head

wei

ght

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5

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38 40BOYS WEIGHT (kg)

99.6

th98

th91

st

th

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

42

66cm

50cm

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31cm

In association with

head

t

14 16 18 20 22 24 26 28 30 32 34

Age in weeks/ month

3 4 5 6 7 8

99.6

th

98th

91st

75th

50th

25th

9th

2nd

0.4th

GIRLS0–1 year

75 leng h

s

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ght(

kg)

Hea

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(cm

)

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4.5

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3.5

3

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40

34 36 38 40 34 36 38 40

Gestation in weeks Gestation in weeks

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Preterm BOYS HEADCIRCUMFERENCE (cm)

50th

25th

9th

2nd

0.4th

99.6

th

98th

91st

75th

50th

25th

9th

2nd

0.4t

h

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4t

h

Actual age

Gestational age(7 weeks preterm)

For preterm infants (lessthan 37 weeks gestation),plot on this chart until 2weeks after expected dateof delivery (42 weeks). Aswith term infants, someweight loss is common inthe early days.

From 42 weeks, plot on the0-1 year charts withgestational correction.Plot at actual age thendraw a line back thenumber of weeks the infantwas preterm and mark spotwith arrow; this is thegestationally correctedcentile.

4232

42

4232

BirthHead Circumference

124cm

120

116

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108

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100

96

92

88

84cm

96cm

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88

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68

64

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t

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3432 36 38 40 42

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(cm

)W

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)

Gestation in weeks

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5

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1

Birth Weight

3432 36 38 40 42

Gestation in weeks8 9

9

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Actual age

Gestational age(7 weeks preterm)

36 38 40 42 44 46 48 50

99.6t

h

98th

91st

75th

50th

25th

9th

2nd

0.4th

99.6

th

98th

91st

75th

50th

25th

9th

2nd

0.4t

h99

.6th

98th

91st

75th

50th

25th

9th

2nd

0.4t

h

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

2nd

9th

25th

50th

75th

91st

98th

99.6th

0.4th

2nd

9th

0.4th

25th

50th

75th

91st

98th

99.6th

head

weight

height

552cm

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48

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40cm

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99.6th

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75th

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2nd

0.4th

13 14 15 16 17

13 14 15 16 17

19 20 21 22 23

19 20 21 22 23

25 26 27 28 29

25 26 27 28 29

31 32 33 34 35

31 32 33 34 35

37 38 39 40

37 38 39 40 41 43 44 45 46 47

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

length

2

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

99.6th

98th

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75th

50th

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9th

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ft/in

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5.10

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5.3

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5.1

5.0

4.11

180

175

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165

160

155

150

99.6th

98th

91st

75th

50th

25th

9th

2nd

0.4th

cm

Adult HeightPrediction

Age in months/ years

Age in months/ years

Measure length until age 2; measureheight after age 2.A child’s height is usually slightly lessthan their length.

Preterm GIRLS1–4 years

Plot child’sheight centile onthe pink linesabove; the blacknumbers showaverage femaleadult height forthis centile;80% of childrenwill be within±6 cm of thisvalue.

52

52

14kg

13.5

0.5kg

Plotting preterm infantsUse the low birthweightchart for infants less than 32weeks gestation and anyother infants requiringdetailed assessment.Use this section for infantsof less than 37 weeksgestation. As with terminfants there may be someweight loss in the early days.From 42 weeks, plot on the0–1 year chart withgestational correction.

Gestational correctionPlot actual age then draw aline back the number ofweeks the infant was pretermand mark the spot with anarrow; this is the gestationallycorrected centile.

