CDC-WHO Growth Charts

September 2012

Washington State Department of Heath

WIC Nutrition Program
 CDC-WHO Growth Charts 1

Contents
Contents ......................................................................... 1

Welcome to the CDC-WHO Growth Chart Training! ...... 2

Agenda ............................................................................ 2

Growth Charts are a Key Tool......................................... 3

History of the Growth Charts ......................................... 3

Comparing the two Growth Charts ................................ 4

The WHO Hypothesis ..................................................... 5

Recommendation to Use the WHO Growth Charts ....... 5

Differences between the Charts..................................... 6

Part 2 begins on Page 13
Comparison of Length-for-age ....................................... 8
After the Client Services
Identifying risks ............................................................ 12 demonstration

Client Services .............................................................. 13

Weighing and Measuring ............................................. 13

The Growth Chart Conversation................................... 14

Transitioning to the new charts ................................... 15

Appendix....................................................................... 17

In accordance with Federal law and Department of Agriculture USDA policy, this institution is
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To file a complaint of discrimination, write USDA, Director, Office of Adjudication, 1400

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Washington State WIC Nutrition Program does not discriminate.

For persons with disabilities, this document is available on request in other formats.
To submit a request, please call 1-800-841-1410 (TDD/TTY 711).

September 2012

DOH 961-956 September 2012

 CDC-WHO Growth Charts 2

Welcome to the CDC-WHO Growth Chart Training!

In 2006 the World Health Organization (WHO) published new growth standards. The
Center for Disease Control (CDC) released growth charts based on the WHO growth
standards. These are the new charts we will be using in the Washington WIC Nutrition
Program. This training will share information about the new charts and how we’ll
implement them.

During this training we’ll use these terms when we talk about the charts:

 CDC charts = the current charts we use in WIC

 WHO charts = the new CDC-WHO charts we will be using soon

We are happy to share the new growth charts with you!

Agenda

Part 1: By the end of this section you will have:

 Learned about the new charts and how they were created
 Discovered the differences between the charts
and identified trends in growth assessment with
the new WHO growth charts
 Seen the new WHO charts

 Reviewed the new growth-related risks

Part 2: By the end of this section you will have:

 Viewed the graphs in Client Services

 Reviewed changes to policy and procedure for
measuring young children
 Explored how WIC Connects skills can help the
growth chart conversation
 Identified additional resources

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Growth Charts are a Key Tool

WIC uses growth charts to:

 Assess growth
 Identify potential nutrition or health
concerns
 Share information with caregivers
 Have open conversations about growth,
Physical growth is a way to assess
nutrition and healthy habits.
the health and wellness of
infants and children.

Keep these things in mind through-out this training and think about how they might be
affected by the new growth charts.

History of the Growth Charts

Growth charts have been around for at least a century! Here’s a brief review of the
recent history of the charts used in WIC.

National Center for Center for Disease World Health

2000 CDC
1977 NCHS

2006 WHO
Health Statistics Control Organization

From 1977 - 2000 Used since 2000 Released 2006

Growth reference Growth reference Growth standard

A Growth Reference or a Growth Standard?

Growth Reference – Describes how certain children grew in a particular place and time.
It gives a point of comparison.

Growth Standard – Describes how healthy children should grow in a healthy

environment regardless of time, place or ethnicity. It defines what is normal or optimal.

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Comparing the two Growth Charts

This table shows the differences between the 2000 CDC and 2006 WHO growth charts.

Characteristic 2000 CDC Charts 2006 WHO Charts

Reference or Reference: Standard:
Standard  Describes growth of  Describes how children should
children in the U.S. grow under optimal conditions
during the 1970’s and regardless of time, place, or
1980’s. ethnicity.
Data Limited number of Large number of measurements taken
measurements taken less often. frequently from birth to 24 months.

