Public Health Nutrition: page 1 of 8 doi:10.

1017/S136898001200105X
Worldwide implementation of the WHO Child Growth
Standards
Mercedes de Onis
1,
*, Adelheid Onyango
1
, Elaine Borghi
1
, Amani Siyam
1
,
Monika Blossner
1
and Chessa Lutter
2
, for the WHO Multicentre Growth Reference
Study Group-
1
Department of Nutrition for Health and Development, World Health Organization, 20 Avenue Appia, 1211
Geneva 27, Switzerland:
2
WHO Region of the Americas, Washington, DC, USA
Submitted 3 November 2011: Final revision received 26 January 2012: Accepted 24 February 2012
Abstract
Objective: To describe the worldwide implementation of the WHO Child Growth
Standards (WHO standards).
Design: A questionnaire on the adoption of the WHO standards was sent to
health authorities. The questions concerned anthropometric indicators adopted,
newly introduced indicators, age range, use of sex-specic charts, previously
used references, classication system, activities undertaken to roll out the stand-
ards and reasons for non-adoption.
Setting: Worldwide.
Subjects: Two hundred and nineteen countries and territories.
Results: By April 2011, 125 countries had adopted the WHO standards, another
twenty-ve were considering their adoption and thirty had not adopted them.
Preference for local references was the main reason for non-adoption. Weight-for-
age was adopted almost universally, followed by length/height-for-age (104
countries) and weight-for-length/height (eighty-eight countries). Several countries
(thirty-six) reported newly introducing BMI-for-age. Most countries opted for
sex-specic charts and the Z-score classication. Many redesigned their child
health records and updated recommendations on infant feeding, immunization
and other health messages. About two-thirds reported incorporating the standards
into pre-service training. Other activities ranged from incorporating the standards
into computerized information systems, to providing supplies of anthropometric
equipment and mobilizing resources for the standards roll-out.
Conclusions: Five years after their release, the WHO standards have been widely
scrutinized and implemented. Countries have adopted and harmonized best
practices in child growth assessment and established the breast-fed infant as the
norm against which to assess compliance with childrens right to achieve their full
genetic growth potential.
Keywords
Growth standards
Growth monitoring
Anthropometric indicators
Child health
WHO
The assessment of growth in children is important for
monitoring health status, identifying deviations from nor-
mality and determining the effectiveness of interventions
(1)
.
The signicance of timely detection of poor growth in
early life resides in its association with adverse functional
consequences, including poor cognition and educational
performance, low adult wages, lost productivity and, when
accompanied by excessive weight gain later in childhood,
increased risk of nutrition-related chronic diseases
(2)
.
In 2004, we reported on child growth monitoring
practices worldwide
(3)
in preparation for the construction
of the WHO Child Growth Standards (hereafter referred
to as the WHO standards). Results of a global survey
conducted in 178 countries on the use and interpretation
of growth charts in national programmes showed that
growth charts are universally used in paediatric care.
Over half of the countries relied on the weight-for-age
indicator alone, two-thirds used the National Center for
Health Statistics/WHO (NCHS/WHO) reference, and 63 %
of charts classied child growth based on percentiles.
Reported problems with the use of growth charts were
both conceptual and practical
(3)
.
Following the launch of the WHO standards in April
2006
(4,5)
, countries could choose to adopt the new stan-
dards and replace existing growth charts. Change implied
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y See Appendix for Members of the WHO Multicentre Growth Reference
Study Group.
*Corresponding author: Email [email protected] r The Authors 2012
a far-reaching shift in the way child growth is con-
ceptualized as the WHO standards depict how children
should grow, on average, in all countries, when properly
fed and cared for, rather than merely describing how they
grew at a particular time and place
(4)
. Five years after the
release of the WHO standards, we conducted a follow-up
survey to document their worldwide implementation and
describe the changes in child growth monitoring practices
that have occurred since our rst report.
