Growh charts by praman

1. GROWTH
CHARTS
Dr Praman Kushwah
DrNB Neonatology

2.  George Buffon (1707-1788)
 Published charts in his Histoire
Naturelle, thus producing the first
height growth curve
 Count Philibert de Montbeillard (1720-
1785)
 The idea of plotting a child’s body
measurements on a chart to illustrate
their pattern of growth first

3. Henry Bowditch - first to use the centiles to
describe the growth of Massachusetts
children in 1891
Lubchenco's chart – 1st intrauterine growth
chart to be widely used in neonates, also
classified newborns based on size at birth

4. “Growth is described as a net increase in size
or mass of tissues as a result of either
multiplication of cells or increase in
intracellular substance.”

5. Fetal growth
 Most rapid phase of growth in humans
 Exponential growth occurs by six folds between 22
and 40 weeks
 Influenced by fetal, placental & maternal factors
 Fetus grows as per its inherent growth potential

6. Postnatal growth
 Depends on genetic potential, internal & external
factors
 I-Infancy(Nutrition)
 C-Childhood(Growth Hormone)
 P-Puberty(Growth Hormone + Sex Steroids)

7.  Graphic representation of growth of reference population for
clinical use
 Comprises of growth curves which display size of child at a
point of age and their growth rate over a period of time
 A growth chart is termed as a ‘road to health’ by Professor
David Morley

8.  It is important to monitor the growth of infants to detect any
deviation from normal.
 Identification of babies at high risk of having poor
neurodevelopmental outcome

9.  Two common types of growth charts
Growth References
Growth Standards
Cole TJ. The development of growth references and growth
charts. Ann Hum Biol. 2012;39(5):382–394

11.  Statistical summary of anthropometry in a reference group of
children, whose health status is not taken into consideration
 Descriptive
 Show how children grow rather than how they should grow.
 Cross sectional data
 Easy to acquire large sample size

12.  Statistical summary of anthropometry in a reference sample
which is selected on health grounds
 Prescriptive model – Represents healthy pattern of growth
 Shows how the child should grow
 Based on prospective and longitudinal monitoring of growth
 Difficult to acquire large sample size

13. Growth
Pattern
Under
Nutrition
Long
Term
Outcomes
Data
Collection

14. Reference growth charts
1. Intrauterine growth charts
2. Post natal growth charts
3. Fetal – Infant growth charts
Standard growth charts
1. INTERGROWTH – 21st
2. WHO-MGRS charts

15.  Derived from data of anthropometric measurements of
preterm infants of different gestational age at birth
 Small sample
 Cross-sectional data
 Not gender specific
 Less reliable GA
 Preterm different from fetus

16.  Available Intrauterine charts are
1. Lubchenco (1966)
2. Usher and McLean (1969)
3. Brenner (1976)
4. Arbuckle (1993)
5. Alexander (1996)
6. Kramer (2001)

17.  Was most widely used
 4700 newborns b/w 26-42 weeks gestation
 Multi centric retrospective study
 Weight, Length & Head circumference
 First described SGA/AGA/LGA using Ponderal Index

18.  Drawbacks
1. Single country(USA)
2. High altitude

20.  Based on longitudinal measurements of parameters of infants
as they grow
 Provide actual postnatal pattern of infant's growth(loss-regain-
subsequent growth)
 Cannot be prescriptive

21.  Postnatal growth charts include
1. Dancis 1948
2. Infant Health and Development Program (IHDP) 1985
3. Shaffer 1987
4. Wright 1993
5. Berry 1997
6. Ehrenkranz 1999

22.  Multicentric Prospective Longitudinal Cohort Study
 12 centers in USA
 1660 infants with BWt between 501 and 1500 g admitted
within 24 h of age
 Longitudinal data on Wt, Lt, HC, MUAC were measured from
birth until discharge, transfer, death, age 120 days, or a body
weight of 2000 g

23.  Strengths of the study
1. Large, heterogeneous population of very low birth weight
infants
2. Included infants, who received more advance treatments
such as surfactant replacement therapy, antenatal steroid
and early aggressive nutritional regimens
 May be used to understand postnatal growth better and to
identify infants developing morbidities affecting growth
such as BPD

24.  Drawbacks are
1. Small sample size
2. Population of a single country
3. Only provides a single line trajectory and not major centiles

26.  Constructed by merging two sets of reference data:
1. Cross-sectional data of anthropometric measurement of
preterm infants at birth
2. Postnatal longitudinal anthropometric data of term infants
 Permit growth comparison with fetus first and then to term
standards
 Advantage – assessment of catch up growth

27. 1. Babson and Benda charts 1967
2. Fenton chart 2003
3. Fenton charts 2013

28.  Caucasian population(GA 27 to 44 weeks born between 1959
and 1966)
 Was Popularly used
 39743(27-44weeks), 3381(27-37weeks)
 3 parameters included – wt, lt, HC

29.  Limitations
1. Younger preterms
(<27 weeks) not
included
2. Had 500 g weight
interval
increments(precise
plotting difficult)
3. Very small sample
size

30.  Based on data from Nicklasson et al, Kramer et al, Beeby et al,
and the US Centers for Disease Control
 Updated Babson–Benda charts
 Gestation – 22 to 50 weeks
 Canada

31.  Allows comparison of growth of a preterm infant with that of
fetus initially starting as low as 22 weeks till 36 weeks and
then later with term infants upto 50 weeks
 Wt, Lt, HC included
 Large sample size with large preterm population
 Data from multiple sources
 Cross sectional data (predominantly)

