Ravi M R
Dept. of Community Medicine
JSS Medical College
Moderator- Dr Narayana Murthy
JSS Medical College
What is growth..?
• Growth is a dynamic process
as an increase in the physical size of the
body as a whole or any of its parts
Associated with increase in cell number
and/or cell size.
Children are distinguished from people in
other age groups by
• physical growth and developmental
changes that are
• A normal healthy child grows at a genetically predetermined rate
• These changes usually proceed in an orderly progression that allows for
• Nutritional, family, emotional, sociocultural and community, as well as
physical, factors play a role in shaping the child‘s psycho logic and
What are these growth charts?
Growth charts are visible display of child’s physical growth and development.
Also called as “road-to-health" chart.
It was first designed by David Morley and was later modified by WHO.
• The assessment of growth may be longitudinal or cross sectional.
• Longitudinal assessment of growth entails measuring the same child at
• Cross sectional comparisons involve large number of children of same age.
• Basic growth assessment involves measuring a child‘s weight and length or
• comparing these measurements to growth standards.
Assessment of Growth
Purpose of growth assessment
• The purpose is to determine whether a child is growing ―normally‖
has a growth problem or trend towards a growth problem that should be
Methods of Nutritional Assessment (2,3)
• Are not mutually exclusive; on the contrary, they are complementary to
Direct methods Indirect methods
Clinical methods Assessment of dietary Intake
Anthropometry Vital statistics
Biochemical methods Ecological studies
Biophysical and radiological
• Can reflect changes in morphological variation due to inappropriate food
intake or malnutrition
• There is no single permanent standard.
-Uniform growth pattern is not seen to occur equally all over
the world and also in subsequent generations
Components of Anthropometric Assessment:
• Normal variation in weight at a given age is wide.
• Ideally what is important is careful measurements at repeated intervals:-
Every month, from birth to 1 year
Every 2 months during the second year
Every 3 months thereafter upto 5 years of age.
• This age group is at the greatest risk from growth faltering.
• By comparing the measurements with reference standards of weight of children of
the same age, the trend of growth becomes obvious.
• This is best done on growth chart. Serial weighing is also useful to interpret the
progress of growth when the age of the child is not known.
• The maximum growth potential of an individual is decided by hereditary factors.
• Among the environmental factors, the most important being nutrition and morbidity.
• Is considered an index of chronic or long duration malnutrition (3).
• Weight-for-height is now considered more important than weight alone.
• It helps to determine whether a child is within range of "normal" weight for his
• Yields a relatively reliable estimation of the body's muscle mass,
• The reduction of which is one of the most striking mechanisms by which
the body adjusts to inadequate energy intakes (2).
• Arm circumference cannot be used before the age of one year
• between ages one and five years, it hardly varies (2).
Scales of Measurements
• Z scores
• Percent of median
Z- Score or standard deviation score
• The deviation of the value for an individual from the median value of the
reference population, divided by the standard Deviation for the reference
(Observed value) - (Median reference value)
Z- Score = --------------------------------------------------------
Standard deviation of reference population
• A fixed Z score interval implies a fixed height or weight difference for
children of a given age .
• Advantage:- Allows mean and SD calculation for a group of Z score in
population based applications
• The rank position of an individual on a given reference distribution, stated
in terms of what percentage of the group the individual equals or exceeds .
Eg. A child of a given age whose weight falls in the 10th percentile weighs
the same or more than 10% of the reference population of children of same
• Summary statistics not possible
• Towards the extremes of the reference distribution there is little change in
percentile values, when there is infact substantial change in weight or
• Commonly used -3,-2 and -1 Z scores are respectively the 0.13th , 2.28th
and 15.8th percentiles and the 1st ,3rd and 10th percentiles correspond
to, respectively, the -2.33,-1.88,and -1.29 Z scores.
Percent of median
• Ratio of a measured value in the individual, for instance weight , to the median
value of the reference data for the same age or height, expressed as a percentage.
• lack of exact correspondence with a fixed point of distribution across age and wt
Eg. Depending on the child‘s age, 80% of the median weight for age might be above or
below -2Z score; in terms of health, it reflects in different classification of risk.
• Cut off points for percent of median are different for the different anthropometric
Comparison of the characteristic of three measures of
Characteristic Z score Percentile Percent of
Yes Yes No
Yes No Yes
Yes Yes No
at extreme of
Yes No Yes
Various indices and cut-off points for defining malnutrition
Indices Indicators Cut-off points for defining
for malnutrition malnutrition
Percentile of ref- % of refer- Z or SD from ref-
erence median ence median erence median #
Wt-for-ht Wasting < 3rd < 80% < - 2
Ht-for-age Stunting < 3rd < 90% < - 2
Wt-for-age Underweight < 3rd < 80% < -2
“Moderate‖ malnutrition classified as the percent falling between – 2 to – 3 SD and
―severe‖ as the percent falls below – 3 SD from the reference median
Interpretation of different indicators
WHAT IS MALNUTRITION?
