To describe the worldwide implementation of the WHO Child Growth Standards (‘WHO standards’).

A questionnaire on the adoption of the WHO standards was sent to health authorities. The questions concerned anthropometric indicators adopted, newly introduced indicators, age range, use of sex-specific charts, previously used references, classification system, activities undertaken to roll out the standards and reasons for non-adoption.

Worldwide.

Two hundred and nineteen countries and territories.

By April 2011, 125 countries had adopted the WHO standards, another twenty-five were considering their adoption and thirty had not adopted them. Preference for local references was the main reason for non-adoption. Weight-for-age was adopted almost universally, followed by length/height-for-age (104 countries) and weight-for-length/height (eighty-eight countries). Several countries (thirty-six) reported newly introducing BMI-for-age. Most countries opted for sex-specific charts and the Z-score classification. Many redesigned their child health records and updated recommendations on infant feeding, immunization and other health messages. About two-thirds reported incorporating the standards into pre-service training. Other activities ranged from incorporating the standards into computerized information systems, to providing supplies of anthropometric equipment and mobilizing resources for the standards’ roll-out.

Five years after their release, the WHO standards have been widely scrutinized and implemented. Countries have adopted and harmonized best practices in child growth assessment and established the breast-fed infant as the norm against which to assess compliance with children's right to achieve their full genetic growth potential.

To (i) validate a recently proposed questionnaire tool for the simple assessment of physical activity (PA) in pre-school children by comparison with accelerometry and heart-rate recordings; and (ii) extend the tool by adding more questions to improve validity and to refine the classification from two to three categories (PA low, medium, high).

Baseline data of an intervention evaluation study.

Pre-school children.

Children were categorized as either physically active or non-active, based on their parents’ answers to the five-item questionnaire. Activity and heart rate were recorded for 6 d (Actiheart device; CamNtech, Cambridge, UK). Nightly sleeping periods were removed and mean accelerometry counts (MACT), time spent in moderate-to-vigorous intensity physical activity (MVPA) and time spent in sedentary behaviour (SB) were computed. In a second step, additional questions that improved validity were added, resulting in an extended seven-item questionnaire.

For 748 (90·4 %) of the participating children aged 2·3–6·7 years, the questionnaires were filled out sufficiently for classification. Children classified as physically active showed 9·6 % higher MACT (P < 0·0003), spent more time in MVPA and insignificantly less time in SB. Using the extended questionnaire, children with PA classified as medium (reference: low) showed 11·0 % more MACT, spent 11·8 % more time in MVPA and 4·8 % less time in SB. Children with PA classified as high showed 16·9 % more MACT, spent 20·2 % more time in MVPA and 7·2 % less time in SB.

With validated PA questionnaires for pre-school children lacking, the proposed questionnaire might be a reasonable option to include for PA assessment in epidemiological studies where more elaborate measurements are unavailable.

To determine whether a possession score or a poverty index best predicts undernutrition and anaemia in women of reproductive age (15–49 years; WRA) and children aged 6–59 months living in Côte d'Ivoire.

Anthropometric measurements were converted to Z-scores to assess stunting, wasting and underweight in children, and converted to BMI in WRA. A venous blood sample was drawn, and Hb concentration and Plasmodium spp. infection were determined. A possession score was generated with categories of zero to four possessions. A five-point (quintile) poverty index using household assets was created using principal component analysis. These socio-economic measures were compared for their ability to predict anaemia and malnutrition.

Data were from a nationally representative survey conducted in Côte d'Ivoire in 2007.

A sample of 768 WRA and 717 children aged 6–59 months was analysed.

Overall, 74·9 % of children and 50·2 % of WRA were anaemic; 39·5 % of the children were stunted, 28·1 % underweight and 12·8 % wasted, while 7·4 % of WRA had BMI < 18·5 kg/m2. In general, there were more stunted and underweight children and thin WRA in rural areas. The poverty index showed a stronger relationship with nutritional status than the possession score; mean Hb difference between the poorest and wealthiest quintiles in children and WRA was 8·2 g/l and 6·5 g/l, respectively (13·9 % and 19·8 % difference in anaemia, respectively; P < 0·001), and Z-scores and BMI were significantly better in the wealthiest quintile (P < 0·001).

