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Persons using assistive technology might not be able to fully access information in this file. In April 2006, the World Health Organization (WHO) released new international growth charts for children aged 0--59 months. In 2006, CDC, the National Institutes of Health, and the American Academy of Pediatrics convened an expert panel to review scientific evidence and discuss the potential use of the new WHO growth charts in clinical settings in the United States. The recommendation to use the 2006 WHO international growth charts for children aged <24 months is based on several considerations, including the recognition that breastfeeding is the recommended standard for infant feeding. The physical growth of infants and children has long been recognized as an important indicator of health and wellness (1,2).
In April 2006, the World Health Organization (WHO) released a new international growth standard for children aged 0--59 months (3).
Because two sets of growth curves exist for assessing child growth, clinicians in the United States need guidelines indicating which curves should be used and for which children. During June 29--30, 2006, CDC, the National Institutes of Health (NIH), and the American Academy of Pediatrics (AAP) convened a meeting in Hyattsville, Maryland, to review scientific evidence and obtain opinions regarding the use of the new WHO growth charts in clinical settings in the United States. Participants were provided background documents describing the development of both sets of curves. In spite of their widespread use, there were numerous concerns about these charts, including a lack of racial diversity in the infant sample, an infant sample composed of infants who were almost all formula fed, and the disjunction in length and stature measurements when transitioning from the charts for younger children to those for older children. The CDC and WHO growth charts differ in their overall conceptual approach to describing growth.
Whereas the WHO charts describe growth of healthy children in optimal conditions, the 2000 CDC growth charts are a growth reference, not a standard, and describe how certain children grew in a particular place and time.
Exclusion criteria for mothers and infants included maternal smoking during pregnancy or lactation, birth at <37 weeks or ?42 weeks, multiple birth, substantial morbidity, low socioeconomic status, and unwillingness of the mother to follow feeding criteria (12). The WHO growth curves for children aged <24 months were based on the longitudinal component of MGRS, in which cohorts of newborns were measured from birth through age 23 months (Table 1). A primary study hypothesis of MGRS based on previous research (13,14) was that all young children have the potential to grow similarly, regardless of their ethnic group or place of birth, if they are in a healthy environment and receive adequate nutrition.
The WHO growth curves for children aged 24--59 months were based on the cross-sectional component MGRS, in which groups of children at specific ages were measured at a specific point in time; the cross-sectional data represented 6,669 children (Table 2).
The CDC growth curves for children aged <36 months were based on cross-sectional data from various sources (Table 1). Careful procedures for training and measurement standardization were followed, and high-quality instruments were used for weight and length (or stature) measurements. Opinions of the participants varied about whether the use of a growth standard or a growth reference would be best for clinical settings in the United States.
When the WHO growth curves were created, the difference in growth between primarily formula-fed infants and primarily breastfed infants was an important consideration (12). The expert panel universally agreed that breastfeeding is the optimal form of infant feeding and recognized that the growth of breastfed infants differs from that of formula-fed infants.
The WHO and CDC charts show different growth patterns that might lead clinicians to different conclusions about variations in growth.
Beginning at approximately age 3 months, WHO curves show a slower rate of weight gain than the CDC charts, both in weight for age and weight for length. CDC curves allow for a transition period from 24--35 months when children can be assessed using either the charts for children aged 0--36 months or for persons aged 2--19 years.
The meeting participants raised concerns that weights >2 standard deviations above the median should not have been deleted in creation of the WHO curves because they were part of the full weight distribution of the study population.
The panel discussed the possibility of using the WHO charts for children aged <24 months but the CDC charts for older children.
Because CDC charts are printed on separate pages, clinicians must switch charts when they switch from length to stature measurements at age 24 months. Predetermined percentiles on growth charts are used to identify children who might not be growing normally. Use of the 2006 WHO international growth standard for the assessment of growth among all children aged <24 months, regardless of type of feeding, is recommended. Clinicians should recognize that the WHO charts are intended to reflect optimal growth of infants and children.
For the first 3 months of age, the WHO charts show a somewhat faster rate of weight gain than the CDC charts, leading to the identification of more infants who appear to be growing slowly.
