A fresh look at growth assessment of infants and young children in the Czech Republic in context of international developments

The growth charts of basic body measurements are an important aid for the daily routine practice of paediatricians. Charts for children from birth to 2 years of age form an integral component of a set of such tools for the age spectrum from birth to 18 years of age. The interpretation of growth charts is highly dependent on the data on basis of which the charts were constructed. In the Czech Republic, the growth reference data have been regularly updated since 1951, in 10-year intervals. These updates are based on data from nation-wide anthropological surveys of children and adolescents. Countries, which do not have their own reference data, have been using for growth assessment the 1977 World Health Organization (WHO) and the National Center for Health Statistics (NCHS) international reference growth charts. These charts, developed for height for age, weight for age, and weight for height, were based for children younger than 2 years on a longitudinal study of North American children. Over the years, use in practice showed that because of the original criteria used to select the child population studied, these reference growth charts were not suitable for assessing growth of breastfed children. The 1977 reference is based on predominantly artificially, that is formula-fed, child population. The evidence shows that breastfed and artificially fed infants grow differently and that the growth pattern of breastfed children most likely better reflects physiological growth. In 1994, based on the accumulated evidence, the WHO started working on new international standards which would be based on a sample of healthy breastfed children. The project, the WHO Multicentre Growth Reference Study (MGRS), was carried out from 1997-2003. It focused on collection of growth and development data of 8440 children from different ethnic and cultural groups. The underlying assumption of the project was that in favourable socio-economic conditions and with a recommended level of nutrition and lack of maternal smoking, children's growth is very similar, regardless of their ethnic origin and geographic location. The new growth standard for children 0-5 years of age will be available early in 2006. In the Czech Republic, we plan to analyse our national reference against this standard. If considered necessary, a process will be put in place for replacing the Czech reference with the WHO standard. The objective of this article is to alert health professionals that growth charts currently used in their country may not represent an optimal tool, especially with regard to the assessment of nutritional status for 0 to 2-year-old children, unless already based on data of breastfed children. Generally, the lack of awareness of the difference between the two growth patterns--the breastfed versus artificially fed child--poses a serious problem since a strict interpretation of the growth charts may lead to early supplementation of breastmilk with infant formula and/or premature introduction of complementary foods. Both of these practices tend to lead to premature cessation of breastfeeding, one of the key strategies to improve child health and development.     

Hierarchical linear models for the development of growth curves: an example with body mass index in overweight/obese adults

When data are available on multiple individuals measured at multiple time points that may vary in number or inter-measurement interval, hierarchical linear models (HLM) may be an ideal option. The present paper offers an applied tutorial on the use of HLM for developing growth curves depicting natural changes over time. We illustrate these methods with an example of body mass index (BMI; kg/m(2)) among overweight and obese adults. We modelled among-person variation in BMI growth curves as a function of subjects' baseline characteristics. Specifically, growth curves were modelled with two-level observations, where the first level was each time point of measurement within each individual and the second level was each individual. Four longitudinal databases with measured weight and height met the inclusion criteria and were pooled for analysis: the Framingham Heart Study (FHS); the Multiple Risk Factor Intervention Trial (MRFIT); the National Health and Nutritional Examination Survey I (NHANES-I) and its follow-up study; and the Tecumseh Mortality Follow-up Study (TMFS). Results indicated that significant quadratic patterns of the BMI growth trajectory depend primarily upon a combination of age and baseline BMI. Specifically, BMI tends to increase with time for younger people with relatively moderate obesity (25 BMI <30) but decrease for older people regardless of degree of obesity. The gradients of these changes are inversely related to baseline BMI and do not substantially depend on gender.     

Who goes into family medicine?

A study was designed to identify criteria that could help select applicants to medical school with a lasting commitment to family medicine and to test the application of such criteria to predict career choice. The sample included 43 residents and physicians who chose family medicine when they entered medical school and five residents who decided on family medicine later. From the initial group, 19 remained stable in their choice of family medicine, and 24 switched to another specialty. Medical school folders and telephone interviews were used as data sources. The characteristics of stable family physicians and those who became specialists were identified, and the predictive power of these criteria was tested with 30 graduates selected at random. Based only on their entrance records, 25 of the 30 graduates were correctly identified as future family physicians or specialists. The use of these criteria in the admission process is discussed in terms of increasing the number of students who will become stable family physicians.     

