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WHO Growth Grids/ 2012 Risk Changes

WHO Growth Grids/ 2012 Risk Changes. Diane Traver Joyce Bryant. Overview. CDC vs WHO Growth Charts- Why Change? Transition from <24 mo to 24-59 mo charts Risks Definition Justifications/Implications. Shift in Population Growth.

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WHO Growth Grids/ 2012 Risk Changes

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  1. WHO Growth Grids/ 2012 Risk Changes Diane Traver Joyce Bryant

  2. Overview • CDC vs WHO Growth Charts- Why Change? • Transition from <24 mo to 24-59 mo charts • Risks • Definition • Justifications/Implications

  3. Shift in Population Growth • Concern for underweight has been replaced with concerns of overweight and obesity • Re-examination of methodologies used in establishing CDC charts reveal improvements needed • USDA requiring implementation by Oct ’12 (will be in Aug release)

  4. CDC Charts • Based on only on US data from 1960’s-90’s • No exclusion criteria • Composition of formula has changed in last 35 years since first data collected • Growth of formula fed infants may not be same now as those used in creation of charts, as a result • Little data available for infants < 2 months old • Several data sets combined to generate the charts • Reference- description of how certain children grew in a particular place and time

  5. WHO Premise All young children have the potential to grow similarly, regardless of ethnic group or place of birth, if they are in a healthy environment and have adequate nutrition In order to identify abnormal growth, healthy growth must be defined and adopting a standard would identify and address environmental conditions negatively affecting growth

  6. WHO Charts • International study- • Participants willing to follow international feeding guidelines • 100% BF for 12 months • Adherence to many exclusion criteria • Longitudinal data collected over 2 year period • Premise confirmed • Standard- how healthy children should grow under optimal conditions

  7. Differences in Growth Breast-fed infants- gain weight more quickly in first few months of life but then weight gain slows the remainder of infancy Formula-fed infants gain weight more slowly in first few months of life but then weight gain increases quickly after 3 months

  8. Case Examples

  9. Case Example #1: Low Weight-for-Length Maya is a healthy 9-month-old girl who was exclusively breastfed for 6 months and continues to breastfeed. Maya's mother began feeding her solid foods at 6 months of age. Maya's mother reports that Maya “is a good eater”.

  10. Example #1: Low Weight-for-Length

  11. Case Example #2: Excess Weight Gain Brady is an 18-month-old boy. Brady is cared for by his grandmother during the day when his mother is working. Brady has been formula-fed since birth, and he was around 5 months of age when he began eating solid foods.

  12. Case Example #2: Excess Weight Gain WHO Weight-for-age CDC Weight-for-age 98th% 95th% What’s the difference?

  13. Connecting WHO to CDC charts • WHO- 0 through 23 months • CDC- 24 through 59 months- knowing there would be a discrepancy 24-36 month olds measured both recumbently and standing to assess the discrepancy between the 2 methods and allow for the connection of growth curves before and after age 24 months

  14. Transitioning from WHO to CDC • WHO Growth Grids- 0 through 23 months- recumbent • CDC Growth Grids- 24-59 months - stature • MI-WIC- Will no longer have ‘R/S’ option If C-2 cannot be measured standing, click ‘Unknown’ and add measurement in ‘Comment’

  15. Percentile Cutoffs • WHO- uses cutoffs at 2.3 and 97.7 percentiles WHO is a standard for growth and based on optimal conditions for growth, therefore, any plot outside is considered abnormal • CDC- continues to use cutoffs at 5th and 95th percentiles

  16. With new WHO curves and cutoffs, what differences can be expected from CDC chart assessments? • Somewhat similar prevalence of low length-for-age (possibly a little higher prevalence) • Lower prevalence of low weight-for-age • Lower prevalence of low weight-for-length • Lower prevalence of high weight-for-age

  17. In transitioning between WHO and CDC charts • Remember that a series of measurements establishes a growth pattern • Use measurements in conjunction with medical and family history • Caution should be used in interpreting any changes

