Growth of children in Greenland exceeds the World Health Organization growth charts

The Korea Infant Physical Growth Examination Survey (KIPGroS): a study protocol

Growth charts are important tools used to evaluate the growth status of children and estimate the nutritional and health status of the general population. In Korea, the national standardized growth charts were updated in 2017. However, the growth charts developed by the World Health Organization (WHO) are being adopted for children under 3 years of age despite a lack of evidence for their applicability to Koreans. Here we aimed to collect accurate physical measurement data, develop growth charts for infants and toddlers under 3 years of age based on breastfeeding, and evaluate the feasibility of adopting WHO growth standards as a reference in Korea. Beginning April 2020, 6 general and local hospitals were selected nationwide. Mothers and newborns without growth restriction-related factors were enrolled at birth, and they were followed up monthly until 12 months and every 3 months until 36 months. Data were collected on physical measurements; eating habits; childhood morbidity; perinatal factors; and socioeconomic, demographic, and environmental characteristics. All participating hospitals used the same standard equipment. The Korea Infant Physical Growth Examination Survey evaluated the suitability of the WHO growth charts and contributed to the next revision of the Korean growth charts. The results of this study provide a basis for developing health-related strategies for treating children in South Korea.

Change in Grading of Stunting in Children aged 0-5 years in a Tertiary Hospital in Western India by Using WHO vs. Indian References

OBJECTIVES

To classify under 5-y-old children into normal, short, severe short and tall categories as per WHO (2006) and Indian 2019 synthetic growth charts and to compare the change in the proportion of stunted children based on these two charts.

METHODS

This study was done on 1557 (795 boys) apparently healthy children of age group 0-5 y who attended outpatient clinics for routine vaccination and their stature categories were compared on WHO 2006 vs. 2019 Indian synthetic charts. Children were categorized into severe short, short, normal and tall on both charts by calculating z scores.

RESULTS

On WHO charts 73.5% children were classified as normal vs. 85.4% on 2019 Indian synthetic charts. The mean Z score for height for age as per WHO was -0.85 (+/-1.62), whereas as for 2019 synthetic charts was -0.37 (+/-1.38). While using WHO growth charts the prevalence of short stature was 15.03%, and severe short stature was 7.51%, which dropped to 7.77% for short stature and 2.38% for severe short stature on 2019 synthetic charts, respectively.

CONCLUSIONS

WHO Growth charts overdiagnose short stature by 12.4% (WHO 22.54% vs. Indian synthetic 10.15%) in an apparently normal population of under five children. Use of regional growth charts may reduce the need to unnecessarily investigate normal children.

Defining clavicle growth in infancy using chest radiographs

Background

Despite the critical role of the clavicle in understanding growth and development in early childhood, there remains a notable paucity of comprehensive studies investigating clavicle growth patterns during this crucial period. This hinders our ability to establish normative growth parameters during these early life stages. Our study sought to measure clavicle dimensions and subsequently construct growth curves spanning from preterm infants to toddlers up to the age of 6 years by measuring routine chest radiographs. Differences between both sides of the body and between the sexes should be analysed. This aimed to provide a nuanced understanding of clavicle growth dynamics and offering a foundation for the establishment of normative values in this understudied context. In this retrospective study, children aged 23 weeks of gestation to 6 years who underwent a chest radiography between January 2010 and June 2020 were enrolled. A total of 5.311 potential radiographs was screened. Clavicle length and width were measured in all radiographs using the Centricity™ Universal Viewer. Statistical analysis was performed using SPSS®.

Results

1.340 images met the quality criteria to be included in our study. The growth curves of clavicle lengths and widths showed a steadily increasing trend with age. Inclusion of premature infants in the age group of one month resulted in a decrease in this age group. Significant differences between both sides of the body and between the sexes could be shown. Measurements of clavicle length and width, derived from routine chest radiographs, are highly accurate. This accuracy underscores the potential for utilizing thoracic radiographs as a reliable tool for assessing clavicle growth in clinical settings or even forensic analysts. The establishment of reference values derived from our measurements provides a basis for normative growth parameters.

