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The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight.
PloS Medicine. 2017 Jan; 14(1):e1002220.BACKGROUND: Perinatal mortality and morbidity continue to be major global health challenges strongly associated with prematurity and reduced fetal growth, an issue of further interest given the mounting evidence that fetal growth in general is linked to degrees of risk of common noncommunicable diseases in adulthood. Against this background, WHO made it a high priority to provide the present fetal growth charts for estimated fetal weight (EFW) and common ultrasound biometric measurements intended for worldwide use. METHODS AND FINDINGS: We conducted a multinational prospective observational longitudinal study of fetal growth in low-risk singleton pregnancies of women of high or middle socioeconomic status and without known environmental constraints on fetal growth. Centers in ten countries (Argentina, Brazil, Democratic Republic of the Congo, Denmark, Egypt, France, Germany, India, Norway, and Thailand) recruited participants who had reliable information on last menstrual period and gestational age confirmed by crown-rump length measured at 8-13 wk of gestation. Participants had anthropometric and nutritional assessments and seven scheduled ultrasound examinations during pregnancy. Fifty-two participants withdrew consent, and 1,387 participated in the study. At study entry, median maternal age was 28 y (interquartile range [IQR] 25-31), median height was 162 cm (IQR 157-168), median weight was 61 kg (IQR 55-68), 58% of the women were nulliparous, and median daily caloric intake was 1,840 cal (IQR 1,487-2,222). The median pregnancy duration was 39 wk (IQR 38-40) although there were significant differences between countries, the largest difference being 12 d (95% CI 8-16). The median birthweight was 3,300 g (IQR 2,980-3,615). There were differences in birthweight between countries, e.g., India had significantly smaller neonates than the other countries, even after adjusting for gestational age. Thirty-one women had a miscarriage, and three fetuses had intrauterine death. The 8,203 sets of ultrasound measurements were scrutinized for outliers and leverage points, and those measurements taken at 14 to 40 wk were selected for analysis. A total of 7,924 sets of ultrasound measurements were analyzed by quantile regression to establish longitudinal reference intervals for fetal head circumference, biparietal diameter, humerus length, abdominal circumference, femur length and its ratio with head circumference and with biparietal diameter, and EFW. There was asymmetric distribution of growth of EFW: a slightly wider distribution among the lower percentiles during early weeks shifted to a notably expanded distribution of the higher percentiles in late pregnancy. Male fetuses were larger than female fetuses as measured by EFW, but the disparity was smaller in the lower quantiles of the distribution (3.5%) and larger in the upper quantiles (4.5%). Maternal age and maternal height were associated with a positive effect on EFW, particularly in the lower tail of the distribution, of the order of 2% to 3% for each additional 10 y of age of the mother and 1% to 2% for each additional 10 cm of height. Maternal weight was associated with a small positive effect on EFW, especially in the higher tail of the distribution, of the order of 1.0% to 1.5% for each additional 10 kg of bodyweight of the mother. Parous women had heavier fetuses than nulliparous women, with the disparity being greater in the lower quantiles of the distribution, of the order of 1% to 1.5%, and diminishing in the upper quantiles. There were also significant differences in growth of EFW between countries. In spite of the multinational nature of the study, sample size is a limiting factor for generalization of the charts. CONCLUSIONS: This study provides WHO fetal growth charts for EFW and common ultrasound biometric measurements, and shows variation between different parts of the world.
Interpretation of World Health Organization growth charts for assessing infant malnutrition: a randomised controlled trial.