Methods
A questionnaire on implementation of the WHO stan-
dards was sent to national health authorities in 219
countries and territories through the WHO regional
and country ofces. The questionnaire was developed
centrally and pre-tested for comprehensibility with
nutrition advisers based in the six WHO regions. For
clarity and to improve responsiveness, all questions had
pre-coded answers and were kept as short as possible.
The original English text was translated into French and
Spanish, and the translated versions were checked for
accuracy by native speakers of these languages with
expertise in child growth assessment and monitoring.
The questionnaire was accompanied by instructions for
completing it and a cover message explaining the surveys
objectives. In addition, countries and territories that had
already adopted the WHO standards were requested to
send samples of their new growth charts or new child
health records. Ministry of Health technical staff members
responsible for national maternal and child health pro-
grammes were asked to complete the questionnaire or
forward it for response to a relevant national institution
(e.g. the Centers for Disease Control and Prevention
(CDC) in the USA) or the national paediatric association.
Whenever clarications were needed, we interacted with
national technical staff to verify unclear responses.
The survey was conducted from November 2009 to April
2011. Information was collected on: the status of adoption
and the main reasons for non-adoption in case of a negative
response; the year of adoption; the anthropometric indica-
tors adopted (weight-for-age (WFA), length/height-for-
age (LHFA), weight-for-length/height (WFLH), BMI-for-age
(BMIFA), head circumference-for-age (HC), mid upper-arm
circumference-for-age (MUAC), subscapular skinfold-for-
age (SS) and triceps skinfold-for-age (TS)); the age range
covered by each indicator; whether or not the charts
were sex-specic; if the indicator was newly introduced;
the growth reference the WHO standards replaced (e.g.
NCHS/WHO, CDC 2000, Tanner, Harvard, national or local
reference); the classication system applied (i.e. Z-scores or
percentiles); and what steps had been taken to roll out the
standards. Respondents also reported on the type of infor-
mation included on the child growth charts and on the main
impediments to implementing the new standards once
adopted. Countries also provided samples of new child
health records/booklets.
The English version of the questionnaire was designed
as a pdf interactive form using Adobe Acrobat 7?0 Pro-
fessional (version 7?1?0; Adobe Systems Incorporated),
which allowed responses to be submitted electronically
in xml (EXtensible Markup Language) format. These
submissions were checked for consistency and incorpo-
rated directly into the master le (in Microsoft Excel
format). The French and Spanish versions of the ques-
tionnaire were distributed in a Microsoft Word format that
could be completed in soft or hard copy. Data from
questionnaires that were returned in non-xml format
(e.g. by fax, scan or courier) were keyed into the English
interactive pdf template, validated and then exported via
xml to the Microsoft Excel master le. Data were analysed
using S-Plus (TIBCO S-Plus 8?2; TIBCO Software AG).
The WHO classication system was used to group the
countries into geographical regions: AFR, African Region;
AMR, Region of the Americas (North America, Latin
America and the Caribbean); EMR, Eastern Mediterranean
Region; EUR, European Region (Europe and Central
Asia); SEAR, South-East Asia Region; and WPR, Western
Pacic Region. The list of countries included in each of
the WHO regions is available at http://www.who.int/
about/structure/en/index.html.
Results
Of the 219 countries and territories contacted, 180 (82%)
responded to the questionnaire. The countries and terri-
tories that did not send responses represent only 0?65% of
the worlds under-5 population as they are mainly small
islands in the Caribbean and the Pacic or European
countries with small populations (e.g. Andorra, Liechten-
stein, Monaco, San Marino). Of the responding countries,
125 had adopted the WHO standards, twenty-ve were
considering their adoption and thirty had not adopted them;
representing, respectively, 75%, 17% and 7% of the worlds
under-5 population. Table 1 shows adoption status by
geographical region. The countries that responded as not
having adopted the standards by April 2011 were mainly in
the European region (n 14), followed by Africa (n 7), the
Western Pacic (n 5) and three in the Americas (Fig. 1).
Only one country in the South-East Asian region had not
adopted them. Preference for local references was the main
reason given for non-adoption: 13/14 countries in EUR, 4/5
in WPR, all three in AMR as well as the one country in SEAR.
