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Guideline Summary
Guideline Title
Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States.
Bibliographic Source(s)
Grummer-Strawn LM, Reinold C, Krebs NF, Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published errata appear in: MMWR Morb Mortal Wkly Rep. 2010 17 Sep;59(36):1184]. MMWR Recomm Rep. 2010 Sep 10;59(RR-9):1-15. [41 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Physical growth of infants and children

Guideline Category
Evaluation
Screening
Clinical Specialty
Family Practice
Nutrition
Pediatrics
Preventive Medicine
Intended Users
Advanced Practice Nurses
Allied Health Personnel
Dietitians
Health Care Providers
Hospitals
Managed Care Organizations
Nurses
Physician Assistants
Physicians
Public Health Departments
Guideline Objective(s)

To provide guidance on the use of the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) growth charts for health-care providers and others who measure and assess child growth

Target Population

Children aged 0–59 months in the United States

Interventions and Practices Considered

Assessment of growth in infants and children:

  • Use of World Health Organization (WHO) international growth charts
  • Use of Centers for Disease Control and Prevention (CDC) growth charts
Major Outcomes Considered
  • Weight for age
  • Length (or stature) for age
  • Weight for length (or stature)
  • Body mass index (BMI) for age

Methodology

Methods Used to Collect/Select the Evidence
Searches of Electronic Databases
Description of Methods Used to Collect/Select the Evidence

Not stated

Number of Source Documents

Not stated

Methods Used to Assess the Quality and Strength of the Evidence
Not stated
Rating Scheme for the Strength of the Evidence

Not applicable

Methods Used to Analyze the Evidence
Review
Description of the Methods Used to Analyze the Evidence

Not stated

Methods Used to Formulate the Recommendations
Expert Consensus
Description of Methods Used to Formulate the Recommendations

During June 29–30, 2006, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), and the American Academy of Pediatrics (AAP) convened a meeting in Hyattsville, Maryland, to review scientific evidence and obtain opinions regarding the use of the new World Health Organization (WHO) growth charts in clinical settings in the United States. The participants at the meeting were selected on the basis of their expertise in child growth, statistical methodology, clinical application, and maternal and child health policy. CDC, NIH, and AAP each had numerous representatives; additional experts from academia, clinical professional groups, and other government agencies were invited.

Participants were provided background documents describing the development of both sets of curves. At the meeting, CDC made presentations on the methods used to create the CDC growth charts, and a principal investigator for the WHO Multicentre Growth Reference Study (MGRS), which generated the data used for the WHO growth curves, made a presentation on the methods used to create the WHO charts. CDC conducted a statistical comparison of the charts and presented the results to participants. Meeting discussions focused on the numerous factors involved in the selection of a chart, including the assessment of child growth using references (i.e., how certain groups of children have grown in the past) compared with standards (i.e., how healthy children should grow in ideal conditions), differences between the growth of breastfed and formula-fed infants, the methods used to create the CDC and WHO charts, and implications of using the charts in clinical practice. At the time of the meeting, WHO was developing but had not released growth charts for head circumference for age; therefore, these charts were not discussed. The charts have since been released and are available at http://www.who.int/childgrowth/standards/hc_for_age/en/index.html External Web Site Policy.

The panel was not asked to arrive at a consensus. At the end of the meeting, CDC asked all participants to provide written opinions on which curves should be recommended, at which ages, and for which children. After the meeting ended, CDC worked with NIH and AAP to develop these CDC recommendations based on the meeting proceedings.

Rating Scheme for the Strength of the Recommendations

Not applicable

Cost Analysis

A formal cost analysis was not performed and published cost analyses were not reviewed.

Method of Guideline Validation
Peer Review
Description of Method of Guideline Validation

Not stated

Recommendations

Major Recommendations

Use of World Health Organization (WHO) Growth Charts for Children Aged <24 Months

Use of the 2006 WHO international growth standard for the assessment of growth among all children aged <24 months, regardless of type of feeding, is recommended. (The charts are available at http://www.cdc.gov/growthcharts/ External Web Site Policy.) When using the WHO growth charts, values of 2 standard deviations above and below the median, or the 2.3rd and 97.7th percentiles (labeled as the 2nd and 98th percentiles on the growth charts), are recommended for identification of children whose growth might be indicative of adverse health conditions. The rationale for use of the WHO growth charts for this age group includes the following: 1) the recognition that breastfeeding is the recommended standard for infant feeding and, unlike the Centers for Disease Control and Prevention (CDC) charts, the WHO charts reflect growth patterns among children who were predominantly breastfed for at least 4 months and still breastfeeding at age 12 months; 2) clinicians already use growth charts as a standard for normal growth; and 3) the WHO charts are based on a high-quality study, the Multicentre Growth Reference Study (MGRS).

