About the author: This article was written by Linda Edmondson, a medical writer with a nursing background, and a mother of two children.
The information in this article is correct at date of publication, August 2010.
Opinions expressed by the author are not necessarily those of the publisher or editorial staff
The 2009 UK-WHO charts for children aged 0–4 years were developed by the Royal College of Paediatrics and Child Health (RCPCH)1,2, using WHO growth standards (Box 1)2. This article discusses how growth might affect long-term health, summarises key features of the 2009 charts, and reports on current experiences with these charts in everyday practice (obtained from informal interviews with seven Healthcare Professionals who are working with the charts).
Box 1: The new UK-WHO charts – background information
A study was undertaken by the World Health Organization in Brazil, Ghana, India, Oman, Norway and the USA, to identify optimum growth patterns. There were very strict inclusion criteria. For at least the first 4 months, infants were predominantly breast fed (cool, boiled water was the only alternative), mothers could not smoke cigarettes during pregnancy or lactation and could not be separated from their infants. The families studied came from a wide spectrum of socio-economic, genetic and cultural backgrounds.
These data were used by the Royal College of Paediatrics and Child Health (RCPCH) as the basis for the new UK-WHO Growth Charts.
The new charts reflect optimum growth and development, not typical growth and development, and show a slower pattern of growth, particularly from 4 months.
In practical terms, this means the old 0.4th centile is equivalent to the 2nd centile. A baby classified as of ‘average’ weight and length (i.e. on the 50th centile) on the previous chart will now be classified as on the 70th centile. Potentially, up to 20% more children could be classified as overweight or obese, although none of the Healthcare Professionals interviewed for this article had observed this, to date.
Why proper growth measurement is important Measuring growth is a vital part of child-health surveillance that helps to identify weight-related issues, growth disorders and signs of neglect. Several publications discuss why accurate anthropometric measurements are important and how to plot data using the new growth charts3–5. In particular, the Infant & Toddler Forum has developed a comprehensive, free, and fully up-to-date resource on growth, which is available online. What the 2009 charts offer The UK-WHO charts are designed to measure the growth of UK children born after 32 weeks’ gestation, since 11 May 20092,3. Different charts have been developed for boys and girls, and there are specialist charts for babies born at 23 – 32 weeks1,2. These growth charts are essential tools that aim to reassure families that their children are developing normally, but also alert professionals to situations requiring intervention. As such, it is vital to remember that growth charts are legal documents that warrant proper usage at all times3,4. In particular:
- All Healthcare Professionals who monitor growth (e.g. Midwives, Nursery Nurses, Health Visitors, General Practitioners) must be competent at taking accurate anthropometric measurements and plotting them properly on the charts3,4. Adequate, ongoing, training is therefore essential
- It is a legal requirement that, when plotting growth, infants are weighed using Class III electronic scales. All measuring equipment should be calibrated and maintained regularly, to ensure accuracy and consistency4
- Healthcare Professionals should be fully aware of the new charts and be able to inform parents about their clinical and legal purposes, frequency of measurements (initially birth, 5 days, 10 days, GP check/ immunisation, 12 weeks, 16 weeks)2 and where growth fits in to the overall pattern of child development – it is not the only measure of progress.
Why were new charts introduced? The previous (1990) UK charts were developed using data from predominantly formula-fed infants, who have a normal growth pattern very different to that observed in exclusively breastfed babies – and very different to the WHO growth standards:
- Formula-fed infants normally have more-rapid weight gain at around 4–6 months
- This is precisely the age when weight gain slows down in breastfed babies
- The typical growth pattern for length is completely different between formula- and breastfed babies1.
The 2009 UK-WHO growth charts illustrate what WHO considers the optimum growth pattern in infancy, which also happens to be the normal growth standard for breastfed infants1,2. This is excellent news for mothers who exclusively breastfeed:
- A breastfed baby’s physical development is now likely to follow the shape of the curve on the chart more closely, reflecting a slower pattern of growth than that depicted in the 1990 charts (see box 1)3,4
- Such changes might help mothers to feel more confident about breastfeeding for longer.
However, given that the charts have not been in widespread use for very long, what these changes mean for formula-fed babies (who would be expected to race upwards through the new centiles, especially from 4–6 months) is unclear. But if the UK-WHO charts help to reduce the number of mothers who introduce formula ‘top ups’, or who cease breastfeeding completely because they think their baby is growing too slowly, this can only be good news. As one Health Visitor commented, “The new chart encourages the breastfeeding mum, saying that ‘your baby is doing fine’.” Other Healthcare Professionals have expressed caution, however. They question how these charts will lengthen the duration of breastfeeding, because many mums have switched to infant formula within 2 weeks of birth, before the growth charts really come in to play.