• poor nutrition due to an insufficient, poorly balanced diet, faulty digestion
or poor utilization of foods. (This can result in the inability to absorb
• Malnutrition is not only insufficient intake of nutrients. It can occur when
an individual is getting excessive nutrients as well.
Classifications for assessment of Nutritional Status
using the aforementioned parameters:
• Gomez' classification (2):
• Gomez' classification is based on weight retardation.
• The "normal" reference child is in the 50th centile of the Boston standards
Normal nutritional status Between 90 & 110%
1st*,mild malnutrition Between 75 and 89%
2nd*,moderate malnutrition Between 60 and 74%
3rd*,severe malnutrition Under 60%
• The disadvantages are :
• A cut-off-point of 90 per cent of reference is high and thus some normal
children may be classified as 1st degree malnourished.
• By measuring only weight for age it is difficult to know if the low weight
is due to a sudden acute episode of malnutrition or to long-standing chronic
Waterlow's classification (2):
• When a child's age is known, measurement o weight enables almost instant
monitoring of growth.
• Measurement of height shows the effect of nutritional status on long-term
• Waterlow's classification defines two groups for protein energy
malnutrition with retarded growth, in which a drop in the height/age ratio
points to a chronic condition— shortness, or stunting.
malnutrition with a low weight for a normal height, in which the weight for
height ratio is indicative of an acute condition of rapid weight loss, or
Nutritional status Stunting
(% of height/age)
(% of weight/height)
Normal >95 >90
Mildly impaired 87.5 - 95 80 – 90
Moderately impaired 80 - 87.5 70 – 80
Severely impaired <80 <70
Indian Academy of Pediatrics (IAP) Classification(based on weight-for-
• IAP designates a weight of more than 80 percent of expected for age as
normal. Grades of malnutrition are :
• Grade I (71-80%)
• Grade II (61-70%)
• Grade III (51-60%)
• Grade IV (≤50%)
of expected weight(50th percentile of reference standard) for that age.
(Alphabet K is postfixed in presence of edema)
• Disadvantage is that it does not take in account the child's height.
• The weight is also dependent on height besides the built;
• Thus children who are short statured (not necessarily because of nutritional
deprivation) are also misclassified as PEM by this classification .
• Welcome trust Classification :
• This is also based on deficit in body weight for age and presence or
absence of edema
1. Children weighing between 60-80 per cent of their expected weight for
age with edema are classified as kwashiorkor.
2. Those weighing between 60-80 per cent of expected without edema are
known as having undernutrition.
3. Those without edema and weighing less than 60 per cent of their expected
weight for age are considered to be having marasmus.
THE GROWTH CHARTS
• These growth charts are primariy designed for longitudinal follow up of a
child(growth monitoring), to interpret the changes over time.
NCHS 1977 growth charts
CDC 2000 growth charts
WHO Growth Charts (2006)
NCHS 1977 growth charts[Hamill et al 1977, 1979]
• Using longitudinal-data from the Fels Research Institute, collected in Yellow
Springs, Ohio between 1929 and 1975
• Its sample was acknowledged to be quite limited in geographic, cultural,
socioeconomic and genetic variability.
CDC 2000 growth charts
1. National Health and Nutrition Examination Surveys (NHANES),
2. National Natality Files
3. NatalityFiles in Wisconsin and-Missouri,
4. The CDC Pediatric Nutrition Surveillance System,
5. The Fels Research Institute child growth study
The primary source of data for the infant charts up to age 6 months was
Table-1 Characteristics of the Fels Research Institute data used for
construction of the NCHS 1977 growth charts and the third National
Health and Nutrition Examination Survey use for construction of the CDC
2000 growth charts
characteristic NCHS 1977(Fels
CDC 2000( Third
National Health and
Location Within a convenient
distance of Yellow
U.S. nationwide, non-
Study design Longitudinal follow up Cross sectional survey
Years of data collection 1929-1975 1988-1994
Exclusion criteria Triplets excluded VLBW(<1500g)
characteristic NCHS 1977(Fels research
CDC 2000( Third National
Health and Nutrition
Middle class Representative of US
Racial/ethnic background Caucasian Representative of U.S. -
distribution for non-
Hispanic white, non-
Hispanic black, and
Other racial groups subject
to random variation.
