1. Using the World Health Organization (WHO) Growth Charts to Assess Children from Birth to 2 Years
Adapted by the State of California CHDP Nutrition Subcommittee
from the online training module:
Using the WHO Growth Charts to Assess Growth in the United States
Among Children Ages Birth to 2 Years
Centers for Disease Control and Prevention, 2012
November 2012

2. Objectives By the end of this presentation, you will be able to:
Describe the new WHO growth chart
Understand differences between WHO and CDC growth charts for infants and children 0-2 years
Plot on the appropriate growth chart
Interpret results and make referrals when appropriate
Talking Points:
After the training module, clinicians will have a good understanding of the new WHO Growth Charts, including:
Describing the WHO Growth chart
Key differences between WHO Growth Charts and CDC growth charts
How to plot
Interpret results and referring when appropriate

3. Growth Chart Recommendations for Health Care Providers
CDC recommends that health care providers:
Use the WHO growth charts for infants and children 0 to 2 years of age
Use the CDC growth charts for children ages 2 to 20 years
CHDP requires transition to the WHO growth charts by October 2013
Talking Points:
Based on the comparison between the CDC and the WHO growth charts, the CDC and the American Academy of Pediatrics (AAP) recommend:
The WHO growth standard charts should be used for children younger than 2 years of age in the United States.
The CDC 2000 growth reference charts should be used for children aged 2 to 19 years. The CDC growth reference charts are better suited for children 2 years and older because these charts can be used continuously up to age 20 years.
CHDP requires providers to transition to the WHO growth charts for infants and children from birth to 24 months by October 2013.

4. WHO Growth Charts for Infants and Children Birth to 24 Months
Child growth is monitored to:
Assess adequacy of nutrition
Identify weight status and potential for obesity
Screen for disease related to abnormal growth
Growth charts are the standard tool for interpreting growth
Talking Points:
Growth assessment is the single most useful tool for defining health and nutritional status.
The way children grow says a lot about their health. Measurement of growth parameters is a key aspect of pediatric care to indicate that there may be a health problem. For this reason, it is recommended that growth of infants, children and teens should be tracked over time by a health professional.

5. Compare the WHO Growth Standards and the CDC Growth Reference
Comparison
WHO Growth Chart
CDC Growth Chart
Studied population
Breastfed infants and toddlers
Breastfed and formula fed infants and toddlers
Growth pattern
How healthy children SHOULD GROW in ideal conditions
How certain groups of children HAVE GROWN in the past
Concept of growth
A STANDARD by which all children should be compared
A REFERENCE does not imply that pattern of growth is optimal
Talking Points:
In 2006, the World Health Organization (WHO) released new international growth charts based on the growth of children who had been raised in six different countries (Brazil, Ghana, India, Norway, Oman and USA).
These children received recommended nutrition and health care, including exclusive breastfeeding to six months, standard pediatric care, and a non- smoking environment.
As a result, these charts are considered to be growth standards., as healthy breastfed babies all around the world, no matter what their ethnicity, grow in a similar way, at a similar rate. In other words, the WHO charts identify how children should grow when living in optimal conditions.
The CDC growth references were developed using data from a single country (USA). The sample of children was presumed to be healthy. In addition, there were no specific health behaviors required for children to be included in the reference sample.
The result was a set of references that described the growth attained by children raised on modes of breast and formula-fed and care that were typical of a particular time period and country.
Therefore, the CDC charts show typical growth patterns that may not be ideal growth patterns.