Continued Use of CDC Growth Charts for Children Aged 24–59 Months

Use of the CDC growth charts for children aged 24–59 months is recommended. The CDC charts also should be used for older children because the charts extend up to age 20 years, whereas the WHO standards described in this report apply only to children aged 0–59 months. The rationale for continuing to use CDC growth charts includes the following: 1) the methods used to create the WHO and CDC charts are similar after age 24 months, 2) the CDC charts can be used continuously through age 19 years, and 3) transitioning at age 24 months is most feasible because measurements switch from recumbent length to standing height at this age, necessitating use of new printed charts.

Use of Recommended Growth Charts in Clinical Settings

CDC recommends the use of modified versions of the WHO curves for children aged <24 months that include the 2.3rd and 97.7th percentiles and are appropriate for clinicians. These curves have been developed and are available at http://www.cdc.gov/growthcharts/ External Web Site Policy. Training tools for clinicians are being developed and also will be available at this website.

Clinicians should recognize that the WHO charts are intended to reflect optimal growth of infants and children. Although many children in the United States have not experienced the optimal environmental, behavioral, or health conditions specified in the WHO study, the charts are intended for use with all children aged <24 months. Therefore, their growth might not always follow the patterns shown in the WHO curves. For example, formula-fed infants tend to gain weight more rapidly after approximately age 3 months and therefore cross upward in percentiles, perhaps becoming classified as overweight. Although no evidence-based guidelines for treating overweight in infancy exist, early recognition of a tendency toward obesity might appropriately trigger interventions to slow the rate of weight gain.

For the first 3 months of age, the WHO charts show a somewhat faster rate of weight gain than the CDC charts, leading to the identification of more infants who appear to be growing slowly. Clinicians should recognize that this slower rate of weight gain is typical for formula fed infants. For breastfed infants identified as growing slowly, clinicians need to carefully assess general health issues and ensure appropriate management of lactation. Only if there is evidence of lactation inadequacy should they consider supplementation with formula.

Differences in the length-for-age WHO and CDC charts are small, and clinical differences based on these charts are expected to be insignificant. In contrast, when the WHO charts are used to assess the growth of U.S. children, fewer children aged 6–23 months will be identified as having inadequate weight for age. Some assert that this might be beneficial because overdiagnosis of underweight might damage the parent-child interaction, subjecting families to unnecessary interventions and possibly unintentionally creating an eating disorder. However, children who are identified as having low weight for age on the WHO charts will be more likely to have a substantial deficiency. Clinicians need to seek out the causes for poor growth and propose changes accordingly. For example, poor weight gain might result from neglect, substantial morbidities, or other medical problems that require immediate attention.

Clinical Algorithm(s)

None provided

Evidence Supporting the Recommendations

Type of Evidence Supporting the Recommendations

The type of supporting evidence is not specifically stated for each recommendation.

Benefits/Harms of Implementing the Guideline Recommendations

Potential Benefits

Appropriate assessment of child growth

Potential Harms

Not stated

Qualifying Statements

Qualifying Statements
  • Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. Department of Health and Human Services.
  • References to non-Centers for Disease Control and Prevention (CDC) sites on the Internet are provided as a service to MMWR readers and do not constitute or imply endorsement of these organizations or their programs by CDC or the U.S. Department of Health and Human Services. CDC is not responsible for the content of these sites. URL addresses listed in MMWR were current as of the date of publication.

Implementation of the Guideline

Description of Implementation Strategy

An implementation strategy was not provided.

Implementation Tools
Chart Documentation/Checklists/Forms
For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

Institute of Medicine (IOM) National Healthcare Quality Report Categories

IOM Care Need
Staying Healthy
IOM Domain
Effectiveness
Patient-centeredness

Identifying Information and Availability

Bibliographic Source(s)
Grummer-Strawn LM, Reinold C, Krebs NF, Centers for Disease Control and Prevention (CDC). Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States [published errata appear in: MMWR Morb Mortal Wkly Rep. 2010 17 Sep;59(36):1184]. MMWR Recomm Rep. 2010 Sep 10;59(RR-9):1-15. [41 references] PubMed External Web Site Policy
Adaptation

Not applicable: The guideline was not adapted from another source.

