Implementation of WHO Growth Charts & Related Risks for Infants and Children

ObjectivesTo explain differences between 2000 CDC growth grids

and WHO growth grids

To understand the rationale for using WHO growth grids for 0-24 month olds

To describe changes to existing risk factors and identify new risk factors

To successfully interpret the new WHO growth grids when used in clinic

Growth charts are key tools used to interpret growth measurements

Activity

Discuss at your table:

How do you use growth charts?

When do you show growth charts to parents?

How do you describe the growth charts to parents?

HistoryFrom 1977 to 2000, National Center for Health

Statistics (NCHS) charts used worldwide as a growth reference

Since 2000, Center for Disease Control (CDC) growth charts used as a growth reference for children ages 0-20 years

April 2006, World Health Organization (WHO) released new international growth standard for children age 0-5 years

Reference Vs. Standard

A REFERENCE describes how children have grown in a particular time and place, gives a point of comparison, does not make a value judgment

Describes how things are

Reference Vs. StandardA STANDARD describes how children should grow

regardless of time or place, defines what is normal or optimal, allows for value judgments

Describes how things should be

CDC Growth ReferenceDescribes growth of children in the U.S. during the

1970s and 1980s

Based on data from national surveys and birth certificates

No special characteristics were required to be included in the data

WHO Growth StandardFrequent data collection from birth to two years of

ageLarge number of observations completed

internationallyFeeding requirements included:

Exclusive/predominant breastfeeding > 4 monthsComplementary feeding by 6 monthsContinued breastfeeding > 12 months

WHO Growth StandardOptimal Nutrition

Breastfed with appropriate complementary feeding

Optimal EnvironmentClean, safe, smoke free

Optimal CareAccess to immunization and medical care

Optimal Growth

WHO Growth StandardHypothesis: Children throughout the world will grow

similarly if exposed to optimal circumstances

Data collected in:United StatesBrazilNorwayIndiaOmanGhana

Growth patterns from birth to 24 months from the 6 WHO countries

Comparison of WHO with CDC Weight-for-Age Percentiles for Girls

Recommendations for the U.S.American Academy of Pediatrics (AAP), National

Institutes of Health (NIH) and CDC recommend : National use of WHO charts from birth to 2 yearsContinued use of the CDC charts from 2 years to 20

years

USDA accepts recommendations for WIC

Differences between Charts

WHO growth standards measured healthy children under optimal conditions so more extreme cutoffs are appropriate for children measured on WHO graphs

New cutoffs at the 2nd and 98th percentiles on WHO growth charts

Continue to use 5th and 95th percentiles on CDC growth charts for older children

Differences between Charts

Fewer infants would be below 5th percentile on WHO weight-for-age chartsFewer children will be identified as Underweight or

Failure to Thrive(FTT), especially from 6 to 23 months

More infants would be above 95th percentile on WHO weight-for-lengthFormula-fed infants tend to gain weight more rapidly

after 3 months and could be identified as overweight

Case StudyCompare the following growth charts for Sally, 11

month old infant.What are the differences between the CDC and WHO

charts?Measurements for Sally at 3 points in time:

AGE WEIGHT (lbs.)

LENGTH (in.)

WEIGHT-FOR-LENGTH (%)

CDC WHO

3 months 9.5 22.1 7.49% 8.11%

7 months 13 .3 25.0 8.92% 9.84%

11 months 17.0 28.8 2.24% 7.05%

Three measurements for Sally plotted on the current CDC chart…

Same three measurements for Sally plotted on the new WHO charts…

Recommendations for the U.S.CDC Charts after Age 2

Charts similar for children after 24 months of ageCDC charts go through age 19 yearsMaking transition at 2 is practical

Minnesota Implementation

WHO charts added to HuBERT in November 2012

HuBERT will continue to plot and assign risk factors from the appropriate chart for age:WHO for children from birth to 2 years of ageCDC BMI charts for children from 2 to 5 years

Minnesota ImplementationCDC weight for length charts for children from 2 to 3 years if they cannot be measured standing up

