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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