Growth Charts: Topic of the Month

SEPTEMBER 6, 2023
Growth charts are percentile curves that show the distribution of a child’s body measurements
including weight and length/height. The charts are used at WIC, by pediatricians, nurses, and
parents to monitor the growth of infants and children. This topic of the month will focus on
what we should know about using growth charts during our WIC appointments and how to
interpret growth charts for parents.

WIC & Growth Charts for Children

Growth charts were created in 1977 by the National Center for Health Statistics (NCHS) as a
clinical tool to be used by health professionals to assess physical growth. WIC uses the Center
for Disease Control and Prevention (CDC) 2000 growth chart for children age 2 and over,
measured while standing, to plot growth at specific times as part of the nutrition assessment
process. The CDC chart illustrates how a child’s growth in weight and height compares to other
children of the same age and gender.

Risk Codes Implications: For children > 2 years of age measured in the standing position and
plotted on the CDC 2000 growth chart, the WIC Information System will assign
anthropometric risk codes.

WIC uses the World Health Organization (WHO) 2006 growth charts for children 0- 59 months
of age to plot children’s growth when less than 2 years of age. The WHO chart represents a
standard growth for children of a certain age and gender raised in “ideal” environments and
illustrates how an individual infant is “supposed” to grow.

Risk Codes Implications: For children < 2 years of age plotted on the WHO 2006 chart, the
WIC information system will assign anthropometric risk codes.

Reading a Growth Chart

On each chart, the growth percentiles are indicated by lines. The 50th percentile is the mean;
the top percentile shown is the 95th, and the lowest percentile displayed is the 5th percentile.
Children with measurements that are about average will plot near the mean. For children who
are larger than average, their measurements will be plotted above the mean, and smaller
children’s measurements will be below the mean.

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It is important that WIC staff use good quality, well maintained equipment and follow correct
procedures when measuring weight, length, or height in WIC clinics as outlined in MOM
Sections 5.3: Nutrition Risk Assessment.

Growth Chart & BMI

Body Mass Index (BMI) is a measurement tool that was created to determine an individual’s
weight status by comparing it as relative to their height. On the CDC growth charts, BMI is used
for children 2 years and above to compare a child’s BMI to a large reference population of
children of the same age and gender. In the WIC setting, we use BMI to evaluate consistency of
the individual’s growth. In population-based studies, BMI tells us something about the health of
the general population but is not a perfect tool to assess individual health.

Assessing the Growth Chart

Growth charts can help us assess health and nutritional status, assign risk codes, inform
nutrition education, and determine what referrals/resources a family may need. Growth charts
are not intended to be used as a definitive diagnostic instrument; they are tools that provide
(or “it is a tool that provides”) us with one piece of the picture when assessing a child’s growth.
▪ It is desirable to have a series of measurements to monitor a child's growth pattern over
time.
▪ When looking at the trajectory of growth, look to determine if there is any significant
movement up or down in the child's rate of growth.
▪ Deviation from the curve may signal further investigation and critical thinking must be done
before determining if there truly is a concern.
▪ Asking clarifying questions can help evaluate any deviations from expected growth. This is
also true if there is just one measurement for a child.

Evaluating Growth

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Growth is influenced by genetic potential. The growth percentiles of one child may be around
the 10th percentile and another may always be at the 90th percentile. If a child is growing
steadily along their own trajectory of growth and is healthy, those growth rates are normal and
likely to be healthy. Discussion of growth charts can be brief in those cases. Assure the
parent/caregiver the child is growing steadily or well. It is not necessary to share the actual
percentile numbers or provide lots of detail about the child’s growth compared to other
children the same age, unless asked.

Occasionally, a child may deviate from their normal growth with accelerated or slowed growth
rates. Those cases warrant some additional assessment of the situation.

First, consider these factors when evaluating a child’s growth:

▪ Inaccurate data: Incorrect measuring techniques or errors in recording measurements can
dramatically impact the growth chart results. When a significant variation is noted on the
charts, remeasure if possible. Consider accuracy of previous measurements.
▪ Normal growth patterns of children: Children do not grow in a continuous, smooth pattern.
They experience times of “growth spurts” and growth-free intervals.
▪ Single measurement: One measurement is of limited usefulness. A child’s normal growth
pattern may be at the high or low end of the growth charts. If there are additional factors
related to health and eating that may be concerning, refer to the physician and/or
remeasure the child in a few months for a better assessment of their growth.
Second, assess other factors that may affect growth and make referrals as needed:
▪ Use the Nutrition Assessment process to evaluate other influences that may be affecting
the child’s growth, including the child’s general diet, physical activity patterns, and lifestyle
factors (such as the living situation, food security, coexisting medical conditions,
medications used). Use (WIC Nutrition Assessment Tools) to clarify any areas of concern.
▪ Based on your evaluation of the child’s growth and other factors related to growth,
determine whether a referral to the health care provider or other resources may be
necessary.
When we have one-on-one conversations about growth, a paradigm shift in how we talk to
participants about it can help. It is important to look at the nutrition assessment as a whole and
avoid explaining an individual’s weight or BMI in a way that creates a feeling of weight shame.
Encourage participants to see that being in the higher percentile or BMI doesn't necessarily
mean that they aren’t or cannot be healthy or achieve a healthy lifestyle. There are many
factors to consider when evaluating one’s growth, and the measurements are just the
beginning.

