Children are entitled to the highest attainable standard of health, Download full-text
and this privilege is recognized and sanctioned worldwide as a
right of every child. A healthy childhood is the keystone of a
country’s aspiration towards a healthy and prosperous community,
since sound health is mandatory for a child, and even for an adult,
to reach the pinnacle of his/her potential. The term ‘health’
encompasses several facets of an individual, of which physical
development is a core element. Several factors play a part in the
growth of a child, one of the most significant being good nutrition.
The attainment of satisfactory nutrition can be a slippery target, as
it has a narrow range on either side of which are the extremes of
malnutrition – undernutrition and overnutrition.
Growth references are an indispensible tool, used by the United
Nations and government agencies alike for aid in the assessment,
correction and maintenance of nutritional requirements of children.
There have been several different formats of growth curves, and
the most recent, revised version are the new WHO growth standard
which were developed using the Multicentre Growth Reference
Study (MGRS) as a foundation. World Health Organization, after a
review of NCHS anthropometric references of 1977 concluded that
these did not adequately represent early childhood growth and that
new growth curves were necessary.
In view of this, WHO generated new curves based on the MGRS.
The MGRS provided exemplary data on the development of
infants and children. This data was based on healthy children
living under ideal conditions who were predominantly breastfed,
thus favoring the achievement of their full genetic growth
potential. This provided a hitherto unsurpassed foundation for a
growth standard. The MGRS also embraced the importance of
universal applicability and included children from a range of
different countries in the study, ensuring ethnic variety. These
standards provide a more robust tool for assessing child growth.
The design characteristics provide a wider array of references for
expanded uses, such as monitoring of childhood obesity and
management of early lactation.
Since the NCHS growth charts were still in use at our hospital and
its satellite centers, we did a study with the following objectives:
1. To assess the nutritional status of under-five children using
NCHS and WHO standards with the weight-for-age and height-
2. To compare the two in detecting malnutrition among children.
3. To study the implications of adopting new WHO standards in
assessing prevalence of malnutrition and detection of
With the application of new WHO standards, we are expected to
find higher prevalence of stunting throughout childhood compared
to the old NCHS/WHO reference. It is also expected to find a
substantial increase in rates of underweight during the first half of
infancy and a decrease thereafter. Our study found that the WHO
growth standards pick up more underweight children as compared
to NCHS standards (19 % to 11 %). The prevalence rates were
higher with the WHO standards for the 0-6 months, 6-12 months
and 2-5 years age groups than with the NCHS standards (26.7 % to
6.7 %, 15.4 % to 7.7 % and 24.1 % to 7.1 % respectively).
However, in the 1-2 years age group, the prevalence was less with
the WHO standards than with the NCHS standards (13.3% to
20%). The prevalence is higher with the WHO standards in the
first half of infancy, as expected, in the present study.
Regarding height-for-age, our study found that the prevalence of
stunting was less with the WHO standards as compared to NCHS
standards (11 % to 13 %). However, the prevalence was higher
upto 6 months of age with the WHO standards (13.3 % to 6.7 %).
Amongst 6-12 months and 1-2 year age group, WHO standards
showed lower prevalence (7.7% to 15.4 % and 13.3% to 20%
respectively). The prevalence was same in the 2-5 years age group
Our study, though small in sample size, showed that adoption of
the new standards would help in picking up more malnourished
children and probably at an earlier stage.
Implications of Applying New WHO Growth Standards on Assessment of Nutritional
Status among Under-Five Children in a Rural Health Center in India
Avika Dixit1,2, MBBS, MPH; Uzma Khan1, MBBS; Jane Philip1, MBBS
1Kasturba Medical College, Manipal, India; 2Harvard School of Public Health, Boston MA
• UNICEF (2006) Progress for Children: A Report Card on Nutrition (No. 4).
• WHO Multicentre Growth Reference Study Group. WHO Child Growth Standards:
Length/height-for-age, weight-forage, weight-for-length, weight-for-height and body
mass index-for-age: Methods and development. Geneva; World Health Organization:
• Garza C, de Onis M. Rationale for developing a new international growth reference.
Food Nutr Bull. 2004 Mar;25(1 Suppl):S5-14.
• de Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J. The WHO
Multicentre Growth Reference Study: planning, study design, and methodology.
Food Nutr Bull. 2004 Mar;25(1 Suppl):S15-26.
• WHO Child Growth Standards - Backgrounders. http://www.who.int/nutrition/
media_page/en/ accessed on October 10, 2008.
• de Onis M, Onyango AW, Borghi E, Garza C, Yang H. Comparison of the World
Health Organization (WHO) Child Growth Standards and the National Center for
Health Statistics/WHO international growth reference: implications for child health
programmes. Public Health Nutr. 2006 Oct;9(7):942-7.
• WHO Child Growth Standards - http://www.who.int/childgrowth/standards/en/
accessed on October 10, 2008.
• Nuruddin R, Lim MK, Hadden WC, Azam I. Comparison of estimates of under-
nutrition for pre-school rural Pakistani children based on the WHO standard and the
National Center for Health Statistics (NCHS) reference. Public Health Nutr. 2008
We conducted a cross – sectional study where we retrieved from
hospital records the anthropometric measurements of 100 under
five children in rural Karnataka, India in September 2008. The
heights and weights of children were plotted on the weight-for-
age and height-for-age charts separately for males and females
on the growth charts based on the NCHS reference. These were
then plotted on the WHO growth charts and the nutritional
statuses according to the two references were compared. .
Our study showed that the WHO growth standards pick up more
underweight children as compared to NCHS standards (19% vs.
11%). The prevalence rates were higher with the WHO standards
for the 0-6 months (n=30), 6-12 months (n=26) and 2-5 years age
groups (n=14) than with the NCHS standards (26.7% vs. 6.7%,
15.4% vs. 7.7% and 24.1% vs. 7.1% respectively). However, in the
1-2 years age group (n=30), the prevalence was less with the WHO
standards than with the NCHS standards (13.3% vs. 20%). The
prevalence was higher with the WHO standards in the first half of
infancy. Regarding height-for-age, the prevalence of stunting was
less with the WHO standards as compared to NCHS standards
(11% vs. 13%). However, the prevalence was higher upto 6 months
of age (n=30) with the WHO standards (13.3% vs. 6.7%). Amongst
6-12 months (n=26) and 1-2 year age group (n=30), WHO
standards showed lower prevalence (7.7% vs. 15.4% and 13.3% vs.
20% respectively). The prevalence (7.1%) was same in the 2-5
years age group (n=14).
Children under five years of age who attended the out-patient
department of a community health center in village Karkala,
Karnataka, India were selected for the study.
The new approach is important to improve early detection and
proper management of malnourished children and prevent life-
long sequelae, which prevent them from achieving their full
potential of physical development.
Normal 89% 81%
Total Underweight 11% 19%
Underweight 0-6m 6.7% 26.7%
Underweight 6-12m 7.7% 15.4%
Underweight 1-2y 20% 13.3%
Underweight 2-5y 7.1% 21.4%
Height-for-age NCHS WHO
Normal 87% 89%
Total Stunting 13% 11%
Stunting 0-6m 6.7% 13.3%
Stunting 6-12m 15.4% 7.7%
Stunting 1-2y 20% 13.3%
Stunting 2-5y 7.1% 7.1%
Age distribution of sample (N = 100)
Prevalence of underweight according to new and old standards
Prevalence of stunting according to new and old standards