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BACKGROUNDER 1 What are the WHO Child Growth Standards? The World Health Organization is launching new global Child Growth Standards for infants and children up to the age of five. With these new WHO Child Growth Standards it is now possible to show how children should grow. They demonstrate for the first time ever that children born in different regions of the world and given the optimum start in life, have the potential to grow and develop to within the same range of height and weight for age. The WHO Child Growth Standards will be widely used as a tool in public health, medicine and by governmental and health organizations for monitoring the well-being of children and for detecting children or populations not growing properly or under- or overweight and may require specific medical or public health responses. Normal growth is an essential expression of health and a way to measure efforts designed to reduce child mortality and disease. The new charts therefore provide a simple tool to assess the effectiveness of such efforts. They will be in use around the world in doctors offices, clinics and other health facilities, and by research institutions, child health advocacy organizations and ministries of health. What do these charts look like, and what do they show? Parents, caregivers and health workers around the world are familiar with growth references. They are the values of weight and height for each age against which they measure the growth of the children under their care. The current references do not indicate how children should grow for the best health outcome, however, rather they simply describe how the average child grows. The WHO Child Growth Standards go beyond the current references. They allow important growth measurements, such as body weight and length/height of infants and children to be assessed against a standard optimum value. There are charts for boys and for girls, and for infants to one year, andfor children up to five years. These measurements are important indicators of health and help determine whether a child or a population of children is healthy and growing well. For example, children who are short for their age (below the red line on the length/height chart) or underweight (below the red line on the weight chart) indicate that their health may be compromised - the further from the red lines, the more indicative of a health problem. In clinical practice, these measurements help with early diagnosis of illness and help monitor progress during treatment.

Importantly, for the first time there now exist standardized Body Mass Index - BMI - charts for infants to age five, which is particularly useful for monitoring the increasing epidemic of childhood obesity. Additionally, the new Child Growth Standards also include Windows of Achievement describing the range and timeline for six key motor development milestones for children, such as sitting, standing and walking. There are more than 30 Child Growth Standard charts in all. Most doctors, healthcare providers and parents will use only a few of these charts regularly (height/length, weight, BMI, for e.g.) but researchers and those working at the population level will use a broader range of charts for measurement and evaluation. WHO Child Growth Standards2How are the new WHO Child Growth Standards different from existing growth charts? The new WHO Child Growth Standards differ from any existing growth charts in a number of innovative ways: For the first time they describe how children should grow, which is a prescriptive approach, not just descriptive. These charts show that all children across all regions can attain a similar standard of height and weight and development with correct feeding practices, good healthcare and a healthy environment. It is, then, a more proactive way of measuring and evaluating child growth, setting out normative conditions and evaluating children and populations against that standard. As such, a key characteristic of the new standard is that it establishes breastfeeding as the biological norm and the breastfed infant as the standard for measuring healthy growth. Previous reference charts were based on the growth of a random mixture of breastfed and artificially-fed children. Furthermore, the pooled sample from the six participating countries allows the development of a truly international standard, which is in contrast to the previous international reference based on children from a single country. The development for the first time of standardized Body Mass Index (BMI) charts for infants to five years of age is a major innovation in assessing healthy weights of children. Additionally, the development of Windows of Achievement for six key motor development milestones will provide a unique link between physical growth and motor development. How were the new WHO Child Growth Standards developed? The new WHO Child Growth Standards are the result of an intensive study initiated by WHO in 1997 to develop a new international standard for assessing the physical growth, nutritional status and motor development in children from birth to five years of age. As a result, The Multicentre Growth Reference Study (MGRS) has been a community-based, multicountry project conducted in Brazil, Ghana, India, Norway, Oman, and the United States. Crucially and by design of the research project, the 8,440 children included in the study were raised in environments that promote healthy growth such as breastfeeding, good diets and prevention and control of infections. In addition, their mothers followed health practices such as not smoking during and after pregnancy, and ensuring adequate healthcare for the children. This project was lead by WHO and supported by several governments, non-governmental organizations and the United Nations University and other UN agencies. It was supported financially by the governments of Brazil, the Netherlands, Norway, Oman, USA, and the Bill & Melinda Gates Foundation.

