Short Stature: Comparison of WHO and National Growth Standards/References for Height

Abstract

The use of appropriate growth standards/references is of significant clinical importance in assessing the height of children with short stature as it may determine eligibility for appropriate therapy. The aim of this study was to determine the impact of using World Health Organization (WHO) instead of national growth standards/references on height assessment in short children. Data were collected from routine clinical practice (1998–2014) from nine European countries that have available national growth references and were enrolled in NordiNet® International Outcome Study (IOS) (NCT00960128), a large-scale, non-interventional, multinational study. The patient cohort consisted of 5996 short pediatric patients diagnosed with growth hormone deficiency (GHD), Turner syndrome (TS) or born small for gestational age (SGA). The proportions of children with baseline height standard deviation score (SDS) below clinical cut-off values (–2 SDS for GHD and TS; –2.5 SDS for SGA) based on national growth references and WHO growth standards/references were compared for children aged <5 years and children aged ≥5 years. In seven of the countries evaluated, significantly fewer children aged ≥5 years with GHD (22%; P<0.0001), TS (21%; P<0.0001) or born SGA (32%; P<0.0001) had height below clinical cut-off values using WHO growth references vs. national references. Likewise, among children aged <5 years in the pooled analysis of the same seven countries, a significantly lower proportion of children with GHD (8%; P<0.0001), TS (12%; P = 0.0003) or born SGA (12%; P<0.0001) had height below clinical cut-off values using WHO growth standards vs. national references. In conclusion, in NordiNet® IOS the number of patients misclassified using WHO growth standards/references was significantly higher than with national references. This study highlights that, although no growth reference has 100% sensitivity for identifying growth disorders, the most recent national or regional growth charts may offer the most appropriate tool for monitoring childhood growth in Europe.

The World Health Organization Fetal Growth Charts: A Multinational Longitudinal Study of Ultrasound Biometric Measurements and Estimated Fetal Weight

“…Some support for this concept was drawn from previous studies [13,14]. Although widely adopted, the applicability of these child growth standards has been questioned on the grounds of lack of fit to some populations [15,16], especially for the head circumference standards [17]. …”

How Much Nutrition for How Much Growth?

“…“The disadvantage of using charts such as these (WHO charts) is that they are likely to overdiagnose underweight and stunting in a large number of apparently normal children in the developing countries such as India” [35]. This also applies for the opposite: using the WHO growth charts in countries with tall populations, like the Netherlands, Germany, and the Scandinavian countries, leads to misclassification of clinically relevant causes of short stature [36, 37]. …”

Growth of children in Greenland exceeds the World Health Organization growth charts

“…These standards were based on data from healthy, breastfed, well-off children born to non-smoking mothers from six countries (3). A WHO growth reference for children [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19] years was created using data from the US National Center for Health Statistics from 1977 (4). Over the past decade, the WHO growth curves have been fully or partly adopted by more than 100 countries, including Denmark (5).…”

“…However, Danish and Swedish growth charts are commonly used in Greenland. Compared to European national references, the WHO growth standards and references have lower means and lower normal ranges or cutoffs that typically define abnormal growth (6)(7)(8)(9)(10).…”