Off the Charts: Why pediatricians are abandoning percentiles. By Jeanne Sager for Babble.com.
Why pediatricians are abandoning percentiles.
With just three words, Christine Coan’s pediatrician reduced the Philadelphia-area mom to tears. The doctor explained that in just the 7th percentile for weight, 12th for height, Alex – who breastfed until he was eight months old – was too small.
“I was devastated. I was embarrassed,” Coan said. “I got this pit in my stomach like I was a failure.”
Coan isn’t crying any more. These days, the topic of her son Alex’s height and weight leaves her spitting mad.
Yes, Alex was, in her words, a “shrimp,” just like she herself was growing up (Coan today is just 5’2″). But his low weight was due in part to the fact that Alex had just begun walking, his body quickly burning through the Gerber Graduates he wolfed down at each meal.
And he was simply growing at his own rate. Now almost four, Alex is neither the shortest nor the tallest kid in his class. Healthcare practitioners have since confirmed what Coan suspected: her doctor’s interpretation of the percentile charts was dead wrong.
Sour experiences like this have led to a trend in the pediatric community away from quoting percentiles to parents. It’s not that percentiles themselves are bad, just that improper reading can be unduly upsetting and that the charts used in the U.S. have certain limitations, especially for breastfed babies like Alex Coan.
According to the World Health Organization (WHO), the fatal flaw of the percentiles used by most U.S. pediatricians to chart growth is this: they compare children to other American children, and other American children are, well, big. Thanks to the U.S. obesity crisis, many of them are in fact way too big. And that leads some parents of smallish children to look at the charts and believe their kids are undernourished.
Instead of looking to the percentiles, we should consider a new kind of chart, says the WHO. By their metrics, we would judge children’s progress in comparison not to each other, but to a fixed ideal. Advocates of the WHO model say that data developed in a study of children given the very best care and raised in the very best circumstances provides a standard less arbitrary than a percentile based on the growth of random children who may or may not be healthy.
But here in the United States, plenty of pediatricians still use the old percentiles, and the U.S. government approves. Introduced in the late 1970s by the National Center for Health Statistics (NCHS), the weight and height charts now fall under the umbrella of the Centers for Disease Control (CDC), which put out an update in 2000. The CDC says these new, detailed charts are optimal for tracking growth and preventing childhood obesity.
But health organizations worldwide have accused the CDC of failing to keep pace with the WHO, which put out its own revamped charts in 2006. The WHO study, which began in the late ’90s and ran through 2003, looked at more than 8,000 children spread across the world, including kids in the United States, Brazil, Ghana, India and Norway. Researchers limited their study to families who fit “specific behaviors that are consistent with current health promotion recommendations (e.g., breastfeeding norms, standard pediatric care and non-smoking requirements).”
A CDC employee, who preferred not to be named, said the WHO standards will likely not be adopted in the U.S. because they’re based on countries where breastfeeding is the norm. Even though the CDC encourages breastfeeding, there has been no effort to use breastfed babies for its charts. Instead, for its latest update, the CDC used data from “five nationally-representative studies” conducted between 1963 and 1994.
Researchers used no controls to maximize the numbers of breastfed babies included in the study, reports a study published in the American Society of Nutrition in January 2007. In fact, a large portion of the data was taken from the Pediatric Nutrition Surveillance System, a project started in 1972 to track children in low-income households using publicly funded health and nutrition programs – a far cry from the WHO study’s standards.
So, why would that matter? Well, because breastfed babies often have a different growth curve than formula-fed babies. A healthy breastfed baby can begin to thin out by six to nine months and become quite lean by nine to twelve months. By the CDC standard, such children sometimes appear underweight.
Posing just this issue to the CDC in the September 2002 issue of Pediatrics, the Official Journal of the American Academy of Pediatrics, Dr. Mary Bender of Norwich, Vt. said:
“Unless practitioners use anticipatory guidance to warn parents about this predictable phenomena (and until the World Health Organization charts are available), they will spend the six-month visit, rather than congratulating parents on having exclusively nursed their infants, trying to reassure away their apparent growth faltering (or worse – beginning a failure to thrive investigation and supplementing with formula).”