6. Benefits of Using WHO Growth Charts
Based on high quality population data
Growth charts align with AAP and WIC growth assessment tools and feeding recommendations
Supports breastfeeding as optimal nourishment
Allows provider to address feeding practices and family environment
Talking Points:
The measurements collected from the infants (0-2 years) were standardized and closely tracked. The data from the CDC charts were collected in various ways (birth certificates, previous studies) and the methods by which the measurements were obtained were not standardized.
The WHO standards bring agreement between the tools used to assess growth and the national guidelines that recommend breastfeeding as the optimal infant feeding method. Providers will be using the same growth charts as the WIC program avoiding confusion on growth interpretation.
Provider will be more confident is plotting and interpreting growth because it is based on optimal feeding standards - the differences between CDC and WHO are clinically significant and allow for improved interpretation of growth rates.
As a result, health policies and public support for breastfeeding will be strengthened.
If a child is not growing optimally, it provides an opportunity for the provider to look into feeding practices and the family environment in which the child is living as they may be affecting the child’s growth and development.
AAP Policy Statement: Breastfeeding and the Use of Human Milk

7. Impact of WHO Growth Charts on the Interpretation of Growth
Mode of feeding can influence infant growth rate
Mode of feeding
Growth in the first 3 months
Growth after 3 months
Breastfeeding
Faster
Slower
Formula
Talking Points:
The growth pattern of exclusively breastfed infants differs from formula-fed infants.
Healthy breastfed infants tend to grow more rapidly in the first 3 months of life and less rapidly from 3 to 12 months.
Formula-fed infants tend to grow slower in the first 3 months and then more rapidly from 3-12 months. Use of the WHO charts in the United States might result in a misperception of poor growth at this age.

8. Growth Rate for Breastfed Infant
Breastfed infants grow faster in the first 3 months
Breastfed infants grow slower from 3 to 12 months
Girls: Birth to 24 months
Weight-for-age curves
Growth Rate for Breastfed Infant
Talking Points:
On this chart, the dark blue continuous lines represent the 5th, 50th and 95th percentiles on the CDC growth chart for infants. The dotted lines represent the 5th, 50th and 95th percentiles on the WHO growth chart.
If you take a look at dark blue dotted line, which is the 95th percentile on the WHO growth chart., you can see that the breastfed infant grows faster in the first three months of life as compared to the predominantly formula-fed infants (the continuous top line)
Now if you look at the bottom lines, the 5th percentile, you can see how the breastfed infant’s growth (the dotted line) begins to slow down as the predominantly formula-fed infant’s growth begins to increase.
If a predominantly breastfed infant was plotted on the CDC growth charts, the health care provider may have unnecessarily recommended supplementing with formula or solids, and often recommend that the mother stop breastfeeding altogether.
Because the patterns of growth for exclusively breastfed and formula-fed infants differ, use caution when interpreting growth of exclusively breastfed infants and those who are formula-fed.
The American Academy of Pediatrics (AAP) recommends exclusive breastfeeding for the first 6 months and continuing for at least 12 months. For further support and education for the family, refer to the WIC program.
Adapted from Figure 2. Use of World Health Organization and CDC Growth Charts for Children Aged Months in the United States. CDC Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports 2010; 59(rr09):1-15.
Available online at:

9. WHO Growth Charts Are Different
Fewer infants are below 5th percentile on Weight-for-age charts
Fewer infants are above 95th percentile on Weight-for-length charts
Fewer infants are below 5th percentile on Weight-for-length charts
A similar number of infants are below 5th percentile on Length-for-age charts
Talking Points:
Fewer infants are likely to be identified as low weight-for-length and those who are identified are more likely to have a significant problem that must be addressed at the time of the visit.
Weight-for-length for formula-fed infants is more likely to trend upward across percentile channels and these infants are also more likely to be identified as high weight-for-length.
Background Information:
The population used to create the CDC charts includes children with various health problems and children who were not fed according to international recommendations.
Use of the 5th and 95th percentiles with the WHO curves to assess the U.S. population might overestimate the prevalence of short stature, underweight, and overweight in the United States.

