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Acta Pediatr Port 2010:41(5):S2 growth during early childhood across human populations means either a recent common origin as some suggest [18] or a strong selective advantage associated with the current pattern of growth and development across human environments. Construction of the WHO Child Growth Standards Of 1743 mother-child dyads enrolled in the MGRS longitudinal sample, 882 complied fully with the study’s infant-feeding and non-smoking criteria and completed the follow-up period of 24 months. This sample was used to cons - truct the WHO standards from birth to 2 years of age combined with 6669 children from the cross-sectional sample from age 2-5 years [19]. Data from all sites were pooled to construct the standards [17]. The generation of the standards followed state-of-the-art statistical methodologies that are described in detail elsewhere [7,20]. Weight-for-age, length/height-for-age, weight-for-length/height, and body mass index-for-age percentile and z-score values were generated for boys and girls aged 0-60 months. The concordance between the smoothed curves and observed or empirical percentiles was excellent and free of bias at both the median and the edges, indicating that the resulting curves are a fair description of physiological growth of healthy children [7]. Detailed results of the MGRS study and the construction of the growth standards are available elsewhere [6,7]. The full set of tables and charts is presented on the WHO website (www.who.int/child- growth/en), together with tools such as software for PC and PDA and training materials that facilitate their application. Windows of achievement for the six gross motor milestones collected in the MGRS (i.e. sitting without support, hands-and-knees crawling, standing with assistance, walking with assistance, standing alone and walking alone) are also available in a published paper [21] and on the website. Standards for a second set of anthropometric variables (i.e. head circumference, mid-upper arm circumference, and triceps and subs capular skinfolds) were released in 2007 [22]; and growth velocity standards for weight, length, and head circumference in 2009 [23]. Innovative aspects of the new standards The WHO Child Growth Standards were derived from children who were raised in environments that minimized constraints to growth such as poor diets and infection. In addition, their mothers followed healthy practices such as breastfeeding their children and not smoking during and after pregnancy. The standards depict normal human growth under optimal environmental conditions and can be used to assess children everywhere, regardless of ethni - city, socioeconomic status and type of feeding. Another key characteristic of the new standards is that they explicitly identify breastfeeding as the biological norm and establish the breastfed child as the normative model for growth and development. As an advocacy tool for the protection and promotion of breastfeeding, the new standards have the potential to significantly strengthen health policies and public support for breastfeeding. Third, the pooled sample from the six participating countries allowed the development of a truly international reference that underscores the fact that child populations grow similarly across the world’s major regions when their health and care needs are met. It also provides a tool that is timely and appropriate for the ethnic diversity seen within countries and the evolution towards increasingly multiracial societies in the Americas and Europe as elsewhere in the world. Fourth, the wealth of data collected allows not only the replacement of the current NCHS international references on attained growth (weight-for-age, length/height-for-age, and weight-for-length/height) but also the development of new standards for triceps and subscapular skinfolds, head and arm circumfe - ren ces, and body mass index. These innovative references allow for more specific nutritional assessment of aspects of body compositions and are thus particularly useful for monitoring the increasing epidemic of childhood obesity. Fifth, the study’s longitudinal nature also allows the development of growth velocity standards. Pediatricians will not have to wait until children cross an attained growth threshold to make the diagnosis of undernutrition or overweight since velocity standards will enable the early identification of children in the process of becoming undernourished or overweight. Lastly, the development of accompanying motor development reference data will pro vide a unique link between physical growth and motor development. Although WHO issued guidelines in the past concerning attained physical growth, it has not previously made recommendations for assessing motor development. To complement the growth standards for children under-five years of age, WHO recently developed a growth reference for school-aged children and adolescents [24]. These 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 appro - priate reference for the 5 to 19 years age group. The full set of clinical charts and tables displayed by sex and age are available on the WHO website (www.who.int/growthref/en). Conclusions The WHO standards provide an improved tool to monitor the rapid and changing rate of growth in