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Why? How? What next?

WHO Child Growth Standards. Why? How? What next?. World Health Organization. WHO Child Growth Standards. Why?. World Health Organization. NCHS/WHO international reference and national references. National Center for Health Statistics (NCHS) and WHO reference recommended in 1977

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Why? How? What next?

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  1. WHO Child Growth Standards Why? How? What next? World Health Organization

  2. WHO Child Growth Standards Why? World Health Organization

  3. NCHS/WHO international reference and national references National Center for Health Statistics (NCHS) and WHO reference • recommended in 1977 • developed based on longitudinal data (0-3 yrs) and on 3 cross-sectional studies (older children) of American population • The infant population predominantly artificially fed National growth references • Mostly also non-breastfed or mixed fed children (well documented in e.g. Czech republic)

  4. Worldwide practices in child growth monitoring Reference population Source: de Onis et al. Worldwide practices in child growth monitoring. Journal of Pediatrics 2004;144:461-5.

  5. Milestones in the development of new international growth reference 1991-1993WHO Working Group on Infant Growth • Comprehensive review shows growth patterns of healthy breastfed infants differ from the current NCHS/WHO international reference • A new growth reference is needed to improve infant health management • The reference population should reflect health recommendations in view of the frequent use of references as “standards” WHO Multicentre Growth Reference Study

  6. Mean z-scores of healthy breastfed infants relative to the NCHS/WHO reference Source: An Evaluation of Infant Growth, WHO, 1994 Source: An Evaluation of Infant Growth, WHO, 1994

  7. Rationale for the development of new international growth reference The current NCHS/WHO international reference is inappropriate for assessing nutritional status: • Individual infants interferes with sound nutritional management of breastfed infants thus increasing risk of morbidity and mortality • Populations provides inaccurate community estimates of under- and overnutrition WHO Multicentre Growth Reference Study

  8. Standard Prescriptive – Showing how children SHOULD grow Reference Descriptive – Showing how a sample of a given population grow (regardless of its nutritional and other conditions) Standard vs. reference

  9. Rationale for the development of new international growth reference Upward bias of reference population childhood obesity

  10. WHO Child Growth Standards How? World Health Organization

  11. A Growth Curve for the 21st Century The WHO Multicentre Growth Reference Study Nutrition for Health and Development World Health Organization Geneva, Switzerland

  12. Growth Reference StudyPrescriptive Approach • Optimal Nutrition • Breastfed infants • Appropriate complementary feeding • Optimal Environment • No microbiological contamination • No smoking • Optimal Health Care • Immunization • Pediatric routines Optimal Growth WHO Multicentre Growth Reference Study

  13. Eligibility criteria of study population • SES that does not constrain growth • Altitude < 1,500m • Low mobility target population • Minimum 20% of mothers follow feeding recommendations • Existing breastfeeding support system • Presence of collaborative institutions WHO Multicentre Growth Reference Study

  14. Eligibility criteria of individuals • No health, environmental or economic constraints on growth • Mother willing to follow feeding recommendations • Term birth • Single birth • Lack of significant perinatal morbidity • No smoking mothers (before and after delivery) WHO Multicentre Growth Reference Study

  15. MGRS study design Longitudinal (0-24 months) year 1 year 2 year 3 Cross-sectional (18-71 mo) WHO Multicentre Growth Reference Study

  16. Time schedule child anthropometry WHO Multicentre Growth Reference Study

  17. Motor development Six universal motor development milestones assessed between 4 and  18 months of age WHO Multicentre Growth Reference Study

  18. WHO Multicentre Growth Reference StudyMotor Development Assessment

  19. Sample size • Total sample > 8,400 by combining: • cohorts  300 newborns per site • 1,400 children aged 18 to 71 months per site • Target of growth curves: 400 both sexes WHO Multicentre Growth Reference Study

  20. Measurement and standardization protocols Rigorous scientific standards are applied to a complex cross-cultural field-based project. WHO Multicentre Growth Reference Study

  21. The WHO Multicentre Growth Reference Study Rationale, Planning & Implementation Food and Nutrition Bulletin vol 25, no.1 (supplement) March 2004 WHO Multicentre Growth Reference Study

  22. WHO Child Growth Standards What next? World Health Organization

  23. WHO Child Growth Standards Timeline Growth Standards 1st set Growth Standards 2nd set WHA Resolution (May 1994) Construction and testing of growth standards WHO Expert Committee recommendation (Nov 1993) (July 97) (Nov 03) WHO Multicentre Growth Reference Study WHO Working Group on Growth Reference Protocol Field implementation WHO Working Group on Infant Growth Growth Standards 1st set: Weight-for-age, length/height-for-age, weight-for-length/ height, BMI-for-age and motor development indicators. Growth Standards 2nd set: Arm-Circumference-for-age, Triceps skinfold-for-age, Subscapular skinfold-for-age and Head circumference-for-age.

  24. WHO - MGRS / reference indicators • Attained growth • weight-for-age • length/height-for-age • weight-for-length/height • head circumference-for-age • mid-upper arm circumference-for-age • triceps skinfold-for-age • subscapular skinfold-for-age • body mass index-for-age • Velocity • weight • length • head circumference • arm circumference • body mass index

  25. WHO Child Growth Standards Innovative aspects • Prescriptive approach recognizing need for standards • Breastfed infant as normative model • International sample • Reference data for assessing childhood obesity • Velocity reference data • Link between physical growth and motor development WHO Multicentre Growth Reference Study

  26. WHO Child Growth Standards2004-2010 • Construction of standards • Evaluation and field testing of provisional standards • Develop WHO/MGRS software to support individual- and population-based uses • Develop training modules to guide appropriate use • Review interventions to prevent/treat impaired child growth • Develop roll-out strategy with partners, oversee global and country level implementation of the new standards • Adapt global monitoring system for MDG tracking WHO Department of Nutrition for Health and Development

  27. Strategy for promoting healthy growth and development Development of a sound international growth reference Training on its appropriate use and interpretation Clinical and Public Health Interventions WHO Multicentre Growth Reference Study

  28. Child survival Physical growth Child development WHO Multicentre Growth Reference Study

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