Reached recently by phone, Bender said she continues to lack faith in the CDC guidelines: “These growth charts do not reflect how babies grow,” she said frankly.
Michele Crasa saw her son Nicholas shoot to the top of the height charts around his first birthday. “These growth charts do not reflect how babies grow.” He was at the 90th percentile for length while his weight was dipping. She said the words “failure to thrive” from her pediatrician threw her into a frenzy. She was pushing Nicholas to eat so hard that the toddler began to become resistant. Each time Crasa put food on the tray of his highchair, Nicholas would refuse. Each time he refused, she’d pull out one of his favorites, because she was desperate to make him eat.
When she returned to the pediatrician for his fifteen-month appointment, his weight was climbing back up the charts. But the doctor had a new criticism for Crasa. “She called me a deli mom,” Crasa said with a sigh. “She said when he doesn’t want something I shouldn’t give in and make him whatever he wants. It’s like I can’t win with her.”
And parents want to win. They want to do the very best for their kids. So they get obsessive over the charts, as if they were test grades.
“So often, parents get attached to ‘My kids is at the 10th percentile, and oh, I wish they were at the 90th,’” Bender said. Bender recalls a parent who was 5’3″ worrying because her child’s height was on the shorter end of the spectrum.
“I’d tell parents, ‘This chart has absolutely nothing to do with the health of your baby,’” she said. “The charts are just not based on the optimal way to feed babies. Considering the issues in this country with obesity in children, what are we trying to do here?”
But percentiles continue to be popular. Included in the packets sent home with most new moms is a CDC growth chart, and the Internet is brimming with “growth calculators” that require minimal information to spit out a number that’s supposed to evaluate your child’s health.
Plotting a child’s weight and height should only be a starting point for pediatricians, says nurse practitioner Nancy Eschenberg, who’s spent her career in family practice in upstate New York, including seven years in a pediatric office and two more working with kids with developmental disabilities.
“I view it as a screening tool,” Eschenberg said. “You to need to compare it to what a child’s growth trajectory is – in other words, if they’re on the 10th percentile, you want them to continue on the 10th percentile or pretty near because that’s their normal trend.”
“You have to look at genetics,” she says. “If you have a father who’s 5’11″ and a mom who’s 5’3″, you’re not going to have a kid in the 95th percentile.”
A jump or drop should be watched, Eschenberg continued, but practitioners can’t immediately raise the alarm. “There are growth spurts children will go through,” she noted. “There are times kids chub up and then they shoot up.”
If a child’s height or weight seems to be fluctuating drastically, Plotting a child’s weight and height should only be a starting point for pediatricians. Eschenberg says she might ask the parent to make another appointment sooner rather than later. She’ll talk with the parent about a child’s eating habits, try to suss out whether a child is drinking more than he eats or if a little girl is running off all of her excess energy.
Bender and Eschenberg prefer to tell parents, “Your child is developing well,” or “Your child is a little too thin; let’s talk about this.” They don’t quote percentiles.
It’s a practice being picked up by an increasing number of doctors frustrated by parents pushing for the secret to attaining the top percentiles – parents who still think higher is better. That’s why many doctors are even dropping the word “percentile” from their lingo. Finally, more pediatricians are looking past the dots charted on a government-approved graph to the baby in front of them.
Photo Credit: Melissa Drenzek
I was so excited to see an article about this issue and so incredibly disappointed! My daughter is (and, since 2 months, has been) off the charts at the heavy end. I assumed this article would also reject the claims that children should not be over 100percentile. I am a thin, 5’4″ adult and my husband is a very tall and skinny 6’2″. My daughter has been ranking over 100% her whole life and is obviously quite chunky. AND she looks exactly like my own baby pictures–in a word: fat. When I was a baby there were no percentiles to worry my mom. I was fed much as my daughter is fed: breast milk until over age 1, lots of fruits and veg, no juice, no refined sugars, etc. Yet she is (and I was) “fat.” I wish this article would have at least given a comparable example of a chubby baby. The only thing this article got right is that the last thing mothers need is another worry.