In AFR the two main reasons for non-adoption were lack of
resources and the recent reprinting of charts in current use.
Table 2 presents the anthropometric indicators used
for assessing growth based on the WHO standards. WFA
was adopted almost universally, with only twelve of the
125 countries not adopting this indicator. LHFA was also
adopted by a large number of countries (n 104), as was
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WFLH (n 88). BMIFA and HC were adopted by fty and
fty-seven countries, respectively, mainly in the AMR and
EUR regions. Many countries reported using the opportu-
nity of implementing the WHO standards to introduce the
monitoring of new indicators (e.g. forty-two countries
introduced LHFA, thirty-eight WFLH, thirty-six BMIFA and
twenty introduced HC). The other indicators (MUAC, TS
and SS) were seldom adopted.
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Table 1 Coverage of the survey and adoption status of the WHO Child Growth Standards by geographical region (April 2011)
Response received
Geographical region No. of countries No. of countries % Adopted Under consideration Not adopted
AFR 47 45 96 31 7 7
AMR 49 37 75 33 1 3
EMR 22 22 100 17 5 0
EUR 57 45 79 23 8 14
SEAR 11 11 100 10 0 1
WPR 33 20 61 11 4 5
Total 219 180 82 125 25 30
AFR, African Region; AMR, Region of the Americas (North America, Latin America and the Caribbean); EMR, Eastern Mediterranean Region; EUR, European
Region (Europe and Central Asia); SEAR, South-East Asia Region; WPR, Western Pacic Region.
Adoption status
Adopted
Under consideration
Not adopted
No response
Fig. 1 Worldwide implementation of the WHO Child Growth Standards (April 2011)
Table 2 Anthropometric indicators used in monitoring child growth based on the WHO Child Growth Standards by geographical region
(April 2011)
Countries adopted AFR AMR EMR EUR SEAR WPR
Anthropometric indicator (n 125) (n 31) (n 33) (n 17) (n 23) (n 10) (n 11)
WFA 113 29 28 14 22 9 11
LHFA 104 20 31 13 22 8 10
WFLH 88 19 30 10 15 7 7
BMIFA 50 5 10 4 21 4 6
HC 57 7 22 6 14 2 6
MUAC 17 6 3 2 2 1 3
SS 2 0 0 0 1 0 1
TS 2 0 0 0 1 0 1
AFR, African Region; AMR, Region of the Americas (North America, Latin America and the Caribbean); EMR, Eastern Mediterranean Region; EUR, European
Region (Europe and Central Asia); SEAR, South-East Asia Region; WPR, Western Pacic Region; WFA, weight-for-age; LHFA, length/height-for-age; WFLH,
weight-for-length/height; BMIFA, BMI-for-age; HC, head circumference-for-age; MUAC, mid upper-arm circumference-for-age; SS, subscapular skinfold-for-
age; TS, triceps skinfold-for-age.
Implementation of WHO growth standards 3
The great majority of countries (n 121, 97 %) adopting
the WHO standards chose to use sex-specic charts, that
is separate charts for boys and girls. Most countries
adopted the full age range from birth to 60 months, with
only a few exceptions that opted for birth to 24 months
(one country) or 2 weeks to 4 years (two countries). On
the growth reference in use prior to adoption of the
WHO standards, eighty-six countries reported using the
NCHS/WHO reference, twenty used a local reference,
fourteen used the CDC 2000 growth charts, and a few
countries used the Harvard or the Tanner standards.
Seven countries were unable to identify the reference
or standard in use prior to the adoption of the WHO
standards. A few countries had been using more than
one reference (i.e. different reference populations for
different anthropometric indicators or in primary v. tertiary
health-care facilities).
On the classication system selected by countries
adopting the WHO standards, eighty-four (67 %) coun-
tries opted for the Z-score classication system while
twenty-eight (22 %) preferred to use percentiles. The
remaining countries reported using both classication
systems for at least some of the anthropometric indicators.