10. Compare the WHO and CDC Growth Prevalence Rates by Age
Talking Points:
This graph illustrates the differences between the CDC growth charts (dark blue) and WHO growth charts (light blue) regarding the prevalence of low length-for-age, low weight-for-age, and high weight-for-length.
In this first set of data (left), you can see there are no significant differences in the prevalence of low length-for-age between the CDC and WHO growth charts.
In the second set of data (middle), the prevalence of low weight-for-age is considerably lower on the WHO growth charts.
The third set of data (right), shows fewer infants with high weight-for-length on the WHO growth charts.
Low length-for-age*
Low weight-for-age*
High weight-for-length†

11. Recommended Cutoffs WHO Growth Charts - Birth to 24 months%
Healthy weight
> 98 %
High weight-for-length
< 2 %
Low weight-for-length 98 50 95 90 75 25 10 5 2
Talking Points:
The WHO growth chart cutoff points of the 2nd and 98th percentiles differ from the traditional CDC growth chart cutoff points of the 5th and 95th percentiles because of the different methods used to create the WHO and the CDC growth charts.
Historically, the 5th percentile was used to define shortness and low weight- for-length and the 95th percentile was used to define high weight-for-length.
Theoretically, children in the WHO population would be expected to be healthy and thus more extreme cutoff values are more appropriate to define the extremes of growth of children.
Babies and toddlers identified at either extreme (< 2 % or over 98 %) are likely to have problems that need further assessment and follow-up.
Note that the classifications that are used for children under two do not include the terms “overweight” and “obese” . These terms are used exclusively to describe children 2 to 20 with BMI-for-age between the 85th - 95th percentiles (overweight) and ≥ 95th percentile (obese)

12. Recommended BMI-for-Age Cutoffs CDC Growth Charts - 2 to 20 Years
5 - < 85 %
Healthy Weight
≥ 95 %
Obese
< 5 %
Underweight 50 95 85 75 25 10 5
85 - < 95 %
Overweight
Talking Points:
Although there are WHO Growth Charts available from ages 2 through 5, these are not recommended for pediatric monitoring in the United States. For children 2-5 years, the methods used to create the CDC growth charts and the WHO growth charts were similar. The CDC chart offers the advantage of BMI from ages 2 to 20 years. If you are using an electronic health record that offers the option of the WHO charts for ages 2 to 5, make sure you are selecting the CDC growth chart.
BMI is determined and plotted for children and teens up to age 20.
The terms “overweight” and “obese” are used exclusively to describe children 2 to 20 with BMI-for-age between the 85th - 95th percentiles (overweight) and ≥ 95th percentile (obese)
The weight status categories and percentile ranges for children are:
Obese Greater than or equal to the 95th percentile
Overweight 85th to below the 95th percentile
Normal 5th to below the 85th percentile
Underweight Below the 5th percentile
Use terms “overweight” and “obese” only for children and teens between 2 and 20
that fall in the corresponding %ile ranges

13. WHO Growth Standards Birth to 24 Months
Growth Parameters
Weight-for-age
Length-for-age
Weight-for-length
Head circumference-for-age
No BMI percentile because this is not a measure used for children younger than 2
Talking Points:
The WHO growth charts for children younger than 2 years have been adapted for use in the United States and are available with metric and English units of measurement.
These growth charts are recommended for clinical use with all infants and young children.
Although electronic health records may automatically calculate BMI, it is not recommended for practitioners to use or interpret these values.

14. Head circumference-for-age Weight-for-length
Boys: Birth to 24 months
Length-for-age
Weight-for-age
Head circumference-for-age Weight-for-length
Talking Points:
The WHO growth charts for children Birth to 24 months have been adapted for use in the United States and are available at
Birth to 2 years: Boys Length-for-age percentiles and Weight-for-age percentiles
Birth to 2 years: Boys Head circumference-for-age percentiles and Weight- for-length percentiles
These growth charts are recommended for clinical use with all infants and young children until 24 months
Note that the WHO Growth Chart lists the Boy: Birth to 24 months in the top left hand corner and lists the Date: November 1, 2009 and Source: WHO Child Growth Standards in the lower left hand corner. These are shown in the orange rectangles on the slide.