B-36 month chartsEducational purposes ONLYNo Risk Factor assignment

WIC Risk Factors Change based on

the WHO Growth Charts

HuBERT will continue to auto assign risk factors based on information entered on the Height, Weight Blood screen

103: Underweight (Infants & Children)Underweight

Birth to < 24 monthsNew! < 2.3rd percentile weight-for-length

2-5 years< 5th percentile BMI-for-age

At Risk of UnderweightBirth to < 24 months

New! > 2.3rd percentile and < 5th percentile weight-for-length2-5 Years

> 5th percentile and < 10th percentile BMI-for-age

103: High Risk WHO charts

Fewer children

Indicates significant issue with weight

HuBERT assignment continues

High Risk follow up needed

113: Obese (Children 2-5 years)

> 95th percentile BMI-for-Age ONLY

New! Only standing height measurements may be used to assign risk

114: Overweight (Children 2-5 years)

> 85th percentile and < 95th percentile BMI-for-Age

Only standing height measurements may be used to assign risk

114: At Risk Of Overweight< 12 months of age

Biological mother with BMI > at time of certificationHuBERT will continue to auto-assign when infant record

is linked to mother

115: High Weight for LengthInfants & Children < 24 Months of Age

Birth to 24 months of Age

> 97.7th percentile weight-for-length

New Risk!

YES

115: High Risk Only for 12 months and olderBased on WHO growth grids with 97.7% thresholdHuBERT assignment continues

High Risk follow up needed

ActivityDiscuss at your table:

What terms do you use when talking to parents about their children’s weight?

What questions would you ask to find out more about the child’s family?

Talking About WeightContinue to use language that avoids “obese” and

“fat” labels

Consider use of supportive phrases such as:Monitor weightWatch weight gainWeight higher than averageWeight above most children at that ageWeight disproportional to heightOther?

121 Short Stature (Infants & Children)

Short StatureBirth to < 24 months:

NEW! <2.3rd percentile length-for-age2-5 years:

< 5th percentile stature-for-age

At Risk of Short StatureBirth to <24 months:

NEW! >2.3rd to <5th percentile length-for-age2-5 years:

>5th to <10th percentile stature-for-age

121 Short Stature:Gestational Age AdjustmentAssigned after age has been adjusted to correct

gestational agesHuBERT will display chronological & age adjusted in

tablePLOT will only occur at adjusted age

Born at 35 weeks; certification at 10 weeks after deliveryPlot will occur at 5 weeks of age

40 – 35 = 5 weeks adjustment for prematurity 10 – 5 = 5 weeks gestation adjusted age

Premature Growth GridsPlots will display on these grids but NO risk

assignmentGestational age & chronological age growth gridsOrigins of these grids unknownPossibly used for educational purposes with parent

but USE WITH CAUTION

But wait…….There are three more changes to Risk Factors!

Modifications to 3 existing Risk Factors152: Low Head Circumference (Infants & Children < 24

months of age)

344: Thyroid Disorders

351: Inborn Errors of Metabolism

152: Low Head Circumference

Birth to < 24 months< 2.3rd percentile head circumference-for-age

Assessed by referral data from health care provider

344: Thyroid DisordersDefinition, Justification, and Clarification sections are

greatly expanded to provide more information about thyroid disorders.HyperthyroidismHypothyroidismCongenital HyperthyroidismCongenital HypothyroidismPostpartum Thyroiditis

351: Inborn Errors of MetabolismCategories now include: Amino Acid Disorders, Urea

Cycle Disorders, Organic Acid Metabolism Disorders, Carbohydrate Disorders, Fatty Acid Oxidation Disorders, Peroxisomal Disorders, Lysosomal Storage Diseases, Mitochondrial Disorders

Definition, Justification, and Clarification sections are greatly expended to provide more information about inborn errors of metabolism.

Nutrition Risk CriteriaFound on Minnesota WIC website

Expanded definition, clarification and justification of risk factor included

New section, Implications for WIC Nutrition ServicesHighlights key nutrients education messages for each criterionPresent in these risk factorsGradually added to all risk factors when updated over time

Found at: http://www.health.state.mn.us/divs/fh/wic/localagency/nutrition/riskcodes/index.html