Growthcharts

Presented by Tuesday pediatrics unit
Under guidance of Dr Pooja Damani

 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.
 A normal healthy child grows at a genetically predetermined rate
 Child development refers to the biological, psychological and
emotional changes that occur in human beings between birth and
the end of adolescence, as the individual progresses from
dependency to increasing autonomy.
 Nutritional, family, emotional, sociocultural and community, as well as
physical, factors play a role in shaping the child’s psycho logic and
physiologic development

 The assessment of growth may be longitudinal or cross sectional.
 Longitudinal assessment of growth entails measuring the same child
at regular intervals.
 Cross sectional comparisons involve large number of children of
same age.
 Basic growth assessment involves measuring a child’s weight and
length or height
 comparing these measurements to growth standards.

 The purpose is to determine whether a child is growing “normally”
or
has a growth problem or trend towards a growth problem that should
be addressed.

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 to adolescence
Indicates the state of the child's health,
nutrition and well being
Growth charts were popularised by David
Morley.

 These growth charts are primariy designed for longitudinal follow up
of a child(growth monitoring), to interpret the changes over time[2].
 NCHS 1977 growth charts
 CDC 2000 growth charts
 WHO Growth Charts (2006)
 NEW 2007 AFFLUENT INDIAN GROWTH CHARTS

 Primarily to identify children with growth deviation and
diseases and conditions that manifest through abnormal
growth.
 Secondarily to discuss health promotion related to
feeding, hygiene, immunisation and other aspects ,
education of parents to allay their anxiety about their
childs growth also to sensitize health care workers to use
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

First 2 years
2 –10 years
>10 years
 Length/age
 Weight/age
 Weight /height
 Head circumference/age
 Height/age
 Weight/age
 BMI/age
 Height/age
 Weight/age
 BMI/age
 pubertal development

 Z scores
 Percentiles
 Percent of median

 The deviation of the value for an individual from the median
value of the reference population, divided by the standard
Deviation for the reference population
(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 age
 Towards the extremes of the reference distribution there is little
change in percentile values, when there is infact substantial change
in weight or height
 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.

Z score Exact percentile Rounded
percentile
0 50 50
-1 15.9 15
-2 2.3 3
-3 0.1 1
1 84.1 85
2 97.7 97
3 99.9 99

 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.
Main disadvantage-
 lack of exact correspondence with a fixed point of distribution across age
and wt status
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 indices.

 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 general population, without making any
association with health(CDC charts)
 Growth reference are descriptive and are prepared from a population
which is thought to be growing in the best possible state of nutrition and
health in a given community. They represent how children are growing
rather than how they should be growing.
 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)
 Growth standards are prescriptive and define how a population of
children should grow given the optimal nutrition and optimal health .

 Advantages of growth standard is that children of all
countries, races, ethnicity can be compared against a
single standard thus assessment becomes more
objective and easy to compare. The disadvantage is
that these are likely to over diagnose underweight and
stunting in a large no. of children in developing
countries such as India.
 Advantages of references is that they are true
representative of the existing growth pattern of children
and allow us to study the secular trend in terms of
height, weight and obesity. Disadvantages include
they need to be updated at least once in a decade and
in modern times likely to define overweight children as
normal

 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 .

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

 Using longitudinal-data from the Fels Research Institute,
collected in Yellow Springs, Ohio between 1929 and 1975
The 1977 growth charts were developed by the National Center for
Health Statistics (NCHS) as a clinical tool for health professionals to
determine if the growth of a child is adequate. [1]
 The 1977 charts were also adopted by the World Health
Organization for international use.
 Its sample was acknowledged to be quite limited in geographic,
cultural, socioeconomic and genetic variability.
 The 2000 CDC growth charts represent the revised version of the
1977 NCHS growth charts

The 2000 CDC growth charts represent
the revised version of the 1977 NCHS
growth charts
The revised growth charts consist of 16
charts (8 for boys and 8 for girls)
introduction of two new body mass index-
for-age (BMI-for-age) charts for boys and
for girls, ages 2 to 20 years.