Journal of Paediatrics and Child Health. 2014 Jan; 50(1):32-9.AIMS: The study aims to assess the effects of switching from National Center for Health Statistics (NCHS) growth references to World Health Organization (WHO) growth standards on health-care workers' decisions about malnutrition in infants aged <6 months. METHODS: We conducted a single blind randomised crossover trial involving 78 health-care workers (doctors, clinical officers, health service assistants) in Southern Malawi. Participants were offered hypothetical clinical scenarios with the same infant plotted on NCHS-based weight-for-age charts and again on WHO-based charts. Additional scenarios compared growth charts with a single final weight against charts with the same final weight plus a preceding growth trend. Reported (i) level of concern, (ii) referral suggestions and (iii) feeding advice were elicited with a questionnaire. RESULTS: Even after adjusting for health-care worker type and experience, using WHO rather than NCHS charts increased: (i) concern: aOR 4.4 (95% CI 2.4-8.1); (ii) odds of referral: aOR 5.1 (95% CI 2.4-10.8); and (iii) odds of feeding advice which would interrupt exclusive breastfeeding (aOR 2.4, 95% CI 1.2-4.9). A preceding steady growth trend line did not affect concern, referral or feeding advice. CONCLUSIONS: Health-care workers take insufficient account of linear growth trend, clinical and feeding status when interpreting a low weight-for-age plot. Because more infants <6 months fall below low centile lines on WHO growth charts, their use may increase inappropriate referrals and risks undermining already low rates of exclusive breastfeeding. To avoid their being misinterpreted in this way, WHO charts need accompanying guidelines and training materials that recognise and address this possible adverse effect. (c) 2013 The Authors. Journal of Paediatrics and Child Health (c) 2013 Paediatrics and Child Health Division (Royal Australasian College of Physicians).
Maternal and Child Nutrition. 2013; 9 Suppl 2:27-45.An estimated 165 million children are stunted due to the combined effects of poor nutrition, repeated infection and inadequate psychosocial stimulation. The complementary feeding period, generally corresponding to age 6-24 months, represents an important period of sensitivity to stunting with lifelong, possibly irrevocable consequences. Interventions to improve complementary feeding practices or the nutritional quality of complementary foods must take into consideration the contextual as well as proximal determinants of stunting. This review presents a conceptual framework that highlights the role of complementary feeding within the layers of contextual and causal factors that lead to stunted growth and development and the resulting short- and long-term consequences. Contextual factors are organized into the following groups: political economy; health and health care systems; education; society and culture; agriculture and food systems; and water, sanitation and environment. We argue that these community and societal conditions underlie infant and young child feeding practices, which are a central pillar to healthy growth and development, and can serve to either impede or enable progress. Effectiveness studies with a strong process evaluation component are needed to identify transdisciplinary solutions. Programme and policy interventions aimed at preventing stunting should be informed by careful assessment of these factors at all levels.
Pilot testing of WHO child growth standards in Chandigarh: implications for India's child health programmes.
Bulletin of the World Health Organization. 2009 Feb; 87(2):116-22.OBJECTIVE: To compare the prevalence of underweight as calculated from Indian Academy of Paediatrics (IAP) growth curves (based on the Harvard scale) and the new WHO Child Growth Standards. METHODS: We randomly selected 806 children under 6 years of age from 45 primary anganwadi (childcare) centres in Chandigarh, Punjab, India, that were chosen through multistage stratified random sampling. Children were weighed, and their weight for age was calculated using IAP curves and WHO growth references. Nutritional status according to the WHO Child Growth Standards was analysed using WHO Anthro statistical software (beta version, 17 February 2006). The chi2 test was used to determine statistical significance at the 0.05 significance level. FINDINGS: The prevalence of underweight (Z score less than -2) in the first 6 months of life was nearly 1.6 times higher when calculated in accordance with the new WHO standards rather than IAP growth curves. For all ages combined, the estimated prevalence of underweight was 1.4 times higher when IAP standards instead of the new WHO standards were used. Similarly, the prevalence of underweight in both sexes combined was 14.5% higher when IAP standards rather than the new WHO growth standards were applied (P < 0.001). By contrast, severe malnutrition estimated for both sexes were 3.8 times higher when the new WHO standards were used in place of IAP standards (P < 0.001). CONCLUSION: The new WHO growth standards will project a lower prevalence of overall underweight children and provide superior growth tracking than IAP standards, especially in the first 6 months of life and among severely malnourished children.
