Use of World Health Organization and CDC Growth Charts for Children Aged 0–59 Months in the United States

Use of World Health Organization and CDC Growth Charts for Children Aged
0–59 Months in the United States


In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new 2006 World Health Organization (WHO) growth charts in clinical settings in the United States. On the basis of input from this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO international growth charts, rather than the CDC growth charts, for children aged <24 months (available at http://www.cdc.gov/growthcharts). The CDC growth charts should continue to be used for the assessment of growth in persons aged 2–19 years. The recommendation to use the 2006 WHO international growth charts for children aged < 24 months is based on several considerations, including the recognition that breastfeeding is the recommended standard for infant feeding. In the WHO charts, the healthy breastfed infant is intended to be the standard against which all other infants are compared; 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. When using the WHO growth charts to screen for possible abnormal or unhealthy growth, use of the 2.3rd and 97.7th percentiles (or ±2 standard deviations) are recommended, rather than the 5th and 95th percentiles. Clinicians should be aware that fewer U.S. children will be identified as underweight using the WHO charts, slower growth among breastfed infants during ages 3–18 months is normal, and gaining weight more rapidly than is indicated on the WHO charts might signal early signs of overweight.

Use of World Health Organization and CDC Growth Charts for Children Aged 0--59 Months in the United States
Recommendations and Reports
September 10, 2010 / 59(rr09);1-15

Prepared by
Laurence M. Grummer-Strawn, PhD1
Chris Reinold, PhD1
Nancy F. Krebs, MD2

1Division of Nutrition, Physical Activity, and Obesity, National Center for Chronic Disease Prevention and Health Promotion

2Department of Pediatrics, University of Colorado Denver

Corresponding preparer: Laurence M. Grummer-Strawn, CDC, 4770 Buford Highway, MS K-25, Atlanta, GA 30341. Telephone: 770-488-5702; Fax: 770-488-5369; E-mail: lxg8@cdc.gov. The material in this report originated in the National Center for Chronic Disease Prevention and Health Promotion, Ursula Bauer, PhD, Director.



Summary
In April 2006, the World Health Organization (WHO) released new international growth charts for children aged 0--59 months. Similar to the 2000 CDC growth charts, these charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index for age. Whereas the WHO charts are growth standards, describing the growth of healthy children in optimal conditions, the CDC charts are a growth reference, describing how certain children grew in a particular place and time. However, in practice, clinicians use growth charts as standards rather than references.

In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. On the basis of input from this expert panel, CDC recommends that clinicians in the United States use the 2006 WHO international growth charts, rather than the CDC growth charts, for children aged <24 months (available at https://www.cdc.gov/growthcharts). The CDC growth charts should continue to be used for the assessment of growth in persons aged 2--19 years.

The recommendation to use the 2006 WHO international growth charts for children aged <24 months is based on several considerations, including the recognition that breastfeeding is the recommended standard for infant feeding. In the WHO charts, the healthy breastfed infant is intended to be the standard against which all other infants are compared; 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. When using the WHO growth charts to screen for possible abnormal or unhealthy growth, use of the 2.3rd and 97.7th percentiles (or ±2 standard deviations) are recommended, rather than the 5th and 95th percentiles. Clinicians should be aware that fewer U.S. children will be identified as underweight using the WHO charts, slower growth among breastfed infants during ages 3--18 months is normal, and gaining weight more rapidly than is indicated on the WHO charts might signal early signs of overweight.

Introduction
The physical growth of infants and children has long been recognized as an important indicator of health and wellness (1,2). Growth charts have been used for at least a century to assess whether a child is receiving adequate nutrition and to screen for potentially inadequate growth that might be indicative of adverse health conditions. Traditionally, attention has focused on undernutrition. However, in the past few decades, concerns about excessive weight gain have increased, and growth charts have been used to screen for overweight, including obesity.

In April 2006, the World Health Organization (WHO) released a new international growth standard for children aged 0--59 months (3). Similar to the 2000 CDC growth reference (4,5), these growth charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index (BMI) for age. WHO growth curves include BMI for age starting at birth, and CDC growth curves include BMI for age beginning at age 2 years. CDC and WHO growth charts also include a curve for head circumference for age; CDC provides values for children aged <36 months, and WHO charts include a head circumference curve for those aged <60 months.

Because two sets of growth curves exist for assessing child growth, clinicians in the United States need guidelines indicating which curves should be used and for which children. This report provides guidance on the use of the WHO and CDC growth charts and is intended for health-care providers and others who measure and assess child growth.

Methods
During June 29--30, 2006, CDC, the National Institutes of Health (NIH), and the American Academy of Pediatrics (AAP) convened a meeting in Hyattsville, Maryland, to review scientific evidence and obtain opinions regarding the use of the new WHO growth charts in clinical settings in the United States. The participants at the meeting were selected on the basis of their expertise in child growth, statistical methodology, clinical application, and maternal and child health policy. CDC, NIH, and AAP each had numerous representatives; additional experts from academia, clinical professional groups, and other government agencies were invited.

Participants were provided background documents describing the development of both sets of curves. At the meeting, CDC made presentations on the methods used to create the CDC growth charts, and a principal investigator for the WHO Multicentre Growth Reference Study (MGRS), which generated the data used for the WHO growth curves, made a presentation on the methods used to create the WHO charts. CDC conducted a statistical comparison of the charts and presented the results to participants. Meeting discussions focused on the numerous factors involved in the selection of a chart, including the assessment of child growth using references (i.e., how certain groups of children have grown in the past) compared with standards (i.e., how healthy children should grow in ideal conditions), differences between the growth of breastfed and formula-fed infants, the methods used to create the CDC and WHO charts, and implications of using the charts in clinical practice. At the time of the meeting, WHO was developing but had not released growth charts for head circumference for age; therefore, these charts were not discussed. The charts have since been released and are available at http://www.who.int/childgrowth/standards/hc_for_age/en/index.html.

The panel was not asked to arrive at a consensus. At the end of the meeting, CDC asked all participants to provide written opinions on which curves should be recommended, at which ages, and for which children. After the meeting ended, CDC worked with NIH and AAP to develop these CDC recommendations based on the meeting proceedings.

open here to see the full-text:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_e#

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_e