Worldwide variation in human growth and the World Health Organization growth standards: a systematic review

Double Burden of Malnutrition in Under-Five Children (NFHS-5 Data) Using Extended CIAF: WHO 2006 Growth Standard Versus 2019 Indian Growth References

OBJECTIVES

To compare the double burden of malnutrition (DBM) in under-five children using extended composite index of anthropometric failure (eCIAF) using WHO 2006 and 2019 Indian standards.

METHODS

Data of 2,32,920 under-five children as per National Family Health Survey-5 were eligible for inclusion. Incomplete records and extreme z-scores were excluded. eCIAF categories included: A No failure; B Wasted; C Wasted + Underweight; D Wasted + Stunted + Underweight; E Stunted + Underweight; F Stunted; G Stunted + Overweight; H Overweight; Y Underweight; Underfailure (UF): A + B + C + D + E + F + Y; Overfailure (OF): G + H.

RESULTS

Records of 1,96,015 under-five children were analyzed. 50.1% versus 74% children were categorized as no failure using WHO and Indian standards, respectively (P < 0.001). Prevalence of DBM, UF and OF using WHO reference was significantly higher than using Indian references [49.9% vs. 26%; 48.4% vs. 24.7%; 3.5% vs. 1.9%, respectively].

CONCLUSION

Using Indian references prevents misclassification of DBM in under-fives.

Head Circumference Versus Length and Weight Deficits up to 2 Years of Age in Bangladesh

Infant undernutrition, defined by length- and weight-based indices, is common in low- and middle-income countries (LMICs), but corresponding deficits in head size have received less attention. In a cohort of term newborns in Dhaka, Bangladesh, we compared the severity of deficits (vs. World Health Organization Growth Standards) in head circumference (HC), length and weight at birth and every 3 months until 2 years of age (n range across timepoints: 843-920). We estimated the mean and 25th, 50th and 75th percentiles of HC-, length- and weight-for-age z-scores (HCZ, LAZ and WAZ, respectively). Differences between HCZ and LAZ (or WAZ) were analyzed using paired t tests and quantile regression. We also derived HCZ using height-age instead of chronological age at 3-24 months. Mean HCZ was significantly higher than mean LAZ and WAZ at birth, but HCZ was significantly lower than LAZ at 6, 9 and 12 months and the HCZ and LAZ deficits were similar from 15 to 24 months. Mean HCZ was lower than WAZ at all ages beyond birth. Patterns were broadly consistent at the 25th, 50th and 75th percentiles. The HCZ deficit remained evident when HC was standardized using height-age at all ages beyond birth, indicating HC was reduced relative to body size. In conclusion, among term-born children in Dhaka, HCs were smaller than international standards at all ages up to 2 years, and there was no evidence of postnatal head sparing. Consideration should be given to routine measurement of HC in population health surveys in LMICs.

Adult head circumference and the risk of cancer: a retrospective cohort study

PURPOSE

Cancer-related genes and pathways have recently been implicated in a genome-wide meta-analysis of head size. In the current study, we aimed to evaluate the association between adult head circumference and the risk of cancer.

METHODS

This is a cohort study using data from the Hong Kong Osteoporosis Study, where 1,301 participants aged 27-96 years with head circumference measured between 2015 and 2019, and without a history of cancer, were followed up to 15 January 2024. Incident cancers were identified using electronic medical records from a territory-wide database. Hazard ratios (HR) and 95% confidence intervals (CI) were estimated using Cox proportional hazards regression, adjusting for age, sex, height, weight, education, smoking, alcohol drinking, physical activity, and family history of cancer, as well as accounting for familial clustering.

RESULTS

The median head circumference was 53 cm (interquartile range [IQR]: 51-54) and 54 cm (IQR: 53-55) for women and men, respectively. During a median follow-up of 6.9 years, 66 individuals were diagnosed with cancer. In the adjusted model, a larger head circumference was associated with an increased risk of any cancer (HR per cm increase: 1.17; 95% CI 1.00-1.36). Results remained similar when adjusting for waist-to-hip ratio instead of weight or when additionally adjusting for serum calcium and phosphorus levels. When stratified by cancer sites, head circumference was most strongly associated with colorectal cancer (HR per cm increase: 1.81; 95% CI 1.14-2.90) and prostate cancer (HR per cm increase: 1.58; 95% CI 1.16-2.16).

CONCLUSION

Head circumference is positively associated with the risk of cancer independently of height, weight, and other cancer risk factors.

Dynamic Changes of Growth and Thyroid Function in Young Children With Chronic Hepatitis B Treated With Peginterferon Monotherapy

BACKGROUND

Peginterferon (PegIFN) has shown promising results in the treatment of chronic hepatitis B (CHB). This study aimed to evaluate the effects of PegIFN α-2b on growth and thyroid function in young children with CHB.

METHODS

A retrospective study was performed by extracting clinical data from children with CHB who received PegIFN α-2b monotherapy at the Public Health Clinical Center of Chengdu between June 2017 and December 2020. Mean, SD, independent samples t test and 1-way repeated analysis of variance were used to evaluate relevant data.

RESULTS

A total of 62 children were included in this study. Overall, significant differences were observed in the weight-for-age z score (WAZ), height-for-age z score (HAZ) and body mass index-for-age z score (BAZ) at different time points ( P < 0.001). WAZ, HAZ and BAZ were not affected by PegIFN α-2b at 24 weeks of treatment (all P > 0.05). WAZ, HAZ and BAZ at the end of treatment and 48 weeks after treatment; WAZ at 96 weeks after treatment were lower than baseline levels (all P < 0.05). No statistical differences were found in HAZ and BAZ at 96 weeks after treatment compared with baseline. Thyroid dysfunction developed in 17.7% of children during the treatment. Thyroid dysfunction was transient and had no effect on growth.

CONCLUSIONS

PegIFN α-2b has inhibitory effects on growth and can increase the incidence of thyroid dysfunction in young children with CHB. These effects are generally reversible with the cessation of therapy, although WAZ had not returned to baseline after 96 weeks of observation.

Assessment of the impact of HIV infection on the hypothalamic-pituitary-ovarian axis and pubertal development among adolescent girls at a tertiary centre in Zimbabwe: a cross-sectional study

BACKGROUND

Proper planning of reproductive health needs for HIV-infected adolescents requires a clear understanding of the effects of HIV infection on adolescents' pubertal development.

OBJECTIVE

To assess the effects of HIV infection on the hypothalamic-pituitary-ovarian (HPO) axis, ovarian reserve and pubertal development in adolescent girls at a tertiary hospital in Zimbabwe.

METHODS

This was a cross-sectional survey of HIV-infected adolescent girls aged 10-19 years, with available CD4 + count results at a tertiary hospital in Zimbabwe. Consecutive sampling was used to select study participants. Pubertal milestones were assessed using the age of menarche and Tanner stage for breast and pubic hair development. Growth was assessed using World Health Organisation growth charts. The HPO axis was evaluated by measuring serum follicular stimulating hormone (FSH), luteinising hormone (LH) and estradiol. The ovarian reserve was assessed in adolescents above 18 years of age by measuring the serum anti-mullein hormone (AMH) levels. Data were analysed in STATA version 13.0, and the results are presented as mean (SD) or median (quartiles) and proportions, as appropriate.

RESULTS

One hundred and one (101) HIV-infected adolescents were recruited for the study. Menarche, thelarche and pubarche were delayed in 15.9%, 28.6% and 46.8% of the adolescents, respectively. A total of 59.4% had moderate to severe stunting, and 53.5% were either overweight or obese. Most participants had normal serum FSH, LH, and estradiol levels, and there was no association between these hormone levels and growth indicators. The serum AMH levels were reduced in 24.1% of the adolescents. There were no significant differences in the hormonal levels and pubertal development between the WHO CD4 classes.

CONCLUSION

HIV infection is associated with stunted growth and delayed sexual maturation with an intact HPO axis in the majority of adolescents. There was no association between growth indicators and FSH and LH levels. The degree of HIV immunosuppression had no significant impact on the HPO axis and pubertal development. A larger study is needed to assess the impact of HIV infection on ovarian reserve.

TRIAL REGISTRATION

This protocol was approved by the Medical Research Council of Zimbabwe (MRCZ) (reference number MRCZ/A/1730).

New French height velocity growth charts: An innovative big-data approach based on routine measurements

AIM

Height velocity is considered a key auxological tool to monitor growth, but updated height velocity growth charts are lacking. We aimed to derive new French height velocity growth charts by using a big-data approach based on routine measurements.

