You are on page 1of 12

Characteristic

CDC

WHO

TABLE 1. Comparison of sample populations used to create the CDC and WHO growth curves for children aged <24 mos

National vital statistics


(birth weights)
Missouri and Wisconsin
vital statistics (birth
lengths)
Pediatric Nutrition
Surveillance System
(lengths, 0.1 to <5 mos)
NHANES I (19711974)
(1223 mos)
NHANES II (19761980)
(623 mos)

MGRS longitudinal
component, with sites in
the following locations:
Pelotas, Brazil
Accra, Ghana
Delhi, India
Oslo, Norway
Muscat, Oman
Davis, California

NHANES III (19881994)


(223 mos)
Type and frequency of data collectionCross-sectional data on

Sample size
Exclusion criteria

Breastfeeding among

weight and length


starting at age 2 mos,
with mathematical
models used to connect
birth weights and
lengths to survey data

Longitudinal data with


measurements of weight
and length at birth; 1, 2,
4, 6, and 8 wks; and 3,
4, 5, 6, 7, 8, 9, 10, 11,
12, 14, 16, 18, 20, 22,
and 24 mos

4,697 observations for


4,697 distinct children

18,973 observations for


882 distinct children

Very low birth weight (<1,500 g [<3 Low


lbs, 4socioeconomic
oz])
status
Birth at altitude >1,500 m
Birth at <37 wks or 42 wks
Multiple birth
Perinatal morbidities
Child health conditions known to affect growth
Maternal smoking during pregnancy or lactation
Breastfeeding for <12 mos
Introduction of complementary foods before age 4 mos o
Weight-for-length measurements >3 standard deviations
Approximately 50% ever breastfed
100% ever breastfed
Approximately 33% breastfeeding at 3 mos

infants in sample

100% predominantly
breastfeeding at 4 mos
100% still breastfeeding
at 12 mos
Complementary foods
introduced at mean age
of 5.4 mos

Abbreviations: MGRS = Multicentre Growth Reference Study; NHANES = National Health and Nutrition Examination Survey
WHO = World Health Organization.
* Source: Kuczmarski RJ, Ogden CL, Guo SS, et al. 2000 CDC growth charts for the United States: methods and development. Vita
Health Stat 2002;246.
Sources: World Health Organization. WHO child growth standards: length/height-for-age, weight-for-age, weight-for-height an
body mass index-for-age: Methods and development. Geneva, Switzerland: World Health Organization; 2006. Available a
http://www.who.int/childgrowth/publications/technical_report_pub/en/index.html. Accessed June 1, 2010; and WHO Multicentr
Growth Reference Study Group. Enrolment and baseline characteristics in the WHO Multicentre Growth Reference Study. Act
Paediatr Suppl 2006;450:715.
Comparison of sample populations used to create the CDC and WHO growth curves for children aged 2459 mos
Characteristic
National vital statistics (birth weights)
MGRS longitudinal component, with sites in the followi
Missouri and Wisconsin vital statistics
Pelotas,
(birth Brazil
lengths)
Pediatric Nutrition Surveillance System
Accra,
(lengths,
Ghana0.1 to <5 mos)
NHANES I (19711974) (1223 mos)
Delhi, India
NHANES II (19761980) (623 mos)
Oslo, Norway
NHANES III (19881994) (223 mos)
Muscat, Oman
Davis, California
Data sources
Longitudinal data with
Cross-sectional data on
measurements of weight and length
weight and length
at birth; 1, 2, 4, 6, and 8 wks; and
starting at age 2 mos,
3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 16,
with mathematical
18, 20, 22, and 24 mos

models used to connect


birth weights and
lengths to survey data
Type and frequency of data collection4,697 observations for

18,973 observations for 882 distinct children

4,697 distinct children


Sample size

Exclusion criteria

Very low birth weight


(<1,500 g [<3 lbs, 4
oz])