Activities undertaken by countries as part of their
implementation of the WHO standards are presented in
Table 3. The great majority of adopting countries (n 104,
83 %) redesigned their child health records to include
the new charts and update recommendations on infant
feeding, immunization and other health messages. As
many as ninety-four (75 %) countries reported having
formed a pool of national trainers that were cascading the
training of the health workforce on the application of the
WHO standards in their respective regions and districts.
In addition, many countries (n 80, 64 %) had incorporated
the new standards into pre-service training for family
doctors, clinical ofcers, nurses and other health per-
sonnel. Other activities ranged from incorporating the
standards into computerized information systems, to
providing new or additional supplies of anthropometric
equipment, to mobilizing resources to support the roll-
out of the growth standards. The challenges encountered
to the implementation process after ofcial adoption of
the standards are summarized in Table 4.
Discussion
In 2006 the WHO launched new growth standards for
children irrespective of ethnicity, socio-economic status
and feeding mode. By April 2011, at least 125 countries,
representing 75% of the worlds under-5 population,
had adopted the standards and were at varying stages
of their implementation. It is very likely that some of the
countries that were still considering implementing the
standards when the survey was closed will have adopted
them by the time the present paper is published.
In adopting the new standards many countries switched
from using only WFA to using multiple indicators to better
characterize growth patterns. Compared with an earlier
report of growth monitoring practices
(3)
, there has been a
signicant rise in the use of LHFA (from fty-nine countries
in 2000 to 104 in 2011). That gure is likely to continue to
increase given the importance of monitoring WFA during
the rst year of life, and thereafter monitoring height in
addition to weight, because faltering patterns are clearly
different for LHFA and WFA
(6)
and short stature (or stunt-
ing) is associated with negative long-term outcomes
(2,7)
.
Similarly, many countries have introduced the indi-
cator WFLH, which is essential to assessing severe acute
malnutrition (i.e. wasting) as well as overweight and
obesity. As many as thirty-six countries also introduced
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Table 3 Summary of activities undertaken as part of the imple-
mentation of the WHO Child Growth Standards (April 2011)
Activity
Countries adopted
(n 125)
New child health card designed 104
Training conducted 94
Child growth assessment incorporated into
pre-service training
80
Anthropometry equipment supplies purchased 81
Resource mobilization ongoing to support
implementation
94
Standards incorporated into computerized
national health information system
45
Nutritional surveillance system has been/is
being set up
84
Table 4 Challenges in the implementation of the WHO Child Growth Standards after adoption by geographical region
Countries having adopted the WHO standards by April 2011
AFR AMR EMR EUR SEAR WPR Total
Impediment (n 31) (n 33) (n 17) (n 23) (n 10) (n 11) (n 125)
Other more urgent priorities 4 7 2 10 1 4 28
Financial and other resource constraints 26 29 11 18 4 8 96
Procedural impediments 14 10 11 12 4 5 56
Coordination challenges 16 13 10 12 3 4 58
Others 6 7 3 5 1 1 23
AFR, African Region, AMR, Region of the Americas (North America, Latin America and the Caribbean), EMR, Eastern Mediterranean Region, EUR, European
Region (Europe and Central Asia), SEAR, South-East Asia Region, WPR, Western Pacic Region.
4 M de Onis et al.
BMIFA, another important indicator for monitoring the
growing epidemic of childhood obesity. In addition,
BMIFA provides continuity with the monitoring of over-
weight and obesity in the 519 age range
(8)
. It is worth
noting that in pre-school children, because WFLH and
BMIFA provide similar information
(9)
, there is no need to
monitor both indicators.
Another improvement relates to the use of separate
charts for boys and girls. Most countries that in the earlier
survey
(3)
reported using combined charts, have opted to
use separate charts for boys and girls. Only four countries
reported continued use of sexes-combined charts, mainly
because of printing costs.
