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Strategic option for updating child growth Standards

Strategic option for updating child growth Standards. Dr AKDutta Director Professor & HOD Dept. of Pediatrics Lady Hardinge Medical College & Kalawati Saran Children’s Hospital New Delhi. Sub Headings. Uses of growth charts Evolution Currently available growth charts

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Strategic option for updating child growth Standards

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  1. Strategic option for updating child growth Standards Dr AKDutta Director Professor & HOD Dept. of Pediatrics Lady Hardinge Medical College & Kalawati Saran Children’s Hospital New Delhi

  2. Sub Headings • Uses of growth charts • Evolution • Currently available growth charts • Comparison of their features • Recommendation for use in our country

  3. Growth charts • 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 thru adolescence • Indicates the state of the child's health, nutrition and well being

  4. Growth monitoring • By using growth charts-screening tool for diagnosis of nutritional, chronic systemic and endocrine diseases • Individual growth monitoring in children in India-Is it possible to achieve? • Who shall use the growth charts? • Pediatricians? Family Physicians? Anganwadi workers? ASHA?

  5. 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 Need for growth charts

  6. Community level • Early identification of children’s growth failure for detection of malnutrition and taking appropriate interventions • Early identification-overweight/obesity • Sensitize health workers • Educate parents and allay their anxiety by showing normal growth in chart

  7. Measurements required: Weight Length/Height Head circumference < 2 years Anthropometric indices: Length / stature for age Weight for age Weight for length /stature BMI for age Head circumference for age Length, wt, BMI in relation to pubertal stage Community level

  8. First 2 years 2 –10 years >10 years Length/age Weight/age Weight /height or BMI Head circumference/age Height/age Weight/age BMI/age Above in relation to pubertal development What needs to be monitored at community level

  9. Earlier available growth charts: Harvard standards • 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 (50th centile taken as 100%)

  10. Earlier available growth charts:ICMR Standards • 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

  11. Charts/Standards currently available • Indian : Dr KN Agarwal • CDC 2000 • WHO

  12. Dr KN Agarwal growth standards 0 - 6 years(Indian Pediatrics,1994) • Study years1985-1987 • Design Mixed-longitudinal study/ cross-linked data collection Minimum of three readings for each child • Cohort a)Birth to first year of age: 418 boys, 332 girls b)12 - 60 months: 1011 boys and 874 girls • Sample zones Bangalore, Calcutta, Delhi, Ludhiana, Kota & Varanasi

  13. Dr KN Agarwal growth standards 5 - 18 years (Indian Pediatrics-1992 & 2001) • Study years:1988-1991 • Design: cross-sectional study minimum of 200 children at each age and sex point. • Sample size: 12,893 male & 10,941 female (23 schools) • Sample Zones(9 states): North - Delhi, Shimla, Dehradun, Nainital West-south - Bombay,Madras, Udaipur Central - Lucknow Allahabad, Varanasi East – Calcutta, Dhanbad

  14. birth – 66 months 6-18 years Height, weight: both sexes 3 monthly interval till 1 year, then 6 monthly 3rd - 97th centile -3SD - +3 SD Height, weight: both sexes 6 monthly interval 3-97th centile Mean & SE Dr KN Agarwal ref. standards available:

  15. Head circumference BMI Each sex birth to 6 years 3 monthly interval for 1yr, then 6 mthly 3rd-97th centile - 3SD to +3 SD 2-18 years Yearly 5th –95th centile Mean And SD Each sex Dr KN Agarwal ref. standards available

  16. Useful upto

  17. CDC growth charts • NCHS growth charts based on growth of American children developed in 1977 • Adopted by WHO for international use • CDC 2000 growth charts a revised version of earlier NCHS chart: Revision of previous existing 14 charts with introduction of 2 new BMI charts • No new primary data collected • Used national studies conducted at various times & places and improved statistical tools

  18. CDC 2000 growth charts: new features • 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

  19. 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 CDC: charts available 2 sets: 3rd-97th centile, 5th – 95th centile for each sex 85th centile for BMI for age & wt for stature

  20. WHO charts • Review of child growth references by WHO expert committee in 1993: NCHS stds do not describe physiologic growth adequately; single country based with many technical /biological drawbacks • WHO multi-centric growth reference study undertaken between 1997 – 2003 • Primary data collected from 8500 children from Brazil, Ghana, India, Norway, Oman & USA • Growth data available for children 0 - 5 years of age

  21. MGRS Study Design and Sample Eligibility Criteria for Individuals • No health, environmental or economic constraints on growth • Mother willing to follow feeding recommendations: Exclusive/ predominant breast feeding for 1st 4 mths, introduction of complementary feeding by 6 mths • Term, single birth • Lack of significant perinatal morbidity • Non smoking mothers before and after delivery

  22. MGRS Study Design and Sample Longitudinal study (birth-24 months) • Mothers & newborns screened & enrolled at birth • Weight, length, head circumference: 21 times over 24 months • Arm circumference: 10 times between 3 and 12 months • Skin fold thickness : 6 times between 14 and 24 months

  23. MGRS Study Design and Sample Cross-sectional survey (18-71 mo) Weight, length, head circumference, arm circumference, skin fold thickness Total sample 8440 children from 6 countries ~300 newborns per site (1743 total) followed up till 24 mo from the longitudinal study ~1400 children per site (6647 total) aged 18-71 mo through the cross sectional surveys

  24. WHO charts • Available: 0– 5 years • Length (birth-2yrs)/height (2-5 yrs) for age • Weight for age • Weight for length/height • BMI for age

  25. Brazil Ghana India Norway Oman 80 USA 70 Mean of Length (cm) 60 50 0 200 400 600 WHO Multicentre Growth Reference Study Group. Assessment of linear growth differences among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl 2006;450:56-65. Age (days) Mean length from birth to 24 months for the six MGRS sites

  26. Comparison of existing growth charts WHO Primary data 1997-2003 6 Countries pooled data. healthy children & practices Birth-5yrs KNA Primary data 1988-1991 Affluent Indian population, multicentric Birth-18 yrs Data charact Source Study period Population Age-group CDC Multiple different studies 1963-1994 US, mixed feeding, no racial/ethnic diff Birth-20 yrs

  27. KNA study vs European & NCHS std

  28. KNA study vs other Asian studies

  29. Which growth chart to use? • Depends upon for what purpose it is used • Who will be monitoring the growth? • It should be represented by National data • The growth charts should be for the entire period of growth from Infancy till full growth potential is achieved • Scientifically collected & analyzed multi-centric data • Their use should prevent unnecessary referrals

  30. Summary • WHO growth charts are excellent ,recent, up- to- date, multicentric, multinational reference charts • Ideal growth chart to be used for children up to 5 yrs of age • Drawback is after that age –Which chart to use? • Can we use two different charts-one up to 5 yrs and the other for the 6-18 yrs age?

  31. THANK YOU

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