Low socioeconomic status


Birth at altitude >1,500 m
Birth at <37 wks or 42 wks
Multiple birth
Perinatal morbidities
Child health conditions known to affect growth
Maternal smoking during pregnancy or lactation
Breastfeeding for <12 mos
Introduction of complementary foods before age 4 mos o
Weight-for-length measurements >3 standard deviations
Approximately 50% ever breastfed 100% ever breastfed
Approximately 33% breastfeeding at 100%
3 mospredominantly breastfeeding at 4 mos

100% still breastfeeding at 12 mos


Complementary foods introduced at mean age of 5.4 mos

The disjunction at 2 years old addresses the issue of differential


measurements between
recumbent length and standing height. The length-for-age curves are
averagely 0.7 cm larger than height-for age
curves at 2-year-old

Tabel: KATEGORI DAN AMBANG BATAS STATUS GIZI ANAK

Indeks
Berat
Badan
menurut Umur (BB/U)
Anak umur 0-24 bulan

Panjang
Badan
menurut umur (PB/U)
atau
Tinggi
Bdan
menurut umur (TB/U)
anak umur 0-24 bulan

Berat
menurut Panjang
(BB/PB)
atau
Badan menurut
Badan
(BB/Tb)

Badan
Badan
Berat
Tinggi
anak

Kategori Status Gizi

Ambang Batas (z-Score)

Gizi Buruk

<-3 SD

Gizi Kurang

-3 SD sampai 2 SD

Gizi Baik

>2 SD

Gizi Lebih

<-3 SD

Sangat Pendek

<-3 SD

Pendek

-3 Sd sampai dengan <2 Sd

Normal

-2 SD sampai dengan 2
SD

Tinggi

> 2 SD

Sangat Kurus

<-3 SD

Kurus

-3 Sd sampai dengan <2 Sd

umur 0-24 bulan

Indeks Massa Tubuh


menurut Umur (IMT/U)
Anak umur 0-24 bulan

Indeks

Normal

-2 SD sampai dengan 2
SD

Gemuk

> 2 SD

Sangat Kurus

<-3 SD

Kurus

-3 Sd sampai dengan <2 Sd

Normal

-2 SD sampai dengan 2
SD

Gemuk

> 2 SD

Kategori Status Gizi

Ambang
(percentile)

Indeks
Massa
Tubuh Overweight
menurut Umur (IMT/U)
Anak umur 5 tahun ke Risiko Overweight
atas

Batas

> 95th
> 85th dan < 95th

Underweight

< 5th

Berat Badan menurut Underweight


Panjang Badan (BB/PB)
atau
Berat
Badan Overweight
menurut Tinggi Badan
(BB/Tb) anak 5 tahun
dan keatas

< 5th

Panjang Badan menurut Perawakan pendek


umur (PB/U) atau Tinggi
Bdan menurut umur
(TB/U) anak umur 5
tahun dan keatas

< 5th

> 95th

Growth Chart memiliki 7 kurva dengan pola yang sama. Tiap kurva tersebut
mewakili persentil yang

berbeda : 5th, 10th, 25th, 50th, 75th, 90th, dan 95th (Clinical Growth Charts,
2001). Persentil 50th
menunjukkan rata-rata nilai pada umur tersebut. Selain itu ada juga grafik
dengan tambahan persentil
10th, 25th, 50th, 75th, 90th, dan 97th. Besar atau rendahnya persentil tidak
berarti menunjukkan adanya
masalah. Seorang bayi dengan lingkar kepala di persentil 90th dapat memiliki
berat badan & tinggi
badan di persentil 90th. Ini artinya dia termasuk anak normal yang
berperawakan besar. Bisa jadi ia
anak dari seorang atlet. Sebaliknya, anak yang memiliki berat badan di
persentil 20th bisa jadi memiliki
orang tua yang tinggi & beratnya juga di bawah rata-rata. Jadi sangat normal
jika sang anak berada
pada persentil 20th. Namun demikian, ada juga pola grafik yang naik tajam
atau turun drastis atau
grafik berada pada kurva paling ekstrim (di luar dari semua kurva) (Height
And Growth Charts, 2011).

