The development of growth references and growth charts

Abstract

Context: De Montbeillard produced the first growth chart in the late 18(th) century. Since then, growth assessment has developed to become an essential component of child health practice.

Objective: To provide a brief history of (i) anthropometry, i.e. growth measurements; (ii) growth references, the statistical summary of anthropometry and (iii) growth charts, the visual representation of growth references for clinical use.

Methods: The major contributors in the three categories over the past 200 years were identified and their historical contributions put in context with more recent developments.

Results: Anthropometry was originally collected for administrative or public health purposes, its medical role emerging at the end of the 19(th) century. Growth reference data were collected in earnest from the 19(th) century, during which time the familiar statistical summary statistics-mean, SD, centiles-were developed. More advanced statistical methods emerged much later. Growth charts first appeared in the late 19(th) century and Tanner and Whitehouse later popularized the concepts of velocity and conditional references for growth in puberty. An important recent reference is the WHO growth standard, which documents optimal growth and has been adopted by many countries including the UK. Arising from it, the UK-WHO charts have pioneered many design features to improve usability and accuracy.

Conclusion: Growth charts have developed considerably in 200 years and they represent an impressive synthesis of anthropometry, statistical summary and chart design.

Figure 1. UK-WHO chart for weight in girls aged 0-1 years illustrating centiles and centile crossing.

Figure 2. Distance plot and velocity plot of height in Count de Montbeillard’s son (Tanner, 1962).

Figure 3. A card containing Francis Galton’s measurements as obtained from his Anthropometric Laboratory at the South Kensington Museum (Johnson et al, 1985).

Figure 4. Galton’s ogive, or cumulative distribution function, showing the median, lower and upper quartile (Galton, 1875).

Figure 5. Two growth chart designs proposed by Henry Bowditch, the first (left) based on Galton’s ogive (Figure 4), height plotted against centile by age group, and the second (right) an inverse ogive of age plotted against centile by height group (Bowditch, 1891).

Figure 6. Bowditch’s third growth chart design, height plotted against age by centile, the forerunner of most modern growth charts (Bowditch, 1891).

Figure 7. Combined height distance and velocity chart for girls (Bayer and Bayley, 1959).

Figure 8. The effect of pubertal growth tempo on mean height velocity: left, with no tempo adjustment, and right, adjusted to age at peak height velocity (Tanner et al, 1966).

The mean velocity curve in each case is the dashed line.

Figure 9. The effect of growth tempo on the height distance curve: left, two growth curves are steeper in puberty than the cross-sectional centiles, and right, similarly for the average longitudinal growth curve (Tanner et al, 1966).

Figure 10. Dual cross-sectional and longitudinal growth charts for height distance and velocity, illustrated with a child growing normally (Tanner et al, 1966).

Figure 11. The use of thrive lines to assess weight velocity in infancy: left, the British 1990 boys weight chart with a baby showing growth faltering, and right, the thrive lines show that their weight velocity is well below the 5^th centile.

See text for details.