What is the classification and management for a child with a measurement between -1 Standard Deviation (SD) and -2 SD on the World Health Organization (WHO) Child Growth Standards charts, potentially at risk for malnutrition?

Classification and Management of Children with Growth Measurements Between -1SD and -2SD

Primary Classification

A child with measurements between -1 Standard Deviation (SD) and -2 SD on WHO Child Growth Standards charts falls within the normal range and should NOT be classified as malnourished or at risk for malnutrition. 1

• Approximately 95% of healthy children fall within the -2SD to +2SD range on WHO Child Growth Standards charts, indicating normal variation 1
• The range between -1SD and -2SD represents the lower end of normal variation, not a pathological state 1
• The World Health Organization defines malnutrition as measurements MORE than 2SD below the median (below -2SD), not between -1SD and -2SD 1

Understanding the Threshold for Malnutrition

The WHO has established clear definitions that distinguish normal variation from true malnutrition:

• Stunting is defined as height-for-age more than 2SD below the WHO median 1
• Wasting is defined as weight-for-height more than 2SD below the WHO median 1
• Underweight is defined as weight-for-age more than 2SD below the WHO median 1
• Values of 2 standard deviations below the median (2.3rd percentile, labeled as 2nd percentile on growth charts) are the recommended threshold for identifying children whose growth might indicate adverse health conditions 2

Clinical Management Approach

For Children Between -1SD and -2SD:

Routine monitoring with serial measurements is the appropriate management strategy, not intervention for malnutrition. 1, 2

• Serial measurements are more important than single values for assessing growth trajectory 1
• Plot measurements on appropriate growth charts: WHO charts for children under 24 months, CDC charts for children 24 months and older 2, 3
• Monitor growth velocity every 3-6 months to ensure the child maintains a parallel trajectory along their percentile curve 2

Key Assessment Factors:

• Consider parental heights when interpreting growth patterns, as genetic factors influence normal variation 1, 2
• Evaluate family growth patterns to assess whether low-normal measurements reflect genetic potential 2
• Growth patterns over time using multiple data points should be used in conjunction with medical and family history 2

When to Escalate Concern

Immediate evaluation is warranted only when:

• Measurements fall below -2SD (3rd percentile) on WHO charts 1, 2
• A downward trajectory crossing multiple percentile lines over time occurs, even if still above -2SD 1, 2
• The child shows a drop of 40 percentile points, representing clinically significant growth faltering 2

Evaluation Triggers:

If the child's growth trajectory changes from between -1SD and -2SD to below -2SD, then comprehensive evaluation should include:

• Assessment of nutritional intake and dietary patterns 2
• Screening for chronic conditions affecting growth (celiac disease, inflammatory bowel disease) 2
• Evaluation for endocrine disorders 2
• Investigation of malabsorption syndromes 2

Common Pitfalls to Avoid

• Do not label children between -1SD and -2SD as "at risk for malnutrition" - this creates unnecessary anxiety and may lead to inappropriate interventions 1
• Do not intervene with nutritional supplementation based solely on a single measurement in this range 1, 2
• Do not overlook the importance of growth velocity - a child consistently tracking along the -1.5SD line is growing normally, while a child crossing downward from 0SD to -1.5SD requires evaluation 1, 2
• Avoid using BMI alone in complex pediatric patients, as lean mass is a better predictor of adverse outcomes 4

Practical Algorithm

1. Plot the measurement on the appropriate WHO or CDC growth chart based on age 2, 3
2. Determine if measurement is between -1SD and -2SD: If yes, classify as normal variation 1
3. Review previous measurements to assess growth trajectory 1, 2
4. If trajectory is parallel to growth curve: Continue routine monitoring every 3-6 months 2
5. If trajectory is crossing downward: Evaluate for underlying causes even if still above -2SD 1, 2
6. Consider parental heights and family growth patterns 1, 2
7. Only intervene if measurements fall below -2SD or show concerning downward trajectory 1, 2