(cid:52)(cid:82)(cid:65)(cid:73)(cid:78)(cid:73)(cid:78)(cid:71)(cid:0)(cid:35)(cid:79)(cid:85)(cid:82)(cid:83)(cid:69)(cid:0)(cid:79)(cid:78)(cid:0)(cid:35)(cid:72)(cid:73)(cid:76)(cid:68)(cid:0)(cid:39)(cid:82)(cid:79)(cid:87)(cid:84)(cid:72)(cid:0)(cid:33)(cid:83)(cid:83)(cid:69)(cid:83)(cid:83)(cid:77)(cid:69)(cid:78)(cid:84) (cid:55)(cid:40)(cid:47)(cid:0)(cid:35)(cid:72)(cid:73)(cid:76)(cid:68)(cid:0)(cid:39)(cid:82)(cid:79)(cid:87)(cid:84)(cid:72)(cid:0)(cid:51)(cid:84)(cid:65)(cid:78)(cid:68)(cid:65)(cid:82)(cid:68)(cid:83)(cid:0) (cid:30) (cid:38)(cid:71)(cid:77)(cid:75)(cid:72)(cid:61)(cid:78)(cid:60)(cid:77)(cid:66)(cid:72)(cid:71) Training Course on Child Growth Assessment WHO Child Growth Standards A Introduction Department of Nutrition for Health and Development WHO Library Cataloguing-in-Publication Data WHO child growth standards : training course on child growth assessment. "The project was designed and coordinated by Adelheid W. Onyango and Mercedes de Onis ..."--Acknowledgements. Contents: A. Introduction -- B. Measuring a child's growth -- C. Interpreting growth indicators -- D. Counselling on growth and feeding -- E. Photo booklet -- Answer sheets -- Facilitator's guide -- Course director's guide -- Boy's growth record -- Girl's growth record -- Job aids. 1.Child development. 2.Growth. 3.Anthropometry - methods. 4.Body weights and measures - standards. 5.Nutrition assessment. 6.Teaching materials. I.Onyango, Adelheid W. II.de Onis, Mercedes. III.World Health Organization. IV.Title: World Health Organization child growth standards. ISBN 92 4 159507 8 (NLM classification: WS 103) ISBN 978 92 4 159507 0 © World Health Organization 2008 All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: [email protected]). Requests for permission to reproduce or translate WHO publications – whether for sale or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]). The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. The named authors alone are responsible for the views expressed in this publication. Printed in China Training Course on Child Growth Assessment WHO Child Growth Standards Acknowledgements This training course has been prepared by the Department of Nutrition, World Health Organization, Geneva. The project was designed and coordinated by Adelheid W. Onyango and Mercedes de Onis who provided the main technical input. Contributions to the technical content by Chessa Lutter (AMRO/PAHO), Cutberto Garza (Boston, MA, USA) and Ilgi Ertem (Ankara, Turkey) are gratefully acknowledged. The field-test version of the materials was reviewed in-depth by staff of the FANTA Project, USAID, and participants in the PAHO regional Training of Trainers workshop in Barbados, May 2006. Version 1, published in November 2006 was reviewed during Regional workshops in EMRO (Cairo, February 2007), AFRO (Addis Ababa, June 2007), WPRO (Shah Alam, September 2007) and SEARO (Bali, October 2007). The comments and suggestions provided by participants at these workshops have been used to refine the course for this final printing. The course modules were developed and laid out by Patricia Whitesell Shirey and Florence C. Johnson of ACT International, Atlanta, Georgia, USA. With funds from the Bill and Melinda Gates Foundation, the course was field-tested in collaboration with the Caribbean Program Coordination, PAHO in Barbados, and its first version further tested and refined with the collaboration of the respective WHO Regional Offices (EMRO, AFRO, WPRO and SEARO) and the Country Offices in Ethiopia, Malaysia and Indonesia. Suggested citation: World Health Organization. Training Course on Child Growth Assessment. Geneva, WHO, 2008. iii iv A: Introduction Contents Child growth assessment......................................................................................................1 The WHO child growth standards.......................................................................................2 Purpose of this training course.............................................................................................3 Course methods and materials.............................................................................................4 Learning objectives..............................................................................................................5 Glossary...............................................................................................................................7 References..........................................................................................................................10 v A: Introduction Child growth assessment Basic growth assessment involves measuring a child’s weight and length or height1 and comparing these measurements to growth standards. The purpose is to determine whether a child is growing “normally” or has a growth problem or trend towards a growth problem that should be addressed. Module B: Measuring a Child’s Growth and module C: Interpreting Growth Indicators explain how to: (cid:120) measure weight, length, and height; (cid:120) calculate body mass index (BMI); (cid:120) plot these measurements on growth charts; and (cid:120) interpret growth indicators. Correct measurement, plotting, and interpretation are essential for identifying growth problems. If a child has a growth problem or trend towards a growth problem, the health care provider should talk with the mother or other caregiver2 to determine the causes. It is then critically important to take action to address the causes of poor growth. Growth assessments that are not supported by appropriate response