Borstvoeding Bruist 25 September 2012

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1 Breastfed Infant as the Standard for Growth: WHO Child Growth Standards Borstvoeding Bruist 25 September 2012 Nutrition for Health and Development World Health Organization Anne Baerug Norwegian Resource Centre for Breastfeeding, Oslo University Hospital, Rikshospitalet, Norway

2 WHO child growth standard (2006) Why? How? Results? 1 year 2 years 3 years 4 years 5 years Use of? World Health Organization

3 15 10 Deaths in children under 5 years that could be prevented (%) CHILD SURVIVAL II, THE LANCET 2003) 5 0 Measels vaccine Tetanus vaccine Water Hygiene HIB vaccine Complementary feeding Malaria prevention Breastfeeding

4 Breastfeeding and health in developed countries - reviews American Academy of Pediatrics (2012). Policy statement. Ip et al (2007). Breastfeeding and maternal and infant outcomes in developed countries. Espghan (2009). Breastfeeding: : A commentary by the Espghan Committee on Nutrition. van Rossum (2005). Quantifications of health effects of breastfeeding. Review of the litterature and model simulation. WHO ( 2007). Evidence on the long-term effects of breastfeeding. SACN (2011). The influence of maternal, fetal and child nutrition on the delvelopment of chronic disease in later life.

5 Breastfed infants assessed with the NCHS- reference Percentiles and Z-scoresZ

6 Percentiles and Z-scoreZ

7 Rationale for the development of new international growth standard: Prescriptive standard versus descriptive reference Upward skewness of reference population childhood obesity

8 Rationale for the development of a new international growth standard The NCHS/WHO international reference (1978) is inappropriate for assessing nutritional status: Individual infants interferes with sound nutritional management of breastfed infants thus increasing risk of morbidity and mortality Populations provides inaccurate community estimates of under- and overnutrition WHO Multicentre Growth Reference Study

9 WHO Child Growth Standards Prescriptive Approach Fullborn babies without disease Optimal Nutrition Breastfed infants Appropriate complementary feeding Optimal Environment No microbiological contamination No smoking - Socio-economic conditions Optimal Health Care Immunization Pediatric routines WHO Multicentre Growth Reference Study Optimal Growth

10 Standard versus reference A growth reference describes a sample without making any claims about the health of its sample (sick( children are, however, excluded) ) : descriptive sample A growth standard represents a healthy healthy population and suggests a model or target to try to achieve: precriptive sample

11 Ethnicity? Do different ethnic groups grow the same in childhood? Should every country/population have their own growth curve?

12 Growth of children 0-5 years old with different ethnic origin is very similar,, given equal nutrition and living conditions. Epidemiology Habicht JP et al. Height and weight standards for preschool children. How relevant are ethnic differences in growth potential? Lancet Genetics King MC et al. Mapping human history. Science Jorde BJ et al. Genetic variation, classification and race. Nature Genetics Supplement Endokrinology Merimee TJ et al. Insulin-like like growth factors in pygmies.. The role of puberty in determining final stature. N Engl J Med 1990.

13 MGRS study design Longitudinal (0-24 months) year 1 year 2 year 3 Cross-sectional sectional (18-71 mo) WHO Multicentre Growth Reference Study

14 Sample size Total sample of 8440 by combining: Longitudinal 0-24 mo: - Included: 1743 included - Compliant and completed: 888 Cross-sectional mo: 6697 included WHO Multicentre Growth Reference Study

15 Eligibility criteria of individuals No health, environmental or economic constraints on growth Mother willing to follow feeding recommendations Term birth Single birth Lack of significant perinatal morbidity No smoking mothers (before and after delivery) WHO Multicentre Growth Reference Study

16 Frequent measurements Longitudinal study 0-24 mo: 21visits Cross-sectionalsectional study mo: Every third month

17 Breastfeeding in the MGRS study populations

18 New international child growth standard Innovative aspects Prescriptive approach recognizing need for standards Breastfed infant as normative model International sample Reference data for assessing childhood obesity Velocity reference data Motor development WHO Multicentre Growth Reference Study

19

20

21

22 Discussions National growth curves or the international WHO Child Growth Standards? The higher weight-for for-age curves in the first months in the WHO CGS may result in more supplementation when qualified lactation counselling is not given.

23 National growth curve or the WHO Child Growth Standards? WHO Child Growth Standards Bergen Growth Study breastfed NCHS reference

24 Implementation WHO Child Growth Standards April 2011 Adoption Status Adopted Under consideration Not adopted No response Source: de Onis M, Onyango AW, Borghi E, et al.worldwide implementation of the WHO Child Growth Standards. Public Health Nutrition, 2012

25 Márta Gúoth-Gumberger, 2007

26 Márta Gúoth-Gumberger Gumberger,, 2007

27 Measurements of two Maldivian children Age Height Weight BMI Girl X 2 yr 2 mo 86 cm 12 kg 16.2 Girl 4 yr 4 mo 86 cm 12 kg 16.2 Source: Department of Nutrition for Health and Development

28 The double burden of malnutrition Source: WHO Global Database on Child Growth and Malnutrition

29 WHO Standards versus NCHS Reference Change in prevalence estimates Underweight will increase substantially 0-6 mo and decrease thereafter when based on WHO standards Stunting rates will increase for all age groups Wasting and severe wasting substantially higher 0-6mo, thereafter severe wasting will continue to be higher Overweight rates will increase in all age groups (about 20-30%) Artifactual decrease of overweight at 24mo with the NCHS reference is resolved

30 Damage suffered in early life leads to permanent impairment Undernourished children are more likely to become short adults and to give birth to low birth weight babies Evidence links stunting to cognitive development, school performance and educational achievement Poor fetal growth or stunting in the first 2 years of life leads to reduced economic productivity in adulthood Child's height for age is best predictor of human capital Source: Lancet Series on Maternal and Child Undernutrition, Paper 2

31 The WHO Child Standards and non-communicable diseases

32 Global prevalence and trends of overweight and obesity among preschool children 2010 by American Society for Nutrition de Onis M et al. Am J Clin Nutr 2010;92:

33 WHO Child Growth Standards Norwegian Resource Centre for Breastfeeding

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