New pre-school UK charts have been produced incorporating the new World Health Organization growth standards based on healthy breastfed infants. This paper describes the process by which the charts and evidence-based instructions were designed and evaluated, and what it revealed about professional understanding of charts and growth monitoring. A multidisciplinary expert group drew on existing literature, new data analyses and parent focus groups as well as two series of chart-plotting workshops for health staff. The first series explored possible design features and general chart understanding. The second evaluated an advanced prototype with instructions, using plotting and interpretation of three separate scenarios on the old charts, compared with the new charts. The first plotting workshops (46 participants) allowed decisions to be made about the exact chart format, but it also revealed widespread confusion about use of adjustment for gestation and the plotting of birthweight. In the second series (78 participants), high levels of plotting inaccuracy were identified on both chart formats, with 64% of respondents making at least one major mistake. Significant neonatal weight loss was poorly recognized. While most participants recognized abnormal and normal growth patterns, 13-20% did not. Many respondents had never received any formal training in chart use. Growth charts are complex clinical tools that are, at present, poorly understood and inconsistently used. The importance of clear guidelines and formal training has now been recognized and translated into supporting educational materials (free to download at http://www.growthcharts.rcpch.ac.uk).

Background Current growth charts depict a child's height allowing for age and gender, but they ignore pubertal development. In adolescence height depends on pubertal development as well as age and gender, so assessment should ideally be a two-step process; first, to clinically assess puberty, and second, to assess height relative to puberty-specific centiles. Aim To design new 4-20 year growth charts for the UK, based on the UK 1990 reference, focusing on pubertal progression as well as growth, in order to define normality. Methods Tanner's five puberty stages were simplified into three phases of puberty – Pre-puberty (Tanner stage 1), In puberty (stages 2 and 3) and Completing puberty (stages 4 and 5). Using data for height, age and Tanner stage from the 1980 Dutch National Survey (N = 6563), Puberty Phase Specific (PPS) centile lines were estimated for each phase separately using the LMS method. Height centiles ignoring stage were also constructed with the same data, and the resulting median curve was adjusted using Cole's SITAR method to closely match the median of the UK 1990 growth reference. The same SITAR adjustments were then applied to the puberty centiles, thus recalibrating the Dutch data to match the UK 1990 reference. These PPS centiles were used to develop various chart designs for consideration by the RCPCH chart design group, along with testing in evaluation workshops. Results The new PPS centiles demonstrate a stepwise increment of growth through puberty. Because the phases overlap widely in age, presentation on one chart is challenging, but they can be presented in a 3-page specialist Puberty Phase Specific chart used in conjunction with a new version of the existing cross-sectional UK 1990 chart. The age ranges of the phases will be presented on the cross-sectional charts as two puberty zones. These will illustrate the normal range for age at the start and end of puberty and for each puberty phase. Conclusions This novel approach to growth chart design allows evaluation of a child's growth adjusted for phase of puberty, as well as age and gender, which should greatly improve the assessment of growth during adolescence.

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