Sebagai contoh, seorang anak memiliki berat badan (BB) di bawah persentil
5th, maka ia dimasukkan
dalam kategori underweight (BB kurang). Sedangkan anak dg BB di persentil
85th akan dimasukkan
dalam kategori overweight (beresiko obesitas) dan mereka yang memiliki BB
di persentil di atas 95th
digolongkan dalam obesitas.Terkadang ada juga grafik dengan kurva melebihi
persentil 95th atau
saling silang antar kurva persentil. Misalkan, awalnya ia berada di kurva
persentil 40th kemudian
langsung loncat ke persentil 75th. Artinya tanpa melewati persentil 50th dan
75th. Jika hal ini terjadi,
maka perlu diperhatikan penyebab terjadinya kondisi tersebut. Di lain pihak,
dapat juga terjadi

pengukuran atau pola grafik jatuh di bawah persentil 5th atau saling silang
antar kurva persentil.
Misalkan, turun drastis dari persentil 50th ke 20th. Jika hal itu terjadi, maka
harus dievaluasi
kemungkinan adanya gangguan kesehatan yang mempengaruhi
pertumbuhan sang anak. Ketika grafik
pertumbuhan dibaca dan dianalisa berulang kali, maka grafik tersebut akan
mengungkapkan suatu pola
pertumbuhan. Pola tersebut akan memberitahukan kita bagaimana
pertumbuhan anak kita dibandingkan
dengan anak-anak sebayanya. Selain itu, pola tersebut juga menunjukkan
kepada kita bagaimana
progress sang anak dari pengukuran sebelumnya. Grafik pertumbuhan akan
sangat bermanfaat jika
dilihat sebagai pola pertumbuhan anak dibandingkan dengan melihat angka
per angka (Height And
Growth Charts, 2011)

Faktor Yang Mempengaruhi Pertumbuhan


A. Faktor Dalam (Internal)
Faktor internal yang mempengaruhi tumbuh kembang anak adalah genetik. Faktor genetik
akan mempengaruhi kecepatan pertumbuhan dan kematangan tulang, alat seksual, serta saraf,
sehingga merupakan modal dasar dalam mencapai hasil akhir proses tumbuh kembang, yaitu
perbedaan ras, etnis, atau bangsa, keluarga, umur, jenis kelamin, dan kelainan kromosom.
B. Faktor Eksternal
Faktor lingkungan yang dapat berpengaruh dikelompokkan menjadi, yaitu :
1. Faktor Prenatal (selama kehamilan), meliputi :
a)

Gizi, nutrisi ibu hamil akan mempengaruhi pertumbuhan janin, terutama selama
trisemester terakhir akhir kehamilan.

b)

Mekanis, posisi janin abnormal dalam kandungan dapat menyebabkan kelainan


kongenital.

c)

Toksin, zat kimia, radiasi

d)

Kelainan endokrin

e)

Infeksi TORCH atau penyakit menular seksual

f)

Kelainan imunologi

g)

Psikologi ibu

2. Faktor Kelahiran
Riwayat kelahiran dengan vakum ekstraksi atau forceps dapat menyebabkan trauma
kepala pada bayi sehingga beresiko terjadinya kerusakan jaringan otak.
3. Faktor Pascanatal
Seperti halnya pada masa prenatal, faktor yang berpengaruh terhadap tumbuh kembang
anak adalah gizi, penyakit kronis/kelainan congenital, lingkungan fisik dan kimia, psikologis,
endokrin, sosio ekonomi, lingkungan pengasuhan, stimulasi dan obat-obatan.
Kurang berat tidak hanya menunjukkan konsumsi nutrisi yang tidak cukup tetapi juga
mencerminkan keadaan sakit yang baru saja dialami yang mengakibatkan berkurangnya berat
badan.