Head circumference values among Inuit children in Nunavut, Canada: a retrospective cohort study

BACKGROUND

Inuit children from Nunavut have been observed to have high rates of macrocephaly, which sometimes leads to burdensome travel for medical evaluation, often with no pathology identified upon assessment. Given reports that World Health Organization (WHO) growth charts may not reflect all populations, we sought to compare head circumference measurements in a cohort of Inuit children with the WHO charts.

METHODS

We extracted head circumference data from a previous retrospective cohort study where, with Inuit partnership, we reviewed medical records of Inuit children (from birth to age 5 yr) born between Jan. 1, 2010, and Dec. 31, 2013, and residing in Nunavut. To create a cohort of Inuit children similar to the cohorts used in the development of the WHO growth charts, we excluded children with preterm birth, documented neurologic or genetic disease, and most congenital anomalies. We compared head circumference values with the 2007 WHO charts using centiles estimated with a generalized additive model.

RESULTS

We analyzed records of 1960 Inuit children (8866 data points), of whom 993 (50.8%) were female. Most data were from ages 0 to 36 months. At all age points, we found that the study cohort had statistically significantly larger head circumferences than WHO medians, with most z scores for head circumference measurements among Inuit children falling 0.5-1 standard deviations above the WHO reference (p < 0.001). At age 12 months, median head circumferences were 1.3 cm and 1.5 cm larger for male and female Inuit children, respectively. Using WHO growth curves, macrocephaly was significantly overdiagnosed and microcephaly was underdiagnosed (p < 0.001).

INTERPRETATION

Our results support the observation that Inuit children from Nunavut have larger head circumferences than other populations, and use of the WHO charts may thus lead to overdiagnosis of macrocephaly and underdiagnosis of microcephaly. Population-specific growth curves for Inuit children should be considered to provide timely and appropriate diagnoses of microcephaly and avoid overinvestigation of macrocephaly.

Disparities with global standards about growth references of mid-upper arm circumference-for-age for Pakistani children aged 6-60 months

AIM

Growth reference values about mid-upper arm circumference (MUAC) are vital for assessing children's nutritional status. However, Pakistan lacks these reference values and growth charts. This study aims to develop these for children aged 6-60 months and compare them with global standards.

METHODS

The data were acquired from the 2018 National Nutrition Survey of Pakistan, which was conducted by the United Nations Children's Fund (UNICEF) during 2018-2019. The final study cohort comprised 57 285 children, with 51% being boys. Percentile values and charts for MUAC-for-age were developed using generalised additive models for location, scale and shape with the Box-Cox power exponential distribution.

RESULTS

The mean MUAC was 14.21 cm (±2.07 cm) and 14.13 cm (±2.12 cm) for the boys and girls, respectively. At 60 months of age, the P3 and P97 percentiles for girls were slightly higher than those for boys. The median percentiles of Pakistani children were smaller than the World Health Organisation 2007 standards and with international references.

CONCLUSION

We observed disparities in MUAC-for-age growth references among Pakistani children compared to global standards, highlighting regional, age and gender variations. This underscores the need for developing countries like Pakistan to establish their growth references.

Systematic Evaluation of the Effects of Voluntary Activation on Lower Extremity Motor Thresholds

The purpose of this investigation was to elucidate the relationship between the resting motor threshold (rMT) and active motor threshold (aMT). A cross-sectional comparison of MTs measured at four states of lower extremity muscle activation was conducted: resting, 5% maximal voluntary contraction (MVC), 10%MVC, and standing. MTs were measured at the tibialis anterior in the ipsilesional and contralesional limbs in participants in the chronic phase (>6 months) of stroke (n = 11) and in the dominant limb of healthy controls (n = 11). To compare across activation levels, the responses were standardized using averaged peak-to-peak background electromyography (EMG) activity measured at 10%MVC + 2SD for each participant, in addition to the traditional 0.05 mV criterion for rMT (rMT50). In all participants, as muscle activation increased, the least square mean estimates of MTs decreased (contralesional: p = 0.008; ipsilesional: p = 0.0015, healthy dominant: p < 0.0001). In healthy controls, rMT50 was significantly different from all other MTs (p < 0.0344), while in stroke, there were no differences in either limb (p > 0.10). This investigation highlights the relationship between rMT and aMTs, which is important as many stroke survivors do not present with an rMT, necessitating the use of an aMT. Future works may consider the use of the standardized criterion that accounted for background EMG activity across activation levels.