METHODS

We extracted all growth data of children aged 1 month-18 years from the electronic medical records of 42 primary care physicians, between 1 January 1990 and 8 February 2018, throughout the French metropolitan territory. We derived annual and biannual height velocity growth charts until age 15 years by using the Lambda-Mu-Sigma method. These new growth charts were compared to the 1979 French and 2009 World Health Organisation (WHO) ones.

RESULTS

New height velocity growth charts were generated with 193 124 and 209 221 annual and biannual values from 80 204 and 87 260 children, respectively, and showed good internal fit. Median curves were close to the 1979 French or 2009 WHO ones, but SD curves displayed important differences. Similar results were found with the biannual height velocity growth charts.

CONCLUSION

We produced new height velocity growth charts until age 15 years by using a big-data approach applied to measurements routinely collected in clinical practice. These updated growth charts could help optimise growth-monitoring performance.

Influence of prenatal hexachlorobenzene, PCB and selenium levels on growth trajectories in the first year of life: Findings from the NEHO birth cohort

Prenatal exposure to endocrine-disrupting chemicals (EDCs) may impact postnatal growth trajectories, increasing the risk of various diseases later in life. This issue is of particular concern in industrially contaminated areas, where environmental matrices contain mixtures of pollutants. This study aimed to evaluate the associations between cord serum concentrations of organochlorine pollutants (hexachlorobenzene-HCB and polychlorinated biphenyls-PCBs) and essential elements (EEs), and weight growth trajectories during the first year of life. We analyzed data from 237 infants enrolled in the Neonatal Environment and Health Outcomes (NEHO) cohort. Using the Group-Based Multivariate Trajectory modeling approach, we identified three distinct growth trajectories from birth to 12 months, classified as "Higher," "Normal," and "Lower." Multinomial regression models were then applied to the whole sample and stratified by sex to assess the associations between individual exposures and the identified child growth trajectories. HCB exposure was associated with an increased risk of reduced growth during the first year of life in both the overall sample and among males [higher vs normal: ORMale = 0.33 (95 % CIMale:0.12;0.87); lower vs normal: ORMale = 2.17 (95 % CIMale:0.94;5.00)]. Conversely, PCB-180 exposure was linked to higher growth only in females [higher vs normal: ORFemale = 24.10 (95 % CIFemale:1.33;438.24)]. Elevated levels of selenium in cord serum were negatively associated with excessive growth [higher vs normal: OROverall = 0.50 (95 % CIOverall: 0.26;0.97)]. These findings suggest sex-specific effects on the growth profile during the first year of life, with different chemical exposures contributing to different outcomes.

Ethnicity and anthropometric deficits in children: A cross-sectional analysis of national survey data from 18 countries in sub-Saharan Africa

Child anthropometric deficits remain a major public health problem in Sub-Saharan Africa (SSA) and are a key target of the UN Sustainable Development Goals (SDGs). The SDGs recommend disaggregation of health indicators by ethnic group. However, few studies have assessed how ethnicity is associated with anthropometric deficits across SSA. Data were extracted from 37 georeferenced Demographic and Health Surveys carried out during 2006-2019 across SSA that recorded anthropometric data for children aged <5 years. In a cross-sectional analysis, the odds of stunting (low height-for-age), wasting (low weight-for-height) and underweight (low weight-for-age) were modelled in relation to ethnic group using a generalised linear hierarchical mixed-effects model, controlling for survey design and environmental, socioeconomic and clinical variables. The study population comprised 138,312 children spanning 45 ethnic groups across 18 countries. In pairwise comparisons (accounting for multiple comparisons) between ethnic groups, height-for-age z-scores differed by at least 0.5 standard deviations in 29% of comparisons, weight-for-height z-scores in 36% of comparisons and weight-for-age z-scores in 20% of comparisons. Compared to a reference group of Fula children (the largest ethnic group), ethnic group membership was associated with both increases and decreases in growth faltering, ranging from a 69% reduction to a 32% increase in odds of stunting (Igbo: adjusted odds ratio (aOR) 0.31, 95% confidence intervals (CI) 0.27-0.35, p<0.0001; Hausa: aOR 1.32, 95% CI 1.21-1.44, p<0.0001); a 13% to 87% reduction in odds of wasting (Mandinka: aOR 0.87, 95% CI 0.76-0.99, p = 0.034; Bamileke: aOR 0.13, 95% CI 0.05-0.32, p<0.0001) and an 85% reduction to 13% increase in odds of underweight (Bamileke: aOR 0.15, 95% CI 0.08-0.29, p<0.0001; Hausa: aOR 1.13, 95% CI 1.03-1.24, p = 0.010). Major ethnic disparities in stunting, wasting and underweight were observed across 18 countries in SSA. Understanding and accounting for these differences is essential to support progress monitoring and targeting of nutrition interventions in children.

Reference growth curves of anthropometric markers in Brazilian children and adolescents aged 7-14 years from southern Brazil

Reference growth curves are viable tools for monitoring somatic growth. Therefore, the objective of this study was to develop reference growth curves for body mass, height, body mass index (BMI), waist circumference (WC) and waist-to-height ratio (WHtR) in Brazilian children and adolescents aged 7-14 years. The reference growth curves were constructed from a cross-sectional panel study using data from four surveys conducted in 2002, 2007, 2012/2013 and 2018/2019, with 9675 children and adolescents aged 7-14 years, of both sexes from Florianopolis, Southern Brazil. Growth curves were constructed using the LMS method, based on anthropometric indicators and indices (body mass, height, BMI, WC and WHtR), measured according to standardised norms. There was an increase in body mass, height, BMI and WC values with increasing age in both sexes and percentiles (P5, P10, P25, P50, P75, P85 and P95). The girls presented higher values of body mass, BMI and WC in the analysed percentiles, compared to the boys. Regarding height, there was a higher value from 10 to 11 years old in girls and from 12 to 14 years old in boys. WHtR decreased with increasing age in both sexes and analysed percentiles. Region-specific reference growth curves can enable the monitoring of somatic growth of particular paediatric populations, expanding discussions in different regions of the world.

Comparison of accuracy of different dental age estimation methods in Finnish and Turkish populations

OBJECTIVE

The aims of this study were to assess the accuracy of Cameriere's and Demirjian's methods in Finnish children, and compare the findings with those of the Turkish children according to dental age.

MATERIAL AND METHODS

Dental panoramic tomography (DPT) of children (482 Finnish, 423 Turkish) aged between 5 and 15 years were evaluated. Comparison of mean difference between estimated and chronological age was evaluated. The difference between two means was analysed using paired t-test at 95% confidence interval (CI). Pearson correlation coefficients were used to estimate the correlation between chronological and estimated ages.  Results: Demirjian's method resulted in overestimation in all age groups except for 8-year-old girls. Dental age, however, was found to be underestimated with Cameriere's method in all age groups but 6-year-old girls and boys. In Northern Finnish children, Demirjian's method was more suitable for boys while Cameriere's method led to better estimation in girls. When comparing Finnish and Turkish children, differences between dental ages and chronological ages differed significantly in 10-year-old boys and 8-year-old girls with both methods.  Conclusion: Dental age of Turkish children seems higher than that of Finnish children. There is a significant difference between chronological and dental ages in both populations assessed by both methods.

Anthropometric indices growth references (length, Weight and Head Circumferences) of children aged 0-24 months in North-East of Iran by GAMLSS

BACKGROUND

Growth references play a crucial role in the screening, evaluation, and surveillance of children, aiding in the early identification of the requirement for diverse growth-promoting interventions. Variations in human growth across distinct ethnic cohorts arise from genetic disparities, lifestyle variances, nutritional diversity, and diverse social and environmental contexts. Consequently, the selection of growth references markedly influences the prevalence of developmental disorders and nutritional imbalances in children. The study aims to assess the growth percentile of children in the north-east of Iran and establish population-specific reference charts for length, weight, and head circumference spanning from birth to 24 months.

METHODS

This cross-sectional population-based research conducted in the north-east of Iran, from 2016 to 2023. The Data extracted from the electronic health records of Mashhad University of Medical Sciences. All apparently healthy children aged from birth to 24 months who were measured at least once by health staff at the ages of birth,1,2,4,6,7,9,12,15,18,24 months were included. The target population of the study were 479,089 children (96.21%), encompassing 233,565 girls (48.75%) and 245,524 boys (51.25%). Gender-specific percentile curves for length, weight, and head circumference concerning age, as well as weight concerning length, were derived using the GAMLSS approach.

RESULTS

From the anthropometric information of 479,089 children (245,524 boys and 233,565 girls), growth charts were constructed. In comparison to the standard WHO chart, Iranian neonates displayed lower weight across all percentiles during the first month after birth, exhibited decreased head circumference at the 3rd percentile, and boys showed reduced length across all percentiles. After this age, Iranian children demonstrated increased weight, length, and head circumference.

CONCLUSIONS

This research introduces the inaugural large-scale endeavor for indigenous reference charts. Through the noted distinctions from the international reference, the utilization of this novel resource offers the potential to enhance the surveillance of children's growth within the area. Moreover, by accurately assessing growth anomalies such as underweight, stunting, and wasting, it expands the domain of impactful policies in this sphere. Simultaneously, it enables the exploration of the secular trend of children's growth in the forthcoming years.

Should a single growth standard be used to judge the nutritional status of children under age 5 years globally? No

Universal growth standards for under-five children, given the worldwide variation in healthy growth and several determinants of anthropometry, are imprecise measures of nutritional status, particularly when used cross-sectionally. In constructing the global-use WHO growth standard, linear growth differences between contributing sites and pooled mean were >0.2 SD in 37% of observations. Systematic reviews confirm even greater variability, notably amplified for weight-for-age and head-circumference-for-age metrics. Unsurprisingly, developed nations had higher, and LMICs lower, growth dimensions. Contextual growth references predict neonatal morbidities, pathological short stature, macrocephaly, cardiometabolic risk factors, and adult noncommunicable diseases better than the WHO standards. Child body composition also varies contextually, with greater adiposity despite comparable weights in South Asian populations. Thus, contextual references, though not the perfect solution, are better suited for everyday practice and nutrition policy. Growth standards should only be used as a screening for clinical judgments aided by precise biomarkers.

Infant growth and tolerance with a formula based on novel native demineralized whey: A randomized double-blind pilot study

OBJECTIVES

The aim of the study was to evaluate the effects on infant growth and tolerance of a Test infant formula based on a novel whey extraction and demineralization process, compared to a Standard formula and a breastfed reference arm.

METHODS

Healthy term infants (n = 61) aged up to 21 days were randomized to Test or Control formula. A breastfed group (n = 39) served as a reference. Growth, tolerance, adverse events, and sleep were evaluated every month until 6 months of age. Plasma amino-acid concentrations at 3 months of age were measured in a subgroup population.

RESULTS

Growth curves of all infants globally agreed with World Health Organization standards across the 6-month period study. Regarding tolerance, no difference between the formula-fed groups was observed on daily number of crying episodes, intensity or time to onset of regurgitations, and stool frequency or consistency, except at 5 months with infants in the Control group having more watery stools. Plasma concentration of some amino acids differed between the groups, especially tryptophan concentration which was higher in infants fed with the Test formula. In parallel, total sleep duration was longer in these infants at 2, 3, and 5 months of age, corresponding to an increase in daytime sleep.

CONCLUSIONS

Test formula supported an adequate infant growth from birth to 6 months of age and was well-tolerated by all infants. An increase in total sleep at several months was also observed with the Test formula.

Should a single growth standard be used to judge the nutritional status of children under age 5 years globally: Yes

Childhood nutritional status serves as a lens through which nations and communities identify missed opportunities to improve health and wellbeing across the life cycle, as well as economic development and other related sectors. Countries have committed to the global nutrition targets endorsed by the World Health Assembly in 2012, which were included in the Sustainable Development Goals framework under the target to end all forms of malnutrition by 2030. The child malnutrition indicators for tracking countries' progress toward the agreed-upon targets are based on standard definitions of nutritional status against the widely adopted and used World Health Organization (WHO) Child Growth Standards. The standards were based on a sample of healthy breastfed infants and young children from diverse ethnic backgrounds and cultural settings as part of the WHO Multicentre Growth Reference Study. The WHO Child Growth Standards developed represent the best description of physiological growth for children aged <5 y. The standards depict normal early childhood growth under optimal environmental conditions and can be used to assess children everywhere, regardless of ethnicity, socioeconomic status, and type of feeding.

Mycoplasma genitalium in pregnancy, including specific co-infections, is associated with lower birthweight: A prospective cohort study

BACKGROUND

Mycoplasma genitalium infection in pregnancy is increasingly reported at similar frequencies to other sexually transmitted infections (STIs). Knowledge on its contribution to adverse pregnancy outcomes is very limited, especially relative to other STIs or bacterial vaginosis (BV). Whether M. genitalium influences birthweight remains unanswered.

METHODS

Associations between birthweight and M. genitalium and other STIs (Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis) and BV in pregnancy were examined in 416 maternal-newborn pairs from a prospective cohort study in Papua New Guinea.

FINDINGS

Compared to uninfected women, M. genitalium (-166.9 g, 95% confidence interval [CI]: -324.2 to -9.7 g, p = 0.038) and N. gonorrhoeae (-274.7 g, 95% CI: -561.9 to 12.5 g, p = 0.061) infections were associated with lower birthweight in an adjusted analysis. The association for C. trachomatis was less clear, and T. vaginalis and BV were not associated with lower birthweight. STI prevalence was high for M. genitalium (13.9%), N. gonorrhoeae (5.0%), and C. trachomatis (20.0%); co-infections were frequent. Larger effect sizes on birthweight occurred with co-infections of M. genitalium, N. gonorrhoeae, and/or C. trachomatis.

CONCLUSION

M. genitalium is a potential contributor to lower birthweight, and co-infections appear to have a greater negative impact on birthweight. Trials examining the impact of early diagnosis and treatment of M. genitalium and other STIs in pregnancy and preconception are urgently needed.

FUNDING

Funding was received from philanthropic grants, the National Health and Medical Research Council, and the Burnet Institute. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Local anthropometric parameters for assessing double burden of malnutrition in South Asian and Southeast Asian countries: a review and retrospective analysis

The double burden of malnutrition (DBM) is a significant public health issue in South and Southeast Asia (SA and SEA). This study aimed to assess the impact of using local and regional ethnicity-specific anthropometric references versus international references on the prevalence of DBM in these regions.A narrative review of DBM prevalence using local versus international standards was conducted. Additionally, deidentified datasets from India and Indonesia were analyzed to evaluate the effectiveness of different growth standards in identifying DBM. Anthropometric Z-scores were compared, and sensitivity, specificity, and positive predictive value (PPV) were calculated.WHO standards had the lowest specificity for identifying short stature in India and Indonesia. BMI-for-age charts using WHO Growth Reference (2007) had lower sensitivity and higher specificity for metabolic risk. Local references showed lower stunting and higher overweight or obesity prevalence. International standards overestimated stunting and underestimated obesity, leading to misclassification and missed cases of metabolic risk.

Funding

None.

Evaluating national guidelines for monitoring early growth using routinely collected data in Bergen, Norway

AIMS

The overarching aim of this study was to evaluate the Norwegian guidelines for growth monitoring using routinely collected data from healthy children up to five years of age. We analysed criteria for both status (size for age) and change (centile crossing) in growth.

METHODS

Longitudinal data were obtained from the electronic health record (EHR) at the well-baby clinic for 2130 children included in the Bergen growth study 1 (BGS1). Measurements of length, weight, weight-for-length, body mass index (BMI) and head circumference were converted to z-scores and compared with the World Health Organization (WHO) growth standards and the national growth reference.

RESULTS

Using the WHO growth standard, the proportion of children above +2SD was generally higher than the expected 2.3% for all traits at birth and for length at all ages. Crossing percentile channels was common during the first two years of life, particularly for length/height. By the age of five years, 37.9% of the children had been identified for follow-up regarding length/height, 33% for head circumference and 13.6% for high weight-for-length/BMI.

CONCLUSIONS

The proportion of children beyond the normal limits of the charts is higher than expected, and a surprisingly large number of children were identified for rules concerning length or growth in head circumference. This suggests the need for a revision of the current guidelines for growth monitoring in Norway.

Comparison of Nutritional Status of Healthy Under-Five Indian Children Using Composite Index of Anthropometric Failure on WHO 2006 versus 2019 Indian Synthetic Growth Charts

OBJECTIVES

To assess nutritional status of apparently-healthy under-five Indian children using Composite Index of Anthropometric Failure (CIAF) and to compare anthropometric failure prevalence using conventional indices and CIAF on World Health Organization (WHO) vs. synthetic Indian growth charts.

METHODS

This observational study was conducted over 2 y. The inclusion criteria was apparently-healthy children (0-60 mo) and the exclusion criteria were acute/chronic illness and small for gestational age.