Chubby Baby: I, too, have an off-the-charts kiddo. He was exclusively breastfed for 6 months, and since then has only had a bit of fresh fruits, veggies, and grains. No formula, no rice cereal, no “puffs.” He is 14 months now and dropping and still breastfeeding on cue and eating what he wants of the foods we offer. Babies are great at self regulating, so I don’t push the issue, just let him eat until he’s done. For breastfed babies it is important to note that during the first 4 months they often weigh more than their formula-fed counterparts. After that, they tend to lean out a bit, which often looks like a percentile drop on the formula-fed/early solids charts.www.kellymom.com has the WHO growth charts, which your babe will probably fare better on.I do rather like the issues this article raises. More important than where a baby falls on the chart are issues such as output (wet/dirty diapers), activity level, motor milestones ….. it boggles my mind why pediatricians do not take these issues into account more. I can’t believe the things that come out of my pediatricians mouth in regards to nutrition and growth. Nor can I believe the mainstream ideas about infant nutrition, either. I would love to see the WHO rec.s take precedence, but agree that it will probably not happen.
I also have two little ones both off the charts on the heavy end. They are not “obese” as this article would have me believe. My family just has big babies. Yes, moms shouldn’t worry and be made to visit the peditrician unnecessarily when in your gut you know that your babies size is typical of those in your family (genetics).
Us too! Our son was 100% breast-fed (actually, it would have been nice for my wife if he took a bottle every now and then – but no such luck!
.Anyway – his weight was very in line with what’s described in this article for breast-fed children. He started OK but became VERY lean around 6-9 months. He was under 10% on the US charts.We became very concerned but fortunately I found the WHO charts and realized that he was actually totally normal from a world standard.He’s now 2 and although still quite lean he’s very normal even in US terms.I think there were two factors at play. First, the 100% breast-feeding. Second, he was and is EXTREMELY active – walking at 11 months, always moving.Although our doctor did a good job helping us interpret the charts and telling us that really the most important thing is that the infant is keeping up developmentally (milestones, etc.), she did NOT inform us of the WHO charts which are very different. If she had that would have helped even more.
Our daughter was exactly like the ones in this article – she started out big – was in the 85% for weight, but by her 9 month appt had sunk to the 10%, and has stayed there (she’s 14 months now). She was exclusively breastfed. Luckily for us, though, our peds are in the swing of things and reassured me that there was nothing amiss. And there’s not! She’s growing like a weed and eats like a horse.
Wow, I am so glad to see this! I went through a whole drama with my doc (who I previously thought was so cool) – my totally breastfed baby (refused bottles, refused food until almost a year) was very high at 5 months and had “dropped significantly” at around a year and THEY WERE VERY ALARMED and I got a serious talking-to. Percentiles were around the 90′s when she was a little baby, went to the 20-30s around 1 year. Oh, and she was 2 weeks late and 9 lbs at birth, so she started out “older” than other babies her age. So I was asked to bring her in for “weight checks” which I did once, I think. That’s a nice start to raising a girl without body issues, huh? And it was totally upsetting and I felt like I had just gotten a “D” in Feeding The Baby. I actually started feeding her ice cream and relented on avoiding sugar to get her to eat as many calories as possible and now I’m really annoyed that I folded on my own ideals for feeding my own child. Meanwhile, my mother and sisters were telling me the whole thing was ridiculous and you could just look at my daughter and see she was thriving. Lo and behold, soon after she got interested in solid food and started a growth spurt. Much ado about NOTHING!!