The poverty index was generally a better predictor of undernutrition in WRA and pre-school children than the possession score.

To evaluate a web-based nutritional knowledge questionnaire for primary-school children.

Children's nutritional knowledge was assessed in five domains: healthy choices (twenty-seven items), estimated recommended portions/servings (eight items), nutrient content (five items), main food function (five items) and categorization of food items (eight items).

The questionnaires were completed in school.

A convenience sample of 576 Belgian children (aged 7–12 years) from fourteen primary schools completed the questionnaire once, 386 completed the questionnaire twice.

Healthy choices could be answered correctly by 73 % of the children, nutrients by 59 %, food categorization by 49 %, main function by 38 % and portion estimation by 36 %. Children's test–retest intra-class correlations were 0·75 for healthy choices, 0·33 for nutrients, 0·61 for food categorization, 0·44 for main function, 0·47 for portion estimation and 0·76 for the total scale. The intra-class correlation was lower in the youngest age group (grade 2: 0·51, grade 4: 0·65, grade 6: 0·66). The total score was significantly lower in the retest. The instrument was in general positively evaluated by the children.

The instrument is a promising, practical, inexpensive tool with acceptable test–retest reliability in fourth and sixth graders.

We aimed to establish associations of duration of breast-feeding with mean BMI and waist circumference, as well as the likelihood of being overweight/obese, during early childhood.

Cross-sectional, population-based study. Height, weight and waist circumference were measured and BMI calculated. Interviewer-administered questionnaire determined whether the child was ever breast-fed and the duration of breast-feeding.

Sydney, Australia.

Infants and pre-school children (n 2092) aged 1–6 years were examined in the Sydney Paediatric Eye Disease Study during 2007–2009.

Of the children aged 1–6 years, 1270 had been breast-fed compared with 822 who were never breast-fed. After multivariable adjustment, 1–6-year-old children who were ever breast-fed compared with those who were not had significantly lower BMI, 16·7 (se 0·1) kg/m2v. 17·1 (se 0·2) kg/m2 (P = 0·01). Decreasing BMI was associated with increasing duration of breast-feeding (Ptrend = 0·002). After multivariable adjustment, each month increase in breast-feeding was associated with an average BMI decrease of 0·04 kg/m2 (P = 0·002) and 0·03 kg/m2 (P = 0·03) among children aged 1–2 years and 3–4 years, respectively. In 1–2-year-old children, each month increase in breast-feeding duration was associated with a 0·06 cm decrease in waist circumference (P = 0·04). Significant associations were not observed among 5–6-year-old children. Children who were ever breast-fed v. those never breast-fed were less likely to be overweight/obese (multivariable-adjusted OR = 0·54; 95 % CI 0·36, 0·83).

We demonstrated a modest influence of breast-feeding on children's BMI during early childhood, particularly among those aged less than 5 years.

To analyse the trends and factors associated with anaemia in 6- to 59-month-old children in Northeast Brazil.

Cross-sectional study assessed information from the second and third Pernambuco State Health and Nutrition Surveys carried out in 1997 and 2006. A multiple regression analysis was performed from a conceptual model addressing biological and socio-economic factors, housing and sanitation conditions, maternal factors, health care and nutrition, consumption, morbidity and nutritional status. Poisson's regression with robust variance was used.

Pernambuco, Brazil.

A total of 777 and 993 children, respectively, in the second and third Pernambuco State Health and Nutrition Surveys.

The prevalence of anaemia (Hb < 11 g/dl) decreased by 19·3 % (40·9 % down to 33·0 %) between surveys. Maternal education level (less than 8 years in school), households ranked in the lowest environmental index tertile and children between 6 and 23 months of age were the variables common to the final models in the surveys of 1997 and 2006. Elements like living in rural areas, household income less than two minimum official wages and low birth weight were still present in the final model of the 1997 survey. Households ranked in the lowest economic index tertile were associated with anaemia in the model of the 2006 survey.

The study results are quite encouraging from the perspective of reducing the prevalence of anaemia. Maternal education level, environmental conditions and child age were determinant factors in both surveys, and economic factors were determinant in 2006.

To compare differences in children's diet quality on weekdays (Monday–Thursday), Fridays and weekend days.