programmes are not effective in improving child health. In circumstances such as extreme poverty or emergencies, growth assessment is aimed at identifying children who need urgent intervention, such as therapeutic or supplementary feeding, to prevent death. In the health facility settings described in this course, children with severe forms of undernutrition should be referred for specialized care. Children with obesity should be referred for medical assessment and specialized management. Non-severe problems can be managed through counselling, including age-appropriate advice on feeding and physical activity, as described in module D: Counselling on Growth and Feeding.3 The WHO child Growth Records include the growth charts and recommendations for feeding and care. These recommendations are a set of messages that could serve as a reference for parents, other child caregivers, and health care providers. The Boy’s Growth Record and Girl’s Growth Record are both provided with this course; the same feeding and care recommendations apply for boys and girls. These recommendations are also included in the annex to module D: Counselling on Growth and Feeding. 1 There are other growth measures (e.g. head circumference), but these are not covered in this course. Length of children less than 2 years old is measured lying down, while standing height is measured for children age 2 years or older. Throughout the modules the phrase length/height is used to indicate that the age-appropriate measurement for linear growth should be used. 2 In this course the word “mother” is often used to refer to the child’s primary caregiver. It is understood that the primary caregiver may be another person, such as the father, grandmother, or another relative or guardian. 3 Note that counselling is only one part of effective growth promotion interventions. The “Growth Promotion Package” includes: 1. Regular assessment of child growth; 2. Decision making and action needed for the child; 3. Decision making and action at the community and program level to support actions in the household; and 4. Follow-up/feedback on the effects of actions taken at household and community/program levels. (See Promoting the Growth of children: What Works, Griffiths M, Dickin K, and Favin M, World Bank Nutrition Toolkit, 1996) A: Introduction – 1 The WHO child growth standards http://www.who.int/childgrowth/ In the past, growth references were developed using data from a single-country sample of children presumed to be healthy. There were no specific health behaviours required for children to be included in the reference sample. The result was a set of references that described the growth attained by children raised on modes of feeding and care that were typical of a particular time period and country. The World Health Organization (WHO) has developed growth standards based on a sample of children from six countries: Brazil, Ghana, India, Norway, Oman, and the United States of America. The WHO Multicentre Growth Reference Study (MGRS)1 was designed to provide data describing how children should grow, by including in the study’s selection criteria certain recommended health behaviours (for example, breastfeeding, providing standard paediatric care, and not smoking). The study followed term babies from birth to 2 years of age, with frequent observations in the first weeks of life. Another group of children, age 18 to 71 months, were measured once, and data from the two samples were combined to create the growth standards for birth to 5 years of age. By including children from many countries who were receiving recommended feeding and care, the MGRS resulted in prescriptive standards for normal growth, as opposed to simply descriptive references. The new standards show what growth can be achieved with recommended feeding and health care (e.g. immunizations, care during illness). The standards can be used anywhere in the world, since the study also showed that children everywhere grow in similar patterns when their nutrition, health, and care needs are met. Additional benefits of the new growth standards include the following: (cid:120) The new standards establish breastfed infants as the model for normal growth and development. As a result, health policies and public support for breastfeeding will be strengthened. (cid:120) The new standards will help better identify stunted and overweight/obese children. (cid:120) New standards such as BMI (body mass index) are useful for measuring the increasing worldwide epidemic of obesity. (cid:120) Charts that show standard patterns of the expected growth rate over time enable health care providers to identify children at risk of becoming undernourished or overweight early, rather than waiting until a problem level is reached. In addition to standards for physical growth, the WHO Child Growth Standards include six gross motor milestones (sitting without support, standing with assistance, hands-and-knees crawling, walking with assistance, standing alone, and walking alone) that healthy children are expected to achieve during specified age ranges between 4 and 18 months. The expected age ranges for achieving these milestones (or “windows of achievement”) are included in the WHO child Growth Records provided with this course. This course, however, focuses on physical growth assessment and does not provide training on assessing motor development. 1 de Onis M, Garza C, Victora CG, Bhan MK, Norum KR, editors. WHO Multicentre Growth Reference Study (MGRS): Rationale, Planning and Implementation. Food Nutr Bull 2004;25 (Suppl 1):S1–89. A: Introduction – 2