Differences in the length-for-age WHO and CDC charts are small, and clinical differences based on these charts are expected to be insignificant. According to WHO, 111 countries had adopted the WHO growth standards as of July 1, 2010 (A. In 2007, the AAP board of directors voted to support the use of the WHO growth charts for children aged <24 months (D. Various studies have compared the WHO growth standards with other growth references (34--37). Because the CDC charts are currently in use in clinical settings to assess growth of children, use of the WHO charts for children aged <24 months will require training of health-care providers and others who measure and assess child growth.
The clinical consequences of using the WHO standards compared with the CDC reference should be evaluated over time to identify advantages and unforeseen adverse consequences of the use of the WHO standards. Scientific Advisory Committee on Nutrition; The Royal College of Paediatrics and Child Health (2007). National Institutes of Health: Gilman Grave, MD, Mary Hediger, PhD, National Institute of Child Health and Human Development, Bethesda, Maryland.
Other Federal Government Agencies: Sue Ann Anderson, PhD, Food and Drug Administration, Washington, DC. Invited Experts: Diane Anderson, PhD, American Dietetic Association, Baylor College of Medicine, Baylor, Texas.
Use of trade names and commercial sources is for identification only and does not imply endorsement by the U.S. This conversion might result in character translation or format errors in the HTML version. An original paper copy of this issue can be obtained from the Superintendent of Documents, U.S. The problem increases with our animals because we cannot as readily see the side effects and the damage that these diagnosis and holistic or alternative therapies may be causing. For example, if I decide to take Goat Weed to treat my ear infection and I get severe anxiety, muscle tension and confusion I can stop taking it because I recognize something within my body is not right.  But if I give my dog the same medication or something similar I might not see any visual side effects, and it could be doing irreparable damage. Alternative therapies are defined as such because they are not scientifically tested or they have been disproved by other studies. Much of our modern knowledge and therapies have come from alternative therapies.  The development of aspirin, digitalis, and ephedrine all came from this ancient experimentation and lore. We tend to think of toxins as coming from industrialized chemicals but plants were the original toxins.
Some herbs and alternative therapies may be completely safe, but some may have harmful if not deadly consequences. Go ahead and do some research on the internet, but only search proven websites.   When I am looking for health information I do not click on any site that is not written or moderated by a licensed veterinarian.
Talk with your vet!  That is what they are there for!  Never add a medication or change anything about your pet’s care without contacting your vet. Get a second opinion, if you think there could be more options or if you are not happy with your vet.  There are often times specialist that can help with all kinds of specific types of veterinary concerns. Even simple things like nutrition and changing the PH of your dog’s urine can be detrimental. When we go on a high protein low carb diet, we can be sure and drink more water so that we don’t damage our liver or kidneys in the process, but your dog doesn’t know to do this.  High protein diets can damage the kidneys of some dogs. I worry about people diagnosing their own, or WORSE other people’s animals and doing damage or inadvertently denying their pet (or someone else’s) medical care.
Truth is, I bet if you look hard enough you could find that chiclets cure cancer, or cause cancer for that matter!  Anyone can post anything on the internet, it certainly does not have to be true.  And, just because you think chiclets cured your cancer doesn’t mean it will work for me or anyone else. Be a smart consumer or reader, even if you are emotionally involved and want to believe the information that you find!  Only search medically proven sites when searching for medical information.
Build a relationship and contact your vet when you have questions.  They went to veterinary medical school and most of the time they know what they are talking about or can point you toward someone else who might! It’s amazing how our pets are pleading with us to understand what they need by the way they are looking at us yet we assume we know all and we know best, for that I thank you very much because you are obviously a person who not only knows about dogs but cares deeply.
School LocationClick Here for a Google Map to the Institute of Complementary & Alternative Therapies Inc. Similar to the 2000 CDC growth charts, these charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index for age. Growth charts have been used for at least a century to assess whether a child is receiving adequate nutrition and to screen for potentially inadequate growth that might be indicative of adverse health conditions.
Similar to the 2000 CDC growth reference (4,5), these growth charts describe weight for age, length (or stature) for age, weight for length (or stature), and body mass index (BMI) for age. This report provides guidance on the use of the WHO and CDC growth charts and is intended for health-care providers and others who measure and assess child growth. The participants at the meeting were selected on the basis of their expertise in child growth, statistical methodology, clinical application, and maternal and child health policy.