World variation in head circumference for children from birth to 5 years and a comparison with the WHO standards

OBJECTIVE

A recent review reported that the WHO 2006 growth standards reflect a smaller head circumference at 24 months than seen in 18 countries. Whether this happens in early infancy and to what extent populations differ is not clear. This scooping review aimed to estimate the rates of children in different populations identified as macrocephalic or microcephalic by WHO standards.

METHODS

We reviewed population-representative head circumference-for-age references. For each reference, we calculated the percentages of head circumferences that would be classified as microcephalic (<3rd WHO centile) or macrocephalic (>97th WHO centile) at selected ages.

RESULTS

Twelve references from 11 countries/regions (Belgium, China, Ethiopia, Germany, Hong Kong, India, Japan, Norway, Saudi Arabia, UK and USA) were included. Median head circumference was larger than that for the Multicentre Growth Reference Study populations in both sexes in all these populations except for Japanese and Chinese children aged 1 month and Indians. Overall, at 12/24 months, 8%-9% children would be classified as macrocephalic and 2% would be classified as microcephalic, compared with the expected 3%. However at 1 month, there were geographic differences in the rate of macrocephaly (6%-10% in Europe vs 1%-2% in Japan and China) and microcephaly (1%-3% vs 6%-14%, respectively).

CONCLUSIONS

Except for Indians and some Asian neonates, adopting the WHO head circumference standards would overdiagnose macrocephaly and underdiagnose microcephaly. Local population-specific cut-offs or references are more appropriate for many populations. There is a need to educate healthcare professionals about the limitations of the WHO head circumference standards.

Reference growth curves to identify weight status (underweight, overweight or obesity) in children and adolescents: systematic review

The identification of somatic growth, through reference curves, can be used to create strategies and public policies to reduce public health problems such as malnutrition and obesity and to identify underweight, overweight and obesity. The purpose of this systematic review was to identify studies providing reference growth curves for weight status in children and adolescents. A systematic search was conducted in eight databases and in gray literature (Google scholar). To assess the risk of bias/methodological quality of studies, the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-sectional Studies (NHLBI) was used. Overall, 86 studies that met the inclusion criteria were included. Through the values   of reference growth curves for the identification of underweight, overweight and obesity, it was possible to verify that there is great variability among percentiles for the identification of underweight, overweight and obesity. The most prevalent percentiles for underweight were P3 and P5; for overweight, the most prevalent was P85 and the most prevalent percentiles for obesity were P95 and P97. The most prevalent anthropometric indicators were Body Mass Index (BMI), Waist Circumference (WC), Body Mass (BM) for age and height for age. Conclusion: Such data can demonstrate that the optimal growth must be reached, through the standard growth curves, but that the reference curves demonstrate a cut of the population growth, raising possible variables that can influence the optimal growth, such as an increase in the practice of physical activities and an awareness of proper nutrition.

Validation of growth standards and growth references: A review of literature

The World Health Organization (WHO) growth standards provide the most recognized and widely accepted way of assessing child growth. To ensure its applicability, accuracy, and reliability, studies have validated WHO growth standards against local populations and other internationally recognized growth references. We reviewed outcomes of evaluations done on WHO growth standards and assess the appropriateness of using these growth standards on a global level. We undertook a systematic quantitative review of studies published from 2011 to 2020 from multiple databases. Studies were included if they considered children aged 59 months and below and reported on validation of growth standards. There was an agreement in studies that validated WHO growth standards against international growth references of its superiority in identifying stunted, overweight, and obese children. However, they were less likely to identify underweight children. None of the studies reviewed reported similar growth trajectories to WHO standards in all indicators considered. Regional differences in child growth were observed in comparison to WHO growth standards. Adoption of regional-specific standards increases the sensitivity of identifying children with adverse nutrition outcomes.

