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Protocol - Growth Charts

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This section will be completed when reviewed by an Expert Review Panel.

Availability:

Publicly available

Description:

The World Health Organization (WHO) and the Centers for Disease Control and Prevention (CDC) growth charts include both standard graph lines and a series of percentile curves that demonstrate the distribution of certain body measurements in individuals. Each growth chart may illustrate a specific gender and age range. The percentile curves on each chart depend on which measurement is being recorded.

The percentile curves on the WHO and CDC growth charts are for individuals who appear to be unaffected by a condition impacting growth. To provide information for special populations, growth charts for specific conditions have been developed; these growth charts contain percentile curves for the distribution of body measurements in individuals with the specific condition. Some conditions with a specific growth chart are cerebral palsy, achondroplasia, Turner syndrome, and Duchenne muscular dystrophy (DMD).

Protocol:

S T E P

1 Obtain accurate measurements When weighing and measuring children, follow procedures that yield accurate measurements and use equipment that is well maintained. For weight and height measurements, refer to the PhenX Height and Weight Measures. (Note: for consistency, this sentence has been modified to reference PhenX measures, instead of the reference in the original protocol)

2 Select the appropriate growth chart Select the growth chart to use based on the age and sex of the child being weighed and measured.

Enter the child’s name and the record number, if appropriate.

Use the charts listed below when measuring weight and length of children from birth up to 2 years of age:

Use the charts listed below when measuring weight and stature in children and teens aged 2 through 19 years:

• WHO Weight-for-age

• CDC Weight-for-age

• WHO Length-for-age

• CDC Stature-for-age

• WHO Weight-for-length

• CDC BMI-for-age

3 Record data After selecting the appropriate chart and entering the patient’s name and record number, if appropriate, complete the data entry table.

First, record information about factors obtained at the initial visit that influence growth.

Enter mother’s and father’s stature as reported.

Enter the gestational age in weeks. (Omit this step when using the CDC growth charts for children and teens aged 2 to 20 years.)

The next line is reserved for recording the child’s birth data. (Omit this step when using the CDC growth charts for children and teens aged 2 to 20 years.)

Enter the date of birth.

Enter birth weight and length.

Add notable comments (e.g., breastfeeding).

Record information obtained during the current visit.

Enter today’s date.

Determine age to the nearest month for infants and children up to 2 years and to the nearest 1/4-year for children aged 2 to 20 years.

Enter the child’s age.

Enter weight, and length or stature, immediately after taking the measurement.

Add any notable comments (e.g., was not cooperative).

Example of how to calculate the child’s age: To calculate Sam’s age, subtract his birth date from the date of the visit or measurement. To subtract, it will be necessary to convert months to days and years to months if either the month or day in the birth data is larger than in the date of measurements. When converting one month to days, subtract 1 from the number of months in the date of measurement, then add 28, 30, or 31, as appropriate, to the number of days. When converting one year to months, subtract 1 from the number of years in the date of measurement, then add 12 to the number of months.

Days à Months

Months à Year

0-15

0

0-1

40

16-31

1

2-4

1/4

Using the guide above, 3 years, 6 months, and 19 days is rounded to 3 years and 7 months. Because age for children over 2 is rounded to the nearest ¼ year, Sam’s age is rounded to 3 ½ years

5-7

1/2

8-10

3/4

11-12

1

Year

Month

Day

Date of Measurement

1998

4

4

Convert one month to days

1998

(-1)

3

(+30)

34

Convert one year to months

(-1)

1997

(+12)

15

34

Birth Date

1994

9

15

Child’s Age

3

6

19

Sam is aged 3 years, 6 months, and 19 days.

4 Calculate BMI when a child is aged 2 to 20 years BMI is calculated using weight and stature measurements, then used to compare a child’s weight relative to stature with other children of the same age and sex in the reference population.

Using a calculator, hand-held device or software, determine BMI using the calculation below. The Rare Genetic Conditions WG slightly revised the below calculation and added the example.

BMI = [Weight (kg) ÷ (Stature (cm) x Stature (cm))] x 10,000

Or

BMI = [Weight (lb) ÷ (Stature (in) x Stature (in))] x 703

For example: If an individual’s weight is 70kg and their stature is 180cm, then their BMI would be calculated as follows:

BMI = [Weight (kg) ÷ (Stature (cm) x Stature (cm))] x 10,000

BMI = [ 70 kg ÷ (180 cm x 180 cm)] x 10,000 = [70 ÷ 32,400] x 10,000 = 0.002160 x 10,000 = 21.60

It is necessary to convert the weight and stature measurements to the appropriate decimal value shown in Table 1.