Early nutrition and future health Growth patterns depicted on the new charts help to support Healthcare Professionals to educate families that ideas about optimum infant health and physical development have changed. As one Health Visitor said, ‘We need to re-educate those who think that healthy babies should always be fat’. The charts help to reinforce that a healthy baby should maintain his growth along the centile lines that are right for him. Indeed, a key function of the new charts is to identify a greater proportion of babies who grow too rapidly4. The 2009 charts illustrate that catch-up growth is unnecessary in small, healthy, term infants (not preterm infants). The goal is not to get smaller babies up to the 50th centile, or for babies to be on the same centile lines for length and weight. Top-up feeds or high-energy infant formulas are only required in babies with confirmed clinical evidence of growth faltering. For small, healthy children, over-feeding will certainly increase their weight, but this will likely result in growth that is too rapid for their long-term needs. How can babies grow too rapidly? The concept of too-rapid growth (caused by over-nutrition) in infancy is a hard one for many professionals to understand, let alone parents! But robust clinical evidence demonstrates that early rapid growth may have undesirable consequences for lifelong health. For example, the composition and volume of food that a baby consumes – even before weaning – may affect his risk of developing obesity6, cardiovascular disease7,8 and other disorders (e.g. early-onset puberty)9. The phrase ‘nutritional programming’ is now commonly used to describe the long-term influence that diet in early infancy may have on the development of health issues7,8,10. Of course, most health problems are likely to have multifactorial causes, but there is certainly evidence that nutritional programming has long-term consequences for appetite, energy intake and growth7–9. In theory, the 2009 growth charts may make it easier to manage growth rate better, because they facilitate earlier identification and assessment of over- (or indeed under-) nutrition. Plotting growth – the early weeks It is important for Healthcare Professionals to remember that the 2009 UK-WHO growth charts should be used for:
- Growth measurement and plotting during the first 2 weeks of life
- Recording growth in premature babies.
Although there are no centile lines between birth and 2 weeks of age, infants born at term should still be weighed at birth, 5 and 10 days, and these measurements should be plotted in the small gap on the growth charts. It is wrong to simply record these data in the notes. Babies show highly variable weight loss and gain in the early days after birth, so HCPs are encouraged to assess percentage weight loss rather than plot before 2 weeks. Plotting early weight fluctuations in this manner clearly indicates whether the expected pattern (up to 10% weight loss) is being observed and careful clinical assessment is required when percentage weight loss exceeds 10%. It also stops parents – and Healthcare Professionals – from thinking that a child belongs on one centile line (because of their birthweight) when the optimum for the baby is at a different level. Preterm growth measurements It is important for the neonatal unit team to record the birthweight, as well as discharge weight, on the growth chart. A community-based nursery nurse commented that, although the standard charts are suitable for all babies born after 32 weeks, specialist low-birthweight/pre-term charts are often being used in hospital, even in the older infants. To stop the practice of replotting information in the community, it is much more helpful for the standard charts to be used in neonatal units, so that there is continuity on the growth chart when the child comes home. Ethnicity issues? As explained in Box 1, the new charts were based on data obtained from a very wide ethnic sample. To date, no issues have emerged that suggest that the 2009 charts consistently plot growth differently for any particular ethnic group. However, it will be interesting to consider whether this remains so. A Health Visitor interviewed for this article questioned how one set of growth-reference information, developed from very diverse populations, would be accurate for all ethnic groups in the UK. She added that, anecdotally, Asian children in her care consistently grow along lower centile lines compared with children from other ethnic groups. Working with old and new charts concurrently All Personal Child Health Records (i.e. the ‘red books’) should now contain the new charts. However, 1990 charts were still being issued to some new babies born in June 2010. Indeed, one Health Visitor interviewed spoke of identical twins born in May 2010, one of whom has the old chart, and one has the new version!
Another Healthcare Professional commented that having a mixture of children of similar age on the ‘old’ and ‘new’ charts could lead to clinical error and parental confusion, for the next 3–4 years, until the 1990 charts are no longer in circulation (growth measurement moves on to School Years charts from 4–18 years). It is important for teams to consider how they might best address this problem locally. The following points may help.