Penyusutan jaringan tubuh yang disebakan kurang pangan yang kronis ditunjukkan oleh
mengecilnya lingkar lengan atas (LLA). Dalam jangka usia anak balita LLA anak yang sehat
adalah sekitar 16 cm. anak yang berada pada usia 1-4 tahun LLAnya berada diantar 12,5 cm
13,5 cm adalah rawan terhadapp kurang gizi. Anak usia 6 bulan hingga 5 tahun dengan lingkar
lengat atas 11.5cm dan kurang adalah gizi buruk.
Hasil penelitian di Indonesia
Jumadias tahun 1964 mengumpulkan data berat dan tinggi badan anak usia 6-18 tahun
dengan menggunakan persentil. Berdasarkan penelitian tersebut didapatlan persentil ke-50
Jumadias berasa dibawah 80% persentil ke-50 NCHS. Sedangkan persentil ke-90 Jumadias
berada pada persentil pada persentil ke-50 NCHS. Husaini YK, dkk, mengumpulkan data
berat dan panjang badan bayi usia 0-12 bulan serta berat dan tinggi badan anak usia 12-60
bulan di klinik gizi Bogor periode 1970
Tabel: Penentuan status gizi menurut kriteria Waterlow, WHO 2006, dan CDC 2000
Status Gizi

BB/TB
median)

Obesitas

>120

(% BB/TB WHO 2006

> +3

IMT CDC 2000

> P95

Overweight

>110

> +2 hingga +3 P85-P95


SD

Normal

>90

+2 SD hingga -2
SD

Gizi Kurang

70-90

<-2 SD hingga -3
SD

Gizi Buruk

<70

<-3 SD

Status gizi lebih (overweight)/obesitas ditentukan berdasarkan indeks massa tubuh


(IMT)
Bila pada hasil pengukuran didapatkan, terdapat potensi gizi lebih (>+1 SD ) atau
BB/TB>110%, maka grafik IMT sesuai usia dan jenis kelamin digunakan untuk menentukan
adanya obesitas. Untuk anak <2 tahun, menggunakan grafik IMT WHO 2006 dengan kriteria
overweight Z score > + 2, obesitas > +3, sedangkan untuk anak usia 2-18 tahun menggunakan
grafik IMT CDC 2000 (lihat algoritma). Ambang batas yang digunakan untuk overweight ialah
diatas P85 hingga P95 sedangkan untuk obesitas ialah lebih dari P95 grafik CDC 2000.

Pemeriksaan laboratorium dan analisis diet dilakukan sesuai indikasi klinis. Diagnosis klinis
merupakan salah satu pertimbangan dalam memformulasikan rencana pemberian nutrisi.
Dalam keadaan tertentu dimana berat badan dan panjang/tinggi badan tidak dapat dinilai
secara akurat, misalnya terdapat organo-megali, edema anasarka, spondilitis atau kelainan tulang,
dan sindrom tertentu maka status gizi ditentukan dengan menggunakan parameter lain misalnya
lingkar lengan atas, knee height, arm span dan lain lain akan dijelaskan dalam rekomendasi
tersendiri.
Tabel 3. Dasar pemilihan penggunaan grafik IMT sesuai usia.
Usia

Grafik
dipakai

IMT

yang Alasan

0-2 tahun

WHO 2006

Grafik IMT (CDC 2000)


tidak
tersedia
unutk
klasifikasi usisa dibawah
2 tahun

>2 -18 tahun

CDC 2000

Dengan

menggunakan

grafik IMT CDC 2000


persentil 95, deteksi dini
obesitas
dapat
ditegakkan

Growth data of children with specific conditions have been compiled into
charts. These data are typically cross-sectional, and the charts are based on
small groups of children.