Example: 37 lbs. 4 oz. = 37.25 lbs., 41-1/2 inches = 41.5 in.

Table 1. Decimal Conversions

Fraction

Ounces

Decimal

1/8

2

.125

1/4

4

.25

3/8

6

.375

1/2

8

.5

5/8

10

.625

3/4

12

.75

7/8

14

.875

Enter BMI to one place after the decimal point (Example: 15.204 = 15.2).

For more information and additional resources on calculating BMI, see Using the CDC BMI-for-age Growth Charts for Children and Teens Aged 2 to 20 Years at [link[www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/page1a.htm|www.cdc.gov/nccdphp/dnpa/growthcharts/training/modules/module1/text/page1a.htm]]

5 Plot measurements On the appropriate WHO or CDC growth chart, plot the measurements recorded in the data entry table for the current visit.

Find the child’s age on the horizontal axis. When plotting weight-for-length, find the length on the horizontal axis. Use a straight edge or right-angle ruler to draw a vertical line up from that point.

Find the appropriate measurement (weight, length, stature, or BMI) on the vertical axis. Use a straight edge or right-angle ruler to draw a horizontal line across from that point until it intersects the vertical line.

Make a small dot where the two lines intersect.

6 Interpret the plotted measurements The curved lines on the growth chart show selected percentiles that indicate the rank of the child’s measurement. For example, when the dot is plotted on the 95th percentile line on the CDC BMI-for-age growth chart, it means that 5 of 100 children (5%) of the same age and sex in the reference population have a higher BMI-for-age.

The WHO growth standard charts use the 2nd and the 98th percentiles as the outer most percentile cutoff values indicating abnormal growth.

The CDC growth reference charts use the 5th and the 95th percentiles as the outermost percentile cutoff values indicating abnormal growth.

Interpret the plotted measurements based on the percentile ranking on the WHO or the CDC growth charts and the percentile cutoff value corresponding to the nutrition indicator shown in the table below. If the percentile rank indicates a nutrition-related health concern, additional monitoring and assessment are recommended.

Determine the percentile rank.

Determine if the percentile rank suggests that the anthropometric index is indicative of nutritional risk based on the percentile cutoff value.

Compare today’s percentile rank with the rank from previous visits to identify any major shifts in the child’s growth pattern and the need for further assessment.

When transitioning from the WHO growth charts to the CDC growth charts at aged 2 years, a change in growth classification may occur. During this transition, caution should be used in interpreting any changes in classification.

Anthropometric Index

Percentile Cut-off Values

Nutritional Status Indicato

WHO Growth Charts 2nd and 98th percentiles

Length-for age

< 2nd

Short stature

Weight-for-length

< 2nd

Low weight-for-length

Weight-for-length

> 98th

High weight-for-length

CDC Growth Charts 5th and 95th percentiles

BMI-for-age

> 95th

Obesity

BMI-for-age

> 85th and < 95th

Overweight

BMI-for-age

< 5th

Underweight

Stature-for-age

< 5th

Short stature

Cerebral palsy:

Growth charts are available for indivduals with cerebral palsy at the Life Expectancy Project’s website: [link[www.lifeexpectancy.org/articles/NewGrowthCharts.shtml|www.lifeexpectancy.org/articles/NewGrowthCharts.shtml]] This site contains weight-for-age, height-for-age, and BMI-for-age growth charts, for individuals age 2 to 20 years old. The charts are strafied by gender and the Gross Motor Function Classification System (GMFCS). Additionally, there are separate charts for individuals with a level 5 GMFCS who require a feeding tube and those who do not require a feeding tube.

Note: the proper use of growth charts require an accurate height and weight of the individual. The Rare Genetic Conditions Working Group recommends investigators use the height and weight measures in the PhenX Toolkit, if they do not have an individual’s height/weight.

Achondroplasia:

Growth charts are available for individuals with achondroplasia at the Little People of America’s (LPA) Medical Resource Center website. The charts are separated by gender and the age range is 0-18 years (depending upon the feature which is being plotted). There are charts to plot height for age, head circumference, segmental growth, and other measurements. See the "Specific Instructions" section for the Rare Genetic Conditions Working Group’s suggestions regarding other measurements.