RESULTS

A total of 1557 children (762 girls) were included in the study. The mean age of the subjects was 21 mo. The Z-scores for height, weight, body mass index (BMI) for age and weight for height in children were lower on WHO vs. synthetic charts (p = 0.0001). Significantly higher proportion of children were moderately and severely underweight, stunted and wasted on WHO charts. Synthetic charts identified significantly higher proportion as normal for weight, height, BMI for age, weight for height, overweight (overall), and a higher prevalence of severe stunting, and severe acute malnutrition (SAM) was noted among girls compared to boys. Using CIAF, 54.1% children were normal on WHO charts vs. 78.0% on synthetic (p = 0.0001). Larger proportion of girls (8.8%) were stunted+underweight (category-E) vs. boys (4.3%) on synthetic charts (p = 0.0003). Significantly higher proportion of children demonstrated failure (single/dual/multiple) on WHO charts except category-Y (higher proportion of underweight on synthetic charts). Maximum difference in CIAF (WHO vs. synthetic) was observed between 0-24 mo age. Of 1215 children normal on synthetic charts, 837 (68.9%) were normal on WHO charts. Of 116 underweight children (category-Y) on synthetic charts, 20 (17.2%) were underweight on WHO charts; remaining had compound failure (wasting+underweight = 49.1%, wasting+stunting+underweight = 14.7%, stunting+underweight = 12.1%) on WHO charts. Among those stunted+underweight (category-E) on synthetic charts, WHO charts classified 1/4th as wasted+stunted+underweight (category-D).

CONCLUSIONS

Synthetic references are more representative of Indian growth patterns, and seem more appropriate for monitoring growth of Indian children to avoid mislabelling as malnourished.

Growth Charts for Shwachman-Diamond Syndrome at Ages 0 to 18 Years

Shwachman-Diamond syndrome (SDS) is one of the most common inherited bone marrow failure syndromes. SDS is characterized by hypocellular bone marrow, with a severe impairment of the myeloid lineage, resulting in neutropenia, thrombocytopenia, and, more rarely, anemia. Almost 15% of patients with SDS develop myelodysplastic syndrome or acute myeloid leukemia as early as childhood or young adulthood. Exocrine pancreatic insufficiency is another common feature of SDS. Almost all patients with SDS show failure to thrive, which is associated with skeletal abnormalities due to defective ossification. Considering these observations, it remains unfeasible to use the common growth charts already available for the general population. To address this issue, we report how we drew up growth charts of patients with SDS aged 0 to 18 years. We analyzed height, weight, and body max index (BMI) in 121 Italian patients with SDS. Results indicated that the 50th and 3rd percentiles of weight and height of the pediatric general population correspond to the 97th and 50th percentiles of patients with SDS aged 0-18 years, respectively. In addition, the percentage increment in weight of subjects aged 14-18 years was higher in patients with SDS than in the general population. SDS-specific growth charts, such as those described here, afford a new tool, which is potentially useful for both clinical and research purposes in SDS.

Secular trends and regional pattern in body height of Austrian conscripts born between 1961 and 2002

The human growth process is influenced not only by genetic factors but also by environmental factors. Therefore, regional differences in mean body heights may exist within a population or a state. In the present study, we described and evaluated the regional trends in mean body heights in the nine Austrian provinces over a period spanning more than four decades. Body height data of 1734569 male conscripts born in Austria with Austrian citizenship between 1961 and 2002 were anonymized and analyzed. From 1961 to 2002 birth cohorts, an overall increase in the mean body height of Austrian recruits was observed, although regional differences were evident. Regions with shorter body heights in the 1961-1963 birth cohorts showed a particularly pronounced increase in mean body heights. Meanwhile, the course of body height growth in the capital city, Vienna, was striking, where the highest body heights were documented for the 1961-1963 birth cohorts. In Vienna, mean body heights continued to decline until the 1984 birth cohort and increased again from the 1988 birth cohorts. In addition to economic factors, increased stress factors in an urban environment and a form of urban penalty are discussed as causes.

Significant differences in the length and weight measurements of Jordanian infants compared to the World Health Organization 2006 growth standards

BACKGROUND

In 2006, the World Health Organization (WHO) introduced new growth standards based on data derived globally from optimally nourished breastfed infants. The aim of this study was to assess the effects of implementing WHO growth standards on the growth patterns of Jordanian infants. In addition, it was to ascertain the necessity of establishing country-specific growth standards and charts tailored to Jordanian infants.

MATERIALS AND METHODS

The data of 102,846 infants (50.1% boys, 49.9% girls) aged 0-24 months, from 115 primary healthcare centers across the country were retrieved from a National E-health Program. Weight and length measurements were analyzed, and age- and sex-specific z-scores were calculated relative to the WHO growth standards. Data was analyzed using SPSS version 26. Mann-Whitney U test was performed to determine significant differences between the measurements for boys and girls in terms of age, length, and weight.

RESULTS

Jordanian infants exhibited significantly shorter length-for-age measurements than WHO standards with mean z-scores of -0.56 and -0.38, for boys and girls, respectively. Weight-for-age measurements showed a good fit and were comparable to the WHO growth standards for boys (mean z score = -0.05) and girls (mean z score = 0.04). Notably, Jordanian infants displayed higher weight-for-length measurements, with mean z-scores of 0.51 for boys and 0.47 for girls.

CONCLUSION

The availability of Jordanian-specific growth standards will improve the accuracy of assessing infant growth and enhance the monitoring and evaluation of their health and development.

Tall stature and gigantism in transition age: clinical and genetic aspects-a literature review and recommendations

PURPOSE

Tall stature is defined as height greater than the threshold of more than 2 standard deviations above the average population height for age, sex, and ethnicity. Many studies have described the main aspects of this condition during puberty, but an analysis of the characteristics that the physician should consider in the differential diagnosis of gigantism-tall stature secondary to a pituitary tumour-during the transition age (15-25 years) is still lacking.

METHODS

A comprehensive search of English-language original articles was conducted in the MEDLINE database (December 2021-March 2022). We selected all studies regarding epidemiology, genetic aspects, and the diagnosis of tall stature and gigantism during the transition age.

RESULTS

Generally, referrals for tall stature are not as frequent as expected because most cases are familial and are usually unreported by parents and patients to endocrinologists. For this reason, lacking such experience of tall stature, familiarity with many rarer overgrowth syndromes is essential. In the transition age, it is important but challenging to distinguish adolescents with high constitutional stature from those with gigantism. Pituitary gigantism is a rare disease in the transition age, but its systemic complications are very relevant for future health. Endocrine evaluation is crucial for identifying conditions that require hormonal treatment so that they can be treated early to improve the quality of life and prevent comorbidities of individual patient in this age range.

CONCLUSION

The aim of our review is to provide a practical clinical approach to recognise adolescents, potentially affected by gigantism, as early as possible.

Global relevance of MGRS growth standards: the case of India

The most common measures of childhood undernutrition are based on anthropometric measures such as height-for-age (stunting/chronic undernutrition) and weight-for-height (wasting/acute undernutrition). It is well recognised that the determinants of undernutrition are multiple, including food intake, dietary diversity, health, sanitation and women's status. Currently, most countries across the world including India use the globally accepted WHO-Multicentre Growth Reference Study (MGRS) growth standards (2006) for the purposes of measurement as well as for evaluating progress on these metrics. However, there is some discussion on the universal relevance of these standards, and in the Indian context, whether these standards overestimate the prevalence of stunting, considering differences in genetic potential for growth. This is especially relevant in the context of increasing burden of obesity and non-communicable diseases in India. Based on a detailed review of literature, policy documents and expert inputs, this review paper discusses the relevance of the WHO growth standards for height/stunting, in the context of India. Issues discussed related to the MGRS methodology include pooling of data and intersite and intrasite variability, opting for standards as opposed to references, and external validity. Other issues related to plasticity of stunting and the influence of maternal heights are also discussed, in the context of analysing the appropriateness of using universal growth standards. Based on the review, it is recommended that the current standards may continue to be used until a newer global standard is established through a similar study.

Comparison of WHO 2006 Growth Standards and Synthetic Indian References in Assessing Growth in Normal Children and Children with Growth-Related Disorders

Introduction

A good screening tool, such as a growth chart, should distinguish between children with normal growth and those with perturbed growth. Suitability of synthetic Indian growth references for diagnosing growth-related disorders for under-five children has not been evaluated. To assess the validity of World Health Organization (WHO) 2006 standards vs synthetic Indian references (2019) (by comparing weight, height, body mass index (BMI), standard deviation scores (SDS) and the composite index of anthropometric failure (CIAF)) in differentiating normal children and children with growth-related disorders.