11kg

10.5

weigh

Age in weeks/ months

1 2 3 4 5 6 7

2 4 6 8 10 12 14 16 18 20 24 26 28 30 32 3422

99.6

th98

th91

st

75th

50th

25th

9th

2nd

0.4th

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91st

75th

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0.4th

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12 48

Data Recording

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Birth Measurement

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 2

Measurement 4

Measurement 6

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 8

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 10

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 3

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 5

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 7

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Measurement 9

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Recording Date

Weight

Head Circumference

Length/Height

Location

Health worker name

Using the new UK–World Health Organization

0–4 years growth charts

Information for healthcare professionals about the use and interpretation of growth charts

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Introduction 4

Weighing and measuring 6

Plotting measurements 8

Interpreting the new growth chart 11

Predicting adult height 15

Weight–height to BMI conversion chart 16

Training and education from the Royal College of Paediatrics and Child Health 18

Notes 22

Contents

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Introduction

New UK–World Health Organization (WHO) 0–4 years growth charts have been introduced in England for all new births from May 2009. The charts, which have been developed for the Department of Health by the Royal College of Paediatrics and Child Health, are based on the growth of breastfed infants and replace previous charts that were based on the growth of predominantly formula-fed babies.

The new charts have been constructed using the WHO standards for infants aged 2 weeks to 4 years. These used data from healthy children from around the world with no known health or environmental constraints to growth who were breastfed exclusively for at least 4 months and partially for one year. For the first time, they provide a description of optimal growth which will help to establish breastfeeding as the norm. The WHO found that infants worldwide have very similar patterns of linear growth; and the new charts describe the ideal patterns of growth that we should aspire to for all UK children, whatever their ethnic origin and however they are fed in infancy. These have been combined with birth data for gestations 23 to 42 weeks from the UK 1990 growth reference, as the WHO dataset did not include preterm infants.

The new charts will have an impact on the interpretation of weight patterns in children. UK children match the charts well for length and height at all ages and for weight in the early weeks, but after the age of 6 months roughly twice as many children will be above the 98th centile for weight compared with the UK 1990 charts, and only about 1 in 200 children will be below the 2nd centile.

This leaflet provides instructions particularly for users of the personal child health record (PCHR) charts; a shorter version of these instructions can also be found on the A4 chart.

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Key new features of the new UK–WHO growth charts:3 A separate preterm section for infants of 32 to 36

weeks’ gestation.

3 A new low birthweight chart available for preterm infants born before 32 weeks’ gestation.

3 No centile lines between 0 and 2 weeks.

3 The 50th centile has been de-emphasised.

No lines between birth and 2 weeks

Term birth measurements plotted at age 0

Preterm births plotted on preterm section

separate

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Weighing and measuring

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When to weigh and measure length› Babies should be weighed in the first week as part of the

assessment of feeding and thereafter as needed.

› Length or height should be measured whenever there are any worries about a child’s weight gain, growth or general health.

› If parents wish, or if there is professional concern, babies can be weighed at 6–8 weeks, 12 and 16 weeks. Babies should usually be weighed at 12–13 months at the time of routine immunisations. Measurements need to be interpreted in relation to length, growth potential and any earlier measurements of the baby.

› If there is concern, weigh more often; however, weights measured too closely together are often misleading, so babies should be weighed no more than:

– once a month from 2 weeks to 6 months of age

– once every two months from 6 to 12 months of age

– once every three months over the age of 1 year.

However, most children do not need to be weighed this often; families should be reassured that they can attend for advice without having their baby weighed.

When to measure head circumferenceHead circumference should be measured around birth, at the 6–8 week check and at any time after that if there are any worries about the child’s head growth or development.

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Plotting measurements

› Plot each measurement on the relevant chart by drawing a small dot in pencil where a vertical line through the child’s age crosses a horizontal line through the measured value.

› The lettering on the charts (‘weight’, ‘length’, etc.) sits on the 50th centile, providing orientation for ease of plotting (see page 2).

For babies born at term (37 weeks or later)› Plot birthweight (and, if measured, length and head

circumference) at age 0 on the 0–1 year chart. The coloured arrows at age 0 represent UK birthweight data and show the child’s birth centile.

