Development of a New Growth Standard for Breastfed Chinese Infants: What Is the Difference from the WHO Growth Standards?

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.

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.

A validation of newly developed weight estimating tape for Korean pediatric patients

Pediatric drug dosages are based on body weight, so accurate measurement thereof is essential. However, this is not possible in emergencies. When using weight-estimating tapes, World Health Organization (WHO) growth charts serve as reference weights; however, local growth charts might be more accurate. This study developed a tape based on 2017 Korean National Growth Charts, which are more suitable for the Korean population than WHO growth charts, and evaluated its performance in a Korean pediatric population. This prospective cross-sectional study analyzed 792 pediatric patients who had visited the emergency department from June 2021 to December 2021. Weights were estimated using the Broselow tape (BT), Pediatric Advanced Weight Prediction in the Emergency Room XL (PAWPER XL), and Body Habitus-based Pediatric Emergency Tape (BHPET). The performance and measurement agreement of the tapes were analyzed. Among the tapes, the BHPET had the smallest mean absolute percentage error (MAPE), of 10.23%, and a root mean square percentage error (RMSPE) of 14.14%. Also, the percentage of weight estimations within 10% of the actual weight (PW10) was 59.6%, indicating better accuracy than the BT and PAWPER XL in all age groups. The intraclass correlation coefficients of the BT, PAWPER XL, and BHPET were 0.931, 0.977, and 0.985, respectively (p < 0.001). The performance and accuracy of the BHPET was similar or slightly superior to that of the other tapes. The body weight estimated using the BHPET for a local pediatric population was sufficiently correlated with the actual body weight.

An Infant Formula with Large, Milk Phospholipid-Coated Lipid Droplets Supports Adequate Growth and Is Well-Tolerated in Healthy, Term Asian Infants: A Randomized, Controlled Double-Blind Clinical Trial

Lipids are essential for healthy infant growth and development. The structural complexity of lipids in human milk is not present in infant milk formula (IF). A concept IF was developed mimicking more closely the structure and composition of human milk fat globules. The current study evaluates whether a concept IF with large, milk phospholipid-coated lipid droplets (mode diameter 3 to 5 μm) is equivalent to standard IF with regard to growth adequacy and safety in healthy, term Asian infants. In this randomized, double-blind, controlled trial, infants were randomized after parents decided to introduce formula. Infants received a standard IF with (Control) or without the specific prebiotic mixture scGOS/lcFOS (9:1 ratio; Control w/o prebiotics), or a Concept IF with large, milk phospholipid-coated lipid droplets and the prebiotic mixture. A group of 67 breastfed infants served as a reference. As a priori defined, only those infants who were fully intervention formula-fed ≤28 days of age were included in the equivalence analysis (Control n = 29; Control w/o prebiotics n = 28; Concept n = 35, per-protocol population). Primary outcome was daily weight gain during the first four months of life, with the difference between the Concept and Control as the key comparison of interest. Additionally, adverse events, growth and tolerance parameters were evaluated. Equivalence of daily weight gain was demonstrated between the Concept and Control group after additional correction for ethnicity and birthweight (difference in estimated means of 0.1 g/d, 90%CI [-2.30, 2.47]; equivalence margin +/- 3 g/d). No clinically relevant group differences were observed in secondary growth outcomes, tolerance outcomes or number, severity or relatedness of adverse events. This study corroborates that an infant formula with large, milk phospholipid-coated lipid droplets supports adequate growth and is well tolerated and safe for use in healthy infants.

Comparative study on the early growth of preterm infants with the World Health Organization growth standards and the China growth charts

BACKGROUND

This study focused on comparing the applicability and efficacy of the World Health Organization (WHO) growth standards and the China growth charts in diagnosing malnutrition and indicating nutritional interventions in preterm infants.

METHODS

Six hundred and eighty-three preterm infants were involved and their anthropometric data were collected. The proportion of weight and head circumference less than the 10th percentile (P10 ), weight less than the 25th percentile (P25 ), and weight for length greater than the 90th percentile (P90 ) identified by the WHO growth standards and the China growth charts were compared.

RESULTS

At corrected age (CA) 1 ~< 2 months (m), the proportion of head circumference P90 assessed by the WHO growth standards was greater than that assessed by the China growth charts.

CONCLUSIONS

Compared with the China growth charts, the WHO growth standards can further reduce the number of diagnoses of abnormal physical growth, are more helpful in avoiding overnutrition interventions, and are more sensitive in the early detection of delayed head circumference growth.