Reviewing the features and functionalities of contraception mPHRs

Background and objective. Women's circumstances and preferences tend to change over times signifying that accessing and choosing a contraceptive method during their reproductive life is crucial. By preventing unintended pregnancies and reducing the need for abortion, effective contraception ensures women's well-being and autonomy, improves their social and economic role, and enables them to fully participate in society while supporting the health and development of their communities. The use of mobile applications (apps) for contraception is considered a promising approach by which to facilitate access to a reproductive health service of this nature and spread awareness about contraception. The aim of this paper is, therefore, to assess the features and functionalities of the contraception mPHRs (Mobile Personal Health Records) that are available on both the Android and iOS platforms.Methods. In order to select, extract data from and evaluate the features and functionalities of existing contraception apps, an analysis process based on the well-known Systematic Literature Review (SLR) protocol was conducted for the contraception apps that are available on both the Android and iOS app platforms. The analysis and assessment of selected apps' features were performed in accordance with a twenty-seven item assessment questionnaire. The latter was developed on the basis of the scientific literature concerning contraception, and a preliminary analysis of the contraception apps currently available.Results. A total of 54 contraception apps were selected, including 38 for Android, 4 for iOS, and 12 for crossed platform apps. The results showed that only 11% of the apps selected do support the World Health Organization's (WHO) medical eligibility criteria for contraception (MEC), and that barely 43% provide relevant information about contraceptive methods, their efficiency, risks, and contraindications.Conclusion. This study will help users, eHealth apps providers, and developers. Users on the one hand will be able to better select the most appropriate contraceptive apps. On the other hand, both eHealth application providers and developers can thereby: (1) identify the relevant features and functionalities implemented by the top-scoring contraceptive apps, and (2) distinguish contraception-related aspects that require further efforts to be properly addressed and improved.     

儿童身体发育标准的制定和集体发育水平的评定法

以秦振庭等对近三千名七岁以下、能获得充分营养及合理护理的男女儿童的身长和体重测量结果为基础,制定了一份七岁以下儿童身体发育标准。把秦氏材料中男女儿童的身长和体重生长曲线和标准差曲线修勺,画成光滑曲线,即为此样本中的“理论”生长曲线。从这些曲线上可以读出以一个月为年龄组距的各年龄组男女儿童的身长和体重的修正平均值和相应的标准差。用这些数值先制成一份表。然后把每一个年龄组的修正平均值M加减一个或两个标准差S,连同超过两端范围的,就可以把每个年龄组的身长或体重的发育水平划分为六个等级。用这些数字来制定一份“七岁以下儿童的身长和体重发育水平评定标准表”。 在评定一个儿童的身长或体重发育水平时,先按照规定的要求,测量儿童的身长或体重,然后根据儿童的准确年龄,在标准表中查出该儿童的测量值在哪一个等级数字的范围内,就可以决定该儿童的身长和体重发育水平属于哪个等级。 用这个标准评定了15个托儿所的1672名儿童的身长和体重发育水平,并在这个基础上,又对每一个托儿所儿童的身长和体重的“集体发育水平”作了评定。结果看出:各单位儿童的身长和体重集体发育水平的高低,是和膳食的营养质量与生活条件有直接关系的,因而这样制定的标准和评定方法都是合用的。     

Development of a WHO growth reference for school-aged children and adolescents

OBJECTIVE: To construct growth curves for school-aged children and adolescents that accord with the WHO Child Growth Standards for preschool children and the body mass index (BMI) cut-offs for adults. METHODS: Data from the 1977 National Center for Health Statistics (NCHS)/WHO growth reference (1-24 years) were merged with data from the under-fives growth standards' cross-sectional sample (18-71 months) to smooth the transition between the two samples. State-of-the-art statistical methods used to construct the WHO Child Growth Standards (0-5 years), i.e. the Box-Cox power exponential (BCPE) method with appropriate diagnostic tools for the selection of best models, were applied to this combined sample. FINDINGS: The merged data sets resulted in a smooth transition at 5 years for height-for-age, weight-for-age and BMI-for-age. For BMI-for-age across all centiles the magnitude of the difference between the two curves at age 5 years is mostly 0.0 kg/m(2) to 0.1 kg/m(2). At 19 years, the new BMI values at +1 standard deviation (SD) are 25.4 kg/m(2) for boys and 25.0 kg/m(2) for girls. These values are equivalent to the overweight cut-off for adults (> or = 25.0 kg/m(2)). Similarly, the +2 SD value (29.7 kg/m(2) for both sexes) compares closely with the cut-off for obesity (> or = 30.0 kg/m(2)). CONCLUSION: The new curves are closely aligned with the WHO Child Growth Standards at 5 years, and the recommended adult cut-offs for overweight and obesity at 19 years. They fill the gap in growth curves and provide an appropriate reference for the 5 to 19 years age group.     