A representative cross-sectional study in which participants completed a 7 d pre-coded food record. Mean intakes of energy, macronutrients and selected food items (g/10 MJ) as well as energy density were compared between weekdays, Fridays and weekend days for each gender in three age groups (4–6, 7–10 and 11–14 years) using Tobit analysis to account for zero intakes.

The Danish National Survey of Dietary Habits and Physical Activity 2003–2008.

Children (n 784; 49·9 % boys) aged 4–14 years.

For both genders in all age groups (P < 0·05), energy intake was higher during weekends than on weekdays, and intakes of sugar-sweetened beverages and white bread were higher, whereas intake of rye bread was lower. This contributed to a higher percentage of energy from added sugars, a lower fibre content and a higher energy density on weekend days v. weekdays. In children aged 4–6 and 7–10 years, the diet on weekend days was also characterized by higher intakes of sweets and chocolate and lower intakes of fruit and vegetables. Overall, the diet on Fridays appeared as a mix of the diets on weekdays and weekend days.

Significant differences and distinct characteristic patterns were found in children's diet quality during weekdays, Fridays and weekend days. The present study suggests that in prevention of childhood overweight and obesity, more attention should be paid to the higher energy intake, especially from sugar-rich foods and beverages, on Fridays and weekend days.

The aim of the present study was to explore knowledge of the UK weaning guidelines and the sources of weaning advice used by UK first-time mothers.

An online survey of UK parents; analysed using mixed methods.

Participants were recruited from a selection of parenting websites that hosted a link to the survey.

In total, 1348 UK first-time mothers were included in the analysis.

Knowledge of the guidelines was high (86 %) and associated with later weaning (P < 0·001), although 43 % of this sample weaned before 24 weeks. The majority of parents used multiple sources of information, the most influential being the health visitor (26 %), the Internet (25 %) and books (18 %). Fifty-six per cent said they received conflicting advice. Younger mothers and those of lower educational attainment were more likely to be influenced by advice from family, which was likely to be to wean earlier. Furthermore, those most influenced by their mother/grandmother were less likely to have accurate knowledge of the guidelines. In this population the Internet was used for weaning advice across all sociodemographic groups and was associated with a later weaning age, independently of sociodemographic factors (P < 0·001). Data from responses to a free-text question are used in illustration.

The study suggests that first-time mothers have a good understanding of the weaning guidelines but seek weaning information from multiple sources, much of which is conflicting. Informal sources of weaning advice appear most influential in younger mothers and those of lower educational attainment, and result in earlier weaning.

To assess the nutritional adequacy of Seychellois children in relation to nutrients reported to be important for cognitive development.

Dietary intakes were assessed by 4 d weighed food diaries and analysed using dietary analysis software (WISP version 3·0; Tinuviel Software, UK). Individual nutrient intakes were adjusted to usual intakes and, in order to investigate adequacy, were compared with the UK Estimated Average Requirements for children aged 4–6 years.

Children 5 years old were followed up as part of the Seychelles Child Development Nutrition Study (SCDNS), located in the high-fish-consuming population of Mahé, Republic of Seychelles.

Analysis was carried out on a sample of 229 children (118 boys, 111 girls).

Children consumed a diet of which fortified cereal and milk products contributed the most to nutrient intakes. The majority (≥80 %) of children met requirements for several nutrients important for child development including Fe, folate and Se. Adjusted dietary intakes of Cu, Zn, iodine, niacin and vitamin A were below the Estimated Average Requirement or Recommended Nutrient Intake. Mean adjusted energy intakes (boys 4769 kJ/d (1139·84 kcal/d), girls 4759 kJ/d (1137·43 kcal/d)) were lower than the estimated energy requirement (boys 5104 kJ/d (1220 kcal/d), girls 5042 kJ/d (1205 kcal/d)) for 88 % of boys and 86 % of girls.

Nutrition was adequate for most children within the SCDNS cohort. Low intakes of some nutrients (including Zn, niacin and vitamin A) could reflect nutritional database inaccuracies, but may require further investigation. The study provides valuable information on the adequacy of intakes of nutrients which could affect the growth and development of Seychellois children.

Misperception of social norms may result in normalising unhealthy behaviours. The present study tested the hypothesis that parents overestimate both the frequency of unhealthy snacking in pre-school children other than their own (descriptive norms) and its acceptability to other parents (injunctive norms).