The charts look different Certainly, the 2009 UK-WHO charts have some very different visual features, which quickly differentiate them from the 1990 version*
*Babies born after 11 May 2009 issued with the 1990 charts may be switched to the 2009 UK-WHO charts. In practical terms, switches may be best left to situations where a baby is growing slowly on the 1990 chart (to see if he is growing normally on the 2009 chart), or where there are practical issues (e.g. identical twins on different charts). Regular training is helpful Until now, training on the 2009 charts has generally been provided in classroom seminars. However, in many cases, this was delivered months before the charts reached widespread circulation. This made it harder for some professionals to recall all key differences between the 1990 and 2009 charts; it has also caused confusion about specific information that needs to be recorded on the new charts (for example, situations where measurements are not being routinely plotted in the first 2 weeks of life). To address such problems, refresher training – run by a local professional with good experience in using the new charts, and delivered to all the team involved in plotting weight within the team (including GPs and midwives) – may be useful. Regular in-practice training sessions, where Healthcare Professionals share knowledge, discuss issues arising in specific cases, and find common solutions that suit how the team operates and communicates, may be very useful. This would also address a concern expressed by a Lecturer in health visiting, who spoke of the inconsistent training provided before the charts became available.
Professionals’ opinions of the 2009 UK-WHO charts
The following comments were made in informal telephone interviews, conducted in June 2010 with seven Healthcare Professionals who are working with the new charts.
Favourable comments
The format of the 2009 UK-WHO charts generated consistently positive comments: the layout has improved and the thicker card makes these charts more resilient.
The majority commented that, apart from the first 2 weeks and the plotting of pre-term growth, there is more space for plotting other information on the main chart, which is beneficial.
Visual differences – some very subtle – between the 1990 and 2009 charts were well received:
- Some centile lines are now dotted, some are straight and the 50th centile is a dotted, not bold, line
- The point of reference for the 50th centile is the bottom of the words ‘head’, ‘length’ or weight, which is far more discrete
- All of the Healthcare Professionals interviewed were pleased about this – parents no longer consider the 50th centile as the ‘ideal’ for infant growth, regardless of their baby’s size
- Taking the focus off the 50th centile helps discourage parents from getting their babies weighted too frequently and encourages parents to look at markers of early development that are not reliant on physical growth (e.g. smiling, head control)
- A word of caution: if the charts are photocopied, subtle printing on the chart may become invisible.
The lack of centile lines for the first 2 weeks of life was considered beneficial. It informs parents that there are no representations of ‘normal’ weight loss or gain over this period, but the plot-marks provide a clear indication of whether any weight loss is within the 10% margin of normality. Bookmarks are also available, to calculate the infant’s weight-loss percentage accurately.
It could be useful for the parent-held version of the charts to provide guidance on the frequency of weighing. This information appears in A4 charts (held in clinical notes) but not the ‘red book’ versions.
Negative comments
- There is no space on the main chart for plotting pre-term length
- It can be awkward to transfer between pages, to plot pre-term growth adequately. This increases the risk of introducing errors and may make it harder to visualise the whole growth picture
- Although it is a legal requirement, there is no box on the new chart to write the child’s name, date of birth and weeks of gestation
- Practical problems will emerge if the child’s details are not recorded and the chart becomes separated from the clinical notes. Local policies are being developed in some areas, so that personal details are recorded consistently on charts
- Slight differences are observed when the same data are plotted on the centile lines on the A4 and A5-sized charts, although these are annoying rather than clinically significant
Previously, Tam Fry, of the Child Growth Foundation and National Obesity Forum warned about a change in centile terminology that may be problematic. A child with a plot mark ¼ of a centile below or above a line is now described as being ‘on’ that centile, which means that being ‘on’ a centile covers a very large margin.
For example, 3½-year-old twins weighing 17.4 and 18.4 kg would both be ‘on’ the 91st centile4. None of the Healthcare Professionals interviewed had experienced this issue, however.
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Growth measurement and staffing issues Several professionals commented that, due to staff shortages, Health Visitors may not see new babies until 3 or 4 weeks after birth. Also, the stipulated ages for growth measurement no longer include one at Day 14, therefore Health Visitors may not routinely measure babies at their first visit. Therefore it is important to have a continuity of professional contact with families in the early postnatal weeks to ensure that growth data is always being routinely plotted during the first 2 weeks. Given that nursery nurses often deal with weight clinics and have the greatest experience with the new charts, Health Visitors commented that it is essential for the entire team to have good communication and internal support mechanisms. Again, the emphasis was on improving skills in growth measurement, but this also extended to knowing the warning signs on the new charts that suggest onward referral is necessary.