The Quadratic-Exponential-Pubertal-Stop model is valid for analysing human growth patterns and developing novel growth references

AIM

Human growth patterns are important, especially in paediatrics and public health, and the aim of this review was to provide an overview of human growth, especially secular changes of growth and pubertal growth.

METHODS

This review of human growth was mainly based on studies published during the 20th and early 21st centuries. Special attention was paid to secular changes, pubertal growth, Nordic growth studies and the contribution of the Quadratic-Exponential-Pubertal-Stop (QEPS) growth model for analysing growth patterns.

RESULTS

Human growth patterns showed wide variations between different individuals, sexes and populations and over time. There were ongoing positive secular change in height in four of the Nordic countries, Denmark, Finland, Norway and Sweden, over four decades. Childhood weight status had linear correlations with specific pubertal growth, in both healthy children and those with severe obesity. The QEPS model provided novel estimates of pubertal growth that made it possible to conduct more detailed analyses of pubertal growth than before. Growth references, adjusted for puberty, have been developed, and future opportunities for using the QEPS model for growth studies are highlighted.

CONCLUSION

The QEPS was a valid growth model for analysing human growth patterns and developing novel types of growth references.

Growth in Exclusively Breastfed and Non-exclusively Breastfed Children: Comparisons with WHO Child Growth Standards and Korean National Growth Charts

BACKGROUND

This study examined the relationship of infant feeding with anthropometric indices of children during their first six years of life relative to the Korean National Growth Charts (KNGC) and the World Health Organization Child Growth Standards (WHO-CGS).

METHODS

The study population consisted of 547,669 Korean infants and children who were 6 months-old to 6 years-old (born in 2008-2009) and participated in the National Health Screening Program for Infants and Children. Data on height, weight, and type of feeding during the first 6 months (exclusively breastfed [BF] vs. mixed- or formula-fed [FF]) were analyzed.

RESULTS

BF boys and girls were significantly shorter and lighter than FF counterparts from the age of 6 months to 4 years, but these differences were not significant after the age of 4 years. BF boys and girls only had significantly lower body mass index at the age of 2 years. Under the age of 2 years 6 months, and especially under the age of 1 year, BF boys and girls were significantly taller and heavier than the 50th percentile values of the 50th percentile value of the WHO-CGS.

CONCLUSION

In this study using large-scaled national data, Korean breastfed children are shorter and lighter by 3 years 6 months-4 years 6 months, but afterward, there is no significant difference from those who had mixed- or formula-feeding. Substantial disparities in the anthropometric indices of Korean infants under the age of 1 compared to KNCG and WHO-CGS were found, regardless of their infantile feeding types. Our results emphasize the importance of constructing a nationwide reference chart based on actual measurements of BF Korean infants.

Anthropometric measures and blood pressure of Greenlandic preschool children

The study aims to describe anthropometric data of Greenlandic preschool children, blood pressure (BP) measures and effects of maternal smoking during pregnancy in a follow-up of the ACCEPT birth cohort. The study included 102 children (55 boys and 47 girls) aged 3.5-5.5 years. Anthropometric measures included weight, height, head circumference (HC), body mass index (BMI), waist and hip circumference, ratio for height/weight, waist/height, waist/hip and BP measurements. Overweight and obesity-prevalence was determined using the international obesity task force BMI references for children. Significant increases in anthropometrics from 3.5 to 5.5 years included weight, height, HC and hip circumference, whereas ratio for height/weight, waist/hip and waist/height decreased. Boys had significantly larger HC than girls. The prevalence of overweight and obesity was similar (35.1%) between genders. Mean systolic and diastolic BP were 104 and 68 mmHg, respectively. Children of mothers smoking during pregnancy had higher hip circumference, lower waist/hip ratio and higher diastolic BP. The study present updated anthropometric data and BP of Greenlandic preschool children and effects of maternal smoking during pregnancy. The prevalence of overweight and obesity was higher than previously reported and maternal smoking during pregnancy affected the child data.Abbreviations ACCEPT: Adaptation to Climate Change, Environmental Pollution and dietary Transition; BMI: Body Mass Index; BP: Blood Pressure; Circ: Circumference; DBP: Diastolic Blood Pressure; FFH: Fisher-Freeman-Halton exact test; HC: Head Circumference; H: Height; HDL: high-density lipoprotein; HiC: Hip Circumference; IOTF International Obesity Task Force, Max: maximum, Min: minimum, P25: 25th percentile, P75: 75th percentile, SBP: Systolic Blood Pressure, SD: Standard Deviation; VDLD: very-low-density lipoprotein; WaC: Waist Circumference, W: Weight, WHO: World Health Organization.