Compared with the previous report
(3)
many countries
have switched from the percentile or per cent-of-median
system to use the Z-score system for nutritional status
classication. Z-scores are preferred because they permit
clinical tracking of patients whose anthropometric classi-
cation lies beyond the measurable limits of the percentile
range, as happens in the case of severely undernourished or
obese children. Occasionally, countries report using both
systems depending on the purpose, e.g. percentile charts
for clinical use and Z-scores for public health purposes.
With only a few exceptions, countries reported using the
WHO charts for the age range birth to 5 years, and several
(n 16) also have adopted the WHO 2007 growth reference
for school-aged children and adolescents to monitor the
nutritional status of children aged 5 to 19 years
(8)
.
The implementation of the WHO standards has taken
different pathways depending on national health systems
and decision-making processes. In almost all cases, the
standards have been adopted nationwide. However,
for countries with decentralized systems like Australia,
Belgium and Spain, some parts of the country have
adopted the WHO standards while others continue to
use previous charts. Generally, most countries with
decentralized administrations decided to adopt the WHO
standards nationally, thus harmonizing the assessment of
child growth in the country.
The scrutiny that the WHO standards have undergone
is without precedent in the history of developing and
applying growth assessment tools, whether national or
international. Governments set up committees
(1012)
to
scrutinize the new standards before deciding to adopt
them and professional groups that use anthropometric
indicators conducted thorough examination of the stan-
dards. Through this process concerns were raised
(1316)
and strengths were noted
(1727)
. The detailed evaluation
made it possible to quantify the impact of the new stan-
dards on estimates of prevalence of malnutrition
(2834)
and their implications for child health programmes
(3558)
.
Rolling out new growth charts is a complex task
affecting all levels of a national health system. It concerns
not only clinicians and health practitioners but also
nutritionists, dietitians, public health specialists, child
and health advocates, parents/caregivers and researchers.
A great deal of coordination is necessary among all these
stakeholders to ensure a smooth implementation. Many
countries have redesigned their child health records,
upgraded their anthropometric equipment, and retrained
health staff to incorporate the WHO standards into their
work. The WHO standards have also been incorporated
into pre-service training programmes for medical and
nursing professionals in several countries. Some countries
have used the opportunity of switching to the new
standards to raise awareness of the importance of child
growth monitoring and redesign their surveillance sys-
tems to enhance decision making. Each aspect has
required a considerable effort to implement and called for
a reallocation of resources.
The introduction of new indicators such as BMIFA
or length/height-based indicators posed considerable
practical challenges with potential for measurement error
and misclassication of children. A large-scale training
programme was set in place by WHO, in coordination
with UNICEF, that resulted in a network of facilitators
to support training and other technical aspects of the
standards implementation at regional and country level.
The training package
(59)
emphasizes the importance of
accurate measurement, plotting and interpretation for the
correct identication of growth problems. If a child has a
growth problem or trend towards a growth problem, the
causes should be determined to take action to address
them. Growth assessments that are not supported by
appropriate response actions to prevent and treat exces-
sive or inadequate growth are not effective in improving
child health.
The implementation of the growth standards at country
level required resources to design and produce new child
health records, print large quantities of the new charts,
buy anthropometric equipment (e.g. weighing scales) or
produce them locally (i.e. height boards), translate docu-
mentation and tools (e.g. the training materials), and
conduct national training workshops. Resource constraints
(e.g. under-stafng in primary health-care facilities and
shortage of equipment) have been an important bottleneck.
UNICEF and other key partners played signicant roles
in supporting the standards implementation but there
continues to be a need for support since signicant costs are
involved in the mass procurement of anthropometric
equipment, in printing new charts, training health person-
nel, and especially in developing or strengthening pro-
grammes to deal with the growth problems identied
through the application of the standards.
Acknowledgements
The work was supported by WHO and the Bill & Melinda
Gates Foundation. The authors are WHO staff members.