Data collected from
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 NHANES III.

Addition of BMI for age charts: 2 – 20
years
Addition of 85th centile on BMI for age & wt
for stature charts
Addition of 3rd & 97th 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

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

 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.

 Participating countries include Brazil, Ghana, India,
Norway, Oman, and USA.
 Data collected by trained staff using a common
protocol
 Sample selected from communities where there
were no environmental constraints to growth.
 The new growth reference is based on breastfeeding
as the biological norm.
 Measurements include weight/age, height/age, and
weight/height. Data on BMI was generated for
children under 5 for the 1st time.

 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

The study includes
 Healthy children
 Living under conditions likely to favor the achievement of their full
genetic growth potential
 Mothers engaged in fundamental health-promoting practices, namely
breastfeeding and not smoking[4].
 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

 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 measurements together.
 length/height-for-age
 weight-for-age
 weight-for-length/height
 BMI (body mass index)-for-age
 Head circumference for age

 Consists of X axis which is usually in years
or months and y axis that changes
according to the reference e.g. cm, inches,
kg, kg/m2.
 the x axis is usually divided into 12 equal
parts (months) for each year. Standard
growth chart has 7 percentile lines and
include 3,10,25,50,75, and 97 percentiles.

Z score Height for age Weight for age BMI for age
>3 May be abnormal May be abnormal obese
>2 Normal Use BMI Overweight
>1 Normal Use BMI Risk of
overweight
0 normal Use BMI normal
<-1 normal normal normal
<-2 stunted underweight wasted
<-3 Severely stunted Severely
underweight
Severe wasted

> 95th percentile
85th to < 95th
percentile
< 5th percentile
Overweight
Risk of overweight
Underweight

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.

 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 overweight

 Do not 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

Comparison WHO Growth Chart CDC Growth Chart
Studied
population
Breastfed
infants and toddlers
Breastfed and
formula fed infants
and toddlers
Growth pattern How healthy
children SHOULD
GROW in ideal
conditions
How certain groups
of children HAVE
GROWN in the past
Concept of
growth
A STANDARD by
which all children
should be
compared
A REFERENCE does
not imply that
pattern of growth is
optimal

CDC recommends that health care
providers:
 Use the WHO growth charts
for infants and children 0 to 2 years of
age
 Use the CDC growth charts
for children ages 2 to 20 years
Growth Chart Recommendations for Health
Care Providers

The WHO standards establish growth of the breastfed
infant as the norm for growth
The WHO standards provide a better description of
physiological growth in infancy
The WHO standards are based on a high-quality study
designed explicitly for creating growth charts.

 The ICMR undertook a nationwide cross sectional
study during 1956-1965 to establish indian referance
charts. Irrelevant now as they were done on lower
socio-economic class.
 The growth charts compiled by Agarwal et al were
based on affluent urban children from all major
zones of India measured 1989-1991.the data is now
20 years old and irrelevant now.
 In 2010-2011 Khadilkar et al have published the
growth charts on affluent children 5-18 years and
have also compared the growth of 2-5 years old
indian children with the new WHO growth charts.
These are the most modern national growth
references available now at present.

 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 [2].
 A joint "Mother and Child Protection Card" has been developed which
provides space for recording [2]:
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

 THE NEED FOR NEW CHARTS- previously available growth
reference curves in india are almost 2 decades old and WHO
recommends that each country should update its growth
references every decade and hence new growth references
were produced in 2009.
 DATA COLLECTION-The IAP divides India into 5 zones-
north, south, east, west and central.the nutritionally well areas
were identified based on per capita income of cities.
 The differences between zones were not significant
 Data collection lasted from june 2007 to january 2008.

