Growth Charts

A growth chart (also called the "road-to-health" chart) is a visual display of a child's physical growth and development over time. First designed by David Morley and later modified by the WHO, it is primarily used for the longitudinal follow-up (growth monitoring) of a child so that changes over time can be interpreted.

Park's Textbook of Preventive and Social Medicine, p. 637

Why Weight is the Primary Measure

Weight is the most sensitive measure of growth - any deviation from normal can be detected easily by comparison with reference curves. A child can lose weight but not height. Growth charts offer a simple, inexpensive way to monitor weight gain and, by extension, overall child health.

Standard Growth Chart Systems

WHO Child Growth Standards (2006) - for children < 2 years

The WHO conducted the Multicentre Growth Reference Study (MGRS) between 1997 and 2003 in Brazil, Ghana, India, Norway, Oman and USA, gathering data from 9,440 healthy breast-fed infants and young children (0-60 months) from diverse ethnic backgrounds. Mothers followed best practices: breastfeeding, non-smoking.

Standards generated include (for boys and girls, 0-60 months):

Length/height-for-age
Weight-for-age
Weight-for-length
Weight-for-height
BMI-for-age

CDC Growth Charts - for children ≥ 2 years

As per the Harriet Lane Handbook, the standard recommendation is:

< 24 months: WHO international growth charts
≥ 2 years: CDC growth charts

Premature Infants

Use corrected age (chronological age minus weeks of prematurity) up to 3 years
Fenton, Bertino, and Olsen charts are used from birth up to ~50 weeks corrected
After 4-8 weeks post-term, the WHO chart applies

Condition-Specific Charts

Condition-specific charts exist for: Down syndrome, Prader-Willi syndrome, Williams syndrome, Cornelia de Lange syndrome, Turner syndrome, and Marfan syndrome - however, WHO or CDC charts are still recommended alongside them.

The Harriet Lane Handbook, 23rd ed., p. 756

WHO vs. NCHS Comparison (Weight-for-Age Z-scores, Girls 0-60 months)

Comparison of WHO with NCHS weight-for-age Z-scores for girls, 0-60 months

Fig. 6 - Solid lines = WHO standards; dashed lines = NCHS reference. Z-score bands labelled -3 to +3. Differences are most notable in infancy.

Key differences when using WHO vs. NCHS:

Stunting is greater throughout childhood with WHO standards
Underweight rates increase in the first half of infancy with WHO standards, then decrease
Wasting rates are substantially higher with WHO standards during infancy
Overweight prevalence is higher with WHO standards

Interpretation Thresholds (Harriet Lane)

Parameter	Threshold	Interpretation
Length/Height-for-age	< 5th percentile	Stunting / short stature
Weight-for-length (< 2 yr)	< 5th percentile	Underweight
BMI-for-age (≥ 2 yr)	< 5th percentile	Underweight
BMI-for-age	5th to < 85th percentile	Healthy weight
BMI-for-age (≥ 2 yr)	85th to < 95th percentile	Overweight
BMI-for-age (≥ 2 yr)	≥ 95th percentile	Obese
Weight-for-length (< 2 yr)	> 95th percentile	Overweight

Normal Growth Milestones (Harriet Lane)

Age	Expected Growth
Birth to 2 weeks	Lose 5-10% birth weight, then regain
0-3 months	20-30 g/day weight gain
3-9 months	15-22 g/day weight gain
9-12 months	6-11 g/day weight gain
4-5 months	Birth weight doubled
1 year	Birth weight tripled
3-4 years	Birth length/height doubled
3-10 years	~2.5 inches (6.3 cm)/year height gain
4 years	Average: 40 inches, 35 lb

Uses of the Growth Chart

Per Park's (p. 637), a growth chart has multiple roles:

Growth monitoring - longitudinal follow-up; the direction of the curve matters more than the absolute position
Diagnostic tool - identifies "high-risk" children; malnutrition can be detected before clinical signs appear
Planning and policy - provides objective basis for health policy at local and national levels
Educational tool - the visual nature helps educate mothers and encourages active participation in child care
Tool for action - prompts the health worker and mother to act when growth falters
Passport to child health care - internationally recognized standard of child health monitoring

Key Principle: Direction Over Position

"It is the direction of growth that is more important than the position of dots on the line."

Flattening or falling of the weight curve = growth failure - the earliest sign of protein-energy malnutrition, often preceding clinical signs by weeks to months.

Growth Chart in India (ICDS)

India adopted the WHO Child Growth Standards 2006 in February 2009 for use in the National Rural Health Mission and ICDS program. A joint "Mother and Child Protection Card" was developed that incorporates the growth chart and:

Family/birth/pregnancy records
Immunization schedule
Breastfeeding and complementary feeding guidance
Developmental milestones
Zones: Normal, Undernutrition (< -2 SD), Severely Underweight (< -3 SD)

The card is kept by the mother and brought to every health centre visit.

Alternative Growth Monitoring Indicators

Beyond weight-for-age charts, other indicators include:

Height-for-age (detects stunting)
Weight-for-height (detects wasting; independent of age)
Mid-upper arm circumference (MUAC) - especially useful when age is unknown
Park's Textbook of Preventive and Social Medicine, p. 637-638
The Harriet Lane Handbook, 23rd ed., p. 756-757

Epidemology studies parks text book

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