The authors alone are responsible for the views expressed
in this publication and they do not necessarily represent the
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Implementation of WHO growth standards 5
decisions or policies of the WHO. No author had a personal
or nancial conict of interest. M.d.O. conceptualized the
paper, guided the analyses and wrote the rst draft of the
paper. A.O. and A.S. developed the questionnaire and
conducted the survey. E.B. analysed the data and wrote up
the methods. M.B. and C.L. participated in the imple-
mentation of the growth standards. All authors participated
in the interpretation of results, preparation of the manu-
script and approved its nal version. The authors are
grateful to UNICEF, the governments of WHO Member
States, non-governmental organizations and the numerous
individuals who have participated in the roll-out of the
WHO Child Growth Standards and facilitated their rapid
global implementation.
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Appendix
WHO Multicentre Growth Reference Study Group
Coordinating Team: Mercedes de Onis (Study Coordinator),
Adelheid Onyango, Elaine Borghi, Amani Siyam
(Department of Nutrition, WHO).
Executive Committee: Cutberto Garza (Chair), Mercedes
de Onis, Jose Martines, Reynaldo Martorell, Cesar G.
Victora, Maharaj K. Bhan.
Steering Committee: Coordinating Centre (WHO, Geneva):
Mercedes de Onis, Jose Martines, Adelheid Onyango,
Alain Pinol. Investigators (by country): Cesar G. Victora,
Cora Luiza Araujo (Brazil); Anna Lartey, William B.
Owusu (Ghana); Maharaj K. Bhan, Nita Bhandari (India);
Kaare R. Norum, Gunn-Elin Aa. Bjoerneboe (Norway);
Ali Jaffer Mohamed (Oman); Kathryn G. Dewey (USA).
Representatives of UN agencies: Cutberto Garza (United
Nations University), Krishna Belbase (UNICEF).
Advisory Group: Maureen Black, Wm. Cameron Chumlea,
Tim Cole, Edward Frongillo, Laurence Grummer-
Strawn, Reynaldo Martorell, Roger Shrimpton, Jan Van
den Broeck.
Participating countries and investigators: Brazil: Cora
Luiza Araujo, Cesar G. Victora, Elaine Albernaz, Elaine
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Implementation of WHO growth standards 7
Tomasi, Rita de Cassia Fossati da Silveira, Gisele Nader
(Departamento de Nutricao and Departamento de
Medicina Social, Universidade Federal de Pelotas;
and Nucleo de Pediatria and Escola de Psicologia,
Universidade Catolica de Pelotas). Ghana: Anna Lartey,
William B. Owusu, Isabella Sagoe-Moses, Veronica
Gomez, Charles Sagoe-Moses (Department of Nutrition
and Food Science, University of Ghana; and Ghana
Health Service). India: Nita Bhandari, Maharaj K. Bhan,
Sunita Taneja, Temsunaro Rongsen, Jyotsna Chetia,
Pooja Sharma, Rajiv Bahl (All India Institute of Medical
Sciences). Norway: Gunn-Elin Aa. Bjoerneboe, Anne
Baerug, Elisabeth Tufte, Kaare R. Norum, Karin Rudvin,
Hilde Nysaether (Directorate of Health and Social
Affairs; National Breastfeeding Centre, Rikshospitalet
University Hospital; and Institute for Nutrition Research,
University of Oslo). Oman: Ali Jaffer Mohamed, Deena
Alasfoor, Nitya S. Prakash, Ruth M. Mabry, Hanadi
Jamaan Al Rajab, Sahar Abdou Helmi (Ministry of
Health). USA: Kathryn G. Dewey, Laurie A. Nommsen-
Rivers, Roberta J. Cohen, M. Jane Heinig (University of
California, Davis).
WHO Regional Ofces staff: Ayoub Al-Jawaldeh (EMR),
Kunal Bagchi (SEAR), Tomasso Cavalli-Sforza (WPR),
Ferima Coulibaly-Zerbo (AFR), Aichatou Diawara
Gbaguidi (AFR), Abel Dushimimana (AFR), Chessa
Lutter (AMR), Charles Sagoe-Moses (AFR), Ursula
Trubswasser (AFR), Trudy Wijnhoven (EUR).
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