Will they cut referrals? The 2009 charts aim to reduce the number of unnecessary paediatric referrals for growth-related issues (especially slow growth, misdiagnosed as growth faltering). Certainly, the Healthcare Professionals interviewed for this article felt that children with suspected growth issues are now referred more selectively (and appropriately). By educating professionals and parents that ‘normal’ now means a slower-growth pattern, worries that would have been more common with the 1990 charts should largely be allayed. Interestingly, to date, there is little evidence that a greater number of formula-fed babies are growing along above-average centile lines or racing upwards through the lines. However, such issues may not become evident until the charts have been in use for several years, across the population. As yet, how many older babies and toddlers will develop growth patterns that classify them as overweight or obese under the new system, and how we will manage them, remains unclear. It is important, however, that if a substantial dip in a baby’s growth pattern is observed over time and that baby is on the new chart, further investigation may be necessary. Conclusions The 2009 UK-WHO growth charts have been well received by the Healthcare Professionals interviewed for this article. However, many raised questions about how parents’ concerns and expectations will be managed over the coming years, while both old and new charts are in circulation among children of the same age, given that the growth patterns displayed are very different. It will take years for us to see the full impact of the 2009 growth charts on issues such as improving breastfeeding rates, spotting the early signs of too-rapid growth, or monitoring weight in toddlerhood. Acknowledgements The author wishes to thank the Healthcare Professionals who agreed to be interviewed about their experiences with the new growth charts, in the preparation of this article.
Box 2: How to plot data – practical tips
Remember, this is a legal document. Information must be completed in as much detail as possible
Write the child’s name on the chart, somewhere that will not affect future growth measurements – ideally develop a local policy to ensure consistency in how this information is recorded. There is no obvious space for writing the child’s details but it is a legal requirement to identify the child concerned. This is also useful in case the chart is ever separated from the notes or red book
Always use dots – never use crosses. Clear plotting is essential
Dot first in pencil, then write over the pencil mark using an indelible pen – once you have checked that the co-ordinates are correct
Always ensure you can see the specific dots. Even if the line between dots is joined up, the individual dots must be clearly visible
Although there is very little space, growth measurements taken in the first 2 weeks of life should still be plotted on the chart
If a child is healthy at delivery, but born any time after 32 weeks, his growth can be plotted on the main (standard) chart
To find out more about measuring growth with the Infant & Toddler Forum interactive learning module and to test your skills and knowledge click here
References
- New UK-WHO growth charts 2009. Available at: http://www.healthforallchildren.co.uk/pro.epl?DO=USERPAGE&PAGE=UKWHO09. Accessed 25 June 2010.
- Royal College of Paediatrics and Child Health. UK-WHO Growth Charts: Early Years. Available at: http://www.rcpch.ac.uk/Research/UK-WHO-Growth-Charts training. Accessed 25 June 2010.
- More J. The new UK-WHO growth charts: are you using them for children from birth to four years? J Fam Health Care 2009; 19(4): 114–117.
- Edmondson L. Interpreting and using the new UK-WHO growth standards. J Fam Health Care 2009; 19: 206–209.
- Growth and its measurement. The Infant and Toddler Forum. Available at : http://www.infantandtoddlerforum.org. Accessed 25 June 2010.
- Koletzko B, von Kries R, Monasterolo RC, et al. Infant feeding and later obesity risk. Adv Exp Med Biol 2009; 646:15–29.
- Singhal A, Cole TJ, Fewtrell M, Deanfield J, Lucas A. Is slower early growth beneficial for long-term cardiovascular health? Circulation 2004; 109(9):1108–1113. Epub 2004 Mar 1
- Singhal A, Cole TJ, Fewtrell M, et al. Promotion of faster weight gain in infants born small for gestational age: is there an adverse effect on later blood pressure? Circulation 2007; 115(2):213–220.
- Ahmed ML, Ong KK, Dunger DB. Childhood obesity and the timing of puberty.Trends Endocrinol Metab 2009; 20(5): 237–242.
- Järvisalo MJ, Hutri-Kähönen N, Juonala M, et al. Breast feeding in infancy and arterial endothelial function later in life. The Cardiovascular Risk in Young Finns Study. Eur J Clin Nutr 2009; 63(5): 640–645.
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