What Growth Charts Are Best?

Patient Presentation
An 86-day-old former 35 week gestation preterm male came to clinic with rhinorrhea and cough for 2 days. He was afebrile and was breastfeeding and urinating well. His sibling had similar symptoms. His mother said she brought him in saying, “because he is so little and was premature. I’m just more worried about him.” The past medical history showed that he was born prematurely with an appropriate gestational weight but had no respiratory distress or other complications. He took an extra day to learn about breastfeeding but was discharged home and had appropriate weight gain since then.

The pertinent physical exam showed his weight to be 4.62 kg and was tracking appropriately. His vital signs were normal HEENT showed moderate clear rhinorrhea and normal tympanic membranes. His lung examination was clear with no signs of increased work of breathing.

The diagnosis of of an upper respiratory tract infection was made and the parent was counseled. The intern also reminded the family that seasonal influenza vaccine is recommended for everyone in the household each year. When staffing the intern noted that the electronic medical record automatically used a premature growth chart to plot the infant’s growth. On the Fenton growth chart the infant’s weight was just above the 10% for 47 weeks. On the WHO chart his weight was 25% for adjusted age when plotted. “When do you change over to the regular growth chart?” he asked. The attending said that growth charts are really tools to help assess the child’s health so you should use the tool that best fits the problem you are trying to assess. “In this case, the child was premature but has quickly caught up to the regular growth chart and now is more than 40 weeks gestation. A regular growth chart should give you the best information from now on. The Fenton charts stop after a certain age and then the WHO charts are used. I don’t remember exactly when the switch over occurs though,” the attending replied.

“The value of growth assessment is thus its principal utility as a key screening tool in order to assess children’s general well-being, to identify faltering and excessive growth, to evaluate maternal lactation performance and infant feeding practices, and to manage her children with medical conditions known to adversely affect growth,….” Thus having assessment tools is important. Growth charts are assessment tools measuring height/length, weight, head circumference and body mass index.

Some commonly used growth charts are:

  • WHO child growth chart standards
    • They were developed using long-term assessment of children in Brazil, Ghana, India, Norway, Oman and the United States. The children studied had to live in homes where the infants were mainly breastfed until 12 months of age, had no maternal smoking and lived in socioeconomic conditions favorable to growth. Therefore they are considered standards for optimal growth for children.
    • The WHO standards are currently the best charts available for children < 2 years of age, international populations that do not have more specific data for their geographical area, or potentially for immigrant children as these are international growth charts.
    • The WHO standards are also very good at identifying children with poor growth or excessive weight especially in the first 2 years of age. The WHO standards “…depict normal human growth under optimal environmental conditions and can be used to assess children everywhere, regardless of ethnicity, socioeconomic status and type of feeding.
    • Fetal growth charts were also released in 2017.
  • Centers for Disease Control (CDC)
    • The Centers for Disease Control (CDC) and Euro Growth Charts (below) are considered references which show the growth of healthy children in geographically defined areas.
    • The CDC charts are based on cross-sectional national data from students between 1976-1994.
    • The CDC recommends using the WHO charts for children 0-2 years of age, and then switching to the CDC charts for children in the United States after age 2.
  • Euro Growth Charts
    • They were developed from longitudinal data on children in 11 European countries between 1990-1993. Data was analyzed cross-sectionally.
  • Fenton Premature Infant Growth Charts
    • They were revised in 2013 based on population surveys from 1991-2007 in Australia, Canada, Germany, Italy, Scotland and the United States.
    • They are smoothed curves from 22-50 gestational weeks and match the WHO standards at 50 weeks gestational age.

Growth chart standards do change over time. One study that reviewed international growth charts from 1830 onward found that mean weight increased from 45 to 75 kg for males and from 40 to 60 kg for females.

Learning Point
Growth charts are common assessment tools in pediatric practice. Overall, one study stated “Biologically, it appears advantageous to use references that are as close to the child as possible, and to depict local growth in order to best mirror a child’s growth patterns with its immediate vicinity. … The use of growth references matched to the individual child eliminates known variation between children, thus enabling more precise and better decision for individuals.”

National growth charts are available for most North American, European and other nations as noted above. There are even different growth charts within some countries that look at geographical populations. For example among army recruits there is as much as a 6 cm height differences among different mountain regions in Switzerland. The “…[WHO] emphasizes the similarity in early childhood growth among diverse ethnic groups. In contrast to early childhood however growth in later childhood and adolescence differs between the different ethnic groups and nations.” One list of regional growth charts can be found here.

One study noted, “…there is rising evidence that it is the peer group of a young adolescent that exhibits significant influence on growth and final height.”

Growth charts are best used with at least 2 measurements to look at trends over time. More measurements providing more data is always helpful to have.

Questions for Further Discussion
1. What growth charts do you use commonly and why?
2. What genetic disorders have their own growth charts?
3. Where can other regional growth charts be found?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Common Cold, Birth Weight, and Premature Babies .

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

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Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa