WHO Growth Grids/ 2012 Risk ChangesDiane TraverJoyce Bryant

Overview CDC vs WHO Growth Charts- Why Change? Transition from <24 mo to 24-59 mo

charts Risks

Definition Justifications/Implications

Shift in Population GrowthConcern 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 PremiseAll 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 guidelines100% BF for 12 monthsAdherence to many exclusion criteria Longitudinal data collected over 2 year

periodPremise confirmedStandard- 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-for-Length

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 Weight-for-Length

Case Example #2: Excess Weight GainBrady 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.

WHO Weight-for-age

What’s the difference?

98th%98th% 95th%95th%

Case Example #2: Excess Weight Gain

CDC Weight-for-age

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 months- recumbent CDC Growth Grids- 24-59 months - stature MI-WIC- Will no longer have ‘R/S’ optionIf 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-for-

length 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 2012WHO Growth Chart (Birth<24 mo.)103.01+ High-risk underweight

103.02 At-risk of underweight115 High Weight-for-Length- NEW121.01 Short stature

121.02 At Risk of Short Stature 152 Low head circumference

Terminology Changes113+ High risk overweight (Obese)114 Overweight or At-risk of overweight

Expanded, Updated Information344+ Thyroid disorders351+ Inborn errors of metabolism

103.01+ High-risk underweightDefinition: •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 underweightJustification/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

103.02At-risk of underweightDefinition:•Birth to less than 24 months:

– Above the 2.3rd percentile for weight-for-length and at or below the 5h percentile for weight-for-length

– 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

103.02At-risk of underweightJustification/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/obeseDefinition (C2-C4) •At or above > 95th percentile BMI-for-ageOR >95th percentile weight-for-stature

CDC gender specific growth charts –Problematic feeding practices –Excessive energy intake–Decreased energy expenditure, lifestyle–Impaired regulation of energy metabolismLANGUAGE: 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/obeseJustification/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/ImplicationsParental 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

relationshipIntervention: – 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-LengthJustification/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 statureDefinition•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 statureJustification/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 factorsIntervention:•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 circumferenceDefinition•Birth to less than 24 months, at or below the 2.3rd percentile head circumference-for-age

– WHO gender specific growth charts

152 Low head circumferenceJustification/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 smokingUse soy with caution

351+ Inborn errors of metabolism

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

Definition: Gene mutations or deletions that alter metabolism of proteins, carbs, or fats •IEMS include, but are not limited to:

Additional information may be found at http://rarediseases.onfo.nih.gov/GARD

351+ Inborn errors of metabolismJustification/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!