Methods

Records of 2188 children (0-60 months) attending a tertiary centre paediatric outpatient department (OPD) were retrospectively studied; 1854 children were healthy and 334 were diagnosed with growth-related disorders as per the European Society for Paediatric Endocrinology (ESPE) classification. The anthropometric parameters converted to Z-scores for weight-for-age (WAZ), height-for-age (HAZ), BMI-for-age (BAZ) and a CIAF were computed using WHO and synthetic charts; Student's t-test was used for assessing differences and Youden's index for validity.

Results

Disease status of children and anthropometric failure on WAZ, HAZ, BAZ and CIAF on both WHO and synthetic charts had a significant association (P-value <0.05). WAZ, HAZ on both charts and CIAF on synthetic chart had a fair to moderate agreement (Kappa statistics) with disease status as per diagnosis (P-value <0.05). The sensitivity and negative predictive value for all anthropometric parameters were higher for synthetic charts.

Conclusion

Indian charts were more sensitive for diagnosing growth-related disorders from birth to 60 months of age when compared to WHO growth standards.

Is there a skeletal age index that can predict accurate curve progression in adolescent idiopathic scoliosis? A systematic review

BACKGROUND

The diagnosis of adolescent idiopathic scoliosis requires clinical and radiographic evaluation; the management options vary depending on the severity of the curve and potential for progression. Identifying predictors of scoliosis progression is crucial to avoid incorrect management; clinical and radiographic factors have been studied as potential predictors. The present study aims to review the literature on radiological indexes for the peak height velocity or curve acceleration phase to help clinicians manage treatment of patients with adolescent idiopathic scoliosis.

METHODS

This systematic review was carried out in accordance with Preferential Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. The search was carried out including only peer-reviewed articles written in English that described the radiological indexes assessing skeletal maturity in patients with adolescent idiopathic scoliosis and evaluated their correlation with curve progression, expressed as peak height velocity and/or curve acceleartion phase.

RESULTS

Thirteen studies were included and showed promising results in terms of reliable radiological indexes. Risser staging gives a general measure of skeletal maturity, but it cannot be used as a primary index for driving the treatment of patients with adolescent idiopathic scoliosis since more reliable indexes are available.

CONCLUSION

Skeletal maturity quantification for adolescent idiopathic scoliosis has the potential to significantly modify disease management. However, idiopathic scoliosis is a complex and multifactorial disease: therefore, it is unlikely that a single index will ever be sufficient to predict its evolution. Therefore, as more adolescent idiopathic scoliosis progression-associated indexes are identified, a collective scientific effort should be made to develop a therapeutic strategy based on reliable and reproducible algorithms.

Height-for-age and weight-for-age growth charts for Pakistani infants under six months: derived from a novel case selection method using multiple indicator cluster survey data

BACKGROUND

In the past two decades, there has been a growing recognition of the need to establish indigenous standards or reference growth charts, particularly following the WHO multicenter growth study in 2006. The availability of accurate and reliable growth charts is crucial for monitoring child health. The choice of an appropriate model for constructing growth charts depends on various data characteristics, including the distribution's tails and peak. While Pakistan has reported some reference growth charts, there is a notable absence of indigenous charts for children under two years of age, especially for infants aged 0-6 months who are exclusively breastfed. Additionally, acquiring data poses a significant challenge, particularly for low-income countries, as it demands substantial resources such as finances, time, and expertise. The Multiple Indicator Cluster Survey (MICS) constitutes a large-scale national survey conducted periodically in low-income countries under the auspices of UNICEF. In this study, we propose methods for generating selection variables utilizing the "Novel Case Selection Method," as previously published. Further our approach enables to select and fit appropriate model to the MICS data, selected, and to develop the standard growth charts.

METHODS

Out of the 11,478 children under 6 months of age included in MICS-6 (Pakistan), 3,655 children (1,831 males and 1,824 females) met the specified criteria and were selected using the "Novel Case Selection Method". The sample was distributed across provinces as follows: 841 (23.0%) from KPK, 1,464 (40.1%) from Punjab, 819 (22.4%) from Sindh, and 531 (14.5%) from Balochistan. This sample encompassed both rural (76.4%) and urban (23.6%) populations. Following data cleaning and outlier removal, a total of 3,540 records for weight (1,768 males and 1,772 females) and 3,515 records for height (1,759 males and 1,756 females) were ultimately available for the development of standard charts. The Bayesian Information Criterion (BIC) was employed to determine the optimal degrees of freedom for L, M, and S using RefCurv_0.4.2. Three families within the gamlss class-namely, Box Cox Cole and Green (BCCG), Box Cox T (BCT), and Box Cox Power Exponential (BCPE)-were applied, each with three smoothing techniques: penalized splines (ps), cubic splines (cs), and polynomial splines (poly). The best-fitted model was selected from these nine combinations based on the Akaike Information Criteria.

RESULTS

The Novel Case Selection Method yielded 3655 cases as per criteria. After cleaning the data, this method lead to selection of 3540 children for "weight for age" (W/A) and 3515 children for "height for age" (H/A). The "BCPE" family and "ps" as smoothing method proved to be best on AIC for all four curves, i.e. the W/A male, W/A female, H/A male, and H/A female. The optimum selected degrees of freedom for the curve "W/A", for both genders were (M = 1, L = 0, S = 0). The optimum degrees of freedom for H/A male were again (M = 1, L = 0, S = 0), but for females the selected degrees of freedom were (M = 1, L = 1, S = 1). The indigenous fitted standard curves for Pakistan were on lower trajectory in comparison to WHO standards.

CONCLUSION

This study uses the Novel Case Selection Method with introduced algorithms to construct tailored growth charts for lower and middle-income countries. Leveraging extensive MICS data, the methodology ensures representative national samples. The resulting charts hold practical value and await validation from established data sources, offering valuable tools for policy makers and clinicians in diverse global contexts.

Evaluating preschool linear growth velocities: an interim reference illustrated in Nepal

OBJECTIVE

An annualised linear growth velocity (LGV) reference can identify groups of children at risk of growing poorly. As a single velocity reference for all preschool ages does not exist, we present an interim tool, derived from published, normative growth studies, for detecting growth faltering, illustrating its use in Nepali preschoolers.

DESIGN

The WHO Child Growth Velocity Standard was adapted to derive 12-month increments and conjoined to the Tanner-Whitehouse Height Velocity Reference data yielding contiguous preschool linear growth annualised velocities. Linear restricted cubic spline regressions were fit to generate sex-specific median and standard normal deviate velocities for ages 0 through 59 months. LGV Z-scores (LGVZ) were constructed, and growth faltering was defined as LGVZ < –2.

SETTING

Use of the reference was illustrated with data from Nepal’s Tarai region.

PARTICIPANTS

Children contributing the existing growth references and a cohort of 4276 Nepali children assessed from 2013 to 2016.

RESULTS

Fitted, smoothed LGV reference curves displayed monotonically decreasing 12-month LGV, exemplified by male/female annual medians of 26·4/25·3, 12·1/12·7, 9·1/9·4, 7·7/7·8 and 7/7 cm/years, starting at 0, 12, 24, 36 and 48 months, respectively. Applying the referent, 31·1 %, 28·6 % and 29·3 % of Nepali children <6, 6–11 and 12–23 months of age, and ∼6 % of children 24–59 months, exhibited growth faltering. Under 24 months, faltering velocities were more prevalent in girls (34·4 %) than boys (25·3 %) (P < 0·05) but comparable (∼6 %) in older preschoolers.

CONCLUSIONS

A LGV reference, concatenated from extant data, can identify preschool groups at-risk of growth faltering. Application and limitations are discussed.

Reporting Diagnostic Reference Levels for Paediatric Patients Undergoing Brain Computed Tomography

Brain computed tomography (CT) is a diagnostic imaging tool routinely used to assess all paediatric neurologic disorders and other head injuries. Despite the continuous development of paediatric CT imaging, radiation exposure remains a concern. Using diagnostic reference levels (DRLs) helps to manage the radiation dose delivered to patients, allowing one to identify an unusually high dose. In this paper, we propose DRLs for paediatric brain CT examinations in Saudi clinical practices and compare the findings with those of other reported DRL studies. Data including patient and scanning protocols were collected retrospectively from three medical cities for a total of 225 paediatric patients. DRLs were derived for four different age groupings. The resulting DRL values for the dose-length product (DLP) for the age groups of newborns (0-1 year), 1-y-old (1-5 years), 5-y-old (5-10 years) and 10-y-old (10-15 years) were 404 mGy cm, 560 mGy cm, 548 mGy cm, and 742 mGy cm, respectively. The DRLs for paediatric brain CT imaging are comparable to or slightly lower than other DRLs due to the current use of dose optimisation strategies. This study emphasises the need for an international standardisation for the use of weight group categories in DRL establishment for paediatric care in order to provide a more comparable measurement of dose quantities across different hospitals globally.