What difference do the new WHO child growth standards make for the prevalence and socioeconomic distribution of undernutrition?
Food and Nutrition Bulletin. 2009 Mar; 30(1):3-15.BACKGROUND: The World Health Organization has recently established revised child growth standards. OBJECTIVE: To assess how the use of these new standards affects the estimated prevalence and socioeconomic distribution of stunting and underweight among children in a large number of low- and middle-income countries. METHODS: We analyzed Demographic and Health Survey data for stunting and underweight in 41 low- and middle-income countries employing these new standards and compared the results with those produced by analyses of the same data using the old growth references. RESULTS: For all 41 countries, the prevalence of stunting increases with the adoption of the new standards, by 5.4 percentage points on average (95% CI: 5.1, 5.7). The prevalence of underweight decreases in all but two of the countries, by an average of 2.9 percentage points (95% CI: 2.7, 3.2). The impact of using the new standards on socioeconomic inequalities is mixed. For stunting, inequalities tend to rise in absolute terms but tend to decline in relative terms. The impact on underweight is inconsistent across countries. Poor children suffer most from undernutrition, but even among the better-off children in developing countries, undernutrition rates are high enough to deserve attention. CONCLUSIONS: These results suggest that the adoption of the new WHO standards in itself is unlikely to affect policies dramatically. They do confirm, however, that different strategies are likely to be required in these countries to effectively address undernutrition among children at different socioeconomic levels.
Impact of new WHO growth standards on the prevalence of acute malnutrition and operations of feeding programs - Darfur, Sudan, 2005-2007.
MMWR. Morbidity and Mortality Weekly Report. 2009 Jun 5; 58(21):591-4.Acute malnutrition among children aged 6-59 months is a key indicator routinely used for describing the presence and magnitude of humanitarian emergencies. In the past, the prevalence of acute malnutrition and admissions to feeding programs has been determined using the growth reference developed by the World Health Organization (WHO), CDC, and the National Center for Health Statistics (NCHS). In 2006, WHO released new international growth standards and recommended their use in all nutrition programs. To evaluate the impact of transitioning to the new standards, CDC analyzed anthropometric data for children aged 6-59 months from Darfur, Sudan, collected during 2005-2007. This report describes the results of that analysis, which indicated that use of the new standards would have increased the prevalence of global acute malnutrition on average by 14% and would have increased the prevalence of severe acute malnutrition on average by 100%. Admissions to feeding programs would have increased by 56% for moderately malnourished children and by 260% for severely malnourished children. For programs in Darfur, this would have resulted in approximately 23,200 more children eligible for therapeutic feeding programs. For the immediate future, the prevalence of acute malnutrition in children should be reported using both the old WHO/CDC/NCHS reference and the new WHO standards. More research is needed to better ascertain the validity of the admission criteria based on the new WHO standards in predicting malnutrition-related morbidity and mortality.
Comparison of the new World Health Organization growth standards and the National Center for Health Statistics growth reference regarding mortality of malnourished children treated in a 2006 nutrition program in Niger.