When and how will the new WHO Child Growth Standards be available to countries and healthcare providers? They will be available from the day of the launch (27 April, 2006) at the WHO website (www.who.int/childgrowth) for consultation, download and use. Ministries of Health, national pediatric associations and other key health decision makers will determine whether and when they will be officially adopted by their country. http://www.who.int/childgrowth/1_what.pdf

WHO Child Growth Standards BACKGROUNDER 2 Why are new WHO Child Growth Standards needed? In 1997, WHO undertook a comprehensive review of child growth references. The review concluded that it was time to develop new standards that show how children should grow in all countries rather than merely describing how they grew at a particular time and place. The existing references provided a basis for making comparisons only: they didnt enable evaluation and judgment. Standards, on the other hand, set benchmarks and therefore are more effective guides to, and evaluators of, interventions to improve healthy development and growth. An international standard to show how children should grow allows for comparisons across countries that can guide policymaking and support child health advocacy efforts. By carefully selecting the children for the study for their optimum growth, the new WHO Child Growth Standards provide a basic, simple tool to assess how well we provide the best start possible for the worlds children as individuals and as populations. The greatest benefits are found when these measurements are linked with action, and used to evaluate progress. Ideally, the new standard will provide the tools for improvements in knowledge and practical skills among health professionals. For example, health professionals will be better able to recognize both sub-optimal or excessive weight gain in children and assist effectively in the prevention of undernutrition, overweight and obesity, and the health problems which arise from both (see backgrounder 4:'Under- and over-nutrition'). What difference will the new WHO Child Growth Standards make for children?

We now have scientific evidence proving that infants and children from geographically diverse regions of the world experience very similar growth patterns when their health and nutrition needs are met. This provides us with a crucially important and scientifically robust tool to assess compliance with a child's right to grow. The standards now serve as a measuring stick by which to evaluate the growth of a child or a population of children. They will serve as a key foundation for advocacy, implementation and measurement of health goals and indicators such as the Millennium Development Goals (MDGs). The standards will play direct roles at the national, regional and international levels in monitoring progress towards meeting four of the seven MDGs, and less directly the other three. The vulnerability of the health of infants and young children make assessments of child growth a 'sentinel' indicator of the health and socioeconomic development of the communities in which they live. Until now, an adequate measurement tool did not exist. Similarly, the new Body Mass Index - BMI - measurement standard for children to age 5 will enable early detection and prevention of overweight and obesity in young children. The standards will also serve to further the UN Convention on the Rights of the Child, which recognizes the duties and obligations to children that cannot be met without attention to normal human development. The WHO Growth Standards, derived from a world-wide sample of children and based on the reality that environmental differences, rather than genetics, are the principal determinant of disparities in physical growth, is an important step towards achieving the right of every child to grow and be healthy. 1What are the optimum conditions for child growth? The WHO Child Growth Standards are based on important 'norms' for childcare, nutrition, and health. For example: Sound nutritional practices are important throughout childhood: healthy breastfeeding should be supported, protected, and promoted and children should be provided safe, wholesome, and nutritionally appropriate foods during the period of complementary feeding (see backgrounder 3: 'WHO Child Growth Standards and Infant and Young Child feeding'). Full implementation of the objectives of the Global Strategy for Infant and Young Child Feeding (2002), as well as national guidelines for child nutrition, are crucial. Breastfed infants are lean babies, a characteristic that is documented by the new reference (see backgrounder 3: 'WHO Child Growth Standards and Infant and Young Child Feeding'). Vaccinations and good health care should be available and accessible to all infants and young children and families and their communities should do all they can to ensure a good pregnancy. Pregnant women and mothers should refrain from using tobacco.

