Growth charts in Newborn, Preterm and term neonates. All historically used charts in NICU are discussed here. Presented by Dr Sujit, in Sir Ganga Ram Hospital

1. Growth Charts
Dr Sujit K. Shrestha

2. Preview
History
Definition
Importance of Growth Monitoring
Types of Growth charts
Timing of Growth Monitoring
On going Studies and Projects
Software available.

3. History - Innovation
• The idea of plotting a child’s body measurements on a chart
to illustrate their pattern of growth first - Count Philibert de
Montbeillard (1720-1785)
• George Buffon (1707-1788) 
published the chart in his Histoire
Naturelle, thus producing the first
height growth curve
(Tanner 1962).
George Buffon, France

4. 20th Century
Effort to Standardize
• Until the late 1970s, clinicians used various
growth charts to assess child growth.
• No uniform measurement methods
• Efforts were made to create a standard growth
chart that could be used for all population.

5. Growth
a net increase in size or mass of tissues as a result of either
multiplication of cells or increase in intracellular substance.
- hypertrophy and/or hyperplasia of cells
• Fetal growth  by fetal, placental and maternal factors.
• Under normal environment fetus grows as per its inherent growth
potential to an appropriate size newborn.
• Post-natal growth  genetic potential and various
internal and external factors.
• Therefore growth monitoring important to detect
deviation from normal

6. Definition: Growth Chart
• A growth chart is a graphic design of a growth reference
presented as a visual display for clinical use.
• comprise growth curves which display both the size of
the newborn at a series of ages, and at the same time
their growth rate or growth velocity over time, based
on the slope of the curve.
• the charts have become an important tool in child health
screening and pediatric clinical workup.

7. Growth Reference
• A statistical summary of anthropometry in a reference group
of children
• usually presented as the frequency distribution at different
ages.
• representative of some geographic region at a particular
time, e.g. Great Britain in 1990
• involves the mean and SD or alternatively the median and
selected centiles, conditioned (usually) on age and sex.
• it describe how children grow
• To establish whether or not their measurements are
typical of the reference group.

8. Growth Standard
• A growth standard is essentially the same as a growth
reference except that the underlying reference sample is
selected on health grounds.
• represents a healthy pattern of growth
• the standard shows how children ought to grow rather
than how they do grow.
• Eg WHO MGRS Growth standards

9. Difference
Reference charts Standard charts
Simply describes the growth of a
population without taking into the
consideration the health of the
population.
Provides guidance on how a child should
grow not just how child is growing.
Based on cross sectional data, relatively
easy to acquire large sample size
Based on prospective and longitudinal
monitoring of healthy growth; and diffi
cult to acquire large sample size.
Increase in incidence of childhood
obesity means future descriptive charts
will enable more children to be classified
as normal even though overweight and
obese.
Have the potential to diagnose over
weight and obesity early which can help
in early intervention.
Have the potential to over diagnose
under nutrition which in turn can lead to
overfeeding
Have the potential to avoid over
diagnosis of under nutrition.

10. Centile and Z score
The centile for an individual indicates his or her size, be it
height, weight or body mass index etc. The centile indicates
the distance they have travelled along the growth road up to
that age. The growth chart quantifies size/distance in terms
of the centile.
Z scrores-. For population-based assessment—including
surveys and nutritional surveillance—the Z-score is widely
recognized as the best system for analysis and presentation
of anthropometric data because of its advantages compared
to the other methods.

11. Z-score (or SD-score) = (observed value - median value of the
reference population) / standard deviation value of reference
population
Interpreting the results in terms of Z-scores has several
advantages:
• same statistical relation to the distribution of the reference
around the mean at all ages, which makes results comparable
across ages groups and indicators.
• Z-scores are also sex-independent, thus permitting the
evaluation of children's growth status by combining sex and
age groups.
• These characteristics of Z-scores allow further computation of
summary statistics such as means, standard deviations, and
standard error to classify a population's growth status.

12. • Furthermore, individuals whose growth curve tracks
along the centiles over time are growing at average
velocity, while if the curve crosses centiles up or down
the individual is growing faster or slower than average –
centile crossing is a measure of relative velocity.
• A growth chart visualizes growth velocity, but it does not
quantify it – centile crossing is uncalibrated.

13. Growth velocity
• With exponential growth, the logarithm of weight results in a
linear function whose slope is equal to the growth velocity.
The growth velocity (GV) between two different days, in terms
of g/kg/day, can be determined with the following equation:
•
• where W1 is the weight (in grams) at the first day (D1) and W2
is the weight at the second day (D2). When exponential
growth is considered-

14. Anthropometric measurements
Length measurement
Instrument- Infantometer

15. Measurement of Weight
Instrument used-
• Measurement of weight in this population should be
taken on a scale that has been properly calibrated.
• The infant should be weighed without clothing or diaper.