Archives of Pediatrics and Adolescent Medicine. 2009 Feb; 163(2):126-30.OBJECTIVE: To compare the National Centre for Health Statistics (NCHS) international growth reference with the new World Health Organization (WHO) growth standards for identification of the malnourished (wasted) children most at risk of death. DESIGN: Retrospective data analysis. SETTING: A Medecins Sans Frontieres (Doctors Without Borders) nutrition program in Maradi, Niger, in 2006 that treated moderately and severely malnourished children. PARTICIPANTS: A total of 53 661 wasted children aged 6 months to 5 years (272 of whom died) in the program were included. INTERVENTIONS: EpiNut (Epi Info 6.0; Centers for Disease Control and Prevention, Atlanta, Georgia) software was used to calculate the percentage of the median for the NCHS reference group, and the WHO (igrowup macro; Geneva, Switzerland) software was used to calculate z scores for the WHO standards group of the 53 661 wasted children. OUTCOME MEASURES: The main outcome measures are the difference in classification of children as either moderate or severely malnourished according to the NCHS growth reference and the new WHO growth standards, specifically focusing on children who died during the program. RESULTS: Of the children classified as moderately wasted using the NCHS reference, 37% would have been classified as severely wasted according to the new WHO growth standards. These children were almost 3 times more likely to die than those classified as moderately wasted by both references, and deaths in this group constituted 47% of all deaths in the program. CONCLUSIONS: The new WHO growth standards identifies more children as severely wasted compared with the NCHS growth reference, including children at high mortality risk who would potentially otherwise be excluded from some therapeutic feeding programs.
Appropriate infant feeding practices result in better growth of infants and young children in rural Bangladesh.
American Journal of Clinical Nutrition. 2008 Jun; 87(6):1852-1859.The World Health Organization and the United Nations International Children's Emergency Fund recommend a global strategy for feeding infants and young children for proper nutrition and health. We evaluated the effects of following current infant feeding recommendations on the growth of infants and young children in rural Bangladesh. The prospective cohort study involved 1343 infants with monthly measurements on infant feeding practices (IFPs) and anthropometry at 17 occasions from birth to 24 mo of age to assess the main outcomes of weight, length, anthropometric indexes, and undernutrition. We created infant feeding scales relative to the infant feeding recommendations and modeled growth trajectories with the use of multilevel models for change. Mean (+or- SD) birth weight was 2697 +or- 401 g; 30%weighed less than 2500 g. Mean body weight at 12 and 24 mo was 7.9 +or- 1.1 kg and 9.7 +or- 1.3 kg, respectively. More appropriate IFPs were associated (P less than 0.001) with greater gain in weight andlength during infancy. Prior IFPs were also positively associated (P less than 0.005) with subsequent growth in weight during infancy. Children who were in the 75th percentile of the infant feeding scales had greater (P less than 0.05) attained weight and weight-for-age z scores and lower proportions of underweight compared with children who were in the 25th percentile of these scales. Our results provide strong evidence for the positive effects of following the current infant feeding recommendations on growth of infants and young children. Intervention programs should strive to improve conditions for enhancing current infant feeding recommendations, particularly in low-income countries. (author's)
Newly developed WHO growth standards: Implications for demographic surveys and child health programs.
Indian Journal of Pediatrics. 2007 Nov; 74(11):987-990.The objective was to compare estimates of undernutrition based on the World Health Organization (WHO) Child Growth Standards ('WHO standards') and the National Center for Health Statistics NCHS/ WHO international growth reference ('NCHS reference'), and discuss implications for child health programs and reporting of prevalence of underweight in demographic surveys. A cross-sectional study was carried out in 20 Anganwadi centers under Primary Health Centre, Anji. Total of 1491 under-six year children attending the Anganwadi centers were studied for nutritional status. Nutritional status was analyzed by NCHS standards by using EPI_INFO 6.04 software package and also by newly introduced WHO Child Growth Standards by Anthro 2005 software package. Chi-square test was used to compare the results. According to WHO standards, the prevalence of underweight and severe underweight for children 0-6 year was 47.4% and 16.9% respectively. By NCHS reference, the overall prevalence of underweight and severe underweight for children 0-6 years was 53% and 15% respectively. The prevalence of underweight as assessed by WHO standards was significantly lower when compared with the assessment based on NCHS reference (p<0.01). But, WHO standards gave higher prevalence of severe underweight than NCHS reference though the difference was not statistically significant (p>0.05). In the light of newly developed WHO Child growth standards, all the nutrition-related indicators in demographic surveys like NFHS should now be derived using the WHO standards. There is need to reanalyze NFHS-I and NFHS-II data using WHO standards and findings should be made available so that it becomes comparable and trends over the years can be studied. (author's)