The growth charts listed below are specific to individuals with achondroplasia. These charts are available via the links below and also on the LPA Medical Resource Center website.

  1. [alink[A_Growth_Charts_Achondroplasia_Height_for_Age_Males.pdf|Growth Charts: Achondroplasia Height for Age: Male]]
  2. [alink[B_Growth_Charts_Achondroplasia_Height_for_Age_Females.pdf|Growth Charts: Achondroplasia Height for Age: Female]]
  3. [alink[C_Growth_Charts_Achondroplasia_Head_Circumference_Males.pdf|Growth Charts: Achondroplasia Head Circumference: Male]]
  4. [alink[D_Growth_Charts_Achondroplasia_Head_Circumference_Females.pdf|Growth Charts: Achondroplasia Head Circumference: Female]]
  5. [alink[E_Growth_Charts_Achondroplasia_Foramen_Magnum_Size.pdf|Growth Charts: Achondroplasia Foramen Magnum Size]]

Turner Syndrome:

A growth chart for height for age is available from the Abbott Nutrition Health Institute:

[link[images.abbottnutrition.com/ANHI2010/MEDIA/BC%20Decker%20Appendix%20Fig%2047-50%20Turner%20Syndrome.pdf|images.abbottnutrition.com/ANHI2010/MEDIA/BC%20Decker%20Appendix%20Fig%2047-50%20Turner%20Syndrome.pdf]]

This chart is for girls with Turner syndrome who are 2-19 years old and have not been receiving hormone therapy.

Duchenne Muscular Dystrophy:

Dr. Nancy West and colleagues have developed growth charts for males with Duchenne muscular dystrophy (DMD). These charts are for weight for age, height for age, and BMI for age and apply to males with DMD who are age 2-12 years, ambulatory, and steroid-naïve. These charts are available in the publication titled: "Patterns of Growth in Ambulatory Males with Duchenne Muscular Dystrophy." Publication details are listed in the "Source" section.

Personnel and Training Required

Technicians should be trained in the basic techniques of anthropometric measurements.

Equipment Needs

Stadiometer with a fixed-length backboard and an adjustable headpiece, digital scale, or beam balances.

Requirements

Requirement CategoryRequired
Average time of greater than 15 minutes in an unaffected individualNo
Major equipmentNo
Specialized requirements for biospecimen collectionNo
Specialized trainingNo

Mode of Administration

Self-administered

Life Stage:

Infant, Toddler, Child, Adolescent, Adult

Specific Instructions:

The Rare Genetic Conditions Working Group (WG) acknowledges that the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) growth charts provide important information for growth comparisons between an individual with a rare genetic condition and others without such a condition. However, when available, the growth of an individual with a rare genetic condition should also be recorded and tracked on growth charts that are specific for their condition.

The protocol for how to measure head circumference is not provided in this protocol. The PhenX protocol for head circumference is widely used.

Note: For achondroplasia and Turner syndrome, the WG recommends the CDC growth charts be used to assess weight for age, weight for height, and BMI for age.

The WHO and CDC growth charts and a detailed online training course are available on the CDC website at [link[www.cdc.gov/growthcharts/who_charts.htm|www.cdc.gov/growthcharts/who_charts.htm]], [link[www.cdc.gov/growthcharts/cdc_charts.htm|www.cdc.gov/growthcharts/cdc_charts.htm]] and [link[www.cdc.gov/nccdphp/dnpao/growthcharts/who/index.htm|www.cdc.gov/nccdphp/dnpao/growthcharts/who/index.htm]], respectively.

Once the appropriate growth charts are obtained, follow the CDC recommendation, background, purpose and six steps (see below) regarding their use and interpretation. (Note this information is also available in a PDF from the CDC website at:

[link[www.cdc.gov/nccdphp/dnpa/growthcharts/resources/growthchart.pdf|www.cdc.gov/nccdphp/dnpa/growthcharts/resources/growthchart.pdf]].)

CDC Recommendation

• Use the WHO growth charts for all children from birth up to 2 years of age to monitor growth in the United States. The WHO growth standards for children younger than 2 years have been adapted for use in the United States.