32.  Not sex specific
 Change in wt. pattern not represented
 Do not show infant growth velocity
 Longitudinal growth influenced by medical and nutritional
conditions
 Designed for plotting as completed gestation weeks
 Limitation in methodological quality and
heterogeneity(affected its validity)

34.  Revised in 2013
 Large preterm birth sample size(approx. 4 million infants)
 1991 and 2007
 Developed countries (Germany, Italy, United States, Australia,
Scotland & Canada)

35. 1. Data from recent population based surveys
2. Sex specific
3. Can be used to assign size for gestational age up to 36 weeks
4. The curves are equivalent to the WHO growth curves at 50
weeks of PMA
5. Comparison for preterm infants as young as 22 weeks of
gestation first with intrauterine and then with post term
references
6. The larger sample sizes and more accurate gestational age
assignments used here may provide better confidence in the
extreme percentiles.
7. Shows 3, 10, 25, 50, 90 and 97 th Percentiles

36.  Does not address the physiological postnatal loss of body water after
birth.
 Different centers used variable methods for measurement of crown-heel
length, making its reliability doubtful
 Initial parts of the curves are based on the size of fetuses at birth, which
do not show the change in weight that occurs after birth
 This is followed by curves based on the growth of term infants who have
not had the growth depressing effect of prematurity.
 Not based on the growth standard for preterm infants, that is, on fetal
growth. Therefore they do not show an infant’s growth velocity or catch-
up in growth relative to the fetus or the term infant
 The curves on a longitudinal growth chart are highly influenced by the
medical and nutritional care of the sample infants; growth patterns may
change with innovations in medical and nutritional care

39.  Fenton growth curves 2013 for girls and boys from 22 to 50
weeks are available from http://www.ucalgary.ca/fenton/
2013chart.

41. Peditools.org is an online clinical tool available for easier calculation of centiles
and z score as described by Fenton
(Available at http://peditools.org/fenton2013.)

42. Intergrowth-21st Project was initiated by International Fetal
and Newborn Consortium
 Aim : to produce new prescriptive standards describing normal
Fetal and newborn growth
 Data collected from 8 geographically different areas
 Countries included were India, Italy, Oman, Brazil, Kenya,
China, UK and USA

43.  Based on
1) Fetal growth longitudinal study (FGLS) - Fetal growth from
early pregnancy
2) Preterm postnatal follow-up study (PPFS) - Postnatal growth
of preterms
3) New born cross-sectional study (NCSS) - New born size at
birth
 Both LMP and USG combined over a time by a two stage
process were used as a measure to ascertain gestation age

44.  Anthropometric data of fetus from 14 weeks gestational age to
birth
 Fetal growth monitored in a healthy population
 Standard fetal growth curves were constructed based on USG
for :
Occipito-frontal diameter,
Head circumference
Abdominal circumference
Biparietal diameter and femur length
 Devised to be used for the clinical interpretation of routinely
taken USG measurements

45.  Preterm newborns of more than 26 weeks and less than 37
weeks were followed post-delivery for evaluation of postnatal
growth, 201 eligible preterm newborns from FGLS ,healthy or
stable preterm
 All babies followed till 64 weeks PMA
 Standards for postnatal growth in preterm infants for weight,
length and head circumference
 Can be used for assessment up to 64 weeks PMA

46.  Weight, length and head circumference of all newborn infants
whose mothers were enrolled in FGLS
 Centile curves for 3rd, 10th, 50th, 90th, and 97th were
obtained according to gestational age and sex
 Prescriptive international anthropometric standards
 To assess newborn size from 33 to 43 weeks gestation were
obtained from this study

47.  Prospective study
 Monitor child growth continuously from early prenatal life up to
the age 5 years.
 Population based, multiethnic, multi-country and sex-specific
 Across all the eight study sites, not only a uniform research
method and same protocol was used but also accurate
gestational age estimation wasensured by 1st trimester USG.
 Therefore, the standards are prescriptive and describe the
optimum size in newborn infants without congenital
abnormalities.

48.  Despite a large sample size, there were relatively few early
preterm births below 33 weeks for PPFS study
 In NCSS the lower limit of the curves was set at 33 weeks of
gestation, because it was not possible to enroll preterm below
this gestation age with very strict criteria

51.  WHO growth standard 2006 for children are based on data
from the WHO MGRS -1997–2003
 Six different countries of different continents including India
 Data were based on both developed and developing nations

52.  Population sample included only full term breast fed infants
whose growth was not restrained by socioeconomic status.
 Growth curves for children aged below 24 months were based
on the longitudinal component of MGRS
 WHO charts are growth standards, prescriptive in nature
 These standards have been used by 125 countries

54.  Measurements weight, length and
head circumference Data type
Longitudinal data
 Drawback is that, the WHO charts
do not address babies of preterm
gestation.
 WHO charts have been used in
premature neonates after they
reach 40 weeks PMA

60.  Intrauterine growth charts such as Lubchenco chart cannot be
used for longitudinal assessment of growth
 Ehrenkranz charts were developed for longitudinal growth
monitoring of preterm infants but the study had a small
sample size and do not provide gestation specific centiles

61.  Intergrowth-21st postnatal growth standard for preterm
infants ,preterm postnatal growth standard from a prospective
cohort from different geographical areas making them the
recommended charts for neonates with gestation week 33 or
more
 However, as it had less number of infants below 33 weeks(28
infants) they may still not be useful in infants of lower
gestation

62.  Fenton charts 2013 lack standard prescriptive benefits,
popular for preterm infants because they include data from 4
million preterm infants, precise sex specific plotting and
smooth transition to WHO MGRS 2006 growth standards
charts and can be used for preterm babies from 22weeks till 50
weeks PMA.
 For term infants, WHO MGRS 2006 growth charts should be
used