Based on data from national Based on data taken in six world

health surveys and birth locations:
certificates in the U.S.  Pelotas, Brazil
 Accra, Ghana
 Delhi, India
 Oslo, Norway
 Muscat, Oman
 Davis, California – U.S.
Requirements No special requirements to be Had to meet these requirements to be
included in the data. included in the data:
 Adequate socioeconomic
status to support growth
 Access to health care and
breastfeeding support
 Full term birth
 No smoking during pregnancy
or breastfeeding
 Exclusive or primarily
breastfeeding > 4 months
 Began feeding solids by 6
months
 Continued breastfeeding > 12
months

Additional factors:
 The American Academy of Pediatrics states that the healthy breastfed infant is the
standard against which all other infants should be compared. The WHO charts are
based on this premise.
 The WHO charts were created with high quality data.
 The WHO charts support the theory that optimal nutrition + optimal environment +
optimal care = optimal growth regardless of time, place or ethnicity.

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The WHO Hypothesis

Children throughout the world will grow similarly if exposed to optimal circumstances.

This chart shows the birth to 24 months growth data from the 6 WHO countries.

“For the first time, we now have a technically robust tool to measure,
monitor and evaluate the growth of all children worldwide, regardless of
ethnicity, socioeconomic status or type of feeding.”

WHO Committee Member

Recommendation to Use the WHO Growth Charts

The Center for Disease Control (CDC), the National Institutes of Health (NIH), and the
American Academy of Pediatrics (AAP) recommend using the WHO growth charts for
children birth to 24 months in the United States.
USDA accepts the recommendation for WIC.

Washington WIC will use these growth charts:

 WHO growth charts for children 0 – 24 months of age
 Length/Age & Weight/Age, Weight/Length & Head Circumference/Age
 CDC growth charts for children 2 – 5 years old
 Height/Age & Weight/Age and BMI/Age
 CDC weight/length and length/age charts for children 24 - 36 months who can’t
be measured standing up. These charts are for education only.

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Differences between the Charts

 The WHO charts show a different pattern

of growth than the CDC charts.

 WHO measured healthy children under

ideal conditions.

 Breastfed infants and children were the

standard.

“The healthy breastfed infant is the standard against

which all other infants should be compared.”
American Academy of Pediatrics

In general the WHO charts show a higher rate of weight gain in the first months of life,
then the rate of weight gain tapers off from 6 to 23 months compared to the CDC
growth charts. The chart below shows this comparison.

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Differences between the Charts

Here are some of the differences you may notice with the
WHO growth charts:

Length-for-age:
 Slightly more infants and children will plot in the
lower length-for-age percentiles.

Weight-for-age:
 Fewer infants and children will be identified with
low weight-for-age, especially between 6 and 23
months of age.

Weight-for-length:
 Slightly lower number of infants and children with
low weight-for-length.
 Fewer infants and children with high weight-for-
length.

This bar graph compares the growth patterns between the CDC and WHO growth charts.

The WHO charts use different percentiles to identify nutrition risks.

 WHO growth standards are based on healthy children living in optimal conditions so
more extreme cutoffs are used to identify nutrition risk.
 Use new cutoffs at the 2nd and 98th percentiles on the WHO charts.
We’ll continue to use the 5th and 95th percentiles on the CDC growth charts for older
children.

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Comparison of Length-for-age

Differences between the Charts

Here is a child plotted on the 2000 CDC and 2006 WHO charts.
 CDC-WHO Growth Charts 9

Comparison of Weight-for-age
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Comparison of Weight-for-length
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Comparison of Head circumference-for-age

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Identifying risks
This table lists all the risk changes related to the new WHO growth charts.

Bolded risks indicate high risk

Category Current Risks New Risks

th
Infant Weight/Length < 5 Weight/Length < 2nd
Infant Weight/Length < 10th Weight/Length > 2nd and < 5th
Infant No overweight risk for infants Weight/Length > 98th
Infant Length/Age < 5th Length/Age < 2nd
Infant Length/Adjusted Age < 5th Length/Adjusted Age < 2nd
Infant Length/Age < 10th Length/Age >2nd and < 5th
Infant Length/Adjusted Age < 10th Length/Adjusted Age >2nd and < 5th
Infant Head Circumference/Age < 5th Head Circumference/Age < 2nd
Infant Head Circumference/Adjusted Age < 5th Head Circumference/Adjusted Age < 2nd