再论儿童生长发育的科学评估

生长发育评价是儿童保健与儿科临床的实践基础.通过生长评价了解儿童生长、营养及健康状况,早期发现异常、协助疾病诊断和评估干预治疗效果.准确的生长评价取决于精确的测量数据、适宜的评价标准、正确的评价方法及合理的结果分析.采用生长曲线图将多项指标有机结合进行动态监测与评估是最有效的临床适宜技术.     

国家基本药物目录与WHO示范目录的差异分析

目的：通过比较我国国家基本药物目录与WHO2011版示范目录的差异,为我国修订和完善国家基本药物目录提供参考。方法：采用WHO官网公开的WHO1977-2011年基本药物示范目录汇总表录入国家基本药物目录西药,进行矩阵表分析。结果：我国国家基本药物目录构成、药物分类方式和适用对象等基本要素,遴选标准、方法等遴选机制,以及收录药品的品种和类别与WHO2011版示范目录存在差异。两目录对同一治疗组推荐药品有所区别,部分国家基本药物品种已被WHO示范目录删除。结论与建议：通过与WHO示范目录比较,可以发现我国基本药物目录存在一些不足,需要进一步完善目录要素和构成,完善遴选机制,并根据wH0示范目录药品的系统证据对现有基本药物品种进行调整。     

不同喂养方式对早产小于胎龄儿生长发育影响的研究

目的 研究不同喂养方式对小于胎龄儿体重、身长、头围的影响。方法 将215名小于胎龄儿按照喂养方式分为5组:早产儿出院后配方奶喂养组、母乳喂养组、足月儿配方奶喂养组、母乳+早产儿出院后配方奶喂养组、母乳+足月儿配方奶喂养组, 比较各组在出生、生后1、3、6、12、18月及24月体重、身长、头围等生长发育指标。结果 不同喂养方式对小于胎龄儿体重、身长、头围发育的影响有统计学意义(P<0.05), 早产儿出院后配方奶喂养组及其与母乳混合喂养组儿童发育指标优于纯母乳喂养及足月儿配方奶喂养组, 其差异有统计学意义(P<0.05)。结论 小于胎龄儿出院后应用早产儿出院后配方奶喂养或与母乳混合喂养能够促进体重、身长、头围发展, 实现小于胎龄儿的追赶生长, 避免发生宫外生长发育迟缓的发生。     

Zero-inflated models for regression analysis of count data: a study of growth and development

Poisson regression is widely used in medical studies, and can be extended to negative binomial regression to allow for heterogeneity. When there is an excess number of zero counts, a useful approach is to used a mixture model with a proportion P of subjects not at risk, and a proportion of 1--P at-risk subjects who take on outcome values following a Poisson or negative binomial distribution. Covariate effects can be incorporated into both components of the models. In child assessment, fine motor development is often measured by test items that involve a process of imitation and a process of fine motor exercise. One such developmental milestone is 'building a tower of cubes'. This study analyses the impact of foetal growth and postnatal somatic growth on this milestone, operationalized as the number of cubes and measured around the age of 22 months. It is shown that the two aspects of early growth may have different implications for imitation and fine motor dexterity. The usual approach of recording and analysing the milestone as a binary outcome, such as whether the child can build a tower of three cubes, may leave out important information.     

