WHO Child Growth Standards World Health Organization (www.who.int/childgrowth/) Why? How? What next? World Health Organization

WHO Child Growth Standards World Health Organization Why? World Health Organization

NCHS/WHO international reference and national references National Center for Health Statistics (NCHS) and WHO reference recommended in 1977 developed based on longitudinal data (0-3 yrs) and on 3 cross-sectional studies (older children) of American population The infant population predominantly artificially fed National growth references Mostly also non-breastfed or mixed fed children (e.g. Czech Republic)

Worldwide practices in child growth monitoring Reference population Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of Pediatrics 2004;144:461-5.

Milestones in the development of new international growth reference 1991-1993 WHO Working Group on Infant Growth Comprehensive review shows growth patterns of healthy breastfed infants differ from the current NCHS/WHO international reference A new growth reference is needed to improve infant health management The reference population should reflect health recommendations in view of the frequent use of references as “standards” WHO Multicentre Growth Reference Study

Standard vs. reference Standard Reference Prescriptive – Showing how children SHOULD grow Reference Descriptive – Showing how a sample of a given population grows (regardless of its nutritional and other conditions)

Mean z-scores of healthy breastfed infants relative to the NCHS/WHO reference Source: An Evaluation of Infant Growth, WHO, 1994 Source: An Evaluation of Infant Growth, WHO, 1994

Rationale for the development of new international growth reference The current NCHS/WHO international reference is inappropriate for assessing nutritional status: Individual infants interferes with sound nutritional management of breastfed infants thus increasing risk of morbidity and mortality Populations provides inaccurate community estimates of under- and overnutrition WHO Multicentre Growth Reference Study

Rationale for the development of new international growth reference Upward bias of reference population childhood obesity

WHO Child Growth Standards World Health Organization How? World Health Organization

The WHO Multicentre Growth Reference Study A Growth Curve for the 21st Century The WHO Multicentre Growth Reference Study To produce overhead and slide, return this to Landscape format Nutrition for Health and Development World Health Organization Geneva, Switzerland

Growth Reference Study Prescriptive Approach Optimal Nutrition Breastfed infants Appropriate complementary feeding Optimal Environment No microbiological contamination No smoking Optimal Health Care Immunization Pediatric routines Optimal Growth WHO Multicentre Growth Reference Study

Eligibility criteria of study population SES that does not constrain growth Altitude < 1,500m Low mobility target population Minimum 20% of mothers follow feeding recommendations Existing breastfeeding support system Presence of collaborative institutions WHO Multicentre Growth Reference Study

Eligibility criteria of individuals No health, environmental or economic constraints on growth Mother willing to follow feeding recommendations Term birth Single birth Lack of significant perinatal morbidity No smoking mothers (before and after delivery) WHO Multicentre Growth Reference Study

MGRS study design Longitudinal (0-24 months) year 1 year 2 year 3 Cross-sectional (18-71 mo) WHO Multicentre Growth Reference Study

Time schedule child anthropometry WHO Multicentre Growth Reference Study

Motor development Six universal motor development milestones assessed between 4 and  18 months of age WHO Multicentre Growth Reference Study

WHO Multicentre Growth Reference Study Motor Development Assessment

Sample size Total sample > 8,400 by combining: cohorts  300 newborns per site 1,400 children aged 18 to 71 months per site WHO Multicentre Growth Reference Study

Measurement and standardization protocols Rigorous scientific standards are applied to a complex cross-cultural field-based project. WHO Multicentre Growth Reference Study

Food and Nutrition Bulletin The WHO Multicentre Growth Reference Study Rationale, Planning & Implementation Food and Nutrition Bulletin vol 25, no.1 (supplement) March 2004 WHO Multicentre Growth Reference Study

WHO Child Growth Standards World Health Organization What next? World Health Organization

WHO Child Growth Standards Timeline 1st set Growth Standards 2nd set WHA Resolution (May 1994) WHO Expert Committee recommendation (Nov 1993) Construction and testing of growth standards (July 97) WHO Multicentre Growth Reference Study (Nov 03) WHO Working Group on Infant Growth WHO Working Group on Growth Reference Protocol Field implementation To produce overhead and slide, return this to Landscape format Growth Standards 1st set: Weight-for-age, length/height-for-age, weight-for-length/ height, BMI-for-age and motor development indicators. Growth Standards 2nd set: Arm-Circumference-for-age, Triceps skinfold-for-age, Subscapular skinfold-for-age and Head circumference-for-age.

WHO - MGRS / reference indicators Attained growth weight-for-age length/height-for-age weight-for-length/height head circumference-for-age mid-upper arm circumference-for-age triceps skinfold-for-age subscapular skinfold-for-age body mass index-for-age Velocity weight length head circumference arm circumference body mass index

WHO Child Growth Standards 2004-2010 Construction of standards Evaluation and field testing of provisional standards Develop WHO/MGRS software to support individual- and population-based uses Develop training modules to guide appropriate use Review interventions to prevent/treat impaired child growth Develop roll-out strategy with partners, oversee global and country level implementation of the new standards WHO Department of Nutrition for Health and Development

Strategy for promoting healthy growth and development of a sound international growth reference Training on its appropriate use and interpretation Clinical and Public Health Interventions WHO Multicentre Growth Reference Study

WHO Child Growth Standards Innovative aspects Prescriptive approach recognizing need for standards Breastfed infant as normative model International sample Reference data for assessing childhood obesity Velocity reference data Link between physical growth and motor development WHO Multicentre Growth Reference Study

Child survival Physical growth Child development WHO Multicentre Growth Reference Study