At the meeting, CDC made presentations on the methods used to create the CDC growth charts, and a principal investigator for the WHO Multicentre Growth Reference Study (MGRS), which generated the data used for the WHO growth curves, made a presentation on the methods used to create the WHO charts. At the end of the meeting, CDC asked all participants to provide written opinions on which curves should be recommended, at which ages, and for which children.
In 1977, the National Center for Health Statistics (NCHS), which became a part of CDC in 1987, published a new set of growth charts for children aged <18 years based on data from the Fels Longitudinal Growth Study and nationally representative surveys (10). Therefore, while planning the third National Health and Nutrition Examination Survey (NHANES III), NCHS decided to oversample children aged <6 years so that the 1970s growth charts could be revised.
The WHO charts are growth standards that describe how healthy children should grow under optimal environmental and health conditions. The CDC charts describe the growth of children in the United States during a span of approximately 30 years (1963--1994).
Weight-for-length measurements of >3 standard deviations from the overall study median were considered to be outliers and excluded from the final sample. Longitudinal data were collected at birth, 1 week, and every 2 weeks for the first 2 months after birth, monthly through age 12 months, and bimonthly from age 14 to 24 months. Data were collected in the same communities as those used to create the curves for children aged <24 months, typically just after completion of the longitudinal study. NHANES is a continuous cross-sectional survey of the health and nutritional status of the U.S.
At age 2 months, 72 weight measurements were available (representing 38 boys and 34 girls), and approximately 200 measurements (each measurement representing one child) per month were available through age 5 years.
In the WHO study, anthropometrists took two measurements independently and repeated measurements that exceeded preset maximum allowable differences. For both sets of curves, the data analysis treated each data point independently, even if two data points were taken for a single child. In contrast, the WHO charts for children aged <24 months were created with longitudinal data that were collected more frequently than the data used for the CDC charts, especially during the first few months of life when children grow the most quickly. The WHO charts were based on the premise that the healthy breastfed infant is the standard against which all other infants should be compared. The panel also recognized that AAP has stated the breastfed infant "is the reference or normative model against which all alternative feeding methods must be measured with regard to growth, health, development, and all other short- and long-term outcomes" (24). Healthy breastfed infants typically gain weight faster than formula-fed infants in the first few months of life but then gain weight more slowly for the remainder of infancy (25,26).
Use of the WHO charts in the United States might lead to an increase in the misperception of poor growth at this age. Because WHO curves are derived from infants who breastfeed through 12 months, infants who are still breastfeeding at approximately age 3 months are more likely to maintain their percentages on the WHO growth charts but to decrease in percentages on the CDC charts. Children in this age range can have their measurements plotted on the chart for younger children to show continuity with previous growth and on the chart for older children to show continuity with subsequent growth. They also noted that the methods for selecting the study participants for this age range was not substantively different between the WHO and CDC charts. During these discussions, participants explained that transitioning from one chart to another might create a disjunction by changing how a particular child's growth is classified. Likewise, clinicians would switch to a separate page if they were to transition from the WHO to the CDC charts at age 24 months. Traditionally, the 5th or 95th percentiles have been used with the CDC charts; however, they are arbitrary statistical values and are not based on analysis of health outcomes. The CDC charts also should be used for older children because the charts extend up to age 20 years, whereas the WHO standards described in this report apply only to children aged 0--59 months. Although many children in the United States have not experienced the optimal environmental, behavioral, or health conditions specified in the WHO study, the charts are intended for use with all children aged <24 months. Clinicians should recognize that this slower rate of weight gain is typical for formula fed infants. Burrowes, American Academy of Pediatrics, personal communication, November 7, 2007), with the recognition that substantial educational measures are needed to assist with interpretation of the charts. Researchers also have analyzed ways in which use of the WHO standards might affect prevalences of wasting, stunting, and underweight worldwide (38), as well as the distribution of z scores, a commonly used indicator of data quality in international surveys (39).