Chinese Color Nest Project : An accelerated longitudinal brain-mind cohort

The ongoing Chinese Color Nest Project (CCNP) was established to create normative charts for brain structure and function across the human lifespan, and link age-related changes in brain imaging measures to psychological assessments of behavior, cognition, and emotion using an accelerated longitudinal design. In the initial stage, CCNP aims to recruit 1520 healthy individuals (6-90 years), which comprises three phases: developing (devCCNP: 6-18 years, N = 480), maturing (matCCNP: 20-60 years, N = 560) and aging (ageCCNP: 60-84 years, N = 480). In this paper, we present an overview of the devCCNP, including study design, participants, data collection and preliminary findings. The devCCNP has acquired data with three repeated measurements from 2013 to 2017 in Southwest University, Chongqing, China (CCNP-SWU, N = 201). It has been accumulating baseline data since July 2018 and the second wave data since September 2020 in Chinese Academy of Sciences, Beijing, China (CCNP-CAS, N = 168). Each participant in devCCNP was followed up for 2.5 years at 1.25-year intervals. The devCCNP obtained longitudinal neuroimaging, biophysical, social, behavioral and cognitive data via MRI, parent- and self-reported questionnaires, behavioral assessments, and computer tasks. Additionally, data were collected on children's learning, daily life and emotional states during the COVID-19 pandemic in 2020. We address data harmonization across the two sites and demonstrated its promise of characterizing the growth curves for the overall brain morphometry using multi-center longitudinal data. CCNP data will be shared via the National Science Data Bank and requests for further information on collaboration and data sharing are encouraged.

Weight-for-height is associated with an overestimation of thinness burden in comparison to BMI-for-age in under-5 populations with high stunting prevalence

BACKGROUND

Thinness at <5 years of age, also known as wasting, is used to assess the nutritional status of populations for programmatic purposes. Thinness may be defined when either weight-for-height or body-mass-index-for-age (BMI-for-age) are below -2 SD of the respective World Health Organization standards. These definitions were compared for quantifying the burden of thinness.

METHODS

Theoretical consequences of ignoring age were evaluated by comparing, at varying height-for-age z-scores, the age- and sex-specific cut-offs of BMI that would define thinness with these two metrics. Thinness prevalence was then compared in simulated populations (short, intermediate and tall) and real-life data sets from research and the National Family Health Survey-4 (NFHS-4) in India.

RESULTS

In short (-2 SD) children, the BMI cut-offs with weight-for-height criteria were higher in comparison to BMI-for-age after 1 year of age but lower at earlier ages. In Indian research and NFHS-4 data sets (short populations), thinness prevalence with weight-for-height was lower from 0.5 to 1 years but higher at subsequent ages. The absolute difference (weight-for-height - BMI-for-age) for 0.5-5 years was 4.6% (15.9-11.3%) and 2.2% (19.2-17.0%), respectively; this attenuated in the 0-5 years age group. The discrepancy was higher in boys and maximal for stunted children, reducing with increasing stature. In simulated data sets from intermediate and tall populations, there were no meaningful differences.

CONCLUSIONS

The two definitions produce cut-offs, and hence estimates of thinness, that differ with the age, sex and height of children. The relative invariance, with age and stature, of the BMI-for-age thinness definition favours its use as the preferred index for programmatic purposes.