• Use the CDC growth charts for children and teens aged 2 through 19 years to monitor growth in the United States.

Background

• The WHO growth charts are international standards that show how healthy children should grow. The standards describe the growth of children living in six countries (including the United States) in environments believed to support optimal growth. One of the several criteria defined for optimal growth is breastfeeding. The WHO growth charts use the growth of breastfed infants as the norm for growth. This is in agreement with national guidelines that recommend breastfeeding as the optimal infant feeding method. The WHO growth charts should be used with all children up to aged 2 years, regardless of type of feeding.

• The CDC growth charts are a national reference that represent how US children and teens grew primarily during the 1970s, 1980s and 1990s. The CDC recommends using the references from ages 2 through 19 years so health care providers can track weight, stature, and body mass index (BMI) from childhood through age 19 years.

Purpose

• This guide instructs health care providers on how to use and interpret the WHO and CDC growth charts to assess physical growth among children and teens. Comparing body measurements with the appropriate age- and sex-specific growth chart enables health care providers to monitor growth and identify potential health- or nutrition-related problems.

During routine screening, health care providers assess physical growth using the head circumference, weight and length of infants and children up to 2 years of age and the weight, stature (also referred to as height), and BMI of children and teens from aged 2 through 19 years. Although one measurement plotted on a growth chart can be used to screen children for nutritional risk, it does not provide adequate information to determine the child’s growth pattern. When plotted correctly, a series of accurate measurements offer important information about a child’s growth pattern. Gestational age, birth weight, and parental stature should be considered since they may influence a child’s growth pattern. Parental stature, for example, should be considered before assuming there is a health or nutrition concern. Other factors, such as the presence of a chronic illness or special health care need, must be considered, and further evaluation may be necessary.

Research Domain Information

Release Date:

April 30, 2015

Definition

A standardized method to record and track the growth of an individual. This method can be used to track growth by length (i.e., height), weight, body mass index (BMI), and head circumference.

Purpose

Information from this measure can be used to monitor growth of infants, children, and adolescents and to identify potential health- or nutrition-related problems, such as obesity. Additionally, this measure can be used to monitor features of specific conditions, such as cerebral palsy, achondroplasia, Turner syndrome, and Duchenne muscular dystrophy (DMD).

Selection Rationale

The Centers for Disease Control and Prevention (CDC) recommends the use of the World Health Organization (WHO) growth charts to monitor growth in individuals from birth to 2 years old and the use of its growth charts for individuals age 2-20 years. Additionally, per the CDC website ([link[www.cdc.gov/growthcharts/|www.cdc.gov/growthcharts/]]), growth charts contribute to forming an overall clinical impression and are not intended to be used as a sole diagnostic tool. The Rare Genetic Conditions Working Group agrees with this recommendation and use of growth charts.

Language

English

Standards

StandardNameIDSource
Common Data Elements (CDE)Growth Charts Assessment Score4798245CDE Browser

Process and Review

This section will be completed when reviewed by an Expert Review Panel.

Source

Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO): www.cdc.gov/growthcharts/ and www.cdc.gov/nccdphp/dnpa/growthcharts/resources/growthchart.pdf

Cerebral Palsy:

The Life Expectancy Project website: www.lifeexpectancy.org/articles/NewGrowthCharts.shtml

Achondroplasia:

Little People of America Medical Resource Center: lpamrs.memberclicks.net/index.php?option=com_content&view=article&id=66

Hecht, J. T., Horton, W. A., Reid, C. S., Pyeritz, R. E., & Chakraborty, R. (1989). Growth of the foramen magnum in achondroplasia. American Journal of Medical Genetics, 32, 528-535.

Horton, W. A., Rotter, J. I., Rimoin, D. L., Scott, C. I., & Hall, J. G. (1978). Standard growth curves for achondroplasia. Journal of Pediatrics, 93, 435-438.

Turner Syndrome:

Lyon, A. J., Preece, M. A., & Grant, D. B. (1985). Growth curve for girls with Turner syndrome. Archives of Disease in Childhood, 60, 932-935.

AbbottNutritionHealthInstitute.org With permission from Duggan C, et al. (2008). Nutrition in pediatrics (4th ed.). Hamilton, Ontario, Canada: BC Decker Inc.