Training should focus on how to interpret growth on the charts, differences between references and standards, the characteristics of the WHO cohort (especially regarding socioeconomic status, infant feeding patterns, and maternal lack of smoking), the disjunction created by switching from the WHO to the CDC curves at age 2 years, growth patterns of children who breastfeed compared with those who formula feed, and the potential contribution of education and support programs for breastfeeding and complementary feeding. Research is needed on health outcomes related to different growth patterns during infancy, particularly with regard to identifying percentiles that are indicative of health problems. Growth charts of height and weight by age for boys and girls scaled according to physical maturity. Development of normalized curves for the international growth reference: historical and technical considerations.
Measurement and standardization protocols for anthropometry used in the construction of a new international growth reference.
Plan and operation of the Third National Health and Nutrition Examination Survey, 1988--94. Characterizing extreme values of body mass index-for-age by using the 2000 Centers for Disease Control and Prevention growth charts. Progress in promoting breast-feeding, combating malnutrition, and composition and use of infant formula, 1981--2006. Comparison of the prevalence of shortness, underweight, and overweight among US children aged 0 to 59 months by using the CDC 2000 and the WHO 2006 growth charts. Using the new UK---World Health Organization 0--4 years growth charts: information for healthcare professionals about the use and interpretation of growth charts. Breastfeeding, growth and growth standards: performance of the WHO growth standards for monitoring growth of Belgian children. Field testing of the 2006 World Health Organization growth charts from birth to 2 years: assessment of hospital undernutrition and overnutrition rates and the usefulness of BMI.
Algorithms for converting estimates of child malnutrition based on the NCHS reference into estimates based on the WHO child growth standards.
Standard deviation of anthropometric Z-scores as a data quality assessment tool using the 2006 WHO growth standards: a cross country analysis. Field testing of new WHO growth standards: assessment of anthropometric outcomes of children from 0 to 5 years from Rosario city, Argentina [Spanish].
Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study. The mean length measurements of these children was virtually identical; the six curves are almost indistinguishable in the figure. In the first few months of life, WHO curves show a faster rate of weight gain than the CDC charts. A substantial difference exists in the prevalence of low weight for age, with the WHO standard showing a lower prevalence beginning at age 6 months.
Mary Ann Best, PhD, National Association of Pediatric Nurse Practitioners, University of Texas Medical Branch, School of Nursing, Galveston, Texas.
Whereas the WHO charts are growth standards, describing the growth of healthy children in optimal conditions, the CDC charts are a growth reference, describing how certain children grew in a particular place and time.
The CDC growth charts should continue to be used for the assessment of growth in persons aged 2--19 years. WHO growth curves include BMI for age starting at birth, and CDC growth curves include BMI for age beginning at age 2 years. CDC, NIH, and AAP each had numerous representatives; additional experts from academia, clinical professional groups, and other government agencies were invited.
CDC conducted a statistical comparison of the charts and presented the results to participants.
After the meeting ended, CDC worked with NIH and AAP to develop these CDC recommendations based on the meeting proceedings. In 1978, CDC extrapolated the published percentiles to compute z scores, allowing for the generation of more extreme cutoffs, including 2 and 3 standard deviations below the median (11). After data collection was completed in 1994, CDC began revising the curves, and the new charts were released in 2000.
The curves were created based on data from selected communities worldwide, which were chosen according to specific inclusion and exclusion criteria. The international infant feeding recommendations in effect at the time of the study included exclusive breastfeeding for at least 4 months (although predominantly breastfed infants were also included in the study), introduction of complementary foods by at least 6 months but not before 4 months, and continued breastfeeding for at least 12 months. Of the initial 1,743 enrolled participants, six were excluded because of substantial morbidities. Other than the infant feeding criteria, the inclusion criteria used for the cross-sectional data collection for ages <24 months and 24--59 months were the same. Although there were some differences in the statistical smoothing techniques used to create the WHO and CDC charts, both used a variant of the lambda-mu-sigma (LMS) statistical method to describe both percentiles and z scores (standard deviation units) (5,18--20).