Using Open-Ended Questions about Growth

For a child with a potential growth concern, use open-ended questions to help assess the
situation. Using open-ended questions (Open-Ended Questions: Sixth in a Series (PDF)) allows

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you to gather some basic information about the participant and their experiences and sets the
stage for deeper questions. Below are some examples of questions that may be used when
discussing a child’s growth during a nutrition assessment.
▪ “How do you feel about Frieda’s growth?” or “What have you noticed about Frieda’s growth
since your last visit?”
▪ “What has Hamza’s doctor said about his growth? or “At your last well-child check, what did
Hamza’s pediatrician share about his growth?”
▪ “We only have one measurement to look at today; what is more important is how this looks
over time. What are your thoughts on Jack’s overall growth? "
▪ “The [growth/weight grid] is only one piece of the puzzle when it comes to nutrition. I
would like to hear more about how [your/your child’s] appetite is.”

Growth Chart Examples

Example 1:
Assessment: This 4-year-old boy’s growth trends around the 20th percentile height/age, 28th
percentile weight/age, and is currently at the 50th percentile for BMI.

Explanation: In this case, it is not necessary to mention the child is shorter than most boys his
age or the actual percentile numbers. Rather, state that “he is growing steadily”. Share
additional information if requested by the parent/caregiver.

Example 2:
Assessment: This 4-year-old girl gained about 1 ½ pounds in the last year and is trending
downward in BMI and weight/age. The child’s BMI is still within a normal range at 25th
percentile and the height growth is steady. Is the downward trajectory of weight a concern?

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Explanation: In this case, the CPA asked some clarifying questions to determine whether there
may be contributing factors to this growth change. While discussing the child’s health and
eating, the mother shared with the CPA that the child has a very poor appetite and complains
of stomach aches after meals. The mom thinks it may be pain from constipation and it is
affecting the child’s willingness to eat. The plan was to schedule a medical appointment for the
child for an evaluation of the stomach pain and constipation.

Example 3:
Assessment: This 4 ½ year old boy was measured on 6/26/2023 and had a weight loss of 2 ½
pounds in the last six months, after a large weight gain recorded on 12/12/2022 at the medical
clinic. The child is healthy and active with no eating concerns. Parent shared that the child was
uncooperative at the December medical clinic appointment and was weighed with his boots
and winter coat! The CPA reasoned the measurements on 12/12/2022 were inaccurate or
documented incorrectly.

Explanation: In this case, the CPA let the family know that the previous measurements
appeared to be inaccurate and encouraged the family to continue with regular well child
checkups (Child is aging out of WIC).

Example 4:
Assessment: This 2 year 10-month-old boy’s growth tracks around the 33rd percentile
height/age, 59th percentile weight/age, and is currently at the 75th percentile for BMI.

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Explanation: In this case, it is not necessary to mention the child is slightly shorter than most
boys his age or the actual percentile numbers. Rather, share that he appears to be at a healthy
weight and height for his age. Ask if the parent has had any concerns about growth, health, or
eating. Let the parent know that we will check the child’s measurements at future WIC visits
and will be able to see how he grows over time. Share additional information if requested by
parent/caregiver.

Next month, we will cover how to use a weight inclusive lens when discussing growth.
Have suggestions for future topics? Email them to Carole.Kelnhofer@state.mn.us.

Staff Tools
Anthropometrics Module - 60 minutes (MDH WIC)
Anthropometric Manual (PDF) (MDH WIC)

Resources
Assessment of Abnormal Growth Charts (Am Fam Physicians, 1998)
BMI and Beyond: Considering Context in Measuring Obesity and its Applications: Proceedings of
a Workshop–in Brief (National Academies of Sciences, Engineering, and Medicine, 2023)
Body Mass Index (BMI) (CDC, 2022)
Clinical Growth Charts (CDC, 2017)
CDC Growth Charts: United States (CDC, 2009)
WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2
Years of Age (CDC, 2010)

Reference – Complete Listing of Hyperlinks:

Sections 5.3: Nutrition Risk Assessment
(https://www.health.state.mn.us/docs/people/wic/localagency/program/mom/chsctns/ch5/sct
n5_3_1.pdf)
WIC Nutrition Assessment Tools
(https://www.health.state.mn.us/people/wic/localagency/training/na.html#NaN)

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Open-Ended Questions: Sixth in a Series

(https://www.health.state.mn.us/docs/people/wic/localagency/wedupdate/2021/topic/1215n
utassess.pdf)
Anthropometrics Module
(https://www.health.state.mn.us/training/cfh/wic/nutrition/anthropometric/story.html)
Anthropometric Manual
(https://www.health.state.mn.us/docs/people/wic/localagency/training/nutrition/nst/anthro.p
df)
Assessment of Abnormal Growth Charts
(https://www.aafp.org/pubs/afp/issues/1998/0701/p153.html)
BMI and Beyond: Considering Context in Measuring Obesity and its Applications: Proceedings of
a Workshop–in Brief (https://nap.nationalacademies.org/read/27185/chapter/1)
Body Mass Index (BMI) (https://www.aafp.org/pubs/afp/issues/1998/0701/p153.html)
Clinical Growth Charts (https://www.cdc.gov/growthcharts/clinical_charts.htm)
CDC Growth Charts: United States
(https://www.cdc.gov/growthcharts/background.htm#:~:text=The%201977%20growth%20char
ts%20were,Health%20Organization%20for%20international%20use)
WHO Growth Standards Are Recommended for Use in the U.S. for Infants and Children 0 to 2
Years of Age
(https://www.cdc.gov/growthcharts/who_charts.htm#The%20WHO%20Growth%20Charts)

Minnesota Department of Health - WIC Program, 625 Robert St N, PO BOX 64975, ST PAUL MN
55164-0975; 1-800-657-3942, health.wic@state.mn.us, www.health.state.mn.us; to obtain this
information in a different format, call: 1-800-657-3942.
This institution is an equal opportunity provider.