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The WHO Multicentre

Growth Reference
Study
(1997-2003)

WHO Growth Reference Study


Prescriptive Approach
Optimal Nutrition

Breastfed infants

Appropriate complementary feeding

Optimal Environment

No microbiological contamination

No smoking

Optimal Health Care

Immunization

Pediatric routines

Optimal
Growth

MGRS study design


Longitudinal (0-24
months)
year
year 2
year 3
1
Cross-sectional (18-71
mo)

MGRS Study Design and


Sample
Eligibility Criteria for Individuals
No health, environmental or economic constraints on growth
Mother willing to follow feeding recommendations:
Exclusive/ predominant breast feeding for 1st 4 mths,
introduction of complementary feeding by 6 mths
Term, single birth
Lack of significant perinatal morbidity
Non smoking mothers before and after delivery

MGRS Study Design and


Sample
Longitudinal study (birth-24 months)
Mothers & newborns screened &
enrolled at birth
Weight, length, head circumference: 21
times over 24 months
Arm circumference: 10 times between 3
and 12 months
Skin fold thickness : 6 times between 14
and 24 months

MGRS Study Design and


Sample
Cross-sectional survey (18-71 mo)
Weight, length, head circumference, arm
circumference, skin fold thickness
Total sample 8440 children from 6
countries
300 newborns per site (1743 total)
followed up till 24 mo from the
longitudinal study
1400 children per site (6647 total) aged
18-71 mo through the cross sectional
surveys

Construction of growth curves


The rigorous methods of data collection yielded very
high-quality dataset
State-of-art statistical methods applied in a methodical
way:
Detailed examination of 30 existing methods, including types of
distributions and smoothing techniques;
Selection of a software package flexible enough to allow
comparative testing of alternative methods and the actual
generation of the curves;
Systematic application of the selected approach to the data to
generate models that resulted in the best fit

WHO Child Growth Standards

Attained growth

Weight-for-age
Length/height-for-age
Weight-for-length/height
Body mass index-for-age
Mid-upper arm circumferencefor-age
Triceps skinfold-for-age
Subscapular skinfold-for- age
Head circumference-for-age

Growth velocity

Weight
Length/height
Head circumference
Arm circumference

Comparison of existing growth


charts
Data charact
Source
Study period

CDC

Multiple
different
studies

Primary data
1997-2003

1963-1994

Population

Age-group

WHO

US, mixed
feeding, no
racial/ethnic
diff
Birth-20 yrs

6 Countries
pooled data.
healthy breastfed
children
Birth-5yrs

WHO standards versus NCHS reference

Important differences that vary by age group,


sex, growth indicator, specific percentile or zscore curve, and the nutritional status of index
populations.
Differences are particularly important during
infancy due to type of feeding and issues
related to study design (eg, measurement
interval)
Difference in shapes of the weight-based
curves in early infancy makes interpretation of
growth performance strikingly different
depending on whether the WHO standard or
the NCHS reference is used
Healthy breastfed infants track along the WHO
weight-for-age mean z-score while appearing
to falter in NCHS from 2 months onwards
implications assessment of lactation

Mean weight-for-age z-scores of healthy breastfed


infants relative to the NCHS, CDC and WHO curves

Comparison of WHO with NCHS and CDC chart

Prevalence of stunting (below -2 SD length/height-for-age) by age based on the WHO


standards and the NCHS reference in Bangladesh

Prevalence of underweight (below -2 SD weight-for-age) by age based on the WHO


standards and the NCHS reference in Bangladesh

Growth charts
Consist of a series of percentile
curves that illustrate the
distribution of selected body
measurements in the study
population
Used to track the growth of
children from infancy thru
adolescence
Indicates the state of the child's

References:
1.World Health Organization. WHO child growth standards: length/height-forage, weight-for-length, weight for height, and body mass index for age:
methods & development. Geneva. World Health Organization. 2006
2.World Health Organization. Physical Status: The use and interpretation of
anthropometry. WHO Technical Report Series 854. Geneva. World Health
Organization; 1995. P. 418, 422-23.
3.Cole TJ. The use and construction of anthropometric growth reference
standards. Nutrition Research Reviews,1993(6):19-50
4. Mercedes O, Ray Y. The WHO Growth Chart: Historical consideration and
current scientific issues. Bibl Nutr Dieta;1996(53):pp 74-89
5. Onis M, Onyango AW, Borghi1 E, Garza C and Yang H. Comparison of the
World Health Organization (WHO) Child Growth Standards and the
National Center for Health Statistics/WHO international growth reference:
implications for child health programmes. Public Health
Nutrition,2006;9(7):942947