growth charts for pediatrician

1. GROWTH CHARTS
BY DR SANTOSH MOGALI

2. INTRODUCTION-
 Growth charts were popularised by David Morley.
 Well baby clinics, PHC, and ICDS programmes utilize
growth charts.
 The wt.measurments of a child over a period of time are
plotted on the growth chart and any deviation from the
normal pattern can be visualised and interpreted.
 An upward curve in the road to health is ideal.
 A flat and downward curves are not desirable.
 WHO charts – blue for boys and pink for girls

3. AIMS AND RATIONALE
 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.

4. USES OF GROWTH CHARTS-
 Diagnostic tool-To identify high risk children.
 Planning and policy making
 Education tool for educating mothers
 Tool for action helps in type of intervention that
is needed
 Evaluation- of effectiveness of corrective
measure and impact of a programme of special
interventions for improving Childs growth and
development
 Tool for teaching.

5. BACKGROUND
 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.

6. WHO GROWTH CHARTS
 MULTICENTRIC GROWTH REFERENCE
STUDY(MGRS)-
 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 bilogical norm.
 Measurements include weight/age, height/age, and

13. BASICS OF GROWTH CHARTS-
 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 devided 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.
 The correlation between Z scores and percentiles can
be confusing and in recent WHO MGRS study these
are tabulated below for clarity.

14. 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

15. Since previous table is difficult to interpret it is
further simplified as follows:
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 Severe wasted
underweight

16. GROWTH STANDARDS VS
REFERENCES
 Growth standards are prescriptive and define how a
population of children should grow given the optimal
nutrition and optimal health .
 Growth reference on the other hand 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.
 WHO 2006 growth charts are ex for growth
standards.
 1989 Agarwal data and 2007 Khadilkar for affluent

17.  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

18. THE INDIAN SCENARIO
 In a recent multicentric study done on 1493
affluent preschool indian children (selected from
all zones of India) the mean Z score for height ,
weight, BMI and weight for height were below
the WHO 2006 standards. The overall
incidence of stunting was 13.6 % and the
underweight was 8.5 % under the age of 5
years. This % is likely to be higher in rural areas
and in underprivileged urban areas although at
present no such data is available from India.

19. NEW 2007 AFFLUENT INDIAN
GROWTH CHARTS
 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 Indial into 5
zones-north, south, east, west and central.the
nutritionally well areas were identied based on per
capita income of cities.
 The differences between zones were not signifiacant
 Data collection lasted from june 2007 to january 2008.

20. OBSERVATIONS-
 SECULAR TRENDS IN HEIGHT- The 50th percentiles
for boys height >1989 values at all ages.
 97th percentile at 18 years was 1.7 cm >1989.
 The 50th percentiles for girls height >1989 values at all
ages.
 ALARMING RISE IN OBESITY- The overall
prevalence overweight and obesity was 18.2% by
IOTF classification and 23.9% by WHO standards.
 Prevalence of overweight and obesity in boys>in girls
 Mean BMI values were significantly >1989 data.
 This rising trend of BMI in this multicentric study rings
alarm bells in terms of associated health

21. REFERENCES-
 IAP-RECENT ADVANCES IN PEDIATRICS
 PARKS TEXTBOOK OF PSM
 NUTRITION AND CHILD DEVELOPMENT -
ELZABETH