1. Growth of Czech infants breastfed in the 1st year (Growth charts of breastfed infants) Riedlová J. 1, Vignerová J. 2, Paulová M. 2 3rd Faculty of Medicine, Charles University, Prague 1 National Institute of Public Health, Prague 2 Grant IGA MZ ČR NS9974-4/2008-11

2. Growth charts Length/ height Weight Weight/height Body mass index (BMI) Head circumference Boys/girls The part of the health and vaccination record Programme GrowthCZ

3. Goal of the survey (2008-11) Compare national growth charts with WHO standards Compare the growth of Czech excl. breastfed infants with Czech growth references Compare the growth of Czech excl. breastfed infants with WHO standards Elaborate guidelines for evaluation of growth of a breasfed child in collaboration with paediatric associations

4. Material and Methods Czech infants breastfed at least 4 months Absence of health problems Birth in term, singleton Birth weight more than 2500 g Mother – nonsmoker before and after birth Mother – al least secondary school Socioeconomic conditions does not constrain growth (conditions in accordance with the WHO sample) Measurements at preventive examinations in 18 months Interview with mother + informed consent Records of all measurements from birth – length, weight, head circumference from Health and Vaccination Record of a child

5. Study design Data collection from 43 pediatricians from March 2009 to May 2010, overall 1775 questionnaires Selection of infants according to WHO criteria  960 infants, 471 boys and 489 girls (11 measurements from every child, i.e. overall 10727 measurements) Percentile charts for particular parameters elaborated Percentile charts of Czech breastfed infants compared with: –WHO standards –Czech reference data from the Nation-wide Anthropological Surveys: 2001 - length and head circumference 1991 – weight and weight/length

6. Is higher in Czech infants compared to WHO sample Czech reference more suitable for assessing Czech breastfed infants. Length Czech reference x Czech breastfed Czech reference x WHO

7. Is lower in Czech infants in first 6 months compared to WHO sample After 3 months relative deceleration of weight gain in BF infants. Take into account in order to prevent preliminary introduction of supplements. Czech references (1991) can be used while considering this fact. Czech reference x WHO Czech reference x Czech breastfed infants Weight

8. Weight for length Cut-off for not thriving well = 3rd percentile: higher values in the WHO sample = higher rate of infants not thriving when using WHO standard Up to cca 65 cm breastfed infants do not differ sign.from Czech reference. Then it is necessary to consider lower weight of BF infants, with lower values in the percentile chart. Using Czech reference for assessing Czech breastfed infants more suitable. Czech reference x WHO Czech reference x Czech breastfed infants

9. Head circumference Is higher in Czech infants compared to WHO sample Differences between curves are increasing with age HC of BF infants corresponds to Czech reference Czech reference more suitable for Czech breastfed infants. Czech reference x WHO Czech reference x Czech breastfed infants

10. Conclusion The growth of a breastfed infant is specific. Neither Czech reference charts nor WHO growth standards can be used without individual interpretation in accordance with the clinical examination. Implementation of WHO standards to the pediatric practice would be very demanding (managament, financial, personal resources). Considering specific growth of a breastfed child (esp. development of weight) it is possible to use current Czech reference charts.

11. Information for lactation counsellors

12. Information for pediatricians via papers in professional journals.

13. Programme GrowthCZ and leaflet: http://www.szu.cz/publikace/data/rust-kojenych-deti

14. Even growth Arrest of growth Acceleration of growth The possible course of growth related to percentile curves

15. Evaluation of weight in the percentile chart Percentile range Evaluation 97 <obese 90 – 97overweight 75 – 90robust 25 – 75 adequate weight 10 – 25slim 3 – 10 low weight < 3thin

16. Decisions taken in other countries England: WHO standards might be used for age from 2 weeks to 24 months. Otherwise use English references. Belgium: WHO standards not adopted, growth of breastfed infants closer to national references. USA: WHO standards adopted for children 0-24 months. India: When using WHO standards there is a high proportion of malnourished infants – thus national references used.