西北部分贫困地区儿童喂养和体格发育现状研究

利用1999年卫生部一联合国儿童基金会在中国西部5省40个项目县调查资料,着重分析3岁以下儿童喂养和生长发育现状以及影响儿童中重度低体重和中重度生长迟缓的因素。结果显示：3岁以下儿童母乳喂养率高,但纯母乳喂养率偏低。4个月和6个月及时添加辅食率较低,分别为18.4%和45.1%。4～6个月以内儿童年龄别体重和年龄别身高基本高于世界卫生组织相应的标准。年龄别体重男童从8个月开始到35个月,女童从11月到35个均低于世界卫生组织的相应标准。影响儿童中重度低体重和中重度生长迟缓的主要因素有：民族、母亲年龄、家庭经济来源、孩子年龄、喂养方式、饮用水和两周腹泻患病。     

Breast feeding,growth and morbidity

The effect of exclusive breast feeding in the first few months of life on physical growth was studied prospectively in a group of 36 full-term healthy newborns. Growth failure was not observed in any infant until after the third month of life. The average growth curve for the entire group was between the 25th and 50th percentile at the end of the study period. However, faltering of growth as judged by weight at or below the tenth percentile of standard for age was seen in three (8%) infants at the age of four months, five (13%) at five months, eight (22%) at six months, nine (25%) at seven months, and twelve (33%) at eight months. Morbidity experience showed a slight but statistically higher frequency of respiratory infections and otitis in those infants who had shown faltered growth. Volume of milk intake was similar in the two groups. These observations suggest that a small proportion of exclusively breast-fed infants may not achieve adequate growth. In such infants, consideration should be given to supplementation after 4 months of age.     

Classification of analytical methods.

The ideal analytical method is one which has been thoroughly evaluated, collaboratively tested by a number of laboratories, and established by long usage. The development of such procedures is time consuming and expensive. However, a classification scheme which recognizes that methods may be used which have not been fully evaluated or collaboratively tested is useful. A scheme with five classes which has been applied to NIOSH analytical methods is presented. It recognizes that many analytical methods have been developed, that other agencies and organizations have examined the literature and published methods, and that unproved or suggested method may be the only information available.     

仡佬族0～1岁婴儿生长发育状况及影响因素分析

目的 分析贵州省数个仡佬族村寨0～1岁新生儿的生长发育水平及影响因素,为仡佬族婴儿健康生长提供科学参考。方法 选取贵州省务川县7个乡镇的少数民族村寨进行调查,对2012年11月1日-2013年11月1日出生的306名仡佬族婴儿及其产妇进行为期1年的体格检查和随访,运用SPSS 22.0软件进行统计分析。结果 务川县产后24 h内的母乳喂养率为92.4%,到6月龄时下降为27.5%;仡佬族男婴体重、身长指标均值高于女婴,而6月龄起男婴头围均值低于女婴(P＜0.05);3月龄后婴儿体重、身长值均低于WHO标准(P＜0.05),产妇的妇幼保健知识平均得分为(4.10±1.36)分;各月龄组男女婴儿中重度低体重和生长迟缓的发生率差异有统计学意义(P＜0.05),其中3～8月龄男婴中重度生长迟缓的发生率高于女婴,而男女婴儿中重度低头围和胸围的发生率差异均无统计学意义(P>0.05);经Logistic回归分析,发现婴儿的生长发育状况受其性别、家庭年收入、父亲教育程度、母亲妇幼知识得分及辅食添加的影响(P＜0.05)。结论 仡佬族婴儿生长发育状况与WHO标准存在一定差异,应及时提出相应的干预意见,改善该群体的生长发育状况。     

河北省5岁以下儿童生长发育Z评分及营养状况评价

【目的】 应用Z评分法对河北省5岁以下儿童生长发育及营养状况进行评价和分析,为做好儿童保健工作提供科学依据。 【方法】 采用分层随机整群抽样法,抽取河北省24个县、3个城市5岁以下儿童15 930人为研究对象,对其进行身高、体重测量,采用WHO Anthroplus 2007软件计算Z评分值。 【结果】 生长发育迟缓(HAZ<2)患病率11.41％(1 818/15 930)、低体重(WAZ<2)患病率7.06%(1 125/15 930)、消瘦(WHZ<2)患病率2.58%(411/15 930),且城乡差异显著,尤其是生长发育迟缓农村患病率12.35%,约是城市的3.2倍;儿童年龄别身高Z评分(HAZ)、年龄别体重Z评分(WAZ)以及身高别体重Z评分(WHZ)均值分别为0.96±1.08、0.51±1.32和0.08±1.68。其中城市分别为0.18±1.37、0.19±1.12和0.52±1.11,农村分别为1.23±1.40、0.63±1.21和0.12±1.24。仅城市WAZ和WHZ为正值,其余均为负值,且平均Z评分随年龄增长呈下降趋势。 【结论】 河北省儿童生长发育水平与WHO推荐的参考标准有一定差距,且城乡差异显著,农村儿童营养状况欠佳。     