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› Weight gain in the early days varies a lot from baby to baby, so there are no lines on the chart between 0 and 2 weeks. Weight collected in this period should still be plotted but for interpretation should be compared with birth weight (see page 11).

For preterm infants› A separate low birthweight chart is available for infants of

less than 32 weeks’ gestation and any other hospitalised neonate or infant requiring detailed assessment.

› For healthy infants born after 32 weeks and before 37 weeks, plot all measurements in the preterm section (to the left of the main 0–1 year chart) until 42 weeks’ gestation, then plot on the 0–1 year chart using gestational correction.

› The preterm section can also be used to assess the relative size of infants at the margin of ‘term’ (e.g. 37 weeks’ gestation), but these measurements should also be plotted at age 0 on the 0–1 year chart.

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Gestational correction› This should only be used for infants born before

37 weeks.

› Plot measurements at the child’s actual age and then draw a line back the number of weeks the infant was preterm. Mark the spot with an arrow (see diagram below): this is the child’s gestationally corrected centile.

› Gestational correction should continue until at least 1 year of age and until 2 years for infants born before 32 weeks.

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Assessing weight loss after birthSome degree of weight loss is common in the first week but 80% of infants will have regained this by 2 weeks of age. Recovery of birthweight by 2 weeks suggests that feeding is effective and that the child is well.

Fewer than 5% of babies lose more than 10% of their weight at any stage, and only 1 in 50 are 10% or more lighter than birthweight at 2 weeks. A weight loss of 10% or more at any stage therefore needs careful assessment.

Percentage weight loss can be calculated as follows:

Weight loss = difference between current weight and birthweight

Percentage weight loss = weight loss ÷ birthweight x 100%

For example:

› A child born at 3.500kg who drops to 3.150kg at 5 days has lost 350g or 10% (0.35 ÷ 3.5 x 100).

› In a baby born at 3.000kg, a 150g loss is 5% (0.15 ÷ 3.0 x 100).

Interpreting the new growth chart

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What do the centiles mean?› The new charts indicate a child’s size compared

with children of the same age and maturity who have shown optimum growth. The chart also shows how quickly a child is growing.

› The centile lines on the chart show the expected range of weights and heights (or lengths); each describes the number of children expected to be below that line, e.g. 50% below the 50th, 91% below the 91st.

› Children come in all shapes and sizes, but 99 out of 100 children who are growing optimally will be between the two outer lines (0.4th and 99.6th centiles); half will lie between the 25th and 75th centile lines.

› Being very small or very big can sometimes be associated with underlying illness. There is no single threshold below which a child’s weight or height is definitely abnormal, but only 4 out of 1000 children who are growing optimally are below the 0.4th centile, so these children should be assessed to exclude any problems. Those above the 99.6th centile for height are almost always healthy. If weight is above the 99.6th centile, calculate body mass index (BMI) (see page 17). Also calculate the BMI if the weight and height centiles appear very different.

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What is a normal rate of weight gain and growth?› Babies do not all grow at the same rate, so a baby’s

weight often does not follow a particular centile line, especially in the first year. Weight is most likely to track within one centile space (the gap between two centile lines – see the diagram on page 10). In infancy, acute illness can lead to sudden weight loss and a weight centile fall, but on recovery the child’s weight usually returns to its normal centile within two to three weeks. However, a sustained drop through two or more weight centile spaces is unusual (fewer than 2% of infants) and should be carefully assessed by the primary care team, including measuring length/height.

› Because it is difficult to measure length and height accurately in pre-school children, successive measurements commonly show wide variation. If there are worries about growth, it is useful to measure length or height on a few occasions over time; if there is a stable average position over time this suggests that growth is normal.

› Head circumference centiles usually track within a range of one centile space. After the first few weeks a drop or rise through two or more centile spaces is unusual (fewer than 1% of infants) and should be carefully assessed.