Exploring Handgrip Strength as a Cross-cultural Correlate of Body Composition and Upper Body Strength in Older Adults from Costa Rica and Kansas

Sarcopenia and disability in older adults are often characterized by body composition measurements; however, the gold standard of body composition measurement, dual-energy X-ray absorptiometry (DEXA), is expensive to acquire and maintain, making its use in low and middle income countries (LMIC) it out-of-reach in developing nations. Because these LMIC will bear a disproportionate amount of chronic disease burden due to global aging trends, it is important that reliable, low-cost surrogates need to be developed. Handgrip strength (HGS) is a reliable measure of disability in older adults but has not been used widely in diverse populations. This study compared HGS to multiple measurements of body composition in older adults from the US (Kansas) and a middle-income country (Costa Rica) to test if HGS is a cross-culturally appropriate predictive measure that yields reliable estimates across developed and developing nations. Percent body fat (%BF), lean tissue mass index (LTMI), appendicular lean soft tissue index (ALSTI), body fat mass index (BFMI), bone mineral density (BMD), and HGS were measured in older Costa Ricans (n = 78) and Kansans (n = 100). HGS predicted lean arm mass with equal accuracy for both samples (p ≤ 0.05 for all groups), indicating that it is a reliable, low-cost and widely available estimate of upper body lean muscle mass. Older adults from Costa Rica showed different body composition overall and HGS than controls from Kansas. Handgrip operates equivalently in the US and Mesoamerica and is a valid estimate of lean arm muscle mass as derived by the more expensive DEXA.

Nerve ultrasound reference values in children and adolescents: Echogenicity and influence of anthropometric factors including hand volume

Background

Nerve cross-sectional area (CSA) reference values in high-resolution ultrasound for children and adolescents are influenced by demographic and anthropometric factors such as age, height and weight.

Objectives

The influence of hand volume as an additional morphometric factor was evaluated and nerve echogenicity was analyzed in a prospective cross-sectional study.

Methods

CSA were measured in 30 healthy children and adolescents from 2 to 17 years in the median, ulnar, radial, tibial, peroneal and sural nerves. Height, weight, age, handedness and gender were recorded, the volume of the hands was measured using the water displacement method. The intra-nerve CSA variability (INV), left/right ratios and absolute differences were calculated. Age groups were compared by the Kruskal-Wallis test. The influence of demographic factors was analyzed using Spearman correlation and multiple linear regression. Echogenicity and fraction of black were determined for each nerve segment.

Results

Nerve CSA values were consistently lower than those reported for adults and correlated in all measured nerve sites with age, height, weight and hand volume. Weight showed the highest correlation coefficient (R = .95) with the best fitting model predicting CSA. Correlation coefficients were higher in a linear than in a logarithmic model. Ratios were stable, the absolute differences increased with age and were significantly different between age groups. Most nerves showed a mixed or hypoechogenic pattern in echogenicity analysis, hyperechogenicity is less frequently observed.

Conclusions

Nerve CSA in children and adolescents is lower than in adults and increases proportionally during growth with a constant INV and left/right ratio in different age groups. Weight and age are predominant anthropometric factors predicting nerve size. Hand volume is correlated with nerve size, but does not predict CSA independently. Echogenicity can provide additional information on nerve structure.

Associations between Health Behaviors, Health Self-Efficacy, and Long-Term Outcomes in Survivors of Childhood Cancer: A Cross-Sectional Study

OBJECTIVES

Many survivors of childhood cancer experience multiple long-term chronic health conditions. Health behaviors are important because they contribute to chronic disease yet are highly modifiable. With growing pressure on cancer services, alternative models of care are required to address survivorship care needs. The authors sought to inform the development of a community-based model of cancer survivorship care for young people. This exploratory cross-sectional study aimed to assess the feasibility of study measures and processes, as well as investigate associations between various modifiable health behaviors, health self-efficacy, quality of life, and persistent symptoms.

DATA SOURCES

Participants were recruited from a long-term follow-up clinic for childhood cancer survivors. A self-report survey was completed, and participants received an activity tracker. Bivariate regression analyses were used to explore the relationship between variables.

CONCLUSIONS

The study measures and processes were deemed feasible with >70% of eligible survivors enrolling in the study and completing >70% of study measures. Thirty participants (mean age 22 ± 4.4 years) were enrolled; 83.3% finished treatment ≥5 years previously and 36.7% were overweight or obese. Bivariate regression identified those with higher scores of health self-efficacy were more likely to meet physical activity guidelines, as were those who achieved more sleep and consumed greater servings of vegetables. Meeting the physical activity guidelines, was significantly positively associated with higher quality of life and self-efficacy.

IMPLICATIONS FOR NURSING PRACTICE

Interventions that target health self-efficacy have the potential to improve a range of health behaviors and long-term outcomes for survivors of childhood cancer. Nurses are ideally placed to use this knowledge to support patients with recommendations to optimise their recovery and rehabilitation.

Growth patterns in children and adolescents with cerebral palsy from Argentina and Germany

To analyze growth patterns of children with CP between countries; to examine differences in growth; and to assess the fit of growth charts. Cross-sectional study in children with CP from 2 to 19 years old, 399 from Argentina and 400 from Germany. Growth measures were converted into z-scores and compared to WHO reference and US CP growth charts. Generalized Linear Model was used to analyze the growth expressed as mean z-scores. 799 children. Mean age 9 years (± 4). Compared to the WHO reference, the decrease in Height z-scores (HAZ) with age in Argentina (- 0.144/year) was double that in Germany (- 0.073/year). For children in GMFCS IV-V, BMI z-scores (BMIZ) decreased with age (- 0.102/year). Using the US CP charts, both countries showed decreasing HAZ with age, in Argentina (- 0.066/year) and in Germany (- 0.032/year). BMIZ increased more among children with feeding tubes (0.062/year), similar in both countries. Argentinian children with oral feeding decrease their Weight z-score (WAZ) by - 0.553 compared to their peers. With WHO charts BMIZ presented an excellent fit for GMFCS I-III. HAZ presents a poor fit to growth references. BMIZ and WAZ presented a good fit to US CP Charts. Growth differences due to ethnicity also act in children with CP, and are related to motor impairment, age and feeding modality, possibly reflecting differences in environment or health care.

Comparison between the World Health Organization and Bahraini children growth standards

OBJECTIVE

The aim of this study was to investigate the growth patterns of Bahraini female and male infants/young children aged 0-24 months in the Kingdom of Bahrain.

METHODS

A cross-sectional approach was employed to track the growth parameters among healthy Bahraini female and male infants/children aged 0-24 months. A multistage probability sampling criteria was used to collect information from official records. Anthropometric measurements (weight and length) and demographic characteristics on feeding practices were gathered. Generalized Additive Models for Location Scale and Shape (GAMLSS)/Lambda-Mu-Sigma methodology was implemented to select distribution type, optimize smoothing parameters, perform regression of growth models, and construct percentiles and Z-score charts and tables for weight for age, length for age, length for weight, and body mass index (BMI) for age.

RESULTS

Findings were compared with WHO Multicentre Growth Reference Study (MGRS) data. A total of 403 healthy infants/children (210 males and 193 females) were recruited. At birth, the mean weight, length, and BMI were 3.2±0.4 kg, 3.1±0.4 kg, 49.7±2.3 cm, 48.8±2.1 cm, 13.2±1.6 kg/m2, and 12.8±1.5 kg/m2 for males and females, respectively. Anthropometrics of males were all statistically significantly higher than those of females at all age levels. The length and weight of the Bahraini infants/children were slightly higher than those of the WHO-MGRS.

CONCLUSION

The outcomes of this study, presented as charts and tables, showed significant differences in comparison with the WHO-MGRS reference charts. Specifically, Bahraini children aged between 0 and 24 months of both sexes were taller and heavier than their cohorts in the MGRS reference charts. Further longitudinal studies are needed for monitoring the growth pattern of children using body composition methods, adiposity markers, and determinant factors of growth to investigate this deviation from the WHO-MGRS.

