Ahmad Umar N, Yiwombe Mwawi, Chisepo Patrick, Cole Tim J, Heikens Geert T, Kerac Marko
UCL Institute for Global Health, University College London, London, United Kingdom.
J Paediatr Child Health. 2014 Jan;50(1):32-9. doi: 10.1111/jpc.12405. Epub 2013 Oct 18.
The study aims to assess the effects of switching from National Center for Health Statistics (NCHS) growth references to World Health Organization (WHO) growth standards on health-care workers' decisions about malnutrition in infants aged <6 months.
We conducted a single blind randomised crossover trial involving 78 health-care workers (doctors, clinical officers, health service assistants) in Southern Malawi. Participants were offered hypothetical clinical scenarios with the same infant plotted on NCHS-based weight-for-age charts and again on WHO-based charts. Additional scenarios compared growth charts with a single final weight against charts with the same final weight plus a preceding growth trend. Reported (i) level of concern, (ii) referral suggestions and (iii) feeding advice were elicited with a questionnaire.
Even after adjusting for health-care worker type and experience, using WHO rather than NCHS charts increased: (i) concern: aOR 4.4 (95% CI 2.4-8.1); (ii) odds of referral: aOR 5.1 (95% CI 2.4-10.8); and (iii) odds of feeding advice which would interrupt exclusive breastfeeding (aOR 2.4, 95% CI 1.2-4.9). A preceding steady growth trend line did not affect concern, referral or feeding advice.
Health-care workers take insufficient account of linear growth trend, clinical and feeding status when interpreting a low weight-for-age plot. Because more infants <6 months fall below low centile lines on WHO growth charts, their use may increase inappropriate referrals and risks undermining already low rates of exclusive breastfeeding. To avoid their being misinterpreted in this way, WHO charts need accompanying guidelines and training materials that recognise and address this possible adverse effect.
本研究旨在评估从美国国家卫生统计中心（NCHS）生长参考标准转换为世界卫生组织（WHO）生长标准对医护人员关于6月龄以下婴儿营养不良决策的影响。
我们在马拉维南部开展了一项单盲随机交叉试验，纳入78名医护人员（医生、临床干事、卫生服务助理）。为参与者提供假设的临床情景，情景中的同一名婴儿分别绘制在基于NCHS的年龄别体重图表上和基于WHO的图表上。另外的情景将单一最终体重的生长图表与具有相同最终体重加上先前生长趋势的图表进行比较。通过问卷调查获取（i）关注程度、（ii）转诊建议和（iii）喂养建议。
即使在对医护人员类型和经验进行校正后，使用WHO图表而非NCHS图表仍会增加：（i）关注程度：调整后比值比（aOR）为4.4（95%置信区间[CI] 2.4 - 8.1）；（ii）转诊几率：aOR为5.1（95% CI 2.4 - 10.8）；以及（iii）会中断纯母乳喂养的喂养建议几率（aOR为2.4，95% CI 1.2 - 4.9）。先前稳定的生长趋势线并不影响关注程度、转诊或喂养建议。
医护人员在解读低年龄别体重图时，对线性生长趋势、临床和喂养状况考虑不足。由于更多6月龄以下婴儿在WHO生长图表上低于低百分位线，使用这些图表可能会增加不适当的转诊，并有可能破坏本就较低的纯母乳喂养率。为避免这些图表被如此误解，WHO图表需要附带认识并解决这种可能的不利影响的指南和培训材料。