15. Head circumference-for-age Weight-for-length
Girls: Birth to 24 months
Length-for-age
Weight-for-age
Head circumference-for-age Weight-for-length
Talking Points:
The WHO growth charts for children Birth to 24 months have been adapted for use in the United States and are available at
Birth to 2 years: Boys Length-for-age percentiles and Weight-for-age percentiles
Birth to 2 years: Boys Head circumference-for-age percentiles and Weight- for-length percentiles
These growth charts are recommended for clinical use with all infants and young children until 24 months
Note that the WHO Growth Chart lists the Boy: Birth to 24 months in the top left hand corner and lists the Date: November 1, 2009 and Source: WHO Child Growth Standards in the lower left hand corner. These are shown in the orange rectangles on the slide.

16. Incorporating the WHO Growth Charts Into Your Practice
CHDP requires that enrolled providers transition to WHO growth charts by October 2013
Review growth at each health assessment and interpret carefully
Understand that an infant will plot differently on the WHO growth chart than on the CDC chart
Encourage breastfeeding
Review feeding with each health assessment and determine if foods are developmentally appropriate
Talking Points:
CHDP requires that enrolled CHDP providers transition to use of the WHO growth charts for CHDP exams by October 2013.
Physical examination includes anthropometric measurements such as weight, length, and head circumference. Serial measurements are essential for growth assessment and should be regularly plotted on growth charts specific for a child's age and sex. It is important to wait for serial measurements when interpreting weight status. Follow the CHDP periodicity table and recommendations of the American Academy of Pediatrics for frequency of measurements .
Understand an infant will plot differently on the WHO growth chart than on the CDC chart. Fewer children may be identified at either end of the extremes. However, those that do should be assessed for other problems and referred, if needed.
To encourage extended and exclusive breastfeeding, refer to WIC program or your county resources for lactation consultants or lactation educators available for support and education. Speaker may add specific information about local lactation resources here.
Follow AAP Bright Futures and WIC guidelines for introduction of complementary foods

17. When Growth Deviates from the Norm
Check accuracy of your measurements
Note that individual growth may not follow a smooth curve
Recognize limitations of a single growth percentile value
Obtain serial measurements over time
If weight-for-length is < 2nd % or > 98 %, assess fully, follow closely and refer, if needed
Talking Points:
While growth for most of the children in your practice will fall within the normal percentile ranges on the WHO growth charts, a baby will occasionally demonstrate some worrisome deviations in weight, length, or head size. Watch for growth trends that cross upward or downward across percentile lines as well as children that fall below 2nd % or above the 98th length-for-age, weight-for-age, head circumference, or weight-for-length. When growth deviates from the expected:
Check your measurements. Sometimes a perceived growth deviation may simply be a matter of inaccurate measuring , recording, or plotting.
Observe that individual growth may not follow a smooth curve
Recognize limitations of a single growth percentile value
Allow time for observation for growth
If weight-for-length or other growth parameters are < 2nd percentile or > 98th percentile, follow closely, assess fully and refer, if needed. he family may need nutritional guidance in the primary practice setting or may need to be referred to a specialist if specific concerns are noted

18. Case Example Graph George’s Growth
George is an 18-month-old boy. George's mother, Rae, works outside the home. George is cared for by his grandmother during the day when Rae is working. George has been formula-fed since birth, and he was around 5 months of age when he began eating solid foods. George has been seen by his health care provider regularly since birth, and his weight and length have been recorded and plotted on the growth chart at each visit.
Instruct class to pull out the blue practice growth charts. Ask them to look over the measurements and the points that are plotted on the charts. Ask the following question:
How do you tell the difference between the WHO and CDC charts?
Answer:
WHO Chart CDC Chart
Upper left hand corner Birth to 24 months Birth to 36 months
Lower left hand corner Source: WHO Source: NCHS (CDC)
Date: Date: 2000
Talking Points:
We are going to walk through a case example to show the differences in plotting on the CDC and WHO growth charts.
George is an 18-month-old boy. George's mother, Rae, works outside the home. George is cared for by his grandmother during the day when Rae is working. George has been formula-fed since birth, and he was around 5 months of age when he began eating solid foods. George has been seen by his health care provider regularly since birth, and his weight and length have been recorded and plotted on the growth chart at each visit.