Bulletin of the World Health Organization. 2007 Sep; 85(9):660-667.The objective was to construct growth curves for school-aged children and adolescents that accord with the WHO Child Growth Standards for preschool children and the body mass index (BMI) cut-offs for adults. Data from the 1977 National Center for Health Statistics (NCHS)/WHO growth reference (1-24 years) were merged with data from the under-fives growth standards' cross-sectional sample (18-71 months) to smooth the transition between the two samples. State-of-the-art statistical methods used to construct the WHO Child Growth Standards (0-5 years), i.e. the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best models, were applied to this combined sample. The merged data sets resulted in a smooth transition at 5 years for height-for-age, weight-for-age and BMI-for-age. For BMI-for-age across all centiles the magnitude of the difference between the two curves at age 5 years is mostly 0.0 kg/m/2 to 0.1 kg/m/2. At 19 years, the new BMI values at +1 standard deviation (SD) are 25.4 kg/m/2 for boys and 25.0 kg/m/2 for girls. These values are equivalent to the overweight cut-off for adults (>/= 25.0 kg/m/2). Similarly, the +2 SD value (29.7 kg/m/2 for both sexes) compares closely with the cut-off for obesity (>/= 30.0 kg/m/2). The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and the recommended adult cut-offs for overweight and obesity at 19 years. They fill the gap in growth curves and provide an appropriate reference for the 5 to 19 years age group. (author's)
BMJ. British Medical Journal. 2007 Apr 7; 334(7596):705-706.In April 2006, the World Health Organization released its new WHO child growth standards, 16 years after a WHO working group on infant growth recommended that these standards should describe how children should grow rather than how they actually grow. The basis for the new growth standards was six population based studies of infants and children from Ghana, India, Norway, Brazil, Oman, and North America, undertaken between 1997 and 2003. Participants were fed according to accepted international nutritional standards (including breast feeding), and their mothers were adequately nourished and avoided known adverse factors such as tobacco exposure. The new growth standards show that children born in different regions of the world can and should grow equally well, and they also show that sex and ethnic origin are minor determinants of growth compared with adequate nutrition, environment, and health. However, as expected, important differences in the diagnosis of malnutrition emerge when the standard cut-offs are applied using either the National Center for Health Statistics (NCHS)-WHO reference or the WHO 2006 growth standards. (excerpt)
SCN News. 2006; (33):27-29.The rising prevalence of overweight and obesity has become a topical issue worldwide. Children have not been spared this problem as childhood obesity is on the increase, even in developing countries, where infectious disease and malnutrition continue to take their toll on children. Concern about childhood obesity stems from the fact that not only does it predict obesity in adult life but it is also associated with the development of unfavourable health outcomes. For example, type 2 diabetes is increasingly a problem among children. Thus, in tackling overweight and obesity, one must put in place an efficient growth monitoring system that would permit then early detection of growth deviation among young children at risk. (excerpt)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S60-S65.The World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) African site was Accra, Ghana. Its sample was drawn from 10 affluent residential areas where earlier research had demonstrated the presence of a child subpopulation with unconstrained growth. This subpopulation could be identified on the basis of the father's education and household income. The subjects for the longitudinal study were enrolled from 25 hospitals and delivery facilities that accounted for 80% of the study area's births. The cross-sectional sample was recruited at 117 day-care centers used by more than 80% of the targeted subpopulation. Public relations efforts were mounted to promote the study in the community. The large number of facilities involved in the longitudinal and cross-sectional components, the relatively large geographic area covered by the study, and the difficulties of working in a densely populated urban area presented special challenges. Conversely, the high rates of breastfeeding and general support for this practice greatly facilitated the implementation of the MGRS protocol. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S53-S59.The World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) South American site was Pelotas, Brazil. The sample for the longitudinal component was drawn from three hospitals that account for approximately 90% of the city's deliveries. The cross-sectional sample was drawn from a community survey based on households that participated in the longitudinal sample. One of the criteria for site selection was the availability of a large, community based sample of children whose growth was unconstrained by socioeconomic conditions. Local work done in 1993 demonstrated that children of families with incomes at least six times the minimum wage had a stunting rate of 2.5%. Special public relations and implementation activities were designed to promote the acceptance of the study by the community and its successful completion. Among the major challenges of the site were serving as the MGRS pilot site, low baseline breastfeeding initiation and maintenance rates, and reluctance among pediatricians to acknowledge the relevance of current infant feeding recommendations to higher socioeconomic groups. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S66-S71.The World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) Asian site was New Delhi, India. Its sample was drawn from 58 affluent neighborhoods in South Delhi. This community was selected to facilitate the recruitment of children who had at least one parent with 17 or more years of education, a key factor associated with unconstrained child growth in this setting. A door-to-door survey was conducted to identify pregnant women whose newborns were subsequently screened for eligibility for the longitudinal study, and children aged 18 to 71 months for the cross-sectional component of the study. A total of 111,084 households were visited over an 18-month period. Newborns were screened at birth at 73 sites. The large number of birthing facilities used by this community, the geographically extensive study area, and difficulties in securing support of pediatricians and obstetricians for the feeding recommendations of the study were among the unique challenges faced by the implementation of the MGRS protocol at this site. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S78-S83.The World Health Organization (WHO) Multicentre Growth Study (MGRS) Middle East site was Muscat, Oman. A survey in Muscat found that children in households with monthly incomes of at least 800 Omani Rials and at least four years of maternal education experienced unconstrained growth. The longitudinal study sample was recruited from two hospitals that account for over 90% of the city's births; the cross-sectional sample was drawn from the national Child Health Register. Residents of all districts in Muscat within the catchment area of the two hospitals were included except Quriyat, a remote district of the governorate. Among the particular challenges of the site were relatively high refusal rates, difficulty in securing adherence to the protocol's feeding recommendations, locating children selected for the cross-sectional component of the study, and securing the cooperation of the children's fathers. These and other challenges were overcome through specific team building and public relations activities that permitted the successful implementation of the MGRS protocol. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S15-S26.The World Health Organization (WHO) Multicentre Growth Reference Study (MGRS) is a community-based, multicountry project to develop new growth references for infants and young children. The design combines a longitudinal study from birth to 24 months with a cross-sectional study of children aged 18 to 71 months. The pooled sample from the six participating countries (Brazil, Ghana, India, Norway, Oman, and the United States) consists of about 8,500 children. The study subpopulations had socioeconomic conditions favorable to growth, and low mobility, with at least 20% of mothers following feeding recommendations and having access to breastfeeding support. The individual inclusion criteria were absence of health or environmental constraints on growth, adherence to MGRS feeding recommendations, absence of maternal smoking, single term birth, and absence of significant morbidity. In the longitudinal study, mothers and newborns were screened and enrolled at birth and visited at home 21 times: at weeks 1, 2, 4, and 6; monthly from 2 to 12 months; and every 2 months in their second year. In addition to the data collected on anthropometry and motor development, information was gathered on socioeconomic, demographic, and environmental characteristics, perinatal factors, morbidity, and feeding practices. The prescriptive approach taken is expected to provide a single international reference that represents the best description of physiological growth for all children under five years of age and to establish the breastfed infant as the normative model for growth and development. (author's)
Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference.
