Growth standards and nutrition guidelines for infants and young children

Growing Child 13When given an optimal start, children from all over the world have the potential to grow in similar patterns. There are always individual differences among children, but across large populations, regionally and globally, the average growth is remarkably similar. Differences in growth of children up to the age of five are more influenced by healthy nutrition, a healthy environment and good health care, than by genetics or ethnicity.1  Guidelines for healthy eating provide a good reference for healthy nutrition in the early years of life.

Key messages:
> Children from all over the world have the same growth potential, when given an optimal start.
> The growth standards of the World Health Organization (WHO) help to determine under- and overnutrition in infants and young children, as well as their motor development.
> Guidelines – such as the WHO complementary feeding recommendations for children aged 6-24 months – provide good insights in key feeding practices that facilitate nutrient adequacy in this important period of life.

Growth standards

In 2006 the WHO published the Growth Standards for infants and young children. These standards are a reference for nutritional status and motor development of children from birth to age five.

Growth indicators

Several growth indicators are helpful to determine undernourished and overweight infants and young children. In annex I the most frequently used indicators, Length/Height-for-Age, Weight-for-Age, Weight-for-Length/Height and BMI-for-Age with reference z-scores for establishing deviation from normal growth patterns, can be found.1

Motor milestones

Six gross motor development milestones for infants and young children are distinguished by the WHO in their Windows of Achievement standard (see table 1). These windows represent normal variation in ages of milestone achievement among healthy children.

They can be used for instance for appropriate screening of individual children and monitoring their progress. The WHO Multicentre Growth Reference Study Group, found that about 90% of children achieved five of the milestones following the sequence in the table, but deviation exists. For example, less than 5% did not exhibit hands-and-knees crawling.2

Table 1: Windows of achievement for six gross motor milestones2

Nutrition recommendations

In line with the Growth Standards, the WHO developed nutrition guidelines to support optimal growth and development of infants and children up to two years. They recommend exclusive breastfeeding for the first six months of life, because breast milk provides a unique mix with everything infants need to thrive in the initial period of life. Furthermore, introduction of nutritionally-adequate and safe complementary (solid) foods is recommended at 6 months, together with continued breastfeeding up to two years of age or beyond.3  Table 2 summarizes the WHO guidelines on nutrient content of complementary foods for breast and non-breast fed children aged 6-24 months.4,5

Table 2: WHO guidelines complementary foods for breast and non-breast fed children (6-24 months)4,5

Recommended foods* Remarks
Breast fed children 6-24 months
  • Meat, poultry, fish or eggs
  • Pro-vitamin A rich fruit and vegetables (e.g. sweet potato, carrots, apricots)
  • A variety of foods with an adequate and diversified fat content (e.g. animal source, foods made from (ground)nuts and seeds)
  • Dairy products
  • Avoid drinks with a low nutrient value
  • Limit the amount of juice offered
  • Should be offered frequently, for meeting iron and zinc requirements
  • Clear health benefits in preventing vitamin A deficiency. Might also help in meeting the needs for many of the other vitamins
  • Provide essential fatty acids, facilitates absorption of fat soluble vitamins, enhances dietary energy and sensory qualities
  • Provides a good source of nutrients such as calcium
  • To avoid interference with iron absorption (tea and coffee) and overconsumption of sugary drinks (soda)
  • To avoid decrease of appetite for other foods and loose stools
Non-breast fed children from 6-24 months**
  • Meat, poultry, fish or eggs, plus milk products
  • Vitamin rich C foods (e.g. citrus fruits, cruciferous vegetables)
  • Foods rich in vitamin B including riboflavin (e.g. milk, mushrooms), vitamin B6 (grains products) and folate (green leafy vegetables)
  • Special attention for animal source foods is required, because diets that do not contain enough of these foods cannot supply all nutrients needed, unless fortified products or nutrient supplements are used or consequently substituted with e.g. grains/legumes
  • Consume with meals to enhance iron absorption
  • To meet essential nutrient requirements

* Feed a variety of the following foods to ensure that children’s nutrient needs are met.
** Recommendations additional to the recommendations for breast fed children.

Other food based and nutrition guidelines

Almost every country has its own food and nutrition guidelines. Local guidelines take food availability and eating habits into account. Table 3 summarizes some other generally recognized international nutrition and health sources, with links to some of their relevant nutrition guidelines.

Table 3: International nutrition and health sources

Organization Relevant resources
World Health Organization (WHO): International leading organization developing evidenced-based nutrition & health guidelines and reports.
Food and Agriculture Organization of the United Nations (FAO):

International organization that aims to achieve global food security, one of their goals is to fight malnutrition for which they published several reports.

European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN):

International scientific society with nutrition as one of their 5 key activities -aiming to promote high quality nutritional practice in infants, children and adolescents.

Institute of Medicine (IOM):
An independent, non-profit organization that works outside of U.S.A. government to provide unbiased and authoritative nutrition and health advice, well known for their reports on Dietary Reference Intakes (DRI)

Annex I

Growth indicators for under- and overnutrition1

Z-Score1 Growth Indicators
Length/Height-for-Age Weight-for-Age Weight-for-Length/Height BMI-for-Age
> 3 See note2 See note3 Obese Obese
> 2 Overweight Overweight
> 1 Possible risk of overweight Possible risk of overweight
0 (Median)
< -1
< -2 Stunted4 Underweight Wasted Wasted5
< -3 Severely stunted Severely underweight Severely wasted Severely wasted
  1. Z-score (or SD score) indicates how far a measurement is from the median. The reference lines on the growth charts (labelled 1, 2, 3, -1, -2, -3) are called z-score lines; they indicate how far points are above or below the median (z-score 0)
  2. A child in this range is very tall, which is rarely a problem. A child in this range is referred for assessment only if suspected of an endocrine disorder
  3. A child whose weight-for-age falls in this range may have a growth problem, but this is better assessed from weight-for-length/height or BMI-for-age
  4. A child whose height-for-age is less than −2 SD is considered stunted, because the chances of the child’s height being normal are less than 3 percent
  5. In adolescents, age-specific low BMI cutoffs (BMI Z score <-2) from the WHO reference for children aged 5-19 years of age are used.

References

  1. World Health Organization. Global Database on Child Growth and Malnutrition: Child growth standards. 2006; Available from: http://www.who.int.
  2. WHO Multicentre Growth Reference Study Group, WHO Motor Development Study: Windows of achievement for six gross motor development milestones. Acta Paediatrica Supplement, 2006. 450: p. 86-95.
  3. World Health Organization, Infant and young child nutrition. Global strategy on infant and young child feeding. 2002. p. paragraph 10.
  4. Pan American Health Organization, Guiding principles for complementary feeding of the breastfeed child. 2003: World Health Organization.
  5. World Health Organization, Guiding principles for feeding non-breastfeed children 6-24 months of age. 2005: World Health Organization.