Child Weight/Length < 5th Weight/Length < 2nd (< 24 months)

th
Child Weight/Length < 10 Weight/Length > 2nd and < 5th (< 24 months)
Child No overweight risk for children 12–24 Weight/Length > 98th (< 24 months)
months
Child Weight/Length > 95th (24 – 36 months) No risk for CDC WHO growth charts for length
between 24 and36 months; use BMI risks when
height is taken
Child Length/Age < 5th Length/Age < 2nd (< 24 months)
Child Length/Adjusted Age < 5th Length/Adjusted Age < 2nd (< 24 months)
Child Length/Age < 10th Length/Age >2nd and < 5th (< 24 months)
Child Length/Adjusted Age < 10th Length/Adjusted Age >2nd and < 5th (< 24
months)
Child No head circumference risk for children Head Circumference/Age < 2nd (< 24 months)
Child No head circumference risk for children Head Circumference/Adjusted Age < 2nd (< 24
months)
Child Premature < 37 Weeks Gestation (< 2 yrs) Premature < 37 Weeks Gestation (< 24 months)
Child Low Birth Weight < 5 lbs 8 oz (< 2 yrs)  Low Birth Weight < 5 lbs 8 oz (< 24 months)
Child Small for Gestational Age (< 2 yrs)  Small for Gestational Age (< 24 months)

Client Services will continue to auto assign growth risks!

This completes Part 1 of the training. Begin Part 2 when you are ready.
 CDC-WHO Growth Charts 13

Part 2 begins here after the Client Services demonstration.

Client Services
Graphs appear in the drop-down list based on age and type of measurements taken.

Height/Age & Weight/Age (together on 1 page)

BMI/Age
 Appear in the list after age 2 when
height or weight is entered

Length/Age (24-36 mos.)

Weight/Length (24-36 mos.)
 Appear only between 24 and 36
months when length is entered
 Use for education only
As a child gets older,
Length/Age & Weight/Age (together on 1 page) the graph selection list is longer.
Head Circ/Age & Weight/Length (together on 1 page) Select any previous graph to view.
• Appear from birth to 24 months
• Head circumference is still optional

Weighing and Measuring

Here is a summary of WIC’s policy for weighing and measuring infants and children:
Category and Age Measurement Clothing
Infants: Length – recumbent board Dry diaper or
Birth to 12 months Weight – infant scale light clothing - onesie
Children: Length – recumbent board Dry diaper or
12 – 24 months Weight – infant scale light clothing - onesie
2 – 5 years Height – stadiometer Light clothing
Weight – adult scale

The standard is to take a standing height measurement for children between 24 and 36
months of age. If you can’t get a height at this age:
 Document the length in Client Services.
 Client Services will plot length measurements on the 24 – 36 month growth charts.
 Client Services won’t identify risks based on length measurements taken between 24
and 36 months.
 Length/Age (24-36 mos.) and Weight/Length (24-36 mos.) charts are for education only.

Accurate measurements are important! Review the online Anthropometric module at:
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 CDC-WHO Growth Charts 14

The Growth Chart Conversation

Listen to a personal experience about a doctor sharing growth information.

Hear how WIC Connects skills could have made the conversation easier and more meaningful.

See the “Tips for Talking with Caregivers about Growth Charts” in the Appendix.

Answer the following questions and share with a partner:

1. How do WIC Connects skills make the growth chart conversation easier for you and
more meaningful for caregivers?

2. What words or phrases could you use for each of the WIC Connects skills listed below
during the growth chart conversation?

 Open-ended questions:

 Affirmations:

 Reflections:

 Summaries:
“I would have felt heard and valued as a
parent. My doctor would have come along
side me to have a conversation about my
daughter’s health and growth.”
See these tools in the Appendix:

 Tips for Talking with Caregivers about Growth Charts

 Steps for the Growth Chart Conversation

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Transitioning to the new charts

Here are some things to consider as we transition to
the new charts:

The infant or child may not look different to you or

the caregiver, but he or she plots at a different
percentile on the WHO growth chart.

 Try framing the new charts with the

caregiver.
 See the “Tips for Talking with Caregivers
about Growth Charts” in the Appendix.