16. Head circumference
• flexible tape
• measure at the maximum diameter through the
supraorbital ridge to the occiput.
• The value should be reported to the nearest 0.01 cm

17. Growth Charts:
Intrauterine Growth Charts Post-natal growth charts
Battaglia and Lubchenco 1967
Usher and Maclean 1969
Babson and Benda 1976
Fenton 2003
Fenton 2013
Berry et al 1997
Ehrenkranz 1999
CDC 2000
WHO 2006
Intergrowth 21st 2014

18. Intrauterine Growth Charts
• Over dozen published world wide
• Only few includes weight, length, and HC
• USA (Lubchenco 1966)
• Canada (Usher & McLean 1969)
• South Wales (Beeby 1996)
• Sweden (Niklasson 1991)
• South Wales/Sweden/Canada (Fenton 2003)
• USA (Olsen 2010)

19. Handbook of Growth and Growth Monitoring in Health and Disease
edited by Victor R. Preedy

20. Limitations of Growth charts

21. Limitation of available Intra
Uterine growth charts
• Small sample size
• Not being gender specific
• Used LMP as mean of Gestation age- 40% error caused
by maternal factors
• Do not describe longitudinal fetal growth.
• Preterm infant is inherently different from fetus, so
concerns about using IU charts as standards.

22. Importance of Growth monitoring
specially in Preterm infants
• During Hospital stay
• Rapid gain- Fluid overload, catch-up
• Low gain- inadequate nutrition, illnesses
• Neurodevelopmental effects
• Standard formula vs Preterm enriched formula
observation
• Erenkranz’s observation
• Metabolic effect
• Overweight , obesity
• Metabolic syndrome

23. Lubchenco 1967
Study Multicenter, Retrospective study.
Population Full-Term and Premature Infant Nurseries
from July, 1948, to January, 1961
Size- 5635
Low socio-economic status
White and Hispanic
Centre Colorado General Hospital ,USA High Altitude
Duration Between August 31, 1994 and August 9, 1995
26-42 weeks POG
Measurements Body weight, length, head circumference, and
weight-length ratio- Ponderal Index.
Data type Cross Sectional

24. Lubchenco
Benefits • Used Ponderal Index, a new parameter in
charts
• A better accepted chart than previous models
• In conjunction with intrauterine weight charts,
permit the identification of infants with
unusual intrauterine growth patterns.
• aid in the design of future research.
Drawbacks Charts of intrauterine growth in length, HC ,
weight, and weight-length ratio are only
approximate definitions of the group pattern of
fetal growth with gestational age.
Population based on only one country and of high
altitude.
Advice

25. Pediatrics. 1999 Aug;104(2 Pt 1):280-9.
Longitudinal growth of hospitalized very low birth weight infants. Ehrenkranz RA1, Younes
N, Lemons JA, Fanaroff AA,

26. Ehrenkranz 1999
Study Large, multicenter, prospective cohort study.
Population 1660 infants with birth weights between 501 to
1500 g admitted by 24 hours of age, included if
they survived >7 days (168 hours) and were
free of major congenital anomalies.
Centre 12 NICHHD Neonatal Research Network
centers, USA
Duration Between August 31, 1994 and August 9, 1995
Measurements Body weight, length, head circumference, and
MAC
Endpoint discharge, transfer, death, 120 days, or body
weight of 2000 g
Data type Longitudinal data

27. Erenkranz
Benefits • These growth curves  better understand
postnatal growth
• help identify infants developing illnesses
affecting growth,
• aid in the design of future research.
Drawbacks Cannot be taken as optimal.
Small Sample Size
Single Population- so cannot be used for world
population.
It is limited by the lack of data describing daily
caloric and nutritional intake, therefore, growth
could not be correlated with nutritional intake
Advice Further RCTs on factors affecting postnatal growth-
Calorie
Pediatrics. 1999 Aug;104(2 Pt 1):280-9.
Longitudinal growth of hospitalized very low birth weight infants. Ehrenkranz RA1, Younes
N, Lemons JA, Fanaroff AA,

30. Babson and Benda chart
• The growth chart by Babson and Benda (1976) shows means and
standard deviations for birth weight, head circumference, and
length from a gestational age of 26 weeks to 1 year of age.
• For the newborns, Babson obtained data from mostly Caucasian
infants born in Portland, Oregon, for the years from 1959
through 1966.
• 39,743 infants with gestational ages from 27 to 44 weeks,
including 3381 infants with gestational ages from 27 to 37 weeks
were included in the study.
• The gestational age was based on the LMP.
• Mean and standard deviation for 3 parameters were measured
from the chart and were converted into percentiles.