early infancy [25]. They also demonstrate that healthy children from around the world who are raised in healthy environments and follow recommended feeding practices have strikingly similar patterns of growth [17]. The ancestries of the children included in the WHO standards were widely diverse. They included peoples from Europe, Africa, the Middle East, Asia and Latin America. In this regard they are similar to growing numbers of populations with increasingly diverse ethnicities. The growth of the children in the various sites was very similar because their environments were similarly healthy. This indicates that we should expect the same potential for growth in any country. It also implies that deviations from this pattern must be assumed to reflect adverse conditions that require correction, e.g. lack of breastfeeding, nutrient-poor or energy-excessive complementary foods, unsanitary environments, deficient health services and/or poverty. The International Pediatric Association has officially endorsed the use of the WHO standards describing them as “an effective tool for detecting both under-nutrition and obesity, thus addressing the double burden of malnutrition affecting populations on a global basis” [26]. The use of the WHO growth standards has also been endorsed by the European Childhood Obesity Group [27] and the ESPGHAN [28]. Since the WHO standards were released in 2006, over 110 countries have adopted them and are at different stages of their implementation. Some of these countries, alike Portugal, were using the 2000 CDC Growth Charts and have redesigned new charts (based on the WHO standards 0-5 years and WHO reference 5-19 years) using the format of the CDC charts (e.g., combining weight and height in the same chart) so that doctors continue to use the design they are used to. Figures 2-5 present samples of these charts for boys [29]. The shift in growth charts provides a unique opportunity to underscore the importance and utility of monitoring child growth; to rethink and redesign surveillance systems so that they are more useful in decision-making and less burdensome in terms of data collection; and, most importantly, to promote infant and young child nutrition within the context of broader efforts that encompasses maternal and child health, full immunization, and adequate attention to physical, motor and cognitive development. Figure 2 – WHO Growth Charts for Canada: Length-for-age and Weight-for-age percentiles, birth to 24 months, boys S2
Acta Pediatr Port 2010:41(5):S3 Figure 3 – WHO Growth Charts for Canada: Head circumference and Weight-forlength percentiles, birth to 24 months, boys Figure 5 – WHO Growth Charts for Canada: Body mass index-for-age percentiles, 2 to 19 years, boys References Figure 4 – WHO Growth Charts for Canada: Height-for-age and Weight-for-age percentiles, 2 to 19 years, boys [1] Shrimpton R, Victora CG, de Onis M, Costa Lima R, Blössner M, Clugston G. Worldwide timing of growth faltering: implications for nutritional interventions. Pediatrics 2001;107(5):E75. [2] Victora CG, Adair L, Fall C, et al, for the Maternal and Child Undernutrition Study Group. Maternal and child undernutrition: consequences for adult health and human capital. Lancet 2008;371:340-57. [3] Caulfield LE, de Onis M, Blössner M, Black RE. Undernutrition as an underlying cause of child deaths associated with diarrhea, pneumonia, malaria and measles. Am J Clin Nutr 2004;80:193-8. [4] Dietz WH. Health consequences of obesity in youth: childhood predictors of adult disease. Pediatrics 1998;101:518-25. [5] American Academy of Pediatrics Policy Statement. Prevention of pediatric overweight and obesity. Pediatrics 2003;112:424-30. [6] de Onis M, Garza C, Onyango AW, Martorell R, editors. WHO Child Growth Standards. Acta Paediatr Suppl 2006;450:1-101. [7] World Health Organization. WHO Child Growth Standards: Length/height-for-age, weightfor-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva: World Health Organization, 2006. [8] WHO. Physical Status: The Use and Interpretation of Anthropometry. Report of a WHO Expert Committee. Technical Report Series No. 854. Geneva: World Health Organization, 1995. [9] Hamill PVV, Drizd TA, Johnson CL, Reed RB, Roche AF, Moore WM. Physical growth: National Center for Health Statistics percentiles. Am J Clin Nutr 1979;32:607-29. [10] Dibley MJ, Goldsby JB, Staehling NW, Trowbridge FL. Development of normalized curves for the international growth reference: historical and technical considerations. Am J Clin Nutr 1987;46:736-48. [11] de Onis M, Yip R. The WHO growth chart: historical considerations and current scientific issues. Bibl Nutr Dieta 1996;53:74-89. [12] WHO Working Group on Infant Growth. An evaluation of infant growth. Geneva: World Health Organization, 1994. [13] WHO Working Group on Infant Growth. An evaluation of infant growth: the use and interpretation of anthropometry in infants. Bull World Health Organ 1995;73: 165-74. [14] Garza C, de Onis M, for the WHO Multicentre Growth Reference Study Group. Rationale for developing a new international growth reference. Food Nutr Bull 2004;25 Suppl 1:S5-14. [15] Forty-seventh World Health Assembly, May 1994. Resolution WHA47.5 on Infant and young child nutrition. Geneva, World Health Organization, 1994. S3
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