The child has a new risk

 Be sure to press the “Identify New Risks” button on the Measures Tab to assign growth-
related risks during the eligibility period.
 You can add new risks at any time.
 See “Assess Nutrition Risk” in Volume 1, Chapter 14 – Nutrition Risk Criteria

The child becomes high risk during the certification

 Be sure to press the “Identify New Risks” button on the Measures Tab to assign growth-
related risks during the eligibility period.
 Refer to the nutritionist for a high risk care plan when there are more than 60 days (2
months) left in the eligibility period.
 If there aren’t 60 days left in the eligibility period, you don’t have to refer to the
nutritionist (but it’s best practice).
 See “Determine High Risk Status” in Volume 1, Chapter 14 – Nutrition Risk Criteria.

The child was high risk and is no longer high risk

 Make sure no other high risk factors apply.

 Write a note in the client’s file about the change from high risk status.
 The risk can’t be removed.
 The client isn’t required to see the nutritionist for a high risk care plan.
 See “Determine High Risk Status” in Volume 1, Chapter 14 – Nutrition Risk Criteria.

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Implementation
The WHO charts will be in Client Services Version 7.2 on Wednesday, September 26, 2012.

Where to get Help

1. Call CIMS Support for Client Services questions: 1-800-841-1410, press 7.
2. State WIC Manual: Volume 1, Chapter 9 – Anthropometrics and Chapter 14 – Nutrition Risk
Criteria. We will post these two chapters on the website by September 26th.
http://www.doh.wa.gov/PublicHealthandHealthcareProviders/PublicHealthSystemResource
sandServices/LocalHealthResourcesandTools/WIC/PolicyProcedures.aspx
3. Call Local Agency Technical Assistance (LATA) for policy or risk questions: 1-800-841-1410,
press 0 and ask for LATA.

Resources
See the list of references located in the Appendix.

Practice Ideas
We know it may take time to feel comfortable using these new tools; whether it’s a new growth
chart or new participant-centered growth chart conversations.
Here are some ideas to practice using WIC Connect skills when sharing growth information.
 Think about a growth chart conversation that went well. What do you think made the
conversation go well? Share your thoughts with a partner.
 Think about a challenging growth chart conversation you may have had in the past.
Work with a partner to practice using some of the WIC Connect skills you think might
make the conversation go better.
 Identify a growth chart conversation with a caregiver between now and your next staff
meeting that goes well and share with your co-workers the words that feel comfortable
and connect with you and the caregiver.

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Appendix
CDC-WHO Growth Charts

Resources

Resource Where to Find

WIC Manual http://www.doh.wa.gov/portals/1/Documents/Pubs/960-105-
Volume 1, Volume1Chapter9.pdf
Chapter 9 –
Anthropometrics
WIC Manual http://www.doh.wa.gov/portals/1/Documents/Pubs/960-105-
Volume 1, Volume1Chapter14.pdf
Chapter 14 –
Nutrition Risk
WIC Online Course http://dohmedia.doh.wa.gov/wictraining/anthropometrics/index.html
- Anthropometrics
WHO Growth http://www.cdc.gov/nccdphp/dnpao/growthcharts/who/index.htm
Chart Training
(CDC) A helpful training with lots of background about why the new WHO charts
are an improvement.
Center for Disease http://www.cdc.gov/growthcharts/who_charts.htm
Control and
Prevention (CDC) “WHO Growth Standards Are Recommended for Use in the U.S. for Infants
website and Children 1 to 2 Years of Age”
Morbidity and http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5
Mortality Weekly 909a1_w
Report (MMWR)
“Use of WHO and CDC growth charts for children aged 0-59 months”
WA WIC Table of WIC CDC-WHO Training materials, page 12.
Risk Changes
American http://pediatrics.aappublications.org/content/128/4/e786
Association of
Pediatrics journal “Parental Perceptions of Weight Terminology That Providers Use With
article Youth”
Wall Street Journal http://online.wsj.com/article/SB100008723963904434375045775448619
– Health Journal 08329668.html?mod=WSJ_article_comments#articleTabs%3Darticle
article
“Is Baby Too Small? Charts Make it Hard to Tell”

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