1. Nutrition and Food Services Department Child growth charts e-learning tool Judith Myers and Kay Gibbons October 2011

2. Nutrition and Food Services Department Session outline n Re-cap child growth and growth charts n New equipment guidelines n Practice examples – WHO under 2; CDC over 2 n Introduce e-learning tool

3. Nutrition and Food Services Department Child Growth = marker of health and development n Quick, non-invasive techniques n Plotting serial measurements on charts n Abnormal growth can indicate underlying health or developmental problems

4. Nutrition and Food Services Department ‘Normal’ growth n Weight and length ‘tracking’ on centiles Growth influenced by: n Genetics and epigenetics n Ethnicity n Birthweight n Nutrition n Environment

5. Nutrition and Food Services Department Birth to 2 years To nearest 0.1cm Weight to nearest 10g purpose‘infantometer’ to nearest 0.1cm

6. Nutrition and Food Services Department 2 & 3 ½ years Portable or fixed ‘for purpose’ To 100g / 0.1cm

7. Nutrition and Food Services Department Use of Growth charts Individuals Growth monitoring Growth failure or excessive growth Impact of illness and response to treatment Screening NHMRC, 2002, NHMRC 2003, Cochrane, (Panpanich) 1999, deOnis 2006, WHO 1995. Garza 2006, NHMRC 2011 Population reporting NHMRC, 2002

8. Nutrition and Food Services Department KAS growth measures and charts n KAS Visits* n Birth – 2 years Weight, length and head circumference Plotting on WHO charts n 2 – 5 years Weight and stature at KAS visits BMI when indicated Plotting on CDC charts * And whenever clinically indicated

9. Nutrition and Food Services Department Charts in the Victorian ‘My health and development’ record GirlsBoysCentiles 0 – 24 monthsWHOHead circ Weight for age Length for age Head circ. Weight for age Length for age 5 th – 98 th 2 – 18 yearsCDCWeight for age Height (stature) for age BMI for age Weight for age Height (stature) for age BMI for age 5 th – 98 th 5 th – 98 th (includes 85 th and 95 th centiles)

10. Nutrition and Food Services Department Birth to 2 years World Health Organisation (WHO) http://www.who.int/childgrowth/standards/en/

11. Nutrition and Food Services Department Effect of ethnicity on infant growth Onis et al. WHO child growth standards. ActaPaed 2006

12. Nutrition and Food Services Department 2 – 5 years CDC (Centre for Disease Control) http://www.cdc.gov/growthcharts/

13. Nutrition and Food Services Department Differences plotting 0 - 2 n Head circumference matches closely at all key ages n Birth weight position is similar on CDC or WHO at all centiles n Length pattern matches closely, but by 2 years, WHO appear slightly ‘taller’ in the lower centile range n At 6 months, infants plotted on WHO appear ‘lighter’ when compared with CDC n At 2 years, children in lower centiles appear ‘heavier’ on WHO compared with CDC

14. Nutrition and Food Services Department Summary of differences: WHO compared to CDC charts n More children 6 months - 2 years appear to grow slower n More children could be ‘overweight’ n More children < 6 months ‘underweight’ n More risk of ‘poor growth’ 2 – 4 months = breastfeeding

15. Nutrition and Food Services Department Principles of child growth assessment n Serial measurements of both weight and length / stature n Head circumference reflects early brain growth n Poor growth – decline in rate of weight gain first, followed by length/height gain n Appropriate growth when weight and length/height track along a curve – even it is ‘off’ chart n Correct for prematurity until 2 years

16. Nutrition and Food Services Department n ‘Flags’ Weight or length / stature < 5 th centile Weight or length /stature > 98 th centile BMI > 85 th centile n Further investigate Unexplained weight loss Weight not regained following acute illness Weight or length stature ‘plateau’ Weight, length / stature or BMI increasing or decreasing centiles

17. Nutrition and Food Services Department Measure and Plotting n 2 week check Birth weight is plotted at age ‘0’ (37+ weeks) If more than 10% below birth weight at 2 weeks need to assess Weight change = current – birth (g) % weight loss = weight loss ÷ birth weight x 100% n Pre-term Pre-term charts used until expected birth date ( Kitchen 1983) ‘Correct’ until 2 years (KAS framework 2009)

18. Nutrition and Food Services Department Measure and plotting 2 years Weigh on either infant, platform scale or with parent/ carer Measure height (stature) or recumbent length depending on child Plot stature on CDC chart (length on WHO) Plot on both if concerned Child may appear ‘lighter’ transferring from WHO to CDC – this is normal Child will appear ‘taller’ transferring from WHO to CDC – this is normal

19. Nutrition and Food Services Department How do key KAS growth points compare? Question

20. Nutrition and Food Services Department Comparison 1: Boy weight for age CDC (left) and WHO (right) at 4 months

21. Nutrition and Food Services Department Comparison 1: Boy weight for age CDC (left) and WHO (right) at 4 months

22. Nutrition and Food Services Department Comparison 2: Boys weight for age: CDC (left) and WHO (right) at 2 years

23. Nutrition and Food Services Department Comparison 2: Boys weight for age: CDC (left) and WHO (right) at 2 years

24. Nutrition and Food Services Department Comparison 2: Boys weight for age: WHO (left) and CDC (right) at 2 years

25. Nutrition and Food Services Department Comparison 3: Boys length for age at 2 – WHO (left) and CDC (right)

26. Nutrition and Food Services Department Does changing to WHO make any difference to children’s growth assessment? Question

27. Nutrition and Food Services Department Comparison 4: ?underweight or normal WHO (left) and CDC (right)

28. Nutrition and Food Services Department Comparison 4: ?underweight or normal WHO (left) and CDC (right)

29. Nutrition and Food Services Department Comparison 5: underweight or normal?

30. Nutrition and Food Services Department Comparison 5: underweight or normal?

31. Nutrition and Food Services Department Comparison 6: normal or overweight?

32. Nutrition and Food Services Department Comparison 6: normal or overweight?

33. Nutrition and Food Services Department Comparison 6: normal or overweight?

34. Nutrition and Food Services Department

35. 18.4 kg/m2 >85 th centile = ‘overweight’

36. Nutrition and Food Services Department Summary of key points n Chart changes don’t change individual child growth n Stick to one chart n Don’t rely on one measurement n Trend is more important than a single measurement n Need accurate measuring and plotting n Need calibrated, high quality equipment n Despite many parents’ perceptions the 50 th percentile is not the goal for each child

37. Nutrition and Food Services Department Key references n www.cdc.gov/growthcharts/ www.cdc.gov/growthcharts/ n www.who.int/childgrowth/standards/en www.who.int/childgrowth/standards/en n http://consultations.nhmrc.gov.au/open_public_cons ultations/public-consultation-draf http://consultations.nhmrc.gov.au/open_public_cons ultations/public-consultation-draf n Cole TJ. BMI cut-offs BMJ 2007 n Garza C. New growth standards for the 21 st century 2006 n de Onis. Comparison of the WHO and CDC growth charts 2007