Ketogenic diet in children and adolescents: The effects on growth and nutritional status

The ketogenic diet is known to be a possible adjuvant treatment in several medical conditions, such as in patients with severe or drug-resistant forms of epilepsy. Its use has recently been increasing among adolescents and young adults due to its supposed weight-loss effect, mediated by lipolysis and lowered insulin levels. However, there are still no precise indications on the possible use of ketogenic diets in pediatric age for weight loss. This approach has also recently been proposed for other types of disorder such as inherited metabolic disorders, Prader-Willi syndrome, and some specific types of cancers. Due to its unbalanced ratio of lipids, carbohydrates and proteins, a clinical evaluation of possible side effects with a strict evaluation of growth and nutritional status is essential in all patients following a long-term restrictive diet such as the ketogenic one. The prophylactic use of micronutrients supplementation should be considered before starting any ketogenic diet. Lastly, while there is sufficient literature on possible short-term side effects of ketogenic diets, their possible long-term impact on growth and nutritional status is not yet fully understood, especially when started in pediatric age.

Latent growth analysis of children's height growth trajectories

Characterizing and quantifying the trajectories of variables of interest through time in their field of study is of interest to a range of disciplines. The aim of this study was to investigate the growth speed in height of children and its determinants. A total of 3401 males and 3200 females from four low- and middle-income countries with measured height on five occasions from 2002 to 2016 were included in the study. Data were analyzed using a latent growth model. The results of the study reported that children in four low- and middle-income countries exhibited substantial growth inequalities. There was a significant gender difference in change of growth with males had a higher baseline, rate of change, and acceleration in height growth than females. Comparing the component of slopes across countries, the growth change inequalities were observed among children. These inequalities were statistically significant, with the highest rate of change observed in Peru and Vietnam.

The past, present, and future of child growth monitoring: A review and primer for clinical genetics

Child growth measurements are critical vital signs to track, with every individual child growth curve potentially revealing a story about a child's health and well-being. Simply put, every baby born requires basic building blocks to grow and thrive: proper nutrition, love and care, and medical health. To ensure that every child who is missing one of these vital aspects is identified, growth is traditionally measured at birth and each well-child visit. While the blue and pink growth curves appear omnipresent in pediatric clinics, it is surprising to realize that their use only became standard of care in 1977 when the National Center for Health Statistics (NCHS) adopted the growth curve as a clinical tool for health. Behind this practice lies a socioeconomically, culturally, and politically complex interplay of individuals and institutions around the world. In this review, we highlight the often forgotten past, current state of practice, and future potential of this powerful clinical tool: the growth reference chart, with a particular focus on clinical genetics practice. The goal of this article is to understand ongoing work in the field of anthropometry (the scientific study of human measurements) and its direct impact on modern pediatric and genetic patient care.

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.

Approach to the Patient With Short Stature: Genetic Testing

The first step in the evaluation of the short child is to decide whether growth parameters in the context of the history are abnormal or a variant of normal. If growth is considered abnormal, system and hormonal tests are likely to be required, followed by more directed testing, such as skeletal survey and/or genetic screening with karyotype or microarray. In a small percentage of short children in whom a diagnosis has not been reached, this will need to be followed by detailed genetic analysis; currently, exome sequencing using targeted panels relevant to the phenotype is the commonly used test. Clinical scenarios are presented that illustrate how such genetic testing can be used to establish a molecular diagnosis, and how that diagnosis contributes to the management of the short child. New genetic causes for short stature are being recognized on a frequent basis, while the clinical spectrum for known genes is being extended. We recommend that an international repository for short stature conditions is established for new findings to aid dissemination of knowledge, but also to help in the definition of the clinical spectrum both for new and established conditions.

Differences in wasting assessment through Middle-Upper Arm Circumference (MUAC) adjusted by sex, age and geographic origin for children aged 6-59 months: New reference based on anthropometric surveys from 22 low-and-middle-income countries

OBJECTIVES

The Middle Upper Arm Circumference (MUAC) bracelet is a widely used instrument in public health assessments and humanitarian assistance projects. The WHO guidelines present a universal cut-off point of 115 mm to determine whether a child has severe acute malnutrition. The objective of this study is to analyze the existing differences in the MUAC for boys and girls aged between 6 and 59 months, from 22 countries distributed in three different continents, in contrast to the use of this single cut-off point. In addition, the creation of MUAC growth charts is presented for reference use.

MATERIALS AND METHODS

This study was carried out with a database developed by Action Against Hunger, composed, after the data pre-processing phase, of 97 921 individuals without anthropometric failure from African, Asian, and American continents. MUAC measurements were compared between countries, dividing by sex and age groups. A k-means method was used to create country clusters to allow comparisons and the variability was resumed using a Principal Component Analysis. For each cluster, growth curves were created and smoothed using the LOESS method.

RESULTS

Our research has revealed the existence of differences in the MUAC between countries in both, males and females, although with different trends. The evidence was confirmed with the creation of two clusters using the k-means method, which, when graphically represented by the Principal Component Analysis, showed that the MUAC was clearly different. There were also differences between males and females within each cluster, where growth curves did not overlap in any age group.

CONCLUSIONS

All statistical analysis indicate that there are differences in the MUAC values for children without anthropometric failure between countries, but also between sexes. With this research, a new reference is proposed that consider the existing variability between human populations to improve the precision in the determination of severe acute malnutrition in children.

Chair Size Design Based on User Height

General principles derived from anatomical studies of human body sizes should be applied to chair designs. Chairs can be designed for a specific user or a particular group of users. Universal chairs for public spaces should be comfortable for the largest possible group of users and should not be adjustable, such as office chairs. However, the fundamental problem is that the anthropometric data available in the literature either come from many years ago and are out of date or do not provide a complete set of all the dimensional parameters of a sitting human body position. This article proposes a way to design chair dimensions solely based on the height range of the intended chair users. For this purpose, based on literature data, the main structural dimensions of the chair were assigned to the appropriate anthropometric body measurements. Furthermore, calculated average body proportions for the adult population overcome the incompleteness, outdated and burdensome access to anthropometric data and link the main chair design dimensions to one easily accessible anthropometric parameter: human height. This is achieved by seven equations describing the dimensional relations between the chair's essential design dimensions and human height or even a height range. The result of the study is a method of determining the optimal functional dimensions of a chair for a chosen range of sizes of its future users based only on users' height range. Limitations of the presented method: the calculated body proportions are correct only for people with a standard body proportion characteristic of adults, i.e., they exclude children and adolescents up to 20 years of age, seniors, and people with a body mass index exceeding 30.

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.

Correlations of intracranial pathology and cause of head injury with retinal hemorrhage in infants and toddlers: A multicenter, retrospective study by the J-HITs (Japanese Head injury of Infants and Toddlers study) group

INTRODUCTION

In infants who have suffered head trauma there are two possible explanations for retinal hemorrhage (RH): direct vitreous shaking and occurrence in association with intracranial lesions. Which possibility is more plausible was examined.

MATERIAL AND METHODS

This multicenter, retrospective study reviewed the clinical records of children younger than four years with head trauma who had been diagnosed with any findings on head computed tomography (CT) and/or magnetic resonance imaging (MRI). Of 452 cases, 239 underwent an ophthalmological examination and were included in this study. The relationships of RH with intracranial findings and the cause of injury were examined.

RESULT

Odds ratios for RH were significant for subdural hematoma (OR 23.41, p = 0.0004), brain edema (OR 5.46, p = 0.0095), nonaccidental (OR 11.26, p<0.0001), and self-inflicted falls (OR 6.22, p = 0.0041).

CONCLUSION

Although nonaccidental, brain edema and self-inflicted falls were associated with RH, subdural hematoma was most strongly associated with RH.

'It is the child with the big head' - Primary healthcare providers' perceptions of paediatric hydrocephalus in Blantyre, Malawi: A qualitative study

Children in Africa are disproportionately burdened by the neurosurgical condition hydrocephalus. In Blantyre, Malawi, paediatric hydrocephalus represents the majority of surgical procedures performed in the neurosurgical department at Queen Elizabeth Central Hospital. To reduce morbidity and mortality, timely detection followed by referral from surrounding primary health centres is crucial. Aiming to explore perceptions and identify enablers and barriers to detection and referral, we conducted a qualitative study among primary healthcare providers (n = 30) from ten health centres in Blantyre district. Using a semi-structured interview-guide, we audio-recorded and transcribed the interviews before conducting a thematic analysis. One main finding is that there is a potential to improve detection through head circumference measurements, which is the recommended way to detect hydrocephalus early, yet healthcare providers did not carry this out systematically. They described the health passport provided by the Malawian Ministry of Health as an important tool for clinical communication. However, head circumference growth charts are not included. To optimise outcomes for paediatric hydrocephalus we suggest including head circumference growth charts in the health passports. To meet the need for comprehensive management of paediatric hydrocephalus, we recommend more research from the continent, focusing on bridging the gap between primary care and neurosurgery.