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S27-S36.Thorough training, continuous standardization, and close monitoring of the adherence to measurement procedures during data collection are essential for minimizing random error and bias in multicenter studies. Rigorous anthropometry and data collection protocols were used in the WHO Multicentre Growth Reference Study to ensure high data quality. After the initial training and standardization, study teams participated in standardization sessions every two months for a continuous assessment of the precision and accuracy of their measurements. Once a year the teams were restandardized against the WHO lead anthropometrist, who observed their measurement techniques and retrained any deviating observers. Robust and precise equipment was selected and adapted for field use. The anthropometrists worked in pairs, taking measurements independently, and repeating measurements that exceeded preset maximum allowable differences. Ongoing central and local monitoring identified anthropometrists deviating from standard procedures, and immediate corrective action was taken. The procedures described in this paper are a model for research settings. (author's)
Managing data for a multicountry longitudinal study: Experience from the WHO Multicentre Growth Reference Study.
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S46-S52.The World Health Organization (WHO) Multicentre Growth Reference (MGRS) data management protocol was designed to create and manage a large data bank of information collected from multiple sites over a period of several years. Data collection and processing instruments were prepared centrally and used in a standardized fashion across sites. The data management system contained internal validation features for timely detection of data errors, and its standard operating procedures stipulated a method of master file updating and correction that maintained a clear trail for data auditing purposes. Each site was responsible for collecting, entering, verifying, and validating data, and for creating site-level master files. Data from the sites were sent to the MGRS Coordinating Centre every month for master file consolidation and more extensive quality control checking. All errors identified at the Coordinating Centre were communicated to the site for correction at source. The protocol imposed transparency on the sites' data management activities but also ensured access to technical help with operation and maintenance of the system. Through the rigorous implementation of what has been a highly demanding protocol, the MGRS has accumulated a large body of very high-quality data. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S37-S45.The objective of the Motor Development Study was to describe the acquisition of selected gross motor milestones among affluent children growing up in different cultural settings. This study was conducted in Ghana, India, Norway, Oman, and the United States as part of the longitudinal component of the World Health Organization (WHO) Multicentre Growth Reference Study (MGRS). Infants were followed from the age of four months until they could walk independently. Six milestones that are fundamental to acquiring self-sufficient erect locomotion and are simple to evaluate were assessed: sitting without support, hands-and-knees crawling, standing with assistance, walking with assistance, standing alone, and walking alone. The information was collected by both the children's caregivers and trained MGRS fieldworkers. The caregivers assessed and recorded the dates when the milestones were achieved for the first time according to established criteria. Using standardized procedures, the fieldworkers independently assessed the motor performance of the children and checked parental recording at home visits. To ensure standardized data collection, the sites conducted regular standardization sessions. Data collection and data quality control took place simultaneously. Data verification and cleaning were performed until all queries had been satisfactorily resolved. (author's)
Food and Nutrition Bulletin. 2004; 25 Suppl 1:S5-S14.The rationale for developing a new international growth reference derived principally from a Working Group on infant growth established by the World Health Organization (WHO) in 1990. It recommended an approach that described how children should grow rather than describing how children grow; that an international sampling frame be used to highlight the similarity in early childhood growth among diverse ethnic groups; that modern analytical methods be exploited; and that links among anthropometric assessments and functional outcomes be included to the fullest possible extent. Upgrading international growth references to resemble standards more closely will assist in monitoring and attaining a wide variety of international goals related to health and other aspects of social equity. In addition to providing scientifically robust tools, a new reference based on a global sample of children whose health needs are met will provide a useful advocacy tool to health-care providers and others with interests in promoting child health. (author's)
Lancet. 2006 Nov 25; 368(9550):1868-1869.Exclusive breastfeeding for 6 months is the normal way to feed all infants. The new WHO growth reference released in April, 2006, is based on breastfed infants under optimum conditions. The sample is highly selected for the factors likely to promote growth in breastfed infants, and less than 10% of those initially surveyed were included in the final study. Most mothers and health professionals are concerned about their infants' growth, particularly for the first 6 months. If they believe their infants are not growing adequately, they are more likely to introduce supplementary foods, including "top-ups" with infant formula or even switching to formula completely. "Insufficient milk" is the most common reason for the early cessation of breastfeeding and mothers often self-diagnose this on the basis of perceived slower growth. (excerpt)
Evaluation of the feasibility of international growth standards for school-aged children and adolescents.