Other participants countered that because many children do not live in ideal environmental conditions, interpreting their growth by comparing them to a growth standard might not be appropriate. However, the panel also was concerned that the exclusion of weight-for-length data that were >3 standard deviations from the median from the WHO charts was inappropriate because these data represented children who were part of the actual distribution of observed physiological growth. These clinicians might inappropriately recommend that mothers supplement breastfeeding with formula or advise them to wean their infants from breastfeeding completely. In contrast, if WHO charts are used to assess the growth of formula-fed infants, these infants might be identified as growing too slowly during the first few months of life but then be identified as gaining weight too quickly after approximately 3 months.

For weight for length (or stature) and length (or stature) for age, assessing children using both curves requires measuring the child both recumbent and supine and therefore is not a common practice. CDC and WHO growth charts for ages 24--59 months were both based on cross-sectional data, and compared with the methods used to create the growth curves for children aged <24 months, the methodological differences between CDC and WHO in creating growth curves for ages 24--59 months were minor. For example, a child aged 24 months who is classified as overweight according to the WHO charts might be classified in the normal range on the CDC charts at the same age. Thus, if the WHO charts were to be used for infants and the CDC charts for older children, transitioning at age 24 months seemed to be the most feasible age to switch. The rationale for continuing to use CDC growth charts includes the following: 1) the methods used to create the WHO and CDC charts are similar after age 24 months, 2) the CDC charts can be used continuously through age 19 years, and 3) transitioning at age 24 months is most feasible because measurements switch from recumbent length to standing height at the this age, necessitating use of new printed charts. Training tools for clinicians are being developed and also will be available at this website. For breastfed infants identified as growing slowly, clinicians need to carefully assess general health issues and ensure appropriate management of lactation. Canada has recommended the use of the WHO growth charts (30), including the more recently published charts for children aged 5--17 years (31).
AAP has waited for the availability of clinically useable charts to publicize this recommendation. WHO has developed an algorithm to convert population prevalences that were computed using the previous NCHS, CDC, and WHO growth curves (10,11) to those expected using the new charts (38).
Finally, research should be conducted on the use of BMI measurements based on length in infants and toddlers as predictive of future adverse health effects.
Collaborative Statement of the Dietitians of Canada, Canadian Paediatric Society, The College Of Family Physicians Of Canada, and Community Health Nurses of Canada. Beginning at approximately age 3 months, WHO curves show a slower rate of weight gain than the CDC charts. The CDC reference identifies 7%–11% of children aged 6–23 months as having low weight for age, whereas the WHO stan¬dard identifies <3%. Grummer-Strawn, PhD, Zuguo Mei, MD, Christopher Reinold, PhD, Diane Thompson, MPH, National Center for Chronic Disease Prevention and Health Promotion, Atlanta, Georgia. Margaret Boland, MD, North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Eastern Ontario, University of Ottawa, Ontario, Canada. The material in this report originated in the National Center for Chronic Disease Prevention and Health Promotion, Ursula Bauer, PhD, Director. However, in the past few decades, concerns about excessive weight gain have increased, and growth charts have been used to screen for overweight, including obesity.
WHO then recommended that these z scores be used as a global reference for the definition of malnutrition. In 1997, WHO launched the MGRS to collect data on the growth of children worldwide based on strict inclusion criteria. Deviation from the WHO growth standard should prompt clinicians to determine whether suboptimal environmental conditions exist, and if so, whether they can be corrected. Study participants were provided breastfeeding support as needed and were counseled on complementary feeding, with an emphasis on timing, energy density, feeding frequency, and micronutrient content.
The infant feeding criteria were much less stringent (breastfeeding for at least 3 months and no requirements for the timing of complementary feeding).
Birth data were based on 82 million birth weight measurements and 445,000 birth length measurements. In general, both WHO and CDC assessed length (measured lying down) for children aged <24 months and stature (measured standing up) for children aged 24--59 months. Because no data (other than length for age) were available to connect the birth data to the cross-sectional data after age 2 months in the CDC curves, a 3-parameter linear mathematical model was used to smooth the weight data from 0--35 months (5). Likewise, some children who live in optimal conditions deviate from the normal growth curve but are not unhealthy. The data for the WHO growth charts were generally considered to be strong during the first several months of age. For these reasons, the expert panel found little reason to recommend a change from the current use of the CDC curves among older children.