No association between early maternal HbA1c and offspring birthweight among women without pre-existing diabetes in Greenland

Studies of the association between maternal blood glucose measured by glycated haemoglobin (HbA1c) during pregnancy and the offspring’s birthweight have been heterogeneous. The aim of this study was to examine the association between maternal HbA1c level before gestational week 20 and the offspring’s birthweight among predominantly indigenous women in Greenland. A retrospective cohort study including all women (n = 503) and their offspring delivered from September 2015 to September 2016 at Queen Ingrid’s Hospital in Nuuk was conducted. Data were obtained from the electronic medical record. Linear regression models were used to analyse the effect of maternal HbA1c on the offspring’s birthweight with adjustment and stratification for relevant confounders and effect modifiers. Birthweight increased with 3.3 g per mmol/mol increase in HbA1c. Yet, no significant association between maternal HbA1c and the offspring’s birthweight was found after adjustment for maternal age, ethnicity, residence, smoking, and parity (β = 0.058, p = 0.711). Among obese women, a borderline significant positive association (β = 0.657, p = 0.059) was found. For term newborns, this corresponded to an increase in birthweight of 31 g per mmol/mol increase in HbA1c. Based on the current study, the use of HbA1c during pregnancy to detect the risk of delivering a newborn with macrosomia is not recommended in Greenland.

Abbreviation: HbA1c: glycosylated haemoglobin; GA: gestational age; SD: standard deviation; CI: confidence interval.

Weight among children born 2005-2011 in Nuuk at the time of school entry

The aim of this study was to explore weight status among children born between 2005–2011 at the time of their school entry in Nuuk, and separately to compare weight status between Nuuk and the rest of Greenland among children born in 2011. Study method was an observational study based on data from the electronic medical records (EMR). All children born between 2005–2011 with an address in Nuuk, and registered weight and height were included. For children born in 2011 two study populations were used: children living in Nuuk, and children living outside Nuuk. Body Mass Index (BMI) was calculated. Atotal of 1,616 children born in 2005–2011, with address in Nuuk between 2011-2017 were identified. 78% were included (N = 1, 280: 676 boys and 604 girls, ranging from 5.4–7.6 years). Prevalence of overweight and obesity were estimated to 12.0% (N = 153) and 5.1% (N = 65)respectively. Among children born in 2011, the prevalence of overweight or obesity was 14.6% in Nuuk, compared to 28.8% in the rest of Greenland (p < 0.001). The prevalence of overweight and obesity was stable for children living in Nuuk. A higher prevalence was observed among children living outside Nuuk. Continued monitoring of weight status is recommended.

Abbreviations: BMI: body mass index; EMR: electronic medical records; IOTF: international obesity task force; SD: standard derivation

Local growth charts for an Iranian child population aged 2–5 years in comparison with the World Health Organization Child Growth Standards

Background

There are no national reference charts in Iran for children aged under five. This study aimed to develop representative growth reference charts of height, weight, and BMI for children aged 2–5 years in Isfahan, Iran, and to compare them with the WHO reference curves.

Results

This population-based study has a combination of longitudinal and cross-sectional design. It included 1325 and 761 healthy children, who were born between 2002 and 2015 in Isfahan, central Iran, in longitudinal and cross-sectional phases. Expert health care providers measured the height and weight of children in health centers. The lambda-mu-sigma method was used to construct the age- and sex-specific growth charts of anthropometric measures. The study sample comprised 1029 boys and 1057 girls. The centiles of height, weight, and BMI of boys were higher than that of girls in all age groups. The weight patterns of studied children were close to those of the WHO references in the lower percentiles. However, our study children, especially girls, were lighter compared with WHO standards based on the middle and upper percentiles of the weight distribution. Compared with WHO standards, boys of our study were taller especially at older ages. The percentiles of the BMI for our study samples were considerably lower than WHO standards.

Conclusion

There are differences between our local growth charts for weight, height, and BMI with WHO standards. The local growth standards could be more precise for assessing growth problems in local and national settings. Due to notable differences between our results with WHO standards, future studies are warranted for constructing nationwide growth charts.