Growth charts Wrik.pptx ................

Growth charts

1. Growth charts Dr Wrik Laha

2. Learning objectives What are growth charts Evolution of Growth charts Brief discussion on various charts in clinical use Special circumstances

3. What is growth? Growth is defined as an increase in physical size of the body as a whole or any of its parts associated with increase in cell number or size. A normal healthy child grows at a genetically predetermined rate Nutritional, familial, emotional, sociocultural, community and other physical factors play a role in growth and development of a child

4. Growth chart It is a visible display of a child ’ s physical growth and development First designed by David Morley and was later modified by WHO Growth chart offers a simple and inexpensive way of monitoring physical growth Any deviation from “ normal ” detected by comparison with reference curves Used at the individual and community level

5. History Latest : IAP 2007 and IAP 2015 charts

6. GROWTH STANDARDS GROWTH REFERENCE Definition Define how a population of children should grow given optimal nutrition and optimal health Represent how children are growing (rather than how they should be growing) Example WHO 2006 growth charts CDC 2000 Advantages Children of all races, countries and ethnicity can be compared Provides objectivity Easy to compare Truly representative of growth pattern of children in a population. Allows to study secular trend in terms of height, weight and obesity Disadvantages Likely to over diagnose underweight and stunting in large number of children in developing countries Need to be update once in a decade Likely to diagnose overweight children as normal in current situation ( underdiagnose )

7. Uses of Growth charts Individual level Monitoring & documenting growth Comparison with growth standards To detect growth faltering Community level Monitoring health status Efficacy of programs Comparison over time National level Identification of problem area National/international comparison Scientific purpose Research tool

8. At the first visit the child’s name , date of birth and other details should entered Explain the chart to the parents Measure the parents and make a note of their heights on the chart. Calculate the child’s target height and plot it at 18 years and mark it with an arrow on the growth chart All the points on the growth chart should be marked only as dots and not circles around the dot The height and weight should be recorded (and head circumference till 3 years ) and plotted on the chart. At all subsequent visits join the dot up to the previous dot. Remind parents of the time for the next measurement How to use growth charts

9. Recommended intervals Birth to 3 years: Immunization contact An additional monitoring visit at 6 months Penile length (PL) and testicular descent should be ascertained in the newborn period 4 to 8 years Height and weight :- 6 monthly BMI, PL and SMR :- Yearly from 6 years of age 9-18 years : height, weight, BMI and SMR yearly

10. Special growth charts: These are available for Achondroplasia Cerebral Palsy-Quadriplegic Turner syndrome Prader willi syndrome Down Syndrome Marfan syndrome Cornelia de Lange Syndrome

11. Intrauterine and neonatal growth charts

12. Lubchenco ’ s intrauterine chart Intrauterine anthropometric measure were calculated on basis of measurement of live born infants at birth Study population -all live born infants admitted to the Colorado General Hospital Full-Term and Premature Infant Study period July, 1948 to January, 1961 Data - Of the 7,827 live born infants included for Weight for intrauterine age - 24 wks to 42 wks (1963) Length for intrauter ine chart Head circumference Weight for length 42 weeks (1966)

13. Lubchenko’ s intrauterine growth chart

14. Lancet 2014

15. Intergrowth 21 Prospective, population based, multiethnic study 3 main components The newborn cross sectional study – all newborns studied over 12 months The fetal growth longitudinal study – Study of fetal growth from <14wks to birth with follow-up to age 2 in women at low risk of fetal growth problems The preterm postnatal follow-up study – Study of preterm infants till age 2

16. Exclusion Criteria Maternal age< 18 yrs or >35 yrs Maternal height< 153 cms BMI > 30Kg/m2 or <18.5 Kg/m2 Current smoker Medical history : Birth of previous baby , < 2.5Kg or> 4.5 Kg Past 2 pregnancy miscarriages Past stillbirths/ neonatal deaths Congenital malformations

17. Figure The Lancet  2016 387, 844-845DOI: (10.1016/S0140-6736(16)00384-6) Copyright © 2016 Elsevier Ltd Terms and Conditions

18. CDC and WHO growth charts

19. CDC charts vs WHO charts

20. Data characteristic CDC Growth reference 2000 WHO Growth standard 2006 Data Source Multiple different studies MGRS longitudinal component (Brazil, Ghana, India, Norway, Oman, United States) Data type Cross sectional starting at 2months of age, with mathematical modelling Longitudinal : birth, 1,2,4,6,8 weeks, 3,4,5,6,7,8,9,10,11,12,14,16,18,20,22,24 months Study period 1963-1994 1997-2003 Age-group Birth-20 yrs Birth-5yrs