Duchenne Muscular Dystrophy:

West, N. A., Yang, M. L., Weitzenkamp, D. A., Andrews, J., Meaney, F. J., Oleszek, J., Miller, L. A., Matthews, D., & DiGuiseppi, C. (2013). Patterns of growth in ambulatory males with Duchenne muscular dystrophy. Journal of Pediatrics, 163, 1759-1763.

General References

American Academy of Pediatrics. (2009). Pediatric nutrition handbook (6th ed.). Elk Grove Village, IL: American Academy of Pediatrics.

Barlow, S. E.; Expert Committee. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120(Suppl. 4), S164-S192.

Brooks, J., Day, S.M., Shavelle, R.M., & Strauss, D.J. (2011). Low weight, morbidity, and mortality in children with cerebral palsy: New clinical growth charts. Pediatrics, 128; e299; originally published online July 18, 2011 (DOI 10.1542/peds.2010-2801).

Dewey, K. G., Cohen, R. J., Nommsen-Rivers, L. A., & Heinig, M. J.; WHO Multicenter Growth Reference Study Group. (2004). Implementation for the WHO Multicentre Growth Reference Study in the United States. Food and Nutrition Bulletin, 25(Suppl. 1), S84-S89.

Grummer-Strawn, L. M., Reinold, C., & Krebs, N. F.; Centers for Disease Control and Prevention. (2010). Use of the World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR Recommendations and Reports, 59(RR-9), 1-15.

Kuczmarski, R. J., Ogden, C., Grummer-Strawn, L., Flegal, K. M., Guo, S. S., Wei, R., Johnson, C. L. (2000). CDC growth charts: United States. Advance Data, 314, 1-27.

Kuczmarski, R. J., Ogden, C. L., Guo, S. S., Grummer-Strawn, L., Flegal, K. M., Mei, Z., Johnson, C. L. (2002). 2000 CDC growth charts for the United States: Methods and development. National Center for Health Statistics. Vital Health Stat 11(246), 1-190.

World Health Organization. (1995). Physical status: The use and interpretation of anthropometry (WHO Technical Report Series 854). Geneva, Switzerland: Author.

World Health Organization. (2006). WHO child growth standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and development. Geneva, Switzerland: Author.

Protocol ID:

221201

Variables:

Export Variables
Variable NameVariable IDVariable DescriptionVersiondbGaP Mapping
PX221201_Growth_Chart_Patient_NamePX221201010000Patient Name4N/A
PX221201_Growth_Chart_Patient_Record_NumberPX221201020000Patient Record Number4N/A
PX221201_Growth_Chart_Mothers_StaturePX221201030000Mother of Patient - Stature4N/A
PX221201_Growth_Chart_Fathers_StaturePX221201040000Father of Patient - Stature4N/A
PX221201_Growth_Chart_Gestational_AgePX221201050000Child's Gestational Age4N/A
PX221201_Growth_Chart_Date_Of_BirthPX221201060000Child's Date of Birth4Variable Mapping
PX221201_Growth_Chart_Birth_WeightPX221201070000Child's Birth Weight4N/A
PX221201_Growth_Chart_Birth_LengthPX221201080000Child's Birth length4N/A
PX221201_Growth_Chart_Notable_CommentsPX221201090000Notable comments on birth4N/A
PX221201_Growth_Chart_Today's_DatePX221201100000Today's date4N/A
PX221201_Growth_Chart_Child's_AgePX221201110000Child's age today4N/A
PX221201_Growth_Chart_Current_WeightPX221201120000Child's weight today4N/A
PX221201_Growth_Chart_Current_LengthStaturePX221201130000Child's length/stature today4N/A
PX221201_Growth_Chart_Current_Notable_CommentsPX221201140000Notable comments on current growth4N/A
PX221201_Growth_Chart_Current_BMIPX221201150000BMI = [Weight (kg) ¿¿ (Stature (cm) x Stature (cm))] x 10,0004N/A
PX221201_Growth_Chart_Short_StaturePX221201160000Short Stature table4N/A
PX221201_Growth_Chart_Low_WeightForLengthPX221201170000Low Weight Table4N/A
PX221201_Growth_Chart_High_WeightForLengthPX221201180000High Weight Table4N/A
PX221201_Growth_Chart_ObesityPX221201190000BMI for Age Obeese4N/A
PX221201_Growth_Chart_OverweightPX221201200000BMI for Age Overweight4N/A