  18. Summary • WHO Growth Charts depict standard of growth • CDC and AAP Recommend: • Birth- <24 months: WHO Growth Charts • 2-20 years: CDC Growth Charts • WHO Growth Chart Cutoffs: 2.3rd and 97.7th • CDC Growth Chart Cutoffs: 5th and 95th • More infants will “fall off” WHO weight-for-age charts up to age 3 months but fewer will “fall off” from 3-18 months • Small differences in the length-for-age WHO and CDC charts

  19. Risk Criteria Changes 2012 WHO Growth Chart (Birth<24 mo.) • 103.01+ High-risk underweight • 103.02 At-risk of underweight • 115 High Weight-for-Length- NEW • 121.01 Short stature • 121.02 At Risk of Short Stature • 152 Low head circumference Terminology Changes • 113+ High risk overweight (Obese) • 114 Overweight or At-risk of overweight Expanded, Updated Information • 344+ Thyroid disorders • 351+ Inborn errors of metabolism

  20. 103.01+ High-risk underweight Definition: • Birth to less than 24 months (I, C1): • At or below < 2.3rd percentile weight-for-length on WHO gender specific growth charts • Children at or above 24 months (C2-C4): • At or below < 5th percentile BMI-for-age • CDC gender specific growth charts Note: If manually plotting, round down percentiles

  21. 103.01+ High-risk underweight Justification/Implications • Sensitive to acute under-nutrition • Can reflect long-term status • Goal: Promote adequate weight gain • Intervention: Counsel families in making nutritionally balanced food choices • Monitor regularly

  22. 103.02 At-risk of underweight Definition: • Birth to less than 24 months: • Above the 2.3rd percentile for weight-for-length and at or below the 5h percentile for weight-for-length • WHO gender specific growth charts • Children at or above 24 months: • Above the 5th percentile and at or below the 10th percentile BMI-for-age • CDC gender specific growth charts

  23. 103.02 At-risk of underweight Justification/Implications: • Sensitive to acute under-nutrition • Also can reflect long-term status • Goal: Promote adequate weight gain • Intervention: Counsel families in making nutritionally balanced food choices • Monitor regularly

  24. 113+ High risk overweight/obese Definition (C2-C4) • At or above > 95th percentile BMI-for-age OR >95th percentile weight-for-stature CDC gender specific growth charts • Problematic feeding practices • Excessive energy intake • Decreased energy expenditure, lifestyle • Impaired regulation of energy metabolism LANGUAGE: Provide sensitivity, compassion, and a conviction that this is an important, treatable chronic medical problem. Focus on future benefit shown to be effective. AMA recommends use of ‘obese & overweight’ in assessment & documentation only.

  25. 113+ High risk overweight/obese Justification/Implications • Goals: Achieve normal growth and development • Reduce risk of adolescent and adult obesity and obesity-related chronic disease • Intervention: • Choose food high in nutritional quality • Avoid unnecessary or excessive amounts of calorie rich foods and beverages • Increase age-appropriate physical activity/ Reduce inactivity Remember: Overweight is a chronic medical problem that can be treated.

  26. 114 Overweight or At-risk of overweight Definition: Overweight - Children ≥ 24 months of age, at or above the 85th and below the 95th percentile BMI-for-age (CDC) At Risk of Overweight: Have 1+ risk factors for at-risk of overweight Infants˂ 12 months Biological mother BMI ≥ 30 at conception or 1st trimester, Self-reported or HCP measurement • Children ≥ 12 months Biological mother BMI ≥ 30 at certification, Self-reported pre-pregnancy BMI or staff measures taken at certification (not PG or delivered in past 6 mo.) • Infants or Children, Biological father with BMI ≥ 30 at certification, Self-reported BMI or staff measurements taken at certification

  27. 114 Overweight or At-risk of overweight Justification/Implications • Parental obesity +/or genetic predisposition • increases risk of overweight in preschoolers, even in the absence of other overt signs of increasing body mass • BUT is Not inevitable • Environmental and other factors mediate the relationship • Intervention: • Positive Encouragement • Food choices, family fun activities • Appropriate referrals for entire family

  28. 115 High Weight-for-Length-New Definition: Infants and children less than 24 months of age, ≥ 97.7th percentile weight-for-length • WHO gender specific growth charts

