Recommendations and Rationale

What to know

Use the World Health Organization (WHO) Child Growth Standards for U.S. infants and children from birth to 2 years. These standards are recommended whether the infant is breastfed or formula-fed.

Doctor reviewing infant growth chart with a mother who is holding young child on her lap.

Introduction

In April 2006, WHO released a new international growth standard for infants and young children from birth to 5 years. This standard describes the growth of healthy children living in well-supported environments in six countries, including the United States. The WHO standard shows how infants and children should grow rather than simply how they do grow in a certain time and place.

Recommended use

CDC and the American Academy of Pediatrics (AAP) recommend that U.S. health care providers in primary-care settings use:

The WHO growth standards describe weight-for-age, length (or stature)-for-age, weight-for-length, and body mass index (BMI)-for-age. The WHO standards are relevant in the United States because U.S. infants and young children were included in the WHO study sample. Also, their growth tracks along the median of the pooled international sample.23

Advantages

The advantages of using WHO Growth Standards are that they:

  • Bring into agreement the tools used to assess growth and national guidelines recommending breastfeeding as the optimal infant feeding method.4
  • Are based on high-quality data collected for children younger than 2 years.
  • Were created with longitudinal length and weight data measured at frequent intervals.56

The CDC growth reference charts are based on cross-sectional length and weight data. However, weight data were not available for infants birth to 2 months; and the sample sizes were small for sex and age groups during the first 6 months of age.7

More Information

Download the recommendations for and advantages of using the WHO Growth Charts.

Rationale for recommended use

Following the release of the WHO Growth Standards in 2006, CDC, AAP, and the National Institutes of Health (NIH) convened a meeting of experts. They considered the potential use of WHO standards in clinical settings to monitor growth among U.S. children. Experts considered the rationale for developing an international standard, the methods, statistical comparisons, differences in growth between breast and formula-fed infants, and practical implications.

Based on the comparison between the CDC growth reference and the WHO growth standards and input from the expert panel, CDC and AAP developed the following recommendations:

  • The WHO growth standards should be used for children younger than 2 years.
  • The CDC growth reference charts should be used for children and adolescents 2 to 20 years.

WHO growth standards can be used for children from birth to 5 years. However, for children 2 to 5 years, the WHO BMI-for-age charts offer little advantage over the CDC BMI-for-age charts for evaluating child growth. Therefore, the CDC growth reference charts are recommended for children 2 years and older because CDC charts can be used continuously to 20 years.

More information

Use of World Health Organization and CDC Growth Charts for children 0–59 months in the United States

Test your knowledge

  1. An advantage of using the WHO Child Growth Standards for infants and children from birth up to 2 years is that:
    1. U.S. children were included in the WHO study sample and their growth is similar to other children in the sample.
    2. The WHO charts do not consider the effects of infant feeding on growth.
    3. The WHO charts are based on limited data for the first 6 months of life.
  2. For children older than 2 years, use of the CDC BMI-for-age charts is recommended.
    1. True
    2. False

See answers.A

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Content Source:
National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP)
  1. Question 1 is A. U.S. children were included in the WHO study sample and their growth is similar to other children in the sample. Question 2 is true. The WHO Child Growth Standards for children 2 years and older offer little advantage over the CDC growth charts because the methods used to construct the WHO and the CDC charts for these ages were similar. The CDC charts are recommended for use continuously from 2 to 20 years of age.
  1. Grummer-Strawn LM, Reinold C, Krebs NF; Centers for Disease Control and Prevention. Use of the World Health Organization and CDC growth charts for children aged 0–59 months in the United States. MMWR Recomm Rep. 2010;59(RR-9);1–15. https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm
  2. Dewey KG, Cohen RJ, Nommsen-Rivers LA, Heinig MJ; for the WHO Multicenter Growth Reference Study Group. Implementation for the WHO Multicentre Growth Reference Study in the United States. Food Nutr Bull. 2004;25(Suppl 1):S84-S89.
  3. WHO Multicentre Growth Reference Study Group. Assessment of differences in linear growth among populations in the WHO Multicentre Growth Reference Study. Acta Paediatr. 2006;450:56–65.
  4. Meek JY, Noble L, American Academy of Pediatrics. Policy Statement. Breastfeeding and the use of human milk. Pediatrics. 2022;150(1):e2022057988.
  5. de Onis M, Garza C, Vicotra CG, Onyango AW, Frongillo EA, Martines J; for the WHO Multicentre Growth Reference Study Group. The WHO Multicentre Growth Reference Study: planning, study design, and methodology. Food Nutr Bull. 2004;25(suppl 1):S15-S26.
  6. World Health Organization. WHO Child Growth Standards: Length/height-for-age, weight-for-age, weight-for-length, weight-for-height and body mass index-for-age: Methods and Development. 2006.
  7. Kuczmarski RJ, Ogden CL, Guo SS, et el. 2000 CDC growth charts for the United States: methods and development. Vital Health Stat 11. 2002;(246):1-190.