19. Graph George’s Growth CDC Weight-for-Age Growth Chart
WHO Weight-for-Age Growth Chart
George
George
Talking Points:
Look at the Length- and Weight-for-Age sides of growth charts side by side.
Weight-for-age is important in early infancy for monitoring weight and helping explain changes in weight-for-length.
Weight-for-age is not used to classify infants and children as under- or overweight. It reflects body weight relative to age and is influenced by recent changes in health or nutrition status.
When George’s measurements are plotted on the CDC weight-for-age growth chart, his weight-for-age crosses upward in percentiles and crosses above the 95th percentile at 18 months of age. His length-for-age tracks along the 50th percentile.
When George’s weight is plotted on the WHO weight-for-age growth chart, his weight is below the 50th percentile for the first three months of age. At six months, his weight-for-age begins moving upward across centiles and at 12 months is above the 98th percentile indicating that his weight is high for his age.
Note that the WHO weight-for-age chart identified high weight-for-age at an earlier age than the CDC weight-for-age chart (12 months versus 18 months). See orange circles.

20. Comparing Weight-for-Length
CDC Weight-for-Length Growth Chart
WHO Weight-for-Length Growth Chart
George
George
Talking Points:
Look at the Weight-for-Length sides of the growth charts side by side.
•    When George's measurements are plotted on the CDC weight-for-length growth chart, his weight-for-length is around the 50th percentile at one month old and begins an upward trend of crossing centiles at three months of age and continues rising to the 95th percentile at 9 months and above the 95th percentile (high weight-for-length) at 12 months of age.
•    When George's weight and length are plotted on the WHO weight-for- length chart, his weight-for-length is below the 50th percentile for the first month of life. The health care provider can assure George's caretakers that he is growing at an appropriate weight and discourage any increase in feeding.
•     At 9 months of age, plotting George's weight-for-length on the WHO growth chart indicates that George's weight is high for his length with weight-for-length between the 95th and 98th percentiles. At 12 months of age, George’s weight-for-length is above the 98th percentile (high weight-for-length using the new cutoffs).
Note that both the WHO and CDC weight-for-age and weight-for-length charts show a similar pattern of growth for George, i.e., an upward trend. However, the WHO weight-for-length chart identified high weight at an earlier age than the CDC weight-for-length chart (9 months versus 12 months).   

21. Moving from WHO to CDC Charts at 2 Years
Recumbent length to standing height measurements (difference is approximately 0.8 cm or ¼ inch)
Optimally fed study population to a reference population using the general pediatric population
WHO weight-for-length to CDC BMI-for-age percentile
5th - 95th cutoff values to 2nd - 98th cutoff values
Talking Points:
Transitioning from WHO charts for children aged < 24 months to the CDC charts for older children may create a difference in classification because:
The difference between recumbent length and stature in national survey data is approximately a 0.8 cm (¼ inch). Standing height measures less than recumbent length.
Changes in the study populations from which the charts were developed. The WHO was developed from a study group in ideal conditions (how infants should grow) while the CDC used reference data from the general pediatric population (how children do grow).
At age 2, providers begin to monitor the child’s BMI-for-age and no longer use a weight-for-length chart.
The cut off values are less extreme on CDC charts.
Background Information:
“They also noted that the methods for selecting the study participants for this age range was not substantively different between the WHO and CDC charts. CDC and WHO growth charts for ages 24–59 months were both based on cross-sectional data, and compared with the methods used to create the growth curves for children aged <24 months, the methodological differences between CDC and WHO in creating growth curves for ages 24–59 months were minor. For these reasons, the expert panel found little reason to recommend a change from the current use of the CDC curves among older children.”
Use of World Health Organization and CDC Growth Charts for Children Age 0-59 Months in the United States. (2010, September 10) MMWR: Morbidity and Mortality Weekly Report, 59(RR-9), 7. Centers for Disease Control and Prevention. Available at: Accessed August 15, 2012.