31. Babson and Benda
• Limitations-
• X axis begins at 26 weeks gestation- limits plotting
younger preterms
• Y axis has 500gm interval increments-Precise plotting
difficult
• Small sample size with only 45 babies of 30 weeks or
lesser gestation.
• 15 years old at time of creating charts and now >50
years old

32. Fenton 2003
Study Meta-analysis of Studies
Population The Newborn parameters were based on
a. Birth weight- Kramer et al 2001 . USG was used
in estimating Gestation age, CDC
b. Length and head circumference- Niklasson and
Beeby. Gestation- LMP and obstetric
assessment.
Gestation age between 22 and 50 weeks.
Centre Calgary,Canada.
Duration 1980 to 2002
Measurements Weight, length and head circumference
Data type Cross sectional data predominantly

34. FENTO
N
Benefits 1. This new fetal-infant chart- updated Babson type
2. This chart will allow a comparison for preterm
infants as young as 22 weeks of gestation first with
intrauterine and then with post term references and
it can replace the one developed by Babson which
has been used in neonatal intensive care for over 25
years.
3. The larger sample sizes and more accurate
gestational age assignments used here may provide
better confidence in the extreme percentiles.
4. It could be used for the assessment of size for
gestational age for infants smaller than 2 kilograms.
5. Shows 3, 10, 25, 50, 90 and 97 th Percentiles

35. Disadvantages:
1. Initial parts of the curves are based on the size of fetuses at
birth, which do not show the change in weight that occurs
after birth.
2. This is followed by curves based on the growth of term
infants who have not had the growth depressing effect of
prematurity.
3. Predominantly data were cross sectional.- Longitudinal
postnatal growth chart- show the pattern of initial weight
loss after birth followed by subsequent growth of a sample of
preterm infants.

36. Disadvantages:
4. Not based on the growth standard for preterm infants,
that is, on fetal growth. Therefore they do not show an
infant’s growth velocity or catch-up in growth relative to
the fetus or the term infant.
5. Further, the curves on a longitudinal growth chart are
highly influenced by the medical and nutritional care of
the sample infants; growth patterns may change with
innovations in medical and nutritional care
6. Like with all metanalysis , heterogenesity of data
sources is a set back.

37. WHO MCGS 2006
Study Recent population based surveys
Population The 2006 WHO growth curves for children are based
on data from the WHO MGRS, a study conducted in
six sites: Pelotas, Brazil; Accra, Ghana; Delhi, India;
Oslo, Norway; Muscat, Oman; and Davis, California.
Centre Multi-centric
Duration 1997-2003
Measurements weight, length and head circumference
Data type Longitudinal data

40. Continued
Benefits 1. Children from socioeconomic status that does not constrain
growth of the child*
2. Six Countries from different continents including both
developed and developing countries.
3. Based on population of breast fed babies. 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)#
4. 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.
Longitudinal data were collected at birth, 1 week, and every 2
weeks for the fi rst 2 months after birth, monthly through age 12
months, and bimonthly from age 14 to 24 months

41. Continued
Benefits 15. The WHO growth curves for children aged 24-59 months were
based on the cross-sectional component MGRS, in which groups
of children at specifi c ages were measured at a specifi c point in
time. The crosssectional data represented 6,669 children.
6. 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.
7. 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.
8. To eliminate the effect of overweight children on the weight
distributions in the WHO curves for children aged 24-59 months,
weight measurements of >2 standard deviations above the study
median were excluded; a total of 226 (2.7%) weight
measurements were excluded.

42. Disadvantages:
- Does not address Growth of Preterm infants.

45. Fenton 2013
Study Metanalysis of studies
Population Large preterm birth sample size of 4 million infants
Data from developed countries including Germany,
Italy, United States, Australia, Scotland and Canada
Centre Alberta, Canada.
Duration 1991 to 2007
Measurements of weight, length and head circumference
Data type Cross sectional data for Preterm infants

48. Continued
Benefits 1. Based on the recommended growth goal
for preterm infants: The fetus and the
term infant
2. Girl and boy specific charts
3. Equivalent to the WHO growth charts at
50 weeks gestational age (10 weeks post
term age).
4. Large Sample size of 4 million, with large
preterm population.
5. More recent Data ( 1991-2007)

49. FENTON
Benefits 1. Data from several Developed nations- can be
used for both developing and developed.
2. Curves are consistent with the data to 36 weeks,
thus can be used to assign size for gestational
age up to and including 36 weeks.
3. Chart is designed to enable plotting as infants
are measured, not as completed weeks. The x
axis adjusted for this chart so that infant size
data can be plotted without age adjustment

50. Disadvantages:
1. These growth charts are growth references and are not a
growth standard
2. Ideal growth pattern of preterm remains undefined as charts
were based on fetal growth and term babies.