21. CDC growth reference (2000) WHO growth standard (2006) Breastfeeding among infants in sample 50% ever breastfed ~ 33% breastfeeding at 3 mo 100% breastfed 100% predominantly breastfeeding at 4 mo 100% breastfeeding at 12 mo Complementary foods introduced at mean age 5.4 mo Exclusion criteria VLBW (<1500 g ) Low socioeconomic status Birth at altitude >1500 m Birth at <37 wk or > 42 wk Multiple birth Perinatal morbidities Child health conditions known to affect growth Maternal smoking during pregnancy or lactation Breastfeeding for <12 mo Complementary foods before 4 mo or after 6 mo

22. CDC Growth Charts New features Addition of BMI for age charts: 2 – 20 years Addition of 85 th centile on BMI for age & wt for stature charts Addition of 3 rd & 97 th centiles (helpful for endocrinologists) Limits of length/ stature extended on weight for length /stature charts Smoothened percentile curves Correction of disjunction that occurred between 24 to 36 months when switching from length to stature in NCHS charts

23. WHO GROWTH CHARTS 2006 Based on Multicenter Growth Reference Study (MGRS) - Between 1997 and 2003 - Study period :- 1997-2003 - Setting : Samples from 6 countries were taken - US, India, Brazil, Norway, Oman ,Ghana

24. Growth Multicentre Growth Reference Study Prescriptive Approach Optimal Nutrition Breastfed infants Appropriate complementary feeding Optimal Environment No microbiological contamination No smoking Optimal Health Care Immunization Pediatric routines Optimal Growth

25. The study design : MGRS(1997-2003) Study population :- 8440 healthy breast fed infants & young children from diverse ethnic background & cultural settings Longitudinal study – 0 - 24months Cross sectional study – 18 – 71months Inclusion criteria :- No known health or environmental constraints to growth Mothers willing to follow MGRS recommendation for feeding practice No maternal smoking before & after delivery , single term birth Absence of significant morbidity A minimum of 3 months of breastfeeding for inclusion in cross sectional study MGRS is Unique :- selects healthy children living under condition favoring full genetic growth potential.

26. WHO growth standards for infants and children age 0 to 5 years Who charts reflect growth pattern among children who are predominantly breast fed for at least 4months. Better description of physiological growth in infancy than CDC charts Based on high quality study design

27. Depicts normal early growth under optimal conditions Can be used to assess children everywhere , regardless of ethnicity ,socioeconomic status and type of feeding Also include windows of achievement for six gross motor- developmental milestones Advantages of WHO charts

28. INNOVATIVE ASPECTS OF THE NEW WHO CHILD GROWTH STANDARDS 2006 The prescriptive approach- recognizing the need for internationally usable standards The breastfed infant as “normative” model International sample of children New standards such as those for skin folds for assessing childhood obesity Growth velocity standards Motor development assessment

29. WHO charts 5-19yrs WHO proceeded to reconstruct the 1977 NCHS/WHO growth reference from 5 to 19 years , using the original sample, supplemented with data from the WHO Child Growth Standards (to facilitate a smooth transition at 5 years. 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.

30. The Indian Scenario There are wide variations in rate of maturation and final adult stature world wide due to difference in ethnicity, regional and geographical factors Hence for assessment, a national representative sample of population data are ideal as growth standards

31. In 2007, IAP growth monitoring guideline committee designed growth charts for Indian Children from birth to 18years of age. It was based on the then available multicentric data that was collected in 1989 on affluent Indian children. Almost 2 decades old. Drawbacks: Rise in incidence of overweight & obesity Rebound adiposity seen at younger age For 5-18years it would not be possible to have prescriptive growth standards bcz environmental variables in this age group cannot be controlled for; So, there was need to construct new growth charts as per Indian standard.

32. Used for 5 to 18 years of Indian children Growth charts available are – for height , weight and BMI To define overweight and obesity in children from 5 to 18 years , adult equivalent of 23 and 27 cut- offs presented in BMI chart can be used Study design: 13 study groups; Age group: 5 to 18years No. of children - 87022 (54086 boys). Study place: 14 cities ( Agartala , Ahmedabad , Chandigarh , Chennai, Delhi, Hyderabad, Kochi, Kolkata, Madurai, Mumbai, Mysore, Pune, Raipur and Surat) in India were collected.

33. Up to 5 years – WHO growth charts 5-18 years – IAP growth charts IAP Recommendation

34. At the first visit the child’s name , date of birth and other details should be entered Explain the chart to the parents Measure the parents and make a note of their heights on the chart. Calculate the child’s target height and plot it at 18 years and mark it with an arrow on the growth chart All the points on the growth chart should be marked only as dots and not circles around the dot The height and weight should be recorded (and head circumference till 3 years ) and plotted on the chart. At all subsequent visits join the dot up to the previous dot. Remind parents of the time for the next measurement How to use Growth charts

35. Thank you