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Why do the length/height centiles change at 2 years?The growth standards show length data up to 2 years of age, and height from age 2 onwards. When a child is measured standing up, the spine is squashed a little, so their height is slightly less than their length; the centile lines shift down slightly at age 2 to allow for this. It is important that this difference does not worry parents; what matters is whether the child continues to follow the same centile after the transition.

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Parents like to know how tall their child will be as an adult. The child’s most recent height centile (aged 2–4 years) gives a good idea of this for healthy children. Plot this centile on the adult height predictor to the right of the height chart to find the average adult height for children on this centile. Four out of five children will have adult heights that are within 6cm above or below this value.

For example: if this boy is on the 75th centile for height, the adult height predictor suggests that he may reach an adult height of 181cm +/– 6cm

Predicting adult height

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Weight–height to BMI conversion chart

BMI indicates how heavy a child is relative to their height and is the simplest measure of thinness and fatness from the age of 2, when height can be measured fairly accurately.

In a child over 2 years of age, the BMI centile is a better indicator of overweight or underweight than the weight centile. The chart on page 18 provides an approximate BMI centile, accurate to a quarter of a centile space.

Instructions for use of the weight–height to BMI conversion chart1. Read off the weight and height centiles from the

growth chart.

2. Plot the weight centile (left axis) against the height centile (bottom axis) on the chart.

3. If between centiles, read across in this position.

4. Read off the corresponding BMI centile from the slanting lines.

5. Record the centile with the date and the child’s age in the data box.

BMI = weight in kg ÷ (height in m x height in m)

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Interpretation› A child whose weight is average for their height will have

a BMI between the 25th and 75th centiles, whatever their height centile.

› BMI above the 91st centile suggests that the child is overweight; a child above the 98th centile is very overweight (clinically obese).

› BMI below the 2nd centile is unusual and may reflect under-nutrition.

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Training and education from the Royal College of Paediatrics and Child Health

The Department of Health and the Royal College of Paediatrics and Child Health recommend the following:

› Anyone who measures a child or plots or interprets charts should be suitably trained or be supervised by someone qualified to do so.

› All users need training with the new UK–WHO growth charts in order to familiarise themselves with the changes:

– Health professionals who occasionally use the new charts will need to complete an introductory training session of 30–60 minutes.

– Those who use the new charts regularly will be required to complete a further two to three hours of training.

› The growth chart educational materials can be downloaded from the Royal College of Paediatrics and Child Health website at: www.growthcharts.rcpch.ac.uk. They include PowerPoint® slides, video clips, notes for tutors and growth chart plotting exercises.

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Useful websiteswww.growthcharts.rcpch.ac.uk

www.sacn.gov.uk/reports_position_statements/index.html

www.who.int/childgrowth/en

Further readingCole TJ (1997). Growth monitoring with the British 1990 growth reference. Archives of Disease in Childhood 76:47–49

Cole TJ (2007). A chart to link child centiles of body mass index, weight and height. Eur J Clin Nutr 56:1194–99

Cole TJ, Freeman JV, Preece MA (1998). British 1990 growth reference centiles for weight, height, body mass index and head circumference fitted by maximum penalized likelihood. Stat Med 174:407–29

De Onis M, Garza C, Victora CG et al. (2004). The WHO Multicentre Growth Reference Study: planning, study design and methodology. Food Nutr Bull 25(1):S15–S26

Macdonald PD, Ross SR, Grant Let al. 2003. Neonatal weight loss in breast and formula fed infants. Arch Dis Child Fetal Neonatal Ed 88(6):F472–F476

McKie A, Young D, Macdonald PD (2006). Does monitoring newborn weight discourage breast feeding? Arch Dis Child 91(1):44–46

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Scientific Advisory Committee on Nutrition and The Royal College of Paediatrics and Child Health (2007). Application of WHO Growth Standards in the UK. London: The Stationery Office

WHO Multicentre Growth Reference Study Group (2006). Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 450:56–65

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