Using the WHO-recommended percentiles with the WHO curves in the United States would result in a prevalence of short stature and overweight that is similar to the prevalence from the CDC curves using the 5th and 95th percentiles (27). For example, formula-fed infants tend to gain weight more rapidly after approximately age 3 months and therefore cross upward in percentiles, perhaps becoming classified as overweight. Only if there is evidence of lactation inadequacy should they consider supplementation with formula. Some assert that this might be beneficial because overdiagnosis of underweight might damage the parent-child interaction, subjecting families to unnecessary interventions and possibly unintentionally creating an eating disorder (28).
The United Kingdom Department of Health has recommended use of the WHO growth standards for children aged 2 weeks to 5 years in combination with United Kingdom birth weight charts (32--42 weeks' gestation) (32,33). Several studies have conducted field testing of the WHO charts in clinical settings worldwide, showing differences in prevalence compared with existing charts but also documenting that the WHO standards generally correspond with clinical assessment of malnutrition (36,40,41). Growth patterns over time using multiple data points should be used in conjunction with other medical and family history to assess appropriate growth. The WHO standard also identifies fewer infants (aged <12 months) as having high weight for length (5%–9%) than the CDC reference (9%–13%). At the time of the meeting, WHO was developing but had not released growth charts for head circumference for age; therefore, these charts were not discussed.
For the 855 infants who did not meet the feeding and maternal nonsmoking criteria, only the birth measurements were used.
Mothers of children aged 24--59 months years did not receive assistance to ensure that the children received optimal nutrition. All NHANES surveys include a household interview and a detailed physical examination that includes anthropometric measurements. A subset of children were measured both recumbent and standing (at ages 18--30 months for WHO, at ages 24--36 months for CDC) to assess the discrepancy between the two measurements and allow for connection of the curves before and after age 24 months. Participants acknowledged that adoption of a standard for assessing growth in children would create a substantial need for the education of clinicians but would also create an opportunity for clinicians to identify and address environmental conditions that might be negatively affecting growth.
In the WHO charts, 100% of the reference population of infants were breastfed for 12 months and were predominantly breastfed for at least 4 months. Therefore, a child aged 2 years might seem to be approximately 1 cm shorter when a clinician transitions from using length to stature measurements, potentially leading to a change in the plotted percentile. Therefore, in pediatric practice, the number of children identified for additional follow-up because of short stature and overweight would be similar to current numbers.
Although no evidence-based guidelines for treating overweight in infancy exist, early recognition of a tendency toward obesity might appropriately trigger interventions to slow the rate of weight gain.
However, children who are identified as having low weight for age on the WHO charts will be more likely to have a substantial deficiency. Training on accurate measurement techniques, especially for recumbent length, is critical for any assessment to be valid.
For children aged 18–23 months, the differences in high weight for length essentially disappear. Ruth Lawrence, MD, University of Rochester School of Medicine and Dentistry, Rochester, New York.
Katherine Dewey, PhD, Site Coordinator, Multicentre Growth Reference Study, University of California, Davis, Davis, California. A total of 18,973 distinct measurements of weight and length were included in the data set.
Meeting participants agreed that in practice, clinicians often use growth references, such as the CDC growth charts, as a standard to evaluate healthy growth rather than a reference as intended. In contrast, use of the 5th and 95th percentiles with the WHO weight charts would result in 10% of the WHO growth curve population being categorized as underweight or overweight, even though the population comprises healthy children who were fed according to international recommendations. For children aged 18--23 months, the differences in high weight for length essentially disappear.
Lori Feldman-Winter, MD, Children's Regional Hospital at Cooper, University of Medicine and Dentistry of New Jersey---Robert Wood Johnson Medical School, Camden, New Jersey. Cutberto Garza, MD, PhD, Co-Principal Investigator, Multicentre Growth Reference Study, Boston College, Chestnut Hill, Massachusetts. Data on participants who were not included in the data set were not available to meeting participants. The population used to create the CDC charts includes children with various health problems and children who were not fed according to international recommendations. For example, poor weight gain might result from neglect, substantial morbidities, or other medical problems that require immediate attention (29).
In addition, the composition of infant formula has changed considerably during the preceding 35 years (23). Van Nguyen, Community Clinic Inc., Women, Infants, and Children Program, Takoma Park, Maryland.

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