  29. 115 High Weight-for-Length Justification/Implication • Client-Centered Counseling • Supportive, empathetic, nonjudgmental, and culturally appropriate • Suggested language (AMA Expert Committee Report): • High weight-for-length • ?Weight disproportional to height, Excess weight • Evaluate & assist: • Recognition of satiety cues • Non-Food Ways to comfort a child • Behavior modeling 

  30. 121.01 Short stature Definition • Birth to less than 24 months, at or below 2.3rd percentile length-for-age • WHO gender specific growth charts • Children 2-4 years of age, at or below the 5th percentile length or stature-for-age • CDC gender specific growth charts Note: Use adjusted gestational age with prematurity

  31. 121.01 Short stature Justification/Implications • Abnormally low • Prolonged undernutrition or repeated illness • Inadequate protein, with poor diet quality • Metabolic conditions, FAS • NOTE per WHO study: Ethnic & racial differences <environmental factors Intervention: • Thorough dietary assessment • Possible HCP referral • Monitor growth with frequent follow-up

  32. 121.02 At Risk of Short Stature (Infants and Children) Definition • Infants and children up to 2 years of age, above the 2.3rd percentile AND at or below 5th percentile length-for-age • WHO gender specific growth charts • Children 2 to 4 years of age, above the 5th percentile AND at or below the 10th percentile stature-for-age • CDC gender specific growth charts Note: Use adjusted gestational age with prematurity

  33. 121.02 At Risk of Short Stature (Infants and Children) Justification/Implications (same as 121.01 • Related to: • Lack of total dietary energy • Inadequate protein, due to poor diet quality Intervention: • Thorough dietary assessment • Possible HCP referral • Monitor growth with frequent F/U

  34. 152 Low head circumference Definition • Birth to less than 24 months, at or below the 2.3rd percentile head circumference-for-age • WHO gender specific growth charts

  35. 152 Low head circumference Justification/Implications • Associated with: • Pre-term birth or Very low birth weight • Potential risk for neurocognitive abilities in light of other factors • Genetic, nutrition, health, Socioeconomic status • factors • LHC not necessarily Abnormal head size • Intervention: Consider medical referral when improvement is slow to respond to dietary interventions

  36. 344+ Thyroid disorders Definition • Diagnosed hyperthyroidism (↑ levels) • Diagnosed hypothyroidism (↓ levels) • Diagnosed postpartum thyroiditis in 1st year post-delivery (thyroid dysfunction)

  37. 344+ Thyroid disorders • Justification/Implications -Hyperthyroidism: ↓ weight despite ↑ appetite -Hypothyroidism: ↑ weight For both : Monitor weight and diet • Intervention: Reinforce & Support medical dietary therapy -Maternal needs for iodine increase PG hyperthyroidism relatively uncommon • Encourage iodine sufficiency,Iodine-rich foods • 150 mcg in prenatal supplements • Promote breastfeeding, Discourage smoking • Use soy with caution

  38. 351+ Inborn errors of metabolism • Definition: • Gene mutations or deletions that alter metabolism of proteins, carbs, or fats • IEMS include, but are not limited to: • Fructoaldolase deficiency • Galactokinas deficiency • Galactosemia • Glutaricaciduria • Glycogen storage disease • Histidinemia • Homocystinuria • Hyperlipoproteinemia • Hypermethioninemia • Maple syrup urine disease • Medium-chain acyl-CoA dehydrogenase (MCAD), • Methylmalonic academia, • Phenylketonuria (PKU), • Propionic academia • Tyrosinemia • Urea cycle disorders Additional information may be found at http://rarediseases.onfo.nih.gov/GARD

  39. 351+ Inborn errors of metabolism Justification/Implications • Can manifest at any stage of life • Early identification important Goal: Achieve normal growth and development Intervention: Reinforce & Support medical dietary therapy • Correct metabolic imbalance • Ensure adequate energy, protein, and nutrients • Continual monitoring • Nutrient intake – Need to follow prescribed dietary regime! • Laboratory values • Growth

  40. Release Webcast July 26,2012

  41. Questions?

  42. THANK YOU!

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