WIC 121 Short Stature or At Risk of Short Stature (Infants and Children)

Short Stature and at risk of Short Stature are defined as follows:

*Based on 2006 World Health Organization international growth standards (3). CDC labels the 2.3rd percentile as the 2nd percentile on the Birth to 24 months gender specific growth charts. For more information about the percentile cut-off, please see Clarification.

Notes:

The Birth to 24 months and the 2000 CDC growth charts are available at www.cdc.gov/growthcharts.

For premature infants and children (with a history of prematurity) up to 2 years of age, assignment of this risk criterion will be based on adjusted gestational age. For information about adjusting for gestational age see: Guidelines for Growth Charts and Gestational Age Adjustment for Low Birth Weight and Very Low Birth Weight Infants.

The CDC uses the 2.3rd percentile weight-for-length (for birth to 24 months of age) and the 5th percentile BMI-for-age (for 2-5 years of age), as the cut-offs to define underweight in its Pediatric Nutrition Surveillance System (1, 2). However, CDC does not have a position regarding the cut-off percentile, which should be used to determine at risk of underweight as a nutrition risk in the WIC Program. At risk of short stature is included in this criterion to reflect the preventive emphasis of the WIC Program.

Abnormally short stature in infants and children is widely recognized as a response to an inadequate nutrient supply at the cellular level (4). This indicator can help identify children whose growth is stunted due to prolonged undernutrition or repeated illness (3). Short stature is related to a lack of total dietary energy and to poor dietary quality that provides inadequate protein, particularly animal protein, and inadequate amounts of micronutrients such as zinc, vitamin A, iron, copper, iodine, calcium, and phosphorus (4). In these circumstances, maintenance of basic metabolic functions takes precedence, and thus resources are diverted from linear growth.

Demonstrable differences in stature exist among children of different ethnic and racial groups. However, racial and ethnic differences are relatively minor compared with environmental factors (1). Growth patterns of children of racial groups whose short stature has traditionally been attributed to genetics have been observed to increase in rate and in final height under conditions of improved nutrition (5, 6).

Short stature may also result from disease conditions such as endocrine disturbances, inborn errors of metabolism, intrinsic bone diseases, chromosomal defects, fetal alcohol syndrome, and chronic systemic diseases (4).

Participation in WIC has been associated with improved growth in both weight and height in children (7). An infant or child determined to be underweight at WIC certification should be monitored at regular intervals during the certification period, as appropriate. Through client-centered counseling, WIC staff can assist families in making nutritionally balanced food choices to promote adequate weight gain. Also, the foods provided by the WIC Program are scientifically-based and intended to address the supplemental nutritional needs of the Program’s target population, and can be tailored to meet the needs of individual participants.

In addition, WIC staff can greatly assist families by providing referrals to medical providers and other services, if available, in their community. Such resources may provide the recommended medical assessments, in order to rule out or confirm medical conditions, and offer treatment when necessary and/or in cases where growth improvement is slow to respond to dietary interventions.

1. Centers for Disease Control and Prevention. Use of World Health Organization and CDC growth charts for children aged 0-59 months in the United States. MMWR 2010; 59(No. RR-9). Available at: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5909a1.htm?s_cid=rr5909a1_w. Accessed September 2010.

2. Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, et al. CDC growth charts: United States. Advance data from vital and health statistics; no. 314. Hyattsville, Maryland: National Center for Health Statistics. 2000.

3. World Health Organization. WHO child growth standards: Length/height-for-age, weight-for-age, weight for height and body mass index-for-age: Methods and development. Geneva, Switzerland: World Health Organization; 2006. Available at: http://www.who.int/childgrowth/publications/technical_report_pub/en/index.html. Accessed September 2010.

4. Institute of Medicine. WIC nutrition risk criteria a scientific assessment. Washington (DC): National Academy Press; 1996. p. 104-109.

5. Pipes PL, Trahms CM. Nutrition in infancy and childhood, 6th edition. Seattle (WA): WCB/McGrawHill; 1997. p. 2.

6. Berhane R, Dietz WH. Clinical assessment of growth. In: Kessler DB, Dawson P., editors. Failure to thrive and pediatric undernutrition: A transdisciplinary approach. Baltimore (MD): Paul H. Brooks Publishing Company, Inc.; 1999. p. 199.

7. Disbrow DD. The costs and benefits of nutrition services: a literature review. J Am Diet Assoc. 1989; 89:S3-66.

The cut-off for underweight for infants and children < 24 months is 2.3; however, for ease of use, CDC labels it as the 2nd percentile on the hard copy Birth to 24 months growth charts. Electronic charts should use the 2.3rd percentile as the cut-off.