A cross-sectional, self-report community survey. Questions assessed the frequency with which respondents’ own child ate unhealthy snacks and their beliefs about the appropriate frequency for children to snack. Perceived descriptive norms were assessed by asking parents to estimate how often other 2–4 year-old children in their area ate snacks. Perceived injunctive norms were assessed by asking them about other parents’ beliefs regarding the appropriate frequency for snacks. Misperceptions were assessed from (i) the difference between the prevalence of daily snacking and parents’ perceived prevalence and (ii) the difference between acceptability of daily snacking and parents’ beliefs about its acceptability to others.

Pre-schools and children's centres in one borough of London, UK.

Parents (n 432) of children age 2–4 years.

On average, parents believed that more than half of ‘other’ children had snacks at least daily, while prevalence data indicated this occurred in only 10 % of families. The same discrepancy was observed for perceived injunctive norms: parents overestimated other parents’ acceptance of frequent snacking, with two-thirds of parents having a self v. others discrepancy.

Misperceptions were identified for descriptive and injunctive norms for children's snacking. Accurate information could create less permissive norms and motivate parents to limit their child's intake of unhealthy snacks.

To assess the presence of an association between vitamin D deficiency and anaemia in Jordanian infants and toddlers, in whom both vitamin D deficiency and anaemia have previously been proved to be common separately.

Cross-sectional prospective study.

Department of Paediatrics, Princess Rahma Teaching Hospital, Jordan.

Healthy infants and children aged 6–36 months who were seen for primary care.

Out of 203 infants and toddlers included in the study, the anaemia prevalence was 40·4 %. The prevalence of anaemia among infants (n 110) was 51·8 %, whereas it was 26·9 % among toddlers (n 93). No association between vitamin D status and anaemia was found.

Vitamin D deficiency is not a risk for anaemia in infants and toddlers.

To determine the prevalence of vitamin A deficiency, infection and adequacy of vitamin A intakes among Zambian children, and the contribution of dietary vitamin A and infection to vitamin A status.

A cross-sectional survey of vitamin A intakes by the 24 h recall method, vitamin A status by plasma retinol and the modified relative dose-response test, and infection by acute-phase proteins.

Rural communities in Central and Eastern Provinces of Zambia.

Children 2–5 years of age.

The prevalence of vitamin A deficiency was 56 % by plasma retinol, 48 % with infection-adjusted plasma retinol and 22 % by the modified relative dose-response test. The majority of children (61 %) had a current infection. Vitamin A intakes were relatively high (331 to 585 μg retinol activity equivalents/d in the harvest/early post-harvest and late post-harvest seasons, respectively) and the prevalence of inadequate intakes was <1 % when compared with the Estimated Average Requirement (210 and 275 μg retinol activity equivalents/d for children aged 1–3 and 4–8 years, respectively). Elevated α-1-acid glycoprotein was negatively associated with plasma retinol (P < 0·0 0 1) and vitamin A intake was positively associated with plasma retinol (P < 0·05), but only when estimated assuming a 26:1 retinol equivalence for provitamin A from green and yellow vegetables.

Infection and vitamin A intakes were significant determinants of plasma retinol. We cannot conclude which indicator more accurately represents the true vitamin A status of the population. Reasons for the persistent high prevalence of vitamin A deficiency in the presence of adequate vitamin A intakes are unclear, but the high rates of infection may play a role.

To determine the association between indicators of infant and young child feeding (IYCF) and anthropometric measures of nutritional status among children aged 0–23 months in a nationally representative data set.

Data from the 2007 Bangladesh Demographic and Health Survey were used. Analyses were conducted using multiple linear regression and logistic regression analyses adjusted for the complex survey design of the survey, controlling for child, maternal and household characteristics, and including regional dummy variables.

Bangladesh.

Pairs (n 2096) of last born infants and their mothers.

Exclusive breast-feeding under 6 months of age was associated with higher weight-for-height Z-score (effect size (ES) = 0·29; P < 0·05). Appropriate complementary feeding in children aged 6–8 months was associated with higher height-for-age Z-score (HAZ; ES = 0·63; P < 0·01) and higher weight-for-age Z-score (WAZ; ES = 0·30; P < 0·05). Higher dietary diversity index (DDI) was associated with higher HAZ (ES = 0·08; P < 0·01 for every 1 point higher DDI) and higher WAZ (ES = 0·04; P < 0·05). Children who achieved minimum diet diversity had higher HAZ (ES = 0·20; P < 0·05). Logistic regression models confirmed that exclusive breast-feeding was protective against wasting and DDI was protective against stunting and underweight.