Journal of Nutrition. 2007 Jan; 137(1):153-157.The development of an international growth standard for the screening, surveillance, and monitoring of school-aged children and adolescents has been motivated by 2 contemporaneous events, the global surge in childhood obesity and the release of a new international growth standard for infants and preschool children by the WHO. If a prescriptive approach analogous to that taken by WHO for younger children is to be adopted for school-aged children and adolescents, several issues need to be addressed regarding the universality of growth potential across populations and the definition of optimal growth in children and adolescents. A working group of experts in growth and development and representatives from international organizations concluded that subpopulations exhibit similar patterns of growth when exposed to similar external conditioners of growth. However, based on available data, we cannot rule out that observed differences in linear growth across ethnic groups reflect true differences in genetic potential rather than environmental influences. Therefore, the sampling frame for the development of an international growth standard for children and adolescents must include multiethnic sampling strategies designed to capture the variation in human growth patterns. A single international growth standard for school-aged children and adolescents could be developed with careful consideration of the population and individual selection criteria, study design, sample size, measurements, and statistical modeling of primary growth and secondary ancillary data. The working group agreed that existing growth references for school-aged children and adolescents have shortcomings, particularly for assessing obesity, and that appropriate growth standards for these age groups should be developed for clinical and public health applications. (author's)
Journal of Nutrition. 2007 Jan; 137(1):149-152.In April 2006 the WHO released a set of growth standards for children from birth to the age of 5 y. Prior to their release, the standards were field-tested in 4 countries. The main objective was to compare children's length/height-for-age and weight-for-length/height based on the new standards with clinician assessments of the same children. The study sampled children < 5-y-old attending well-child clinics in 2 affluent populations (Argentina and Italy) and 2 less-affluent ones (Maldives and Pakistan). Length/height and weight were measured by doctors and epidemiologists who also recorded a clinical assessment of each child's length/height in relation to age and weight relative to length/height. Anthropometric indicators of nutritional status were generated based on the WHO standards. As expected, Pakistan and the Maldives had higher rates of stunting, wasting, and underweight than Italy and Argentina, and the reverse was true for overweight and obesity. Where stunting was prevalent, the children classified as short were a mean < -22 SD for height-for-age. In all sites, the children classified as thin were indeed wasted < -22 SD for weight-for-height) and a positive association in trend was evident between weight-for-height and the line-up of groups from thin to obese. The overall concordance between clinical assessments and the WHO standards-based indicators attested to the clinical soundness of the standards. (author's)
Journal of Nutrition. 2007 Jan; 137(1):142-143.Charts that depict expected ranges and trajectories of anthropometric measurements and indicators, e.g., length/height-forage, weight-for-age, and BMI (kg/m2) are among the principal tools used by researchers, clinicians, and policymakers to assist in assessing the health and nutritional well-being of individuals at nearly all life stages and/or the general well-being of communities and broader populations. The utility of these charts to diverse professional groups and the interest of parents, children, and the general population in the information that they convey make a strong case for assuring that growth charts are scientifically robust and effective for educational purposes and in advocacy arenas to motivate improved individual or population health. The articles that follow focus on a global effort to develop a new international growth standard to assess infant and young child growth and to establish an initiative that explores how best to respond to an increasing need for new tools that can assess growth in older children and adolescents. The WHO released a new growth standard for infants and young children in April 2006. The new standard is a response to the recognition of significant flaws in the previous international growth reference. The previous international growth reference was hampered by an inadequately low frequency of measurements during infancy (when growth is most rapid and dynamic) and outdated analytical methods. The new standard is based on the WHO Multicentre Growth Reference Study (MGRS) that was designed specifically to construct a standard. (excerpt)