Weight monitoring at
monthly in 1st year
every 2 months during 2nd year
every 3 months up to 6 years

 Birth to 3 years
Immunization contacts at birth, 6, 10 and 14
weeks, 9 months, 15-18 months and
thereafter every 6 months
 4 to 8 years:
height and weight be measured 6 monthly
BMI, PL and SMR should be assessed yearly
from 6 years of age.
 9-18 years:
height, weight, BMI and SMR be assessed
yearly

First three years
 Length/height, weight or head circumference below 3rd
percentile or above 97th percentile on growth chart.
 • Crossing of two major percentile lines (upward or
downward) e.g., going from above 75th percentile to below
50th percentile on height or weight chart.
 • A child below or above mid parental range for height/length
(see calculation for target height range in Fig. 2)
 • Weight loss or lack of weight gain for a month in the first 6
months.
 • Absence of weight gain for 2-3 months from 6-12 months of
age.
 • Micropenis.

 • Unilateral or bilateral undescended testis.
 • Ambiguous genitals.
Three to nine years
 Length/Height below 3rd percentile or above 97th
percentile on growth chart.
downward) e.g., going from above 75th percentile to
below 50th percentile on height or weight chart.
 • A child below or above mid parental range for height
 • BMI over the 85th percentile at all ages.
 • Rate of growth less than 5 cm/year.

 • Girls with axillary, pubic hair growth or breast budding before
8 years and boys with axillary, pubic hair growth, genital
growth or and testicular enlargement before 9 years.
 • Children with craniospinal irradiation or surgery for brain
tumors.
 • Micropenis.
Nine to eighteen years
 • Height below 3rd percentile or above 97th percentile on
growth chart.
downward) e.g., going from above 75th percentile to below
50th percentile on height or weight chart.
 • A child below or above mid parental range for height

What are Tanner stages?
Tanner stages defines different levels of sexual maturity,
based on the development of primary (genitalia) and
secondary sex (pubic hair and breasts) characteristics.
These stages were first described by James
Mouilyan Tanner.
Sexual maturity rating is important in cases where
delayed or precocious puberty is suspected It provides a
means of documentation and standardization.

 Stage 1 represents the
prepubertal breast in
which
there is elevation only of
the papilla.
 stage 2, a "breast
bud"forms below the
areola
 stage 3, there is further
enlargement and elevation
of both breast and areola

 stage 4, the areola
forms a secondary
mound above the
contour of the breast
 stage 5 breast is fully
mature, with
recession of the
secondary mound
and a smooth breast
contour.

 Stage 1 describes
prepubertal genitalia.
 stage 2, there is
enlargement of the testes
and scrotum, with
reddening and thinning of
the scrotum, but no
enlargement of the penis.
 stage 3, the penis begins
to enlarge, first in length
and later in diameter.

stage 4, continued
lengthening of the
penis and
enlargement of the
glans.
Stage 5 represents
genitalia of adult
size and proportion

 In the prepubertal stage
1, there may be fine
vellus hair that is no
different from that found
over the abdominal wall.
 In stage 2, there is
growth of sparse straight
hair, primarily at the base
of the penis or along the
labia.
 In stage 3, hair increases
in quantity and is darker
and Curlier.

 Stage 4 is characterized
by pubic hair that
resembles adult pubic
hair, although the
escutcheon covers a
smaller are than seen in
adults.
 stage 5, pubic hair has
increased further in
volume, spread onto the
medial thighs,and taken
on characteristic male or
female configuration.