Our results highlight the importance of IYCF practices as determinants of child growth outcomes in this context, and reinforce the need for interventions that address the spectrum of IYCF practices, from exclusive breast-feeding to age-appropriate complementary feeding, especially diet diversity, in efforts to improve nutrition of infants and young children.

To explore associations of early infant feeding with (i) eating patterns in the second year of life and (ii) weight status in the fourth year of life in a prospective cohort of children in Scotland.

Growing Up in Scotland (GUS) longitudinal birth cohort study (2005–2008).

Scotland, UK.

Children aged 9–12 months (n 5217) followed through to 45–48 months.

Infant feeding was associated with eating patterns, defined by using SPSS two-step cluster analysis, in the second year of life. Children who were ever breast-fed compared with never breast-fed (adjusted OR = 1·48, 95 % CI 1·27, 1·73) were more likely to have a positive eating pattern (Cluster 2). Children who started complementary feeding at 4–5 months or 6–10 months compared with 0–3 months (adjusted OR = 1·32, 95 % CI 1·09, 1·59 or AOR = 1·50, 95 % CI 1·19, 1·89) were more likely to belong to Cluster 2. Breast-feeding was negatively associated with being overweight or obese in the fourth year of life compared with no breast-feeding (adjusted OR = 0·81, 95 % CI 0·81, 1·01). Introduction of complementary feeding at 4–5 months compared with 0–3 months was negatively associated with being overweight or obese (adjusted OR = 0·74, 95 % CI 0·57, 0·97).

Breast-feeding and introduction of complementary feeding after 4 months were associated with a positive eating pattern in the second year of life. Introduction of complementary feeding at 4–5 months compared with 0–3 months was negatively associated with being overweight or obese.

To report on the trends and determinants of undernutrition among children <5 years old in Kenya.

Data from four nationwide Kenya Demographic and Health Surveys, conducted in 1993, 1998, 2003 and 2008–2009, were analysed. The Demographic and Health Survey utilizes a multistage stratified sampling technique.

Nationwide covering rural and urban areas in Kenya.

The analysis included 4757, 4433, 4892 and 4958 Kenyan children aged <5 years in 1993, 1998, 2003 and 2009–2009, respectively.

The prevalence of stunting decreased by 4·6 percentage points from 39·9 % in 1993 to 35·3 % in 2008–2009, while underweight decreased by 2·7 percentage points from 18·7 % in 1993 to 16·0 % in 2008–2009. The effects of household wealth, maternal education and current maternal nutritional status on child nutrition outcomes have changed dynamically in more recent years in Kenya. Inadequate hygiene facilities increased the likelihood of chronic undernutrition in at least three of the surveys. Small size of the child at birth, childhood diarrhoea and male gender increased the likelihood of undernutrition in at least three of the surveys. Childhood undernutrition occurred concurrently with maternal overnutrition in some households.

The analysis reveals a slow decline of undernutrition among young children in Kenya over the last three decades. However, stunting and underweight still remain of public health significance. There is evidence of an emerging trend of a malnutrition double burden demonstrated by stunted and underweight children whose mothers are overweight.

To investigate whether high doses of folic acid supplementation in early pregnancy are associated with child neurodevelopment at 18 months of age.

The study uses data from the prospective mother–child cohort ‘Rhea’ study. Pregnant women completed an interviewer-administered questionnaire on folic acid supplementation at 14–18 weeks of gestation. Neurodevelopment at 18 months was assessed with the use of the Bayley Scales of Infant and Toddler Development (3rd edition). Red-blood-cell folate concentrations in cord blood were measured in a sub-sample of the study population (n 58).

Heraklion, Crete, Greece, 2007–2010.

Five hundred and fifty-three mother–child pairs participating in the ‘Rhea’ cohort.

