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Annals of Saudi Medicine logoLink to Annals of Saudi Medicine
. 2016 Jul-Aug;36(4):265–268. doi: 10.5144/0256-4947.2016.265

Growth reference for Saudi school-age children and adolescents: LMS parameters and percentiles

Mohammad El Mouzan a,✉, Abdullah Al Salloum a, Ahmad Al Omer a, Mansour Alqurashi a, Abdullah Al Herbish b
PMCID: PMC6074406  PMID: 27478912

Abstract

BACKGROUND

Information on LMS parameters and percentiles reference for Saudi children and adolescents is not available.

OBJECTIVE

To report the L, M, and S parameters and percentile reference graphs for growth.

DESIGN

Field survey of a population-based sample of Saudi school-age children and adolescents (5–18 years of age).

SETTING

A stratified listing of the Saudi population.

SUBJECTS AND METHODS

Data from the national study of healthy children were reanalyzed using the Lamba-Mu-Sigma (LMS) methodology. The LMS parameters of percentiles for weight, height, and body mass index for age were calculated for children and adolescents from 5 to 18 years of age.

MAIN OUTCOME MEASURE

The main outcomes were the LMS parameters and percentiles of growth.

RESULTS

There were 19 299 and 9827 (50.9%) were boys. The data for weight, height, and BMI for age for boys and girls are reported for the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles including LMS parameters for each percentile and age. Figures corresponding to each table are color coded (blue for boys and pink for girls).

CONCLUSIONS

This report provides a reference for growth and nutrition of Saudi school-age children and adolescents. The detailed LMS and percentile tables and graphs provide essential information for clinical assessment of nutritional status and growth in various clinical conditions and for research.

LIMITATIONS

This report does not reflect regional variations in growth.

Growth charts have long been used worldwide to assess nutritional status. However, regular revisions were performed to account for secular changes in growth and to take advantage of modern statistical techniques.1 The American growth charts, including the previous 1978 National Center for Health Statistics (NCHS) and the current revised National Center for Disease Control reference growth charts (CDC 2000), which reflect the growth of children of the United States, are commonly used.2,3 However, in an attempt to provide growth charts more applicable to populations other than the United States, the World Health Organization (WHO) created the WHO Growth Reference Charts for School-age Children and Adolescents in 2007.4 Despite the common use of the CDC 2000 and WHO growth reference charts in some countries, others developed local growth reference more suitable to their population.5–8

In Saudi Arabia, growth charts from a representative sample of children have been published in the form of charts only.9 Therefore, the objective of this article is to report detailed percentile values of commonly used growth parameters, including LMS values, in children and adolescents from 5 to 18 years of age.

SUBJECTS AND METHODS

The methodology has been reported in a previous study.9 In brief, multistage probability sampling was used to select a representative sample from each region of the country. Only healthy children were included. Weight is expressed in kilograms (kg) and length/height in centimeter (cm). As in previous analysis, the age was converted in Gregorian to facilitate comparison with growth charts of other populations.

Statistical methods

The L, M, and S method was used to synthesize the distribution of growth parameters as a function of age. The LMS parameters are the median (M), the generalized coefficient of variation (S), and the power in the Box-Cox transformation (L). The method models the entire distribution taking into account degree of skewness (L), central tendency (M), and dispersion (S). The parameters L, M and S were calculated according to the method of maximum penalized likelihood.10 Percentiles for all the anthropometric measures were calculated using the following formula.11

P=M [1+LSZ] 1/L, L≠0

Where the L, M, and S are the values from the appropriate table corresponding to the age in years of the child. Z is the z-score that corresponds to the percentile.

For this study, we have calculated the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th and the 97th percentiles for weight, height, and added the 85th percentile for body mass index, commonly used to define overweight. The LMS Chart Maker Light 2.1 (Medical Research Council, London, UK) was used to process the data and Q-test was used to assess the goodness of fit of all L, M, and S models.12

This analysis is based on data from health profile of Saudi children and adolescents study funded and approved by King Abdul Aziz City for Science and Technology, Riyadh, Saudi Arabia.

RESULTS

The sample size consisted of 19 299 Saudi children and adolescents from 5 to 18 year of age. All were Saudi nationals and 9 827 (50.9 %) were boys. For boys, the L, M, and S parameters and percentiles for weight for age, height for age, and BMI for age are presented in the

Tables 1 to 3, respectively, and the Figures 1 to 3 represent plots corresponding to the tables. Similarly, Tables 4 to 6 show L, M, and S parameters and percentiles for girls, including weight for age, height for age, and BMI for age. Figures 4 to 6 are plots of the data in Tables 4 to 6.

Table 1.