The first step should be implementing the new standard in every country and ensuring that every child has his/her own chart against which his/her growth is assessed followed by an appropriate follow up. Are the new standards just for children in developing countries? The new WHO Child Growth Standards are global and for all children. They are intended to monitor the growth of every child worldwide, regardless of ethnicity, socioeconomic status and type of feeding. Therefore, the standards are meant for use in both developing and developed countries. Many developed countries are concerned about obesity in young children but have local growth curves that identify the problem only after a child has become obese. For such countries, the new standard will be a useful tool for identifying overweight and obesity problems before they become too difficult to control or to prevent. The new WHO Child Growth Standards provide a solid instrument for helping to meet the health and nutritional needs of all the worlds children. How will the new WHO Child Growth Standards be used by: Health practitioners? The new standards and training materials provide health practitioners with an effective screening tool to assess growth of children in their care, ensure timely and adequate treatment if necessary, and counsel parents or caregivers. Nutritionists? Through the easy-to-use application kit, the standards will serve as a robust tool to assess nutritional status of individuals or populations and monitor child growth and development. Child and health advocates? As a tool that underscores the right of every child to grow to their full potential and by demonstrating that children from diverse geographical regions grow similarly, one can promote and protect the right of children to grow normally. The WHO Child Growth Standards also provide a means to advocate for protection, promotion and support of breastfeeding and adequate complementary feeding and thus for full implementation of the Global Strategy for Infant and Young Child Feeding (2002).Parents/caregivers? As a tool to better monitor the growth of their child to age five, to understand and follow nutritional recommendations and also to seek timely health care for their child. http://www.who.int/childgrowth/2_why.pdf

WHO Child Growth Standards BACKGROUNDER 3 What is the connection between the new WHO Child Growth Standards and infant and young child feeding practices? The growth of an infant is strongly linked to how he or she is fed. The nutritional, immunological and growth benefits of breastfeeding have been proven, and so the breastfed infant is the natural standard for physiological growth. The adequacy of human milk to support not only healthy growth but cognitive development and long term health provided a clear rationale for basing the new Standards on breastfed infants. As a departure, then, from previous growth reference charts used to measure babies and children, the new WHO Child Growth Standards are based on the premise that the breastfed baby is the norm for healthy growth among infants. Until now, existing child growth references were based on infants who were breast and/or artificially fed, but this variable was not controlled for in these early studies. Because breastfed babies are lean babies, the shape of the curve in the new WHO Child Growth Standards differs from these earlier references, particularly during the first six months of life when growth is rapid. Additionally, the children selected in the study were fed after the first six months according to guidelines for complementary feeding recommended in the Global Strategy for Infant and Young Child Feeding. What is the Global Strategy for Infant and Young Child Feeding? Infant and young child feeding is a cornerstone of care for childhood development. WHO and UNICEF jointly developed the Global Strategy for Infant and Young Child Feeding in 2002 as a guide for countries to develop policies addressing feeding practices and the nutritional status, growth, health, and therefore the very survival, of infants and children. The Strategy states that breastfeeding is an unequalled way of providing ideal food for the healthy growth and development of infants. It recommends that infants should be exclusively breastfed for the first six months of life to achieve optimal growth, development and health. Thereafter, to meet their evolving nutritional requirements, they should receive adequate and safe complementary foods while breastfeeding continues up to two years or beyond. Complementary food is the additional food and drink rich in nutrients that is recommended for children at the end of the first six months of life. The transition from exclusive breastfeeding to complementary feeding typically covers the period from 6 to 18-24 months of age, and is a very vulnerable period. It is the time when malnutrition starts in many children. Thus it is essential that infants receive appropriate, adequate and safe complementary foods to ensure the right transition from breastfeeding to the full use of family foods.

The Strategy is based on evidence that nutrition plays a crucial role in the early months and years of life and the importance of appropriate feeding practices in achieving optimal health. Lack of breastfeeding can set up risk factors for ill-health. The life-long impact may include poor school performance, reduced productivity, impaired intellectual and social development, or chronic diseases. Inadequate infant growth due to poor nutrition leads to under-nutrition in children in many developing countries, which if followed later in life by an increased intake of calories e.g. carbohydrates, fats, etc., could result in overweight or obesity. It is not uncommon to see an undernourished child in the same 1household as an overweight adult. This is becoming known as the 'double burden of malnutrition'. (see backgrounder 4: 'WHO Child Growth Charts and the Double Burden of Malnutrition') How will the new WHO Child Growth Standards support implementation of the Global Strategy on Infant and Young Child Feeding? The Standards are a crucial new tool for monitoring infant and child growth and for evaluating efforts to implement the Global Strategy. As such, they provide a means to advocate for protection, promotion and support of breastfeeding and adequate complementary feeding. Full implementation of the objectives of the Global Strategy will enable supportive environments for mothers to breastfeed their children. The new Child Growth Standards provide the necessary measurement and evaluation tool for parents, caregivers, health practitioners, policymakers and advocates with which to monitor healthy growth, ensure timely screening and treatment, recommend and follow positive nutritional practices. http://www.who.int/childgrowth/3_standards_and_feeding.pdf