My ped. office now uses a growth curve software instead of percentiles. They still put them on our baby well visit documents (which are drastically out of date, they still include CIO as a method for sleep training), but the ped.s actually go by the growth curve, not the percentiles. My daughter started out a normal weight and is now below 3% according to the percentiles. Her height and head size are very low in the percentiles as well. Yet people still can guess her age correctly and she is growing, 2-3 pounds between each appointment. The growth charts by the CDC are probably crazy out of date. We can only expect now that 75% of moms breastfeed and kids are supposed to start solid foods at 6 months or even later, that children will smaller that in previous generations. Or bigger. Statistically people now are taller and weigh more then our parents. People come in all shapes and sizes and infants do too. I see exclusively breastfed babies that are giant and some that are itsy bitsy.
Thanks to those of you who posted about your large kids. I, too, assumed that this article would discuss babies off the large end of the chart. My son has been 97th percentile (height and weight) all along. I am 5’5″ and his dad is 6′, so his destiny is not the NBA, but he’s 14 months old and wearing 3T clothing. The clothing manufacturers use the same charts as the doctors, so I can’t find onesies that fit anymore.Discovery Channel had a show on a condition that makes kids huge, and I was afraid to watch it . . . I guess only 4 kids in the world had that particular problem.
Me too! My baby is on the heavy end, though proportionally big—in the 90th percentile for everything (height, weight, head circ.) It worries me because both her dad and I were chunky as kids, though we are both healthy weights now. The last thing I needed was an article like this to make me even more paranoid about it.
My baby has always been on the lower end of weight (25%) and higher in length (85%), but fortunately I have a pediatrician that seems have a good handle on perspective. He is more interested in the fact that my son is healthy and developing normally than the actual percentage. I agree with the author that the WHO model would be better, but I think there is a larger issue here which is that pediatricians need to be better educated or informed about their own charts and graphs and able to see the whole picture.
I don’t understand why a pediatrician doesn’t know enough to say, “Sometimes breastfed babies grow differently than the chart indicates,” or, better yet, “All kids grow at different rates but otherwise s/he is very healthy!” Our pediatrician watches for changes in where he sits on the curve, and even when there is a change, she says, “Sometimes kids find a new curve, we’ll watch it.” Perfect.
I live in Europe, and here I don’t hear the word percentile. 90 percent of mothers breastfeed at 3 months, and the government goal is that as many as possible should do it at 6 months, Our pediatricians looks at the baby’s curve since birth, and expects the baby to stay in that curve. If he/she moves up a curve, fine, if he/she drops a curve or two you discuss why (Been sick? Just started crawling?). Babies are different, and it seems stressful to be compared like that.
Yes! So great to hear from the parents of fatties! I dread the well-baby visits because my pediatrician is obsessed with BMIs, which, come on, for 6-month-old breastfed babies just feels hysterical to me. My girl came into the world overdue and big, and was an absolute tank until just recently (she just turned 3). She has probably gained, like, 5 pounds since she turned 1. Oh, but do you think the doc is patting anyone on the back or laying off the diabetes speeches? She’s suddenly looking to me like she’s slimming down (might be the missing bulk of a diaper). We didn’t do anything special — including NOT ending night nursing when she was a baby, as suggested by the pediatrician. We try to eat healthy, we drink mostly water, we do 1 or 2 percent milk, we’re moderately active.The thing is/was, the doc never asked any questions about what our family eats, what we do. She just launched right into worst-case scenarios about heart disease at the age of 12. I understand these are concerns, but putting a baby on a diet is just weird. Oh, and I stopped combining my baby’s appointments with my older daughter’s (lean, lean, lean)because she was hearing it all and getting super confused and worried.Great article!
Our baby girl has stuck to the 3rd percentile weight curve her entire life. She’s always been healthy and very happy but the doctors insist she needs monthly visits to track her weight. One doc, whom we no longer see, had us endure a weekend hospital stay and numerous test because she thought our baby’s “failure to thrive” was due to CF! We’re being punished because we have a small baby.Thank you so much for bringing this up. Can someone post a link to the WHO charts?