Differences between WHO Growth Standards and China Growth Standards in Assessing the Nutritional Status of Children Aged 0-36 Months Old

Background: At present, whether to use the World Health Organization’s (WHO) growth standards or native growth standards to assess the nutritional status in a given population is unclear. This study aimed to compare the differences between the WHO’s growth standards and China’s growth standards in assessing the nutritional status of children aged 0~36 months. Methods: We used z-scores to evaluate the nutritional status of children. The weight-for-age z-scores (WAZs), length/height-for-age z-scores (LAZ/HAZs), and weight-for-length/height z-scores (WLZ/WHZs) were calculated using the WHO’s growth standards and China’s growth standards. MeNemar’s test was used to compare the nutritional status of children. Results: The results in this study showed that there were differences between the WHO’s standards and China’s standards in assessing children’s nutritional status except for stunting and obesity. The prevalence of underweight assessed using China’s standards was higher than when using the WHO’s standards (except when 3 and 36 months old). The prevalence of wasting was significantly higher when assessed using China’s standards than when using the WHO’s standards from 12 to 36 months. The prevalence of overweight was higher when assessed using the WHO’s standards from 3 to 8 months. Conclusions: Both the WHO’s and China’s growth standards are useful measures in assessing children’s nutritional status but with key significant differences. Therefore, caution should be taken in selecting appropriate measures in a given population.

Sex differences in the application of WHO standards to Shanghai infants from birth to 18 months

BACKGROUND

The number of obese children in Shanghai has increased annually. Shanghai growth standards are higher than the World Health Organization's (WHO's) growth standards, which may influence caregiver feeding practices and enhance the risk of overweight in infants.

METHOD

A cluster-randomized controlled trial analysed 15,019 infants (healthy newborns, ≥3 clinical consultations in one year) from 19 community health service centers in two urban areas in Shanghai. Randomization was performed at the community level. A total of 8510 infants in the S-group were assessed with the Shanghai growth standards, and 6509 infants in the W-group were assessed by the WHO growth standards. Follow-up data were collected at 1, 2, 4, 6, 9, 12 and 18 months. Changes in the weight-for-age z score (WAZ), length-for-age z score (LAZ), and weight-for length z score (WLZ) were assessed using mixed regression models. Sex differences were compared between groups at all follow-up periods.

RESULTS

Compared to the S-group, the percent of overweight in boys in the W-group significantly decreased starting at 9 months (4.9% vs 3.3%, P = 0.011 at 9 months, 4.5% vs 2.5%, P < 0.001 at 12 months and 3.1% vs 0.8%, P < 0.001 at 18 months), and the percent of overweight in girls in the W-group significantly decreased starting at 12 months (3.0% vs 1.8%, P = 0.009 at 12 months and 1.7% vs 0.6%, P = 0.039 at 18 months). A decreased weight in boys (from 4 months to 18 months, P < 0.05) and an increased length in girls (from 6 months to 18 months, P < 0.05) were the key reasons for the decreased overweight percentage in the W-group.

CONCLUSION

The adoption of the WHO growth standards could result in markedly decreased weight gain in boys and increased length gain in girls beyond the age of 18 months among urban Shanghai infants.

TRIAL REGISTRATION NUMBER

ChiCTR1800015371.

Comparison of the effects of different growth standards on infants in Urban Shanghai: a cluster-randomized controlled trial

BACKGROUND

The Shanghai growth standards are higher than World Health Organization (WHO) growth standards, which may influence the feeding practices of the caregivers and increase the risk of overweight in these infants. This study aimed to compare the effects of different growth standards on childhood obesity in Shanghai metropolitan area.

METHODS

This was a cluster-randomized controlled trial conducted in 2 downtown areas with 19 community health service centers in Shanghai from November 2013 to December 2015. Randomization was done at the level of the community. Infants (health newborns) were assessed and monitored by the Shanghai growth standards (S-group) and the 2006 WHO growth standards (W-group), respectively. Measurements were taken at 1.0, 2.0, 4.0, 6.0, 9.0 and 12.0 months of age during follow-up period. Based on the values of length and weight measurements, according to the group's growth standards, doctors provided the caregivers with corresponding clinical consultation. Changes in weight-for-age z-score (WAZ), length-for-age z-score (LAZ), and weight-for length z-score (WLZ) between 2 groups were assessed using mixed regression models. Overweight was compared between 2 group at all follow-up measurements.

RESULTS

A total of 6509 infants (52.1% were boys) were in the W-group, and 8510 infants (51.4% were boys) were in the S-group. The overweight ratios between two groups were distinct at 9 months of age (3.4% in W-group and 4.3% in S-group) and 12 months of age (2.2% in W-group and 3.8% in S-group), and the differences were statistically significant (P = 0.020 and P < 0.001, respectively). Compared to W-group, the increase in WAZ (coefficient = 0.04, P = 0.004) and WLZ (coefficient = 0.09, P < 0.001) were significantly greater, and the LAZ was lower (coefficient = -0.04, P = 0.047) in S-group (W-group values were used as reference in mixed regression models).

CONCLUSION

Compared to the Shanghai growth standards, the adoption of WHO 2006 growth standards would reduce the risk of infant overweight in Shanghai metropolitan area up to 1 year of age.