WHO Child Growth Standards BACKGROUNDER 4 What is the double burden of malnutrition? There are 170 million underweight children globally, 3 million of whom will die each year as a result of being underweight. Additionally, WHO estimates worldwide at least 20 million children under five years of age are overweight, as well as more than a billion adults, and at least 300 million adults who are clinically obese. These problems are often thought of as separate issues of rich and poor, but in reality both are increasingly rooted in poverty. This is the double burden of malnutrition. Malnutrition, Under-nutrition, Over-nutrition:Malnutrition refers to deficiencies, excesses or imbalances in intake of energy, protein and/or other nutrients. Contrary to common usage, the term 'malnutrition' correctly includes both under-nutrition and over-nutrition.

Under-nutrition is the result of food intake that is continuously insufficient to meet dietary energy requirements, poor absorption and/or poor biological use of nutrients consumed. This usually results in loss of body weight. Over-nutrition refers to a chronic condition where intake of food is in excess of dietary energy requirements, resulting in overweight and/or obesity. How does under-nutrition affect children? A healthy start in life is important to every newborn baby. The first 28 days, the neonatal period, is critical. It is during this time that fundamental health and feeding practices are established (see also backgrounder 3: WHO Child Growth Standards and Infant and Young Child Feeding). It is also during this time that the child is at highest risk for death. The 30 million low-birth-weight babies born annually (23.8% of all births) often face severe shortand long-term health consequences. Low birth weight is a major determinant of death: 53% of all newborn and infant deaths have under-nutrition as an underlying cause. It can also lead to longterm impact on health outcomes in later life. Furthermore, the consequences of poor nutritional status and inadequate nutritional intake for women during pregnancy not only directly affects womens health status, but may also have a negative impact on the child's birth weight and early development. Low birth weight also results in substantial costs to the health sector and imposes a significant burden on society as a whole. Whereas the global prevalence of such births is slowly dropping, it is as high as 30% in many developing countries. What is the growing problem of over-nutrition? A substantial disease burden, including chronic diseases such as heart disease, stroke, diabetes and cancer, is attributable to health risks related to over-nutrition or the over-consumption of certain food or food components. Chronic diseases were the cause of 35 million deaths globally in 2005, 80% of which were in low and middle income countries. In many developing countries, especially in the urban populations, there is an increase in the consumption of energy-dense nutrient poor foods (high in fats and sugars and not enough nutrients) and a decrease in physical activity. Social and economic progress has led to the greater consumption of meats, oils and sugars as cheap processed foods. At the same time, the consumption of fruits, vegetables and grains has decreased. 1Health problems associated with inadequate calorie consumption and insufficient micronutrients now coexist with the growing presence of diet related chronic diseases, such as heart disease, stroke, cancer and diabetes, among adults. This double burden of malnutrition often manifests itself as a life-cycle problem. Inadequate infant growth leads to under-nutrition in children in many developing countries, which if followed later in life by an increased intake of calories e.g. carbohydrates, fats, etc., could result in overweight or obesity. It is not uncommon to see an under-nourished child in the same household as an overweight adult. How can the WHO Child Growth Standards help counter malnutrition?

The WHO Child Growth Standards will help monitor and assess the nutritional status of infants and young children. When used over an entire population, high levels of under- or over-weight will signal a risk of health and nutritional problems across that population. The standards will therefore work as a diagnostic tool to assess unhealthy trends. Additionally, the WHO Child Growth Standards will help spot trends in children towards overweight or underweight by measuring the rate at which they lose or gain weight. The new standards will therefore help monitor and counter the growing global phenomena of under- and over-nutrition, also referred to as the double burden of malnutrition. How do the WHO Child Growth Standards help achieve the Millennium Development Goals? As noted, the WHO Child Growth Standards will be tools to help monitor the nutritional status of communities and alert practitioners and policymakers to unhealthy trends in the population. Several of the MDGs - eradication of extreme poverty and hunger (MDG 1), achievement of universal primary education (MDG 2), gender equality and empowerment of women (MDG 3) and those of reduction in child mortality (MDG 4) and maternal health (MDG 5) in particular - depend on ensuring proper growth and development of children. The standards will significantly contribute to implementation and to measuring progress. 2 http://www.who.int/childgrowth/4_double_burden.pdf