Here’s the link to the WHO charts:http://www.who.int/childgrowth/standards/en/
We had a similar experience to springdaddy’s – my daughter has consistently been at the 5th% for weight and height since babyhood. Two different doctors have worried about this and subtly suggested there were problems with feeding. Luckily, I knew that I, my brother, my father, my aunt, my grandmother etc. etc. had all been very small children who turned out to be healthy, slim, strong adults of average height. It was also obvious to me as a mom that my daughter was thriving and growing consistently, albeit behind others her age. Too often, numbers on a chart are focussed upon, and people forget the evidence before them – a healthy child with a specific genetic endowment.
All the percentile stuff can get out of hand, especially in a culture like ours, which is obsessed with success… therefore a higher percentile must be “better” than a lower one.I feel very lucky to have a family doctor who told me (a typical nervous new parent) very early after my first child was born: “I don’t look at charts, I look at the baby. If the baby looks healthy, then the baby is healthy.”
I was kind of surprised too that there was no real mention of the larger babies in this article. There was a quote toward the end about how we should look more at the trajectory of the curve, but that’s it.Like some others on here, I have an almost 2 year old who has consistently been above the 97th percentile since the day he was born (10lbs 2oz!). He was exclusively breastfed for the first 6 months and still nurses a few times a day. He’s not the best veggie eater, but he eats pretty well. I haven’t worried about him because the doctors have pointed out at every visit that he is staying on his own curve. It IS too bad that not everyone has doctors like mine! They actually DID warn me that he could thin out between 6 and 9 months. When he just kept getting chubby, they didn’t worry. Now he looks totally proportionate, just BIG. BTW, my hubby and I are just average sized people, but we were both big babies.
This article describes my baby perfectly. Recently her pediatrician noted his concern that she was only in the third percentile for her weight. He didn’t use the words “failure to thrive,” and said that she seemed healthy enough developmentally, but it still worried me. My mother and husband thought I should start giving her formula but I was hesitant. After reading this I know my very active, breastfed 9 month old will be fine the way she is. Thanks to the writer of this article for making me feel better about the way I feed my daughter.
I am a pediatrician, and in my opinion there has never been any teaching in my profession to try and keep kids in the higher growth percentiles. Percentiles have always been used, and are intended to be used, to track children’s growth trajectories only. 98% of the children in my practice are breast fed, and I know that some exclusively breast fed babies are amazingly chubby, and some are skinny — as long as children continue to grow there is no concern. This is not my personal view, but the accepted view of my profession, and therefore the idea that pediatricians are”abandoning the percentiles” seems inaccurate to me. What you are describing is either a misinterpretation of percentile ranking by parents, or a minority amongst pediatricians who either do not understand how to map growth or are uncomfortable with exclusive breast feeding.
I liked this article because I worry about my son being in the lower percentile on the growth chart. I should mention that he was born at 23wks 5 days gestation so he’s a little behind for his actual age (he was 465g, less than a pint of ice cream!). His doctor has been great! She points out that he is at the lower end of the chart but he is healthy so she’s not really worried (he finally passed the 20lbs mark at 20 months). The doctors at the hospital (where he spent 4.5 months after birth) warned us that he might gain slower, one even warned us not to try stuffing to get him to gain more!
Unfortunately, I still worry about him being smaller than other children. He eats well (except when teething), but is very active. The only people who seem concerned with his weight are the people at WIC. They are very tied to charts! One of the people at the first office we went to asked us if we believed in “adjusted ages” (that is going by the due date age rather than the actual age on premature babies).
More education all around!
I really appreciated my son’s doctor not freaking me out about my son being in the lower percentiles (since birth). At his 12 month checkup he just suggested that I start to breastfeed a bit less and offer food a bit more, which is totally acceptable. The only pressure I have had is from my concerned MIL who had chubby babies. I have had to explain to everyone that my son is a skinny kid just like I was!
It doesn’t matter what percentile your kid is on as long as they are growing. I have a friend who has a whole family is overweight both her kids ( one now 5) have been labeled as failure to thrive because they are tiny and she spends her days cramming them full of anything to fatten them up. I can’t imagine this is setting them up for healthy eating later in life neither dropped off the charts they are just small.