand adolescents. Bull World Health Organ 2007;85:6607.

32. Scientic Advisory Committee on Nutrition; Te Royal College oPaediatrics and Child Health (2007). Application o WHO GrowthStandards in the UK. London: Te Stationery Oce; 2007. Availableat http://www.rcpch.ac.uk/doc.aspx?id_resource=2862. Accessed

June 1, 2010.

33. Department o Health (United Kingdom). Using the new UKWorldHealth Organization 04 years growth charts: inormation or healthcare proessionals about the use and interpretation o growth charts2009. Available at http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110425.pd. Accessed

June 1, 2010.34. Ziegler EE, Nelson SE. Growth charts compared. Nestle Nutr Workshop

Ser Pediatr Program 2010;65:197212.35. Roelants M, Hauspie R, Hoppenbrouwers K. Breasteeding, growth

and growth standards: perormance o the WHO growth standards omonitoring growth o Belgian children. Ann Hum Biol 2010;37:29.

36. Nash A, Secker D, Corey M, Dunn M, OConnor DL. Field testing othe 2006 World Health Organization growth charts rom birth to 2 yearsassessment o hospital undernutrition and overnutrition rates and theuseulness o BMI. JPEN J Parenter Enteral Nutr 2008;32:14553.

37. de Onis M, Garza C, Onyango AW, Borghi E. Comparison o theWHO child growth standards and the CDC 2000 growth charts. J Nut2007;137:1448.

38. Yang H, de Onis M. Algorithms or converting estimates o childmalnutrition based on the NCHS reerence into estimates based on the

WHO child growth standards. BMC Pediatr 2008;8:19.39. Mei Z, Grummer-Strawn LM. Standard deviation o anthropomet

ric Z-scores as a data quality assessment tool using the 2006 WHO

growth standards: a cross country analysis. Bull World Health Organ2007;85:4418.

40. Onyango AW, de Onis M, Caroli M, et al. Field-testing the WHO childgrowth standards in our countries. J Nutr 2007;137:14952.

41. Sguassero Y, Moyano C, Aronna A, Fain H, Orellano A, Carroli B. Fieldtesting o new WHO growth standards: assessment o anthropometricoutcomes o children rom 0 to 5 years rom Rosario city, Argentina[Spanish]. Arch Argent Pediatr 2008;106:198204.
http://www.cps.ca/english/publications/cps10-01.htmhttp://www.cps.ca/english/publications/cps10-01.htmhttp://www.rcpch.ac.uk/doc.aspx?id_resource=2862http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110425.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110425.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110425.pdfhttp://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_110425.pdfhttp://www.rcpch.ac.uk/doc.aspx?id_resource=2862http://www.cps.ca/english/publications/cps10-01.htmhttp://www.cps.ca/english/publications/cps10-01.htm


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Paricipas i he 2006 Exper Pael Reviewof World Healh Orgaizaio ad CDC Growh Chars

CDC: Katherine Flegal, PhD, Cli Johnson, MSPH, Cynthia Ogden, PhD, Edward Sondik, PhD, Rong Wei, PhD, National Center or Health StatisticsHyattsville, Maryland. Laurence M. Grummer-Strawn, PhD, Zuguo Mei, MD, Christopher Reinold, PhD, Diane Tompson, MPH, National Center oChronic Disease Prevention and Health Promotion, Atlanta, Georgia.

National Institutes of Health: Gilman Grave, MD, Mary Hediger, PhD, National Institute o Child Health and Human Development, Bethesda, Maryland

Van S. Hubbard, MD, PhD, Wendy Johnson-Askew, PhD, Robert Kuczmarski, DrPH, National Institute o Diabetes and Digestive and Kidney DiseasesBethesda, Maryland.

American Academy of Pediatrics: Ellen Buerk, MD, Oxord, Ohio. Arthur Eidelman, MD, Shaare Zedek Medical Center Jerusalem, Israel. Frank Greer, MDMeriter Hospital, Madison, Wisconsin. Nancy Krebs, MD, University o Colorado Denver, Denver, Colorado. Ruth Lawrence, MD, University o RochesteSchool o Medicine and Dentistry, Rochester, New York. Lori Feldman-Winter, MD, Childrens Regional Hospital at Cooper, University o Medicine andDentistry o New JerseyRobert Wood Johnson Medical School, Camden, New Jersey.

Other Federal Government Agencies: Sue Ann Anderson, PhD, Food and Drug Administration, Washington, DC. Donna Blum-Kemelor, PhD, PatriciaDaniels, Jay Hirschman, U.S. Department o Agriculture, Alexandria, Virginia; Elizabeth Frazao, PhD, U.S. Department o Agriculture, Washington, DCSteve Kessel, MD, PhD, Department o Health and Human Services, Washington, DC. Iris Mabry-Hernandez, MD, Agency or Healthcare Research andQuality, Washington, DC. Denise Soka, MPH, Health Resources and Services Administration.

Invited Experts: Diane Anderson, PhD, American Dietetic Association, Baylor College o Medicine, Baylor, exas. Mary Ann Best, PhD, National Associationo Pediatric Nurse Practitioners, University o exas Medical Branch, School o Nursing, Galveston, exas. Margaret Boland, MD, North American Society orPediatric Gastroenterology, Hepatology, and Nutrition, Childrens Hospital o Eastern Ontario, University o Ottawa, Ontario, Canada. Nancy Butte, PhDBaylor College o Medicine, Baylor, exas. Katherine Dewey, PhD, Site Coordinator, Multicentre Growth Reerence Study, University o Caliornia, DavisDavis, Caliornia. Cutberto Garza, MD, PhD, Co-Principal Investigator, Multicentre Growth Reerence Study, Boston College, Chestnut Hill, Massachusetts

John Himes, PhD, University o Minnesota School o Public Health, Minneapolis, Minnesota. Chessa Lutter, PhD, Pan American Health OrganizationWashington, DC. Reynaldo Martorell, PhD, Emory University, Atlanta, Georgia. Van Nguyen, Community Clinic Inc., Women, Inants, and ChildrenProgram, akoma Park, Maryland. Eckhart Ziegler, MD, University o Iowa Childrens Hospital, Iowa City, Iowa.


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U.S. Government Printing Oce: 2010-623-026/41275 Region IV ISSN: 1057-5987

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Child Growth Standards Rr5909

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