Stage
Female Male
Age range
(years)
Breast
growth
Pubic hair
growth
Other
changes
Age range
(years)
Testes
growth
Penis
growth
Pubic hair
growth
Other
changes
I 0–15 Pre-
adolescent
None Pre-
adolescent
0–15 Pre-
adolescent
testes
(≤2.5 cm)
Pre-
adolescent
None Pre-
adolescent
II 8–15 Breast
budding
(thelarche)
; areolar
hyperplasi
a with
small
amount of
breast
tissue
Long
downy
pubic hair
near the
labia, often
appearing
with breast
budding or
several
weeks or
months
later
Peak
growth
velocity
often
occurs
soon after
stage II
10–15 Enlargeme
nt of
testes;
pigmentati
on of
scrotal sac
Minimal or
no
enlargeme
nt
Long
downy
hair, often
appearing
several
months
after
testicular
growth;
variable
pattern
noted with
pubarche
Not
applicable
III 10–15 Further
enlargeme
nt of
breast
tissue and
areola,
with no
separation
of their
contours
Increase in
amount
and
pigmentati
on of hair
Menarche
occurs in
2% of girls
late in
stage III
1½–16.5 Further
enlargeme
nt
Significant
enlargeme
nt,
especially
in diameter
Increase in
amount;
curling
Not
applicable

IV 10–17 Separation
of
contours;
areola and
nipple
form
secondary
mound
above
breasts
tissue
Adult in
type but
not in
distribution
Menarche
occurs in
most girls
in stage
IV, 1–3
years after
thelarche
Variable:
12–17
Further
enlargeme
nt
Further
enlargeme
nt,
especially
in
diameter
Adult in
type but
not in
distribution
Developm
ent of
axillary
hair and
some
facial hair
V 12.5–18 Large
breast with
single
contour
Adult in
distribution
Menarche
occurs in
10% of
girls in
stage V.
13–18 Adult in
size
Adult in
size
Adult in
distribution
(medial
aspects of
thighs;
linea alba)
Body hair
continues
to grow
and
muscles
continue
to
increase in
size for
several
months to
years;
20% of
boys
reach
peak
growth
velocity
during this
period

The Fenton growth chart for preterm
infants has been revised to
accommodate the World Health
Organization Growth Standard and
reflect actual age instead of completed
weeks, in order to improve preterm
infant growth monitoring.”

Mid-parental Centile
 Plot the the Mother’s and Father’s
heights on their respective scales and
join the two points with a line. The mid-
parental centile is where this line crosses
the centile line in the middle.
 Compare the mid-parental centile to
the child’s current height centile, plotted
on the adult height predictor centile
scale.
 Nine out of ten children’s height
centiles are within ±two centile spaces of
the mid-parental centile.

 Plot the most recent
height centile on the
relevant centile line
Read off the predicted
adult height for this
centile.
 Four out of five children
will be within ±6 cm of
this value.
Predicted Adult Height

 [1] Rakel. Textbook of Family Medicine. 7th ed. Philadelphia: Saunders;
2007. P. 555.(Growth and development; chap 31).
 [2] Park K. Textbook of Preventive and Social Medicine. 21st ed.
Jabalpur(India): Banarsidas Bhanot Publishers; 2011. P.502.
 [3]Srilakshmi B. Nutrition Science. 2nd ed. New Delhi: New Age International
(P) Ltd.; 2006.
 [4] WHO. WHO child growth standards. Geneva(Switzerland): WHO;2007
 [5] World Health Organization. Training Course on Child Growth Assessment.
Geneva, WHO, 2008.
[6]Ghai OP. Ghai Essential Pediatrics: CBS Publishers & Distributors pvt Ltd;
2006
 [7] Rosen, D. Physiologic Growth and Development During Adolescence.
 Pediatrics in Review. 2004;25:194-200.

Plot on fenton chart
Preterm, male child at 30 wks Total length
41 cms, HC 28 cms, wt 1.18 kg
At 32 wks total length 42.1,HC 28.9 , HC
1.26 kg

Ayan sandhi,10 months old.
Wt 5.28 kg
HC 44
TL 73

Imarankhan pathan 2 yrs old
Wt 3.9 kg
HC 41
Ht 68

Gunvanti 10 years old, female
Wt 25 kg
Ht 123 kg
Mother ht 150 cm
Father ht 161 cm

Ravi 4 months
Total length 62 cm
Wt 10.5 kg

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