53. Intergrowth 21st Chart:
For the first time (panel), international standards for newborn
size for each gestational age based on data from its NCSS
subpopulation, which conformed at population and individual
levels to the prescriptive approach used in the WHO MGRS.
1. These new standards - conceptual and practical link to WHO
Child Growth Standards, which have been adopted by more than
125 countries worldwide.
2. Gestation age based on USG
3. Included 20,486 eligible women between May 14, 2009, and
Aug 2, 2013.
4. Bridges gaps in clinical and population assessments for fetuses,
neonatal babies, and infants through provision of similar
instruments to monitor child growth seamlessly from early
pregnancy to age 5 years and to screen for stunting and wasting.

54. 5 Studies are included in the
Project
• Fetal Longitudinal Growth Study - a multicentric, population-
based assessment of fetal growth in eight countries.
• USG was taken for fetal anthropometric measurements
prospectively from 14+0 weeks gestation until birth in a
cohort of women. women had a reliable estimate of
gestational age confirmed by USG measurement of fetal
crown–rump length in the first trimester.
• The five primary ultrasound measures were obtained every 5
weeks (within 1 week either side) from 14 weeks to 42 weeks
of gestation.
• The best fitting curves for the five measures were selected
using second-degree fractional polynomials and further
modelled in a multilevel framework to account for the
longitudinal design of the study.

55. • A total 4607 eligible women were included.
• A cohort of women with adequate nutrition and health status
with less risk of intrauterine growth restriction were selected.
• All women had reliable estimate of gestational age confirmed
by USG. A 3rd, 5th 10th, 50th, 90th, 95th and 97th centile
curves according to gestational age for these ultrasound
measures were obtained, representing the international
standards for fetal growth .
• These international fetal growth standards for the clinical
interpretation of routinely taken ultrasound measurements
and for comparisons across populations.

56. PPFS and NCSS
• For Preterm Postnatal Follow-up Study, all preterm newborns
of more than 26 weeks and less than 37 weeks were followed
post-delivery for evaluation of postnatal growth. All preterms
from FLGS who met criteria of healthy or stable preterm were
included.
• The Newborn Cross-Sectional Study, a component of
intergrowth-21st project, weight, length, and head
circumference in all newborn infants were measured, in
addition to the data collected prospectively for pregnancy and
the perinatal period. Newborn anthropometric measures were
obtained within 12 h of birth. A total of 20,486 eligible
women were enrolled between May 14, 2009, and Aug 2,
2013. A 3rd, 10th, 50th, 90th, and 97th centile curves were
obtained according to gestational age and sex.

57. 5. Software for clinical and epidemiological use free of charge,
including an app to calculate Z scores and centiles.
6. The standards are prescriptive—ie, they describe optimum
size in newborn infants without congenital abnormalities.
7. These standards are population-based, multiethnic,
multicountry, and sex-specific, and they arise from a
prospective study.

58. 8.Several processes were applied across all eight study
sites— All were uniform and followed a standarized
protocol.
9. Present centiles for birthweight, length, and head
circumference by sex and gestational age based on a
prescriptive approach that are integrated with the
corresponding fetal growth standards.
10. The observed and smoothed centiles were almost
identical and presented the 3rd, 10th, 50th, 90th, and 97th
centile curves according to gestational age and sex.

59. Disadvantages
• A shortcoming of studying such a low-risk group is that there
were relatively few early preterm births despite the large
sample size; hence, we had to limit the range of the standards
by setting the lower limit of the curves to those born at 33
weeks of gestation.
• It might not be feasible to construct standards for very
preterm newborn infants using such a strictly defined
subpopulation of preterm babies who are at higher risk of
intrauterine growth restriction and other major pregnancy and
neonatal complications

60. Time Schedule for Monitoring

61. • Sri Lanka becomes the first country to adopt the
INTERGROWTH-21st Preterm Standards
• 125 nations have adopted so far

62. THANK YOU

63. • THE END