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
WHO child growth standard (2006) Why? How? Results? 1 year 2 years 3 years 4 years 5 years Use of? World Health Organization
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
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.
Breastfed infants assessed with the NCHS- reference Percentiles and Z-scoresZ
Percentiles and Z-scoreZ
Rationale for the development of new international growth standard: Prescriptive standard versus descriptive reference Upward skewness of reference population childhood obesity
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
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
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
Ethnicity? Do different ethnic groups grow the same in childhood? Should every country/population have their own growth curve?
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 1974. Genetics King MC et al. Mapping human history. Science 2002. Jorde BJ et al. Genetic variation, classification and race. Nature Genetics Supplement 2004. 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.
MGRS study design Longitudinal (0-24 months) year 1 year 2 year 3 Cross-sectional sectional (18-71 mo) WHO Multicentre Growth Reference Study
Sample size Total sample of 8440 by combining: Longitudinal 0-24 mo: - Included: 1743 included - Compliant and completed: 888 Cross-sectional 18-71 mo: 6697 included WHO Multicentre Growth Reference Study
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
Frequent measurements Longitudinal study 0-24 mo: 21visits Cross-sectionalsectional study 18-71 mo: Every third month
Breastfeeding in the MGRS study populations
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
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.
National growth curve or the WHO Child Growth Standards? WHO Child Growth Standards Bergen Growth Study breastfed NCHS reference
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
Márta Gúoth-Gumberger, 2007
Márta Gúoth-Gumberger Gumberger,, 2007
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
The double burden of malnutrition Source: WHO Global Database on Child Growth and Malnutrition
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 1.5-2.5 higher Overweight rates will increase in all age groups (about 20-30%) Artifactual decrease of overweight at 24mo with the NCHS reference is resolved
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
The WHO Child Standards and non-communicable diseases
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;92:1257-1264
WHO Child Growth Standards www.who.int/childgrowth/en Norwegian Resource Centre for Breastfeeding http://www.chrisdellavedova.com