Sixty-eight per cent of the study participants reported high doses of supplemental folic acid use (5 mg/d), while 24 % reported excessive doses of folic acid (>5 mg/d) in early pregnancy. Compared with non-users, daily intake of 5 mg supplemental folic acid was associated with a 5-unit increase on the scale of receptive communication and a 3·5-unit increase on the scale of expressive communication. Doses of folic acid supplementation higher than 5 mg/d were not associated with additional increase in the neurodevelopmental scales.

This is the first prospective study showing that high doses of supplementary folic acid in early pregnancy may be associated with enhanced vocabulary development, communicational skills and verbal comprehension at 18 months of age. Additional longitudinal studies and trials are needed to confirm these results.

The purpose of the present study was to evaluate the effects of a school-based, 2-year, multi-component intervention on BMI, eating and physical activity behaviour in Flanders, Belgium, targeting children aged 3–6 years in communities of high and low socio-economic status (SES).

Cluster-randomized controlled trial.

Thirty-one pre-primary and primary schools in three different intervention communities and three paired-matched (on SES profile) control communities in Flanders, Belgium.

BMI Z-scores at baseline and follow-up were calculated for 1102 children. Questionnaires with sociodemographic data and FFQ were available from 694 of these 1102 children.

No significant effects were found on BMI Z-scores for the total sample. However, there was a significant decrease in BMI Z-score of 0·11 in the low-SES intervention community compared with the low-SES control community, where the BMI Z-score increased by 0·04 (F = 6·26, P = 0·01). No significant intervention effects could be found for eating behaviour, physical activity or screen-time. There were no significant interaction effects of age and gender of the children on the outcome variables.

Although no significant effects were found for BMI Z-scores in the total sample, this intervention had a promising effect in the low-SES community of reducing excess weight gain among young children.

To determine which interventions can reduce linear growth retardation (stunting) in children aged 6–36 months over a 5-year period in a food-insecure population in Ethiopia.

We used data collected through an operations research project run by Save the Children UK: the Child Caring Practices (CCP) project. Eleven neighbouring villages were purposefully selected to receive one of four interventions: (i) health; (iii) nutrition education; (iii) water, sanitation and hygiene (WASH); or (iv) integrated comprising all interventions. A comparison group of three villages did not receive any interventions. Cross-sectional surveys were conducted at baseline (2004) and for impact evaluation (2009) using the same quantitative and qualitative tools. The primary outcome was stunted growth in children aged 6–36 months measured as height (or length)-for-age Z-scores (mean and prevalence). Secondary outcomes were knowledge of health seeking, infant and young child feeding and preventive practices.

Amhara, Ethiopia.

Children aged 6–36 months.

The WASH intervention group was the only group to show a significant increase in mean height-for-age Z-score (+0·33, P = 0·02), with a 12·1 % decrease in the prevalence of stunting, compared with the baseline group. This group also showed significant improvements in mothers’ knowledge of causes of diarrhoea and hygiene practices. The other intervention groups saw non-significant impacts for childhood stunting but improvements in knowledge relating to specific intervention education messages given.

The study suggests that an improvement in hygiene practices had a significant impact on stunting levels. However, there may be alternative explanations for this and further evidence is required.

To determine if supplementation with corn–soya blend (CSB) or lipid-based nutrient supplement (LNS) improved the weight gain of moderately underweight infants and children when provided through the national health service.

A randomised, controlled, assessor-blinded clinical trial. Infants and children were randomised to receive for 12 weeks an average daily ration of 71 g CSB or 43 g LNS, providing 1188 kJ and 920 kJ, respectively, or no supplement (control). Main outcome was weight gain. Secondary outcomes included changes in anthropometric indices and incidence of serious adverse events. Intention-to-treat analyses were used.

Kukalanga, Koche, Katema and Jalasi health centres in Mangochi District, rural Malawi.

Underweight (weight-for-age Z-score <−2) infants and children aged 6–15 months (n 299).

Mean weight gain was 630 g, 680 g and 750 g in control, CSB and LNS groups, respectively (P = 0·21). When adjusted for baseline age, children receiving LNS gained on average 90 g more weight (P = 0·185) and their weight-for-length Z-score increased 0·22 more (P = 0·049) compared with those receiving no supplementation. No statistically significant differences were observed between the CSB and control groups in mean weight and length gain.

LNS supplementation provided during the lean season via through the national health service was associated with a modest increase in weight. However, the effect size was lower than that previously reported under more controlled research settings.