'Now I understand': consulting parents on chart design and parental information for the UK-WHO child growth charts

Background Regular assessment of growth is an important part of child health surveillance in the UK and most parents are very interested in their child's growth. UK parents are given a personal child health record (PCHR), including growth charts, which are plotted during baby clinic visits. Parents were consulted as part of the process of designing new UK charts to incorporate the World Health Organization growth standard. This paper describes the main themes that emerged and how they influenced the final design. Method Three sets of consultations with 47 parents were conducted to collect preliminary information, and to evaluate proposed chart designs, instructions and written information for parents. Results At every consultation, the impact of the depiction of the 50th centile line in bold was mentioned spontaneously by parents. They also found aspects of the charts unclear, including the implications of a recorded weight on any particular centile, the difficulty of understanding existing text about charts in the PCHR, their preference for using pounds and ounces rather than metric weights and confusion about how frequently babies should be weighed. This led to the production of parental information including explanation of these issues which were then tested in two further sets of focus groups. Conclusion Involving parents in the process of designing growth charts and information influenced the finished design and the text in the PCHR. Ensuring information meets parents' needs is important to ensure successful growth monitoring.     

Individual growth curve models for assessing evidence-based referral criteria in growth monitoring

The goal of this study is to assess whether a growth curve model approach will lead to a more precise detection of Turner sydnrome (TS) than conventional referral criteria for growth monitoring. The Jenss-Bayley growth curve model was used to describe the process of growth over time. A new screening rule is defined on the parameters of this growth curve model, parental height and gestational age. The rule is applied to longitudinal growth data of a group of children with TS (n=777) and a reference (n=487) group. The outcome measures are sensitivity, specificity and median referral age. Growth curve parameters for TS children were different from reference children and can therefore be used for screening. The Jenss-Bayley growth model, which uses all longitudinal measurements from birth to a maximum age of 5 years with at least one measurement after the age of 2, together with parental height and gestational age can achieve a sensitivity of 85.2 per cent with a specificity of 99.5 per cent and a median referral age of 4.2 (the last measurement between the age of 2 and 5 of each child is considered to be the moment of referral). Sensitivity increases by 2 percentage points when decreasing the specificity to 99 per cent. The Jenss-Bayley growth model from birth to a maximum age of 8 years with at least one measurement after the age of 2, together with parental height results in a sensitivity of 89.0 per cent with a specificity of 99.5 per cent and a median referral age of 6.1. For a specificity of 98 per cent, we obtain a sensitivity of 92.3 per cent. In comparison to conventional rules applied to the same data, sensitivity is about 11-30 percentage points higher at the same level of specificity for the Jenss-Bayley growth rule. We conclude that from the age of 4, growth curve models can improve the screening on TS to conventional screening rules.     

Effect of child labour on growth of children

This community based group comparison study was undertaken to assess the effect of child labour on the growth of children. The study subjects were 223 child labourers aged between 8-15 y who were matched by age to an equal number of controls and pair matched for gender. The mean weight of the male child labourers and the controls increased from 23.8 (+/-5.9) to 41.2 (+/-9.7) kg and 23.9 (+/-4.8) to 44.4 (+/-10.3) kg respectively, while mean height increased from 121.5 (+/-12.6) to 151.9 (+/-10.6) cm and 122.0 (+/-8.4) to 154.8 (+/-10.8) cm respectively from 8-15 y. At older ages (12 y and above for weight and 14 y and above for height) the difference was statistically significant. The same was not observed for the female study subjects. Similarly standard deviation (s.d.) scores for weight for age and height for age of male comparison subjects was significantly (P<0.01) nearer to National Centre for Health Statistics (NCHS) standard than that of the child labourers. Body mass index (BMI) below normal value, that is, 18.5 was observed in significantly (P=0.0261) more child labourers 180 (80.7%) than controls 160 (71.1%). With increasing duration of employment BMI decreased from 18.1 (+/-3.5) to 17.3 (+/-2.2). Genital development was observed to be delayed significantly in male child labourers. Therefore, it can be concluded that labouring at a young age has a deleterious effect on the growth of the child.