1. WHO Child Growth Standards World Health Organization(
Why?
How?
What next?
World Health Organization

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

3. 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)

4. 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.

5. Milestones in the development of new international growth reference
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

6. 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)

7. 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

8. 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

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

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

11. The WHO Multicentre Growth Reference Study
A Growth Curve for the
21st Century
The WHO Multicentre Growth Reference
Study
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Nutrition for Health and Development
World Health Organization
Geneva, Switzerland

12. 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

13. 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

14. 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

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

17. Time schedule child anthropometry
WHO Multicentre Growth Reference Study

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

19. WHO Multicentre Growth Reference Study Motor Development Assessment

20. 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

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

22. 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

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

24. 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
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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.

25. 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

26. 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

27. 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

28. 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

29. Child survival Physical growth Child development
WHO Multicentre Growth Reference Study