Influence of ecoregional and lifestyle factors on growth and body composition of I ndian children and adolescents aged 9–18 years—A multicenter study

OBJECTIVES

Ecoregion comprises all the environmental factors such as climate, vegetation, geomorphology, and soil taken together. The objectives of this study were to (1) assess differences in growth and body composition (BC) in 9-18-year-old children and adolescents (CA), across six ecoregions of India, (2) evaluate and compare the magnitude of the effect of ecoregional and lifestyle factors (LSF) on growth and BC in urban (U) and rural (R) children and adolescents, and (3) reassess the applicability of Bergmann's Rule and Allen's Rule to humans.

SUBJECTS AND METHODS

Data on 1845 CA (925 boys; 920 girls) were collected (2016-2017) from urban and rural areas of six ecoregions of India. Anthropometric and BC parameters were measured; Z-scores were computed. Lifestyle Index score (LIS) based on LSF-(socioeconomic status [SES], diet, physical activity) was computed (categorized as low, medium, high-indicates better LSF). Univariate analysis was performed to estimate effect size.

RESULTS

Significant differences were observed in growth and BC across urban and rural ecoregions. CA with high LIS were taller and heavier than those with low LIS (p < .05). Ecoregion had greater effect on growth (Partial eta square (η² ) for R = 0.136 vs. U = 0.057) and BC (η² for R = 0.094 vs. U = 0.058) of rural CA than urban (p < .01). LSF had more effect on the BC of urban CA (η²  = 0.017) than rural (η²  = 0.002, p < .01).

CONCLUSION

Disparities among the six ecoregions were not large enough to fully support Bergmann's Rule and Allen's Rule. Ecoregion had greater effect on growth and BC of rural CA than urban, while lifestyle factors had more effect on the BC of urban CA.

Growth charts for small sample sizes using unsupervised clustering: Application to canine early growth

Breed-specific growth curves (GCs) are needed for neonatal puppies, but breed-specific data may be insufficient. We investigated an unsupervised clustering methodology for modeling GCs by augmenting breed-specific data with data from breeds having similar growth profiles. Puppy breeds were grouped by median growth profiles (bodyweights between birth and Day 20) using hierarchical clustering on principal components. Median bodyweights for breeds in a cluster were centered to that cluster’s median and used to model cluster GCs by Generalized Additive Models for Location, Shape and Scale. These were centered back to breed growth profiles to produce cluster-scale breed GCs. The accuracy of breed-scale GCs modeled with breed-specific data only and cluster-scale breed GCs were compared when modeled from diminishing sample sizes. A complete dataset of Labrador Retriever bodyweights (birth to Day 20) was split into training (410 puppies) and test (460 puppies) datasets. Cluster-scale breed and breed-scale GCs were modelled from defined sample sizes from the training dataset. Quality criteria were the percentages of observed data in the test dataset outside the target growth centiles of simulations. Accuracy of cluster-scale breed GCs remained consistently high down to sampling sizes of three. They slightly overestimated breed variability, but centile curves were smooth and consistent with breed-scale GCs modeled from the complete Labrador Retriever dataset. At sampling sizes ≤ 20, the quality of breed-scale GCs reduced notably. In conclusion, GCs for neonatal puppies generated using a breed-cluster hybrid methodology can be more satisfactory than GCs at purely the breed level when sample sizes are small.

Development of physiologically-based toxicokinetic-toxicodynamic (PBTK-TD) model for 4-nonylphenol (4-NP) reflecting physiological changes according to age in males: Application as a new risk assessment tool with a focus on toxicodynamics

Environmental exposure to 4-nonylphenol (4-NP) is extensive, and studies related to human risk assessment must continue. Especially, prediction of toxicodynamics (TDs) related to reproductive toxicity in males is very important in risk-level assessment and management of 4-NP. This study aimed to develop a physiologically-based-toxicokinetic-toxicodynamic (PBTK-TD) model that added a TD prostate model to the previously reported 4-n-nonylphenol (4-n-NP) physiologically-based-pharmacokinetic (PBPK) model. Modeling was performed under the assumption of similar TKs between 4-n-NP and 4-NP because TK experiments on 4-NP, a random-mixture, are practically difficult. This study was very important to quantitatively predict the TKs and TDs of 4-NP by age at exposure using an advanced PBTK-TD model that reflected physiological-changes according to age. TD-modeling was performed based on the reported toxic effects of 4-NP on RWPE-1 cells, a human-prostate-epithelial-cell-line. Through a meta-analysis of reported human physiological data, body weight, tissue volume, and blood flow rate patterns according to age were mathematically modeled. These relationships were reflected in the PBTK-TD model for 4-NP so that the 4-NP TK and TD changes according to age and their differences could be confirmed. Differences in TK and TD parameters of 4-NP at various ages were not large, within 3.61-fold. Point-of-departure (POD) and reference-doses for each age estimated using the model varied as 426.37-795.24 and 42.64-79.52 μg/kg/day, but the differences (in POD or reference doses between ages) were not large, at less than 1.87-times. The PBTK-TD model simulation predicted that even a 100-fold 4-NP POD_man dose would not have large toxicity to the prostate. With a focus on TDs, the predicted maximum possible exposure of 4-NP was as high as 6.06-23.60 mg/kg/day. Several toxicity-related values estimated by the dose-response curve were higher than those calculated, depending upon the PK or TK, which would be useful as a new exposure limit for prostate toxicity of 4-NP.

Dynamics of human milk oligosaccharides in early lactation and relation with growth and appetitive traits of Filipino breastfed infants

Human milk oligosaccharides play a key role in the maturation of the infant gut microbiome and immune system and are hypothesized to affect growth. This study examined the temporal changes of 24 HMOs and their associations to infant growth and appetitive traits in an exploratory, prospective, observational, study of 41 Filipino mother-infant dyads. Exclusively breastfed, healthy, term infants were enrolled at 21-26 days of age (≈ 0.75 mo) and followed for 6 months. Infant growth measures and appetitive traits were collected at visit 1 (V1) (≈ 0.75 mo), V2 (≈ 1.5 mo), V3 (2.5 mo), V4 (2.75 mo), V5 (4 mo), and V6 (6 mo), while HMOs were measured at V1, V2, V3 and V5. Overall exposure to each HMO was summarized as area under the curve from baseline to 4 months of age and examined in association with each measure of growth at 6 months using linear regression adjusted for maternal age at birth, infant sex, birth weight, and mode of delivery. We saw modest associations between several HMOs and infant growth parameters. Our results suggest that specific HMOs, partly as proxy for milk groups (defined by Secretor and Lewis status), may be associated with head circumference and length, increasing their relevance especially in populations at the lower end of the WHO growth curve. We did not identify the same HMOs associated with infant appetitive traits, indicating that at least in our cohort, changes in appetite were not driving the observed associations between HMOs and growth.Clinical trial registration: NCT03387124.

Establishing Height-for-Age Z-Score Growth Reference Curves and Stunting Prevalence in Children and Adolescents in Pakistan

Height-for-age Z-score (HAZ) curves are widely used for detecting children with stunting. The aim of this study was to provide smoothed HAZ growth reference values and their curves for Pakistani children and adolescents aged 2-18 years. The prevalence of stunting in Pakistani children was determined. A total of 10,668 healthy Pakistani participants were included. Information related to age, sex, city of residence and height (cm) was used. Age- and sex-specific smoothed HAZ growth reference values and associated graphs were obtained using the lambda-mu-sigma (LMS) method. The prevalence of stunting was calculated by applying WHO 2007 and USCDC 2000 height-for-age references and local reference of the study population. In both sexes, the smoothed HAZ curves increased with age. For 2 and 3 years of age, the height values of the girls were greater than those of the boys. The boys were then taller than the girls. Comparing our median height (z = 0) growth reference data from WHO, USCDC and corresponding data from other countries, Pakistani children and adolescents have significantly different reference values than their counterparts in the reference group. A marked overestimation of the prevalence of stunting was observed (10.8% and 17.9% according to WHO and USCDC, respectively) compared to the local reference (3.0%). It is recommended that the prevalence of stunting in children and adolescents is determined by applying local height growth references to plan health strategies and treatments in the local population.

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.