1. Strategic option for updating child growth Standards Dr AKDutta Director Professor & HOD Dept. of Pediatrics Lady Hardinge Medical College & Kalawati Saran Children’s Hospital New Delhi

2. Sub Headings  Uses of growth charts  Evolution  Currently available growth charts  Comparison of their features  Recommendation for use in our country

3. Growth charts  Consist of a series of percentile curves that illustrate the distribution of selected body measurements in the study population  Used to track the growth of children from infancy thru adolescence  Indicates the state of the child's health, nutrition and well being

4. Growth monitoring  By using growth charts-screening tool for diagnosis of nutritional, chronic systemic and endocrine diseases  Individual growth monitoring in children in India-Is it possible to achieve?  Who shall use the growth charts?  Pediatricians? Family Physicians? Anganwadi workers? ASHA?

5. Need for growth charts Individual level Community level National level Scientists  Monitoring &documenting growth  Comparison with references std  To detect growth faltering  Monitoring health status  Performance of programs  Comparison over time  Identification of problem areas  National/international comparisons  Research tool

6. Community level  Early identification of children’s growth failure for detection of malnutrition and taking appropriate interventions  Early identification-overweight/obesity  Sensitize health workers  Educate parents and allay their anxiety by showing normal growth in chart

7. Community level Measurements required:  Weight  Length/Height  Head circumference < 2 years Anthropometric indices:  Length / stature for age  Weight for age  Weight for length /stature  BMI for age  Head circumference for age  Length, wt, BMI in relation to pubertal stage

8. What needs to be monitored at community level First 2 years 2 –10 years >10 years  Length/age  Weight/age  Weight /height or BMI  Head circumference/age  Height/age  Weight/age  BMI/age  Above in relation to pubertal development

9. Earlier available growth charts: Harvard standards  Reference data from Boston children’s hospital Hospital based Longitudinal study Small sample size Top fed babies  Still served the purpose of creating an awareness re need for monitoring & growth assessment  Used in Indian growth charts & for classification of malnutrition since mid 1970s (50 th centile taken as 100%)

10. Earlier available growth charts:ICMR Standards  Banik Dutta et al: ICMR Technical report series no. 18, 1972: Growth & Physical development of Indian infants & children  Not affluent population, but mixed group  Community based  Criticised for method of sample selection & data collection

11. Charts/Standards currently available  Indian : Dr KN Agarwal  CDC 2000  WHO

12. Dr KN Agarwal growth standards 0 - 6 years (Indian Pediatrics,1994)  Study years 1985-1987  Design Mixed-longitudinal study/ cross-linked data collection Minimum of three readings for each child  Cohort a)Birth to first year of age: 418 boys, 332 girls b)12 - 60 months: 1011 boys and 874 girls  Sample zones Bangalore, Calcutta, Delhi, Ludhiana, Kota & Varanasi

13. Dr KN Agarwal growth standards 5 - 18 years (Indian Pediatrics-1992 & 2001)  Study years: 1988-1991  Design: cross-sectional study minimum of 200 children at each age and sex point.  Sample size: 12,893 male & 10,941 female (23 schools)  Sample Zones (9 states): North - Delhi, Shimla, Dehradun, Nainital West-south - Bombay,Madras, Udaipur Central - Lucknow Allahabad, Varanasi East – Calcutta, Dhanbad

14. Dr KN Agarwal ref. standards available: birth – 66 months 6-18 years  Height, weight: both sexes  3 monthly interval till 1 year, then 6 monthly  3 rd - 97 th centile  -3SD - +3 SD  Height, weight: both sexes  6 monthly interval  3-97 th centile  Mean & SE

15. Dr KN Agarwal ref. standards available Head circumference BMI  Each sex  birth to 6 years  3 monthly interval for 1yr, then 6 mthly  3 rd -97 th centile  - 3SD to +3 SD  2-18 years  Yearly  5 th –95 th centile  Mean And SD  Each sex

18. Useful upto

23. CDC growth charts  NCHS growth charts based on growth of American children developed in 1977  Adopted by WHO for international use  CDC 2000 growth charts a revised version of earlier NCHS chart: Revision of previous existing 14 charts with introduction of 2 new BMI charts  No new primary data collected  Used national studies conducted at various times & places and improved statistical tools

24. CDC 2000 growth charts: new features  Addition of BMI for age charts: 2 – 20 years  Addition of 85 th centile on BMI for age & wt for stature charts  Addition of 3 rd & 97 th centiles  Limits of length & stature extended on wt for length & wt for stature charts  Smoothened percentile curves & Z scores  Correction of disjunction that occurred between 24 & 36 months when switching from length to stature in NCHS charts

25. CDC: charts available Birth – 36 months 2 - 20 years 2-5 years  Length & weight for age  Head circumference for age  Weight for length  Stature & weight for age  BMI for age  Weight for stature 2 sets: 3 rd -97 th centile, 5 th – 95 th centile for each sex 85 th centile for BMI for age & wt for stature

26. WHO charts  Review of child growth references by WHO expert committee in 1993: NCHS stds do not describe physiologic growth adequately; single country based with many technical /biological drawbacks  WHO multi-centric growth reference study undertaken between 1997 – 2003  Primary data collected from 8500 children from Brazil, Ghana, India, Norway, Oman & USA  Growth data available for children 0 - 5 years of age

27. Eligibility Criteria for Individuals  No health, environmental or economic constraints on growth  Mother willing to follow feeding recommendations: Exclusive/ predominant breast feeding for 1 st 4 mths, introduction of complementary feeding by 6 mths  Term, single birth  Lack of significant perinatal morbidity  Non smoking mothers before and after delivery MGRS Study Design and Sample

28. Longitudinal study (birth-24 months)  Mothers & newborns screened & enrolled at birth  Weight, length, head circumference: 21 times over 24 months  Arm circumference: 10 times between 3 and 12 months  Skin fold thickness : 6 times between 14 and 24 months

29. MGRS Study Design and Sample Cross-sectional survey (18-71 mo) Weight, length, head circumference, arm circumference, skin fold thickness Total sample 8440 children from 6 countries ~300 newborns per site (1743 total) followed up till 24 mo from the longitudinal study ~1400 children per site (6647 total) aged 18-71 mo through the cross sectional surveys

30. WHO charts  Available: 0– 5 years  Length (birth-2yrs)/height (2-5 yrs) for age  Weight for age  Weight for length/height  BMI for age

31. Mean length from birth to 24 months for the six MGRS sites WHO Multicentre Growth Reference Study Group. Assessment of linear growth differences among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:56-65.

32. Comparison of existing growth charts Data charact Source Study period Population Age-group CDC Multiple different studies 1963-1994 US, mixed feeding, no racial/ethnic diff Birth-20 yrs WHO Primary data 1997-2003 6 Countries pooled data. healthy children & practices Birth-5yrs KNA Primary data 1988-1991 Affluent Indian population, multicentric Birth-18 yrs

33. KNA study vs European & NCHS std

34. KNA study vs other Asian studies

39.  Depends upon for what purpose it is used  Who will be monitoring the growth?  It should be represented by National data  The growth charts should be for the entire period of growth from Infancy till full growth potential is achieved  Scientifically collected & analyzed multi- centric data  Their use should prevent unnecessary referrals Which growth chart to use?

40. Summary  WHO growth charts are excellent,recent, up- to- date, multicentric, multinational reference charts  Ideal growth chart to be used for children up to 5 yrs of age  Drawback is after that age –Which chart to use?  Can we use two different charts-one up to 5 yrs and the other for the 6-18 yrs age?