Ages Measurements made at
Birth, 1,3 and 6
Cross-section of population
spanning 2 to
6 months of age.
characteristic NCHS 1977(Fels
CDC 2000( Third National Health and
Nutrition Examination survey)
Nearly all formula fed Currently
2mos 56.3 32.2
4mos 37.3 19.4
6mos 27.9 9.5
All measurements well-
length and stature data
have raised questions
about the quality of
the recumbent length
All measurements well-standardized
[Lohman et al. 1988] Data quality considered
Advantages of CDC 2000 Growth Charts
• Most importantly the 2000 charts were representative, of all (non-VLBW) infants
in the U.S., not a select group of middle-class.white infants in a, small US
• Extent of breastfeeding in the NHANES III. sample was certainly greater than
was the case for the Fels study sample
Disadvantage of CDC 2000 Growth Charts
•pooling of multiple datasets to construct the curves.
•Though great care to ensure the comparability of the datasets being pooled, we
cannot rule out,the possibility that the shape of the curves was affected by using
different datasets at different ages.
WHO Growth Charts 2006
• In 1993 the World Health Organization (WHO) undertook a comprehensive
review of the uses and interpretation of anthropometric references
• Did not adequately represent early childhood growth and that new growth
curves were necessary.
• The World Health Assembly endorsed this recommendation in 1994.
• In response WHO undertook the Multicentre Growth Reference Study
(MGRS) between 1997 and 2003 to generate new curves for assessing the
growth and development of children the world over.
Multicentre Growth Reference Study (MGRS)
• Between 1997 and 2003
• longitudinal follow-up from birth to 24 months
cross-sectional survey of children aged 18 to 71 months
• Primary growth data and related information were gathered from 8440
healthy breastfed infants and young children from widely diverse ethnic
backgrounds and cultural settings
• Healthy children
• Living under conditions likely to favor the achievement of their full genetic growth
• Mothers engaged in fundamental health-promoting practices, namely breastfeeding
and not smoking.
• The new standards show that growth can be achieved with recommended feeding
and health care (e.g. immunizations, care during illness)
• The standards can be used anywhere in the world
• study also showed that children everywhere grow in similar patterns when their
nutrition, health, and care needs are met
Additional benefits of the new growth standards include the
• The new standards establish breastfed infants as the model for normal growth and
development. As a result, health policies and public support for breastfeeding will be
• The new standards will help better identify stunted and overweight/obese children
• New standards such as BMI (body mass index) are useful for measuring the
increasing worldwide epidemic of obesity.
• Charts that show standard patterns of the expected growth rate over time enable
health care providers to identify children at risk of becoming undernourished or
overweight early, rather than waiting until a problem level is reached
• For the assessment WHO has provided charts for both boys and girls.
• Growth indicators are used to assess growth considering a child‘s age and
BMI (body mass index)-for-age
To plot in Growth charts
• In the Growth Record graphs, some x-axes show age and some show length/height.
Plot points on vertical lines corresponding to completed age (in weeks, months, or
years and months), or to length or height rounded to the nearest whole centimetre.
• In the Growth Record graphs, the y-axes show length/height, weight, or BMI. Plot
points on or between horizontal lines corresponding to length/height, weight or BMI
as precisely as possible
• plotted point– the point on a graph where a line extended from a measurement on
the x-axis (e.g. age) intersects with a line extended from a measurement on the y-
axis (e.g. weight)
To interpret the plotted graph
Measurements in the shaded boxes are in the normal range.
1. A child in this range is very tall. Tallness is rarely a problem, unless it is so excessive
that it may indicate an endocrine disorder such as a growth-hormone-producing
tumor. Refer a child in this range for assessment if you suspect an endocrine
disorder (e.g. if parents of normal height have a child who is excessively tall for his
or her age).
2. A child whose weight-for-age falls in this range may have a growth problem, but this
is better assessed from weight-for-length/height or BMI-for-age.
3. A plotted point above 1 shows possible risk. A trend towards the 2 z-score line shows
4. It is possible for a stunted or severely stunted child to become overweight.
5. This is referred to as very low weight in IMCI training modules. (Integrated
Management of Childhood Illness, In-service training. WHO, Geneva, 1997).
Interpretation – A boy Aged 3 years and 11 months. He weighs 19.5 kg and is 109.6
cm tall. His weight-for-age is above the 1 z-score line, and his height-for-age is above
the 1 z-score line. His weight-for-height, shown on the chart , is in the normal range.
Interpret trends on growth charts
When interpreting growth charts, be alert for the following situations, which
may indicate a problem or suggest risk:
• A child‘s growth line crosses a z-score line.