TRIAL REGISTRATION NUMBER

ChiCTR1800015371, http://www.chictr.org.cn/ Chinese Clinical Trial Registry.

Postnatal growth in preterm infants during the first year of life: A population-based cohort study in China

In preterm infants (i.e. the gestational age less than 37 weeks), postnatal growth remains a concern. This study used multicenter longitudinal data from China's Under 5 Child Nutrition and Health Surveillance System to investigate the postnatal growth in the weight and length of preterm infants. Gender-stratified differences in weight and length were assessed between preterm and term infants. 1221 preterm infants and 1221 matched term infants were included. The rates of growth in weight and length in preterm infants was greater than those in term infants, especially from the first to sixth month. The rates were higher in males compared to females in the first 3 months. The differences of weight and length between preterm and term infants decreased with increasing age, however, these measurements did not reach the level of their term peers until 12 months before adjusting for gestational age. The median values of weight and length were even larger in preterm infants in the first month after adjusting for gestational age.

Growth in syphilis-exposed and -unexposed uninfected children from birth to 18 months of age in China: a longitudinal study

Early infant growth and development has attracted worldwide attention. Although numerous studies have demonstrated that maternal syphilis increases the risk of adverse pregnancy outcomes and congenital syphilis, the subsequent growth pattern and morbidity of syphilis-exposed uninfected infants are less understood. We conducted a longitudinal study to compare the growth pattern and disease distribution of syphilis-exposed and syphilis-unexposed uninfected children, and World Health Organization (WHO) reference standards from birth to 18 months of age. We obtained data from a prospective cohort study in three representative regions of Zhejiang Province in China. A total of 333 syphilis-uninfected children born to women with syphilis were recruited at birth and matched with 333 syphilis-uninfected children born to women without syphilis during pregnancy. Children were followed-up by medical staff every 3 months until 18 months of age. The mixed-effects model was used to compare changes in growth patterns and influencing factors between the two groups. Mean weight, length, and head circumference of children, as well as disease prevalence, were similar between the groups. Multilevel analysis indicated that, after controlling confounders, growth velocities were comparable in both weight and length measures from birth to 18 months old between the two groups; however, low birth weight had a negative impact on weight gain in both groups. There was no significant negative association between syphilis exposure and early growth and health in children, under 18 months in a setting with universal coverage of therapeutic interventions for maternal syphilis. These findings may contribute to improving prevention efforts for mother-to-child transmission of syphilis, such as early screening for syphilis in pregnant women, universal coverage of treatment, and interventions for exposed children. Children with low birth weight should be given priority as this is a risk factor for weight gain.

Growth patterns from birth to 24 months in Chinese children: a birth cohorts study across China

Background

Assessment of child growth is important in detecting under- and over-growth. We aimed to examine the growth patterns of healthy Chinese infants from birth to 24 months.

Methods

This study was based on six recent birth cohorts across China, which provided data (from 2015) on 4251 children (2174 boys, 2077 girls) who were born at term to mothers without gestational or preexisting diabetes, chronic hypertension, preeclampsia, or eclampsia. Analyses were performed using 28,298 longitudinal anthropometric measures in 4251 children and the LMS method to generate smoothed Z-score growth curves, which were compared to the WHO growth standards (which are based on data from 2003) and current Chinese growth references (which are based on data from 2005).

Results

Most (80.3%) of mother had college education or more, and maternal smoking was rare (0.4%). Compared to the WHO longitudinal growth standards for children aged 0 to 2 years, the growth references from this longitudinal study (length-, weight-, head circumference-, BMI-for-age, and weight-for-length) were significantly higher, for boys and girls; Specifically, the median length-, weight-, head circumference-, BMI-for-age, and weight-for-length was on average 0.9 (range 0.2–1.3) cm, 0.51 (range 0.09–0.74) kg, 0.17 (range − 0.24 to 0.37) cm, 0.70 (range 0.01 to 0.92) kg/m², and 0.43 (range 0.01 to 1.07) kg higher in Chinese boys, and 1.3 (range 0.5–1.9) cm, 0.73 (range 0.10–0.91) kg, 0.45 (range 0.15–0.62) cm, 0.7 (range 0.0 to 1.0) kg/m², and 0.42 (range 0.00 to 0.64) kg greater in Chinese girls, respectively. Compared to the current China cross-sectional growth references (based on data from a decade ago), growth references from this study were also higher, but the difference was less than that between growth references of this study and WHO growth standards.

Conclusions

This recent multicenter prospective birth cohort study examined early growth patterns in China. The new growth curves represent the growth patterns of healthy Chinese infants evaluated longitudinally from 0 to 24 months of age, and provide references for monitoring growth in early life in modern China that are more recent than WHO longitudinal growth standards from other countries and previous cross-sectional growth references for China.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1328-z) contains supplementary material, which is available to authorized users.