The WHO or the CDC Growth Chart: Which Is Better?
In every well-child check with your pediatrician or family doctor, your baby’s weight will be checked and plotted on a growth chart. Why is that done? Because ensuring healthy growth is important for infant health, brain development, and immune protection from infectious diseases. When an infant’s weight is less than the 5th percentile on the CDC or the WHO growth chart, or an infant’s weight percentile decreases more than 2 major percentile lines (from 50th to the 8th percentile, for example), this is called “failure to thrive,” which has been shown to increase the risk of developmental delays and impaired academic achievement. [1-3]
This can be an upsetting diagnosis for parents to hear about their babies. For some mothers, this diagnosis will come after weeks of concerted effort breastfeeding, some “cluster-feeding” or near-constantly feeding around the clock in the attempt to increase milk supply and/or maintain exclusive breastfeeding status. Some may have even endured weeks of “triple feeding,” where a mom directly breastfeeds, then pumps for 15 minutes, then supplements her baby, to try to increase her milk supply. Mothers whose babies develop this condition commonly report feeling like they have somehow failed their babies because of messages they have received from health professionals that even small amounts of formula is harmful to a child’s future health and development—which is false.
For those who feel this, remember that this feeling comes from the widely perpetuated myth that true insufficient breast milk is rare and having a full milk supply is fully dependent on a mother doing the right things and putting enough effort to achieve a full supply. This not true. Research shows that even with intense lactation support, 15 percent of mothers motivated to exclusively breastfeed will have persistent problems with milk supply at one month . . .That is 1 in 7 birthing mothers![3] So if you find that you have problems with low milk supply, you are not alone and you are not rare. You are quite normal.
If parents received more honest education about breastfeeding, then you would know that you were not rare or failing your infant. You would understand that you are an expected part of a wide spectrum of ability to produce milk in the population and that human evolution allowed infants like yours to thrive with supplementation. You would recognize that failure to thrive in most healthy newborns is fully preventable by listening to your baby and making sure they are fully fed with breast milk, formula, or a combination of both. You would also realize that supplementation could easily be done while maintaining the stimulus to produce milk with regular nursing and pumping.
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But which growth chart should you use?
The WHO growth chart is commonly favored over the CDC growth chart by exclusive breastfeeding advocates because it is believed to better represent the normal growth pattern of breastfed infants. It also has lower weight thresholds for diagnosing underweight status or failure to thrive, which is often treated with formula supplementation. This runs counter to the goal of exclusive breastfeeding advocates to maintain exclusive breastfeeding status for as many mothers as possible.
Most parents rightly feel that protecting their child’s health and brain development is more important than maintaining breastfeeding exclusivity. If this applies to you, you would want to use the chart that better detects concerning growth patterns that increase the risk of these problems.
A study published in the pediatric medical journal Pediatrics asks the question: “which growth chart is better at detecting failure to thrive that puts infant health and development at risk?”[3] The investigators examined outcomes in over 18,000 children based on caregiver/parent reports on child health, development, and hospitalizations. They then looked back at their weights to look at whether the child was classified as “failure to thrive” on the WHO, CDC, or both growth charts.
The study found that infants who were classified as underweight on the CDC growth chart but not on the WHO growth chart were more than three times more likely to be at higher risk for adverse health and developmental outcomes compared to infants who were not underweight on either chart. Those considered underweight on both charts had more than seven-fold increased odds of having adverse outcomes. Therefore, the WHO growth chart may be missing infants at risk for poor outcomes related to poor nutrition that the CDC growth chart can detect.
The Take Home Points
This study highlights the fundamental principle that a fully fed child—with human milk, formula, or both—will have better outcomes than a child who becomes malnourished for whatever reason. The top priority for any child should be that they get adequate nutrition to support healthy growth.
If a nursing mother has low milk supply even with optimal lactation support, then supplementation of breastfeeding will provide the best outcomes for that baby in the long run. If exclusive formula feeding is necessary for whatever reason, then meeting a child’s nutritional requirement with formula will provide similar outcomes.
The data also shows that preventing failure to thrive is better than correcting it, as the data shows that even a single exposure malnutrition can cause long-term impairments even if it is eventually corrected. New research shows that the CDC growth chart performs better than the WHO growth chart in representing growth patterns associated with better health and developmental outcomes and should be the preferred method of measuring infant growth .
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References
- Smith AE, Shah M, Badireddy M. Failure to Thrive. [Updated 2023 Nov 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459287/
- L. T. Singer and J. F. Fagan, “Cognitive Development in the Failure-to-Thrive Infant: A Three-Year Longitudinal Study,” Journal of Pediatric Psychology 9, no. 3 (September 1984): 363–83, https://doi.org/10.1093/jpepsy/9.3.363.
- S. S. Corbett and R. F. Drewett, “To What Extent Is Failure to Thrive in Infancy Associated with Poorer Cognitive Development? A Review and Meta-Analysis,” Journal of Child Psychology and Psychiatry, and Allied Disciplines 45, no. 3 (March 2004): 641–54, https://doi.org/10.1111/j.1469-7610.2004.00253.x.
- Meyers et al., “Health of Children Classified as Underweight by CDC Reference but Normal by WHO Standard,” Pediatrics 131, no. 6 (June 2013): e1780–1787, https://doi.org/10.1542/peds.2012-2382.