Date Released
2010 Sep
Guideline Developer(s)
Centers for Disease Control and Prevention - Federal Government Agency [U.S.]
Source(s) of Funding

United States Government

Guideline Committee

Expert Panel Review of World Health Organization and CDC Growth Charts

Composition of Group That Authored the Guideline

CDC: Katherine Flegal, PhD, Cliff Johnson, MSPH, Cynthia Ogden, PhD, Edward Sondik, PhD, Rong Wei, PhD, National Center for Health Statistics, Hyattsville, Maryland. Laurence M. Grummer-Strawn, PhD, Zuguo Mei, MD, Christopher Reinold, PhD, Diane Thompson, MPH, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia

National Institutes of Health: Gilman Grave, MD, Mary Hediger, PhD, National Institute of Child Health and Human Development, Bethesda, Maryland. Van S. Hubbard, MD, PhD, Wendy Johnson-Askew, PhD, Robert Kuczmarski, DrPH, National Institute of Diabetes and Digestive and Kidney Diseases, Bethesda, Maryland

American Academy of Pediatrics: Ellen Buerk, MD, Oxford, Ohio. Arthur Eidelman, MD, Shaare Zedek Medical Center, Jerusalem, Israel. Frank Greer, MD, Meriter Hospital, Madison, Wisconsin. Nancy Krebs, MD, University of Colorado Denver, Denver, Colorado. Ruth Lawrence, MD, University of Rochester School of Medicine and Dentistry, Rochester, New York. Lori Feldman-Winter, MD, Children's Regional Hospital at Cooper, University of Medicine and Dentistry of New Jersey—Robert Wood Johnson Medical School, Camden, New Jersey

Other Federal Government Agencies: Sue Ann Anderson, PhD, Food and Drug Administration, Washington, DC. Donna Blum-Kemelor, PhD, Patricia Daniels, Jay Hirschman, U.S. Department of Agriculture, Alexandria, Virginia; Elizabeth Frazao, PhD, U.S. Department of Agriculture, Washington, DC. Steve Kessel, MD, PhD, Department of Health and Human Services, Washington, DC. Iris Mabry-Hernandez, MD, Agency for Healthcare Research and Quality, Washington, DC. Denise Sofka, MPH, Health Resources and Services Administration

Invited Experts: Diane Anderson, PhD, American Dietetic Association, Baylor College of Medicine, Baylor, Texas. Mary Ann Best, PhD, National Association of Pediatric Nurse Practitioners, University of Texas Medical Branch, School of Nursing, Galveston, Texas. Margaret Boland, MD, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada. Nancy Butte, PhD, Baylor College of Medicine, Baylor, Texas. Katherine Dewey, PhD, Site Coordinator, Multicentre Growth Reference Study, University of California, Davis, Davis, California. Cutberto Garza, MD, PhD, Co-Principal Investigator, Multicentre Growth Reference Study, Boston College, Chestnut Hill, Massachusetts. John Himes, PhD, University of Minnesota School of Public Health, Minneapolis, Minnesota. Chessa Lutter, PhD, Pan American Health Organization, Washington, DC. Reynaldo Martorell, PhD, Emory University, Atlanta, Georgia. Van Nguyen, Community Clinic Inc., Women, Infants, and Children Program, Takoma Park, Maryland. Eckhart Ziegler, MD, University of Iowa Children's Hospital, Iowa City, Iowa

Financial Disclosures/Conflicts of Interest

Not stated

Guideline Status

This is the current release of the guideline.

Guideline Availability

Electronic copies: Available from the Centers for Disease Control and Prevention (CDC) Web site External Web Site Policy.

Print copies: Available from the Centers for Disease Control and Prevention, MMWR, Atlanta, GA 30333. Additional copies can be purchased from the Superintendent of Documents, U.S. Government Printing Office, Washington, DC 20402; (202) 512-1800.

Availability of Companion Documents

Growth charts and data tables are available from the CDC Web site External Web Site Policy.

Patient Resources

None available

NGC Status

This NGC summary was completed by ECRI Institute on April 13, 2011.

Copyright Statement

No copyright restrictions apply.

Disclaimer

NGC Disclaimer

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

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