• There is a sharp incline or decline in the child‘s growth line.
• The child‘s growth line remains flat (stagnant); i.e. there is no gain in
weight or length/height.
Growth chart used in India
• India has adopted the new WHO Child Growth Standards (2006) in February 2009
• These standards are available for both boys and girls below 5 years of age .
• A joint "Mother and Child Protection Card" has been developed which provides
space for recording :
o family identification and registration
o Birth record
o Pregnancy record
o Institutional identification
o Care during pregnancy
o Preparation for delivery
o Registration under Janani Suraksha Yojana
o Details about immunization procedures
o Breast-feeding and introduction of supplementary food
o Milestones of the baby
• Weight b/w curves 1 & 3-undernourished,require supplementary feeding at home
• Weight below curve 3-consult the doctor and follow his advice.
• Weight below curve 4-hospitalized for treatment
Uses of growth charts
• Growth monitoring
• Diagnostic tool
• Planning and policy making
• Educational tool
• Tool for action
• Tool for teaching
WHO Growth charts
• Seen as ‗gold standard‘ of growth charts in terms of promoting good health
outcomes, including across cultures.
• Establishes breastfeeding as the biological norm.
• More suitable to the aboriginal population as the infants, especially in
remote communities, are predominantly brestfed
• Have greater capacity to assist the early identification of development of
• Donot reflect current feeding practices.
• The rapid weight gain demonstrated in the breastfed infants first six months
may not be appropriate for all breastfed babies May inadvertently
discourage exclusive breastfeeding
• Slower than expected growth rates may be interpreted as neglect especially
in aboriginal communities
Implications for diagnosing over or underweight
The CDC 2000 charts and the WHO 2006 charts produce slightly different curves for
children at different age points
• More children could be assessed as underweight prior to six months of age and less
after six months of age by using the WHO 2006 charts compared to the CDC 2000
• Breast fed infants may track well against the CDC reference for the fisrt four to six
months of life but poorly after the first four to six months
• Mothers of breast fed babies who do not show the rapid growth rates in the WHO
2006 model in the first two to four months may also be at greater risk of introducing
complimentary feeding at an early age.
Reference versus standard
• Previous growth charts were established as reference points to which health
professionals and parents could compare the growth of individual children.
This distinction is important in the assessment of which growth chart is the
most appropriate to a given population
• A growth reference describes the growth of a sample of individuals who are
representative of the genereal population, without making any association
with health(CDC charts)
• A standard, on the other hand, describes the growth of a healthy population
and provides a reference to which all populations can aspire.(WHO charts)
Effectiveness of growth charts:
• To what exatent does growth monitoring results in positive health out comes for
-systematic review of studies in developing countries which
compared the health outcomes of children whose growth was monitores using
standardized charts to those of children not monitored in this way, found no
difference in outcomes for the two groups.
• Growth is an individual process. Individual do not grow according to statistical
distributions of size and age
• The wide range with in normal growth patterns is not always well understood by
health professionals or parents leading to unnecessary anxiety for parents and the
possibility of ceasing breastfeeding too soon, or of overfeeding
• The effectiveness of using growth depends on the knowledge and
understanding that mothers have pf growth charts and the value that
mothers place on them.
• Researchers have found that mothers do not always define their childrens
growth patterns according to the standards set by growth charts or by the
health professionals who use them
• Parents perceptions of the ideal weight for their children is culturally
• No existing Growth chart is a perfect match in Indian context
• The CDC 2000 and WHO 2006 growth charts both have their benefits and
– Indian breast feeding practices, birth weight, multicultural population mix.
• CDC recommends
The WHO growth standard charts should be used for children younger than 2.
The CDC 2000 growth reference charts should be used for children aged 2 through
19 years, because these charts can be used continuously up to age 20
• Growth assessments that are not supported by appropriate response programmes are
not effective in improving child health.
•  Rakel. Textbook of Family Medicine. 7th ed. Philadelphia: Saunders; 2007. P.
555.(Growth and development; chap 31).
•  Park K. Textbook of Preventive and Social Medicine. 21st ed. Jabalpur(India):
Banarsidas Bhanot Publishers; 2011. P.502.
• Srilakshmi B. Nutrition Science. 2nd ed. New Delhi: New Age International (P)
•  WHO. WHO child growth standards. Geneva(Switzerland): WHO;2007
•  World Health Organization. Training Course on Child Growth Assessment.
Geneva, WHO, 2008.
• Ghai OP. Ghai Essential Pediatrics: CBS Publishers & Distributors pvt Ltd; 2006