22. Possible Changes for an Individual Child at Age 2
Length-for-age percentile may be similar
CDC weight-for-age may be lower
CDC BMI-for-age percentile may be lower than WHO weight-for-length
Talking Points:
In general, the WHO and the CDC length-for-age growth charts are somewhat similar.
Transitioning from WHO weight-for-age to CDC weight-for-age chart may result in the child having a lower percentile. For example, a 24-month old boy with a weight of 26 ¾ pounds is at about the 50th percentile on the WHO weight-for-age chart. On the CDC weight-for-age chart this plots between the 25th and the 50th percentile. Both percentile classifications are within the healthy range.
Moving from the WHO weight-for-length chart to the CDC BMI-for-age chart may also result in a change in a child's percentile classification. For example, a 24-month-old boy weighing 24 pounds and 4 ounces with a length of inches is plotted between the 25th and 50th percentiles on the WHO weight-for-length chart. When plotted on the CDC BMI-for-age chart, the same boy is plotted just above the 10th percentile. Both percentile classifications are within the healthy range.

23. How to Get Started Develop protocol for weighing and measuring
Select appropriate charts for age and gender
Record and plot on growth charts
Interpret growth indicators
Counsel on growth and feeding
Support breastfeeding
Talking Points:
With the introduction of the WHO Growth Standards, this is a good time for health care providers to reevaluate the tools they use and the approach they take for measurement, plotting and interpretation of growth charts in the clinical setting
CHDP staff is available to provide training on proper measuring and weighing techniques.
In offices using Electronic Health Records (EHR), the percentiles may be displayed automatically on a growth chart when height and weight are entered in the EHR. Some EHR programs provide an alert about counseling and screening for related conditions when the value is below the 2nd or greater than the 98th percentile.
For those of you who have yet to switch over to EHRs, you may need to be careful about selecting the appropriate growth charts at first. They do look quite similar to each other.
Take time to go over any concerns the parent may have about the child’s growth
Finally, provide support and resources to encourage breastfeeding and good nutrition.

24. References WHO Growth Chart Trainings
CDC Morbidity and Mortality Weekly Report (MMWR) Recommendations and Reports
WHO Growth Charts
AAP Policy Statement: Breastfeeding and the Use of Human Milk
Talking Points:
An interactive WHO Growth Chart Training Module is available on CDC and World Health Organization websites.
The report outlining the recommendations was published in the CDC Morbidity and Mortality Weekly Report. The link is listed here.
WHO Growth Charts for boys and girls 0-2 years can be downloaded and printed from the CDC web link shown here

25. Training and Education Tools
CHDP Training Modules
How to Accurately Weight and Measure Children
Using Body Mass Index-for-Age Growth Charts
Counseling the Overweight Child
Promoting Physical Activity
Glucose and Cholesterol Screening
Breastfeeding materials
Women, Infants and Children Program (WIC) Slides 11 and 12 of this presentation were adapted from the WIC WHO Growth Charts In-Service Training:
Talking Points:
This and other CHDP Training Modules for providers and provider staff are available on the state CHDP website.
Here are a few resource links for breastfeeding education and support.
The California WIC Program offers a wealth of information about the WIC Program, breastfeeding, baby food, infant crying and sleeping, healthy eating, active living as well as child nutrition problems.
Slides 11 and 12 of this presentation were adapted from a presentation developed by the California WIC Program for in-service training of local WIC program staff. This training and accompanying materials are available at the website listed.