These charts are useful for comparing individual children to other children
with similar diagnoses, but should not be used alone. Rather, data should be
plotted on CDC charts, then on specialty charts. Weight for length (or Body
Mass Index - BMI) is not available on many of these specialty charts and must
be plotted on CDC charts.

It is important to remember that the children used to compile these charts


may not have been adequately nourished. Thus, weights may be higher or
lower than what is ideal.

Growth charts for children with Down syndrome can be found in the journal
Pediatrics (81) 1988. The charts on this website were adopted from these
charts using the method shown below. If you would like to read more about
growth charts as they relate to Down syndrome, you may want to check out
Medical & Surgical Care for Children with Down Syndrome, A Guide for
Parents, Woodbine House, 1995.

Each chart shows five percentile curves. An example of how percentiles work
is as follows:
Suppose we sample 100 children with DS (all the same age) and arrange
them according to ascending height. We can find the 10th percentile by
plotting child number 10, and the 90th percentile would be the height of child

number 90. If you plot your child's data, and he or she is shown as being in
the 50th percentile, you could assume if we lined up 100 children your child's
age, that 49 would be shorter and 50 taller than he or she.

For interpretation, Dr. Len Leshin suggests:


"As long as your child is between the 5th and 95th percentiles and is
generally following the growth curves, then he/she is doing well. If you have
questions about where your child falls on this chart, or his/her growth pattern,
please consult your pediatrician."

The standards for the birth to 3 years charts are were derived from a chart
which was based on a longitudinal study of 90 children with Down Syndrome
conducted at the Developmental Evaluation Clinic at Boston Children's
Hospital. They included the following note:

Children with Down Syndrome are less likely than typical children to remain at
a given percentile level. Deviations occur most commonly between 9 and 24
months.

Down syndrome is a genetic condition in which there are three 21st


chromosomes instead of the usual two. Most people have 46 chromosomes
per cell -- originating from the 23 chromosomes in the mother's egg and 23 in
the father's sperm. Not all people with Down syndrome have the same
chromosomal arrangement, however.
Ninety-five percent of people with Down syndrome (trisomy 21) have 47
chromosomes per cell (they have an extra #21 chromosome). This common
type of trisomy 21 is called non-disjunction.

Three to four percent of people with Down syndrome have Robertsonian


Translocation, where the number of chromosomes is normal, but the extra
chromosome 21 material is attached with chromosome 14.

The remainder have a rare type of Down syndrome in which some of their
cells have 46 chromosomes and some have 47 chromosomes. This is called
mosaicism.

If you would like an in-depth description of the history and genetics of Down
syndrome, see Dr. Len Leshin's essay from his excellent internet resource on
Down syndrome, www.ds-health.com.

Although children with Down syndrome do not have the same genetic
makeup as other children, they are more like typical children than they are
different.

Head Circumference Charts for Children with Down Syndrome

Charts should fit on one page if left an right margins are set to 0.5 inches.
Click on File and then Page Setup (usually) to change margins.
You may be wondering (as I did) why we only have charts for children from
birth to three years of age. I asked Dr. Len Leshin about this and he said,
"Pediatricians stop measuring head circumferences of all children at about
three years of age. That's because if there's a problem with microcephaly or
hydrocephalus, we'll find it by then."

Each head circumference chart shows three curves labelled +2 Std Dev, 50th
Percentile, and -2 Std Dev.
The 50th Percentile curve represents the average head circumference growth
for children with Down syndrome. 95% of children with Down syndrome will
fall between the lower curve (-2 Std. Dev.) and the upper curve (+2 Std.
Dev.).
Interpretation: If your child's head circumference falls between the lower and
upper curves and follows along the path of the curves on the chart, that is an
indication of normal head growth. If you have questions or concerns about
your child's head circumference, you should consult your child's pediatrician.

Reference: Palmer, et al. (1992). Head circumference of children with Down


syndrome (0-36 months). American Journal of Medical Genetics, 42, 61-67.