L, M, and S parameters and percentiles for weight for age: boys 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 90th 95th 97th
5 −1.046774 16.65079 0.1550993 12.90855 13.28112 13.89993 15.07723 16.65079 18.60172 20.80742 22.40426 23.58309
6 −1.032594 18.64088 0.1685233 14.17041 14.60824 15.33896 16.74133 18.64088 21.03668 23.80084 25.83963 27.36547
7 −1.015487 20.66037 0.1819188 15.40283 15.90975 16.75961 18.4042 20.66037 23.55329 26.95761 29.51515 31.45556
8 −0.991157 23.2016 0.1951612 16.96528 17.558 18.55585 20.5014 23.2016 26.71622 30.92749 34.14503 36.61717
9 −0.9524795 26.06358 0.2080576 18.68911 19.38161 20.55156 22.84711 26.06358 30.30098 35.4506 39.43634 42.52811
10 −0.8979311 29.04166 0.2201021 20.42467 21.22672 22.58539 25.26373 29.04166 34.05786 40.20527 44.99669 48.73124
11 −0.8295125 32.4206 0.2305578 22.38467 23.31419 24.89148 28.00907 32.4206 38.29382 45.50162 51.1186 55.49237
12 −0.7531365 36.42373 0.2388563 24.73617 25.81763 27.65393 31.28576 36.42373 43.24885 51.58274 58.03479 63.02903
13 −0.678714 40.85276 0.2446715 27.37162 28.62171 30.74394 34.93716 40.85276 48.66688 58.12203 65.36768 70.92835
14 −0.6195751 45.73953 0.2479675 30.36456 31.79524 34.22245 39.01013 45.73953 54.57247 65.16076 73.1944 79.31055
15 −0.5869272 50.75983 0.2490815 33.55655 35.16184 37.88363 43.24485 50.75983 60.58089 72.28175 81.10396 87.78738
16 −0.5862568 55.13887 0.2485967 36.47562 38.21821 41.17227 46.98918 55.13887 65.78262 78.45399 88.00129 95.23035
17 −0.6082383 58.58773 0.2471192 38.90816 40.74362 43.85572 49.98706 58.58773 69.84454 83.28848 93.45201 101.1684
18 −0.6401284 61.25766 0.2451296 40.89868 42.79431 46.00937 52.34879 61.25766 72.95528 86.9922 97.65765 105.788
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Table 2.

L, M, and S parameters and percentiles for height for age: boys 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 90th 95th 97th
5 1.484274 107.9784 5.40E-02 96.72755 98.17271 100.3781 104.0118 107.9784 111.8757 115.3279 117.3701 118.6872
6 1.139618 113.6109 5.22E-02 102.3724 103.7914 105.971 109.5992 113.6109 117.6028 121.1796 123.3131 124.6959
7 0.9419675 119.1193 5.06E-02 107.8147 109.2292 111.4093 115.0578 119.1193 123.1889 126.8584 129.0574 130.4867
8 0.9449131 124.4657 4.94E-02 112.9265 114.3706 116.5963 120.3204 124.4657 128.6186 132.3627 134.6062 136.0643
9 0.9488391 129.4396 4.91E-02 117.5055 118.9993 121.3014 125.1531 129.4396 133.7335 137.6041 139.9232 141.4304
10 0.6246465 133.9074 4.98E-02 121.5972 123.117 125.4709 129.4415 133.9074 138.4299 142.5483 145.0346 146.6579
11 9.42E-02 138.638 5.08E-02 125.9425 127.4751 129.8681 133.9576 138.638 143.4659 147.9409 150.6791 152.4818
12 −7.27E-02 144.0198 5.19E-02 130.6711 132.2703 134.774 139.0717 144.0198 149.1572 153.9494 156.8961 158.8421
13 0.2517995 149.6053 5.24E-02 135.4007 137.1248 139.8117 144.3891 149.6053 154.9613 159.9034 162.9168 164.8965
14 0.9325199 155.8014 5.17E-02 140.697 142.5861 145.4981 150.3728 155.8014 161.2428 166.1509 169.0929 171.0054
15 1.843215 161.4386 4.97E-02 145.703 147.7542 150.8666 155.9498 161.4386 166.7743 171.4564 174.2076 175.9748
16 2.715764 165.1562 4.69E-02 149.2968 151.4456 154.6555 159.7773 165.1562 170.2502 174.6213 177.1498 178.7593
17 3.411383 167.4663 4.42E-02 151.8744 154.0466 157.2535 162.2847 167.4663 172.2878 176.3651 178.7004 180.1785
18 3.980551 168.8105 0.0417342 153.6481 155.8031 158.9572 163.8451 168.8105 173.3751 177.1976 179.3726 180.7441
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Table 3.

L, M, and S parameters and percentiles for body mass index for age: boys 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 85th 90th 95th 97th
5 −1.1546 14.425 0.11715 11.85398 12.12153 12.56001 13.37456 14.42514 15.67127 16.44123 17.01084 17.93816 18.60128
6 −1.1749 14.535 0.12861 11.74748 12.03238 12.50179 13.38225 14.53462 15.92714 16.80206 17.45674 18.53642 19.31935
7 −1.1943 14.712 0.13997 11.70181 12.00415 12.50487 13.45289 14.71178 16.26175 17.25246 18.00262 19.25692 20.18026
8 −1.2098 15.083 0.15111 11.81397 12.13688 12.67425 13.70075 15.08292 16.81615 17.9431 18.80676 20.27145 21.36678
9 −1.2071 15.628 0.16196 12.0571 12.40471 12.98559 14.10385 15.62799 17.57034 18.85257 19.84589 21.55233 22.84696
10 −1.1782 16.265 0.17227 12.36124 12.7369 13.36675 14.5866 16.26476 18.42953 19.87483 21.00345 22.96081 24.46162
11 −1.1235 16.946 0.18163 12.69091 13.09729 13.78019 15.10806 16.94554 19.33282 20.93661 22.1942 24.38563 26.07443
12 −1.0488 17.642 0.18983 13.0272 13.46638 14.20533 15.64509 17.6423 20.2427 21.9916 23.36342 25.75361 27.59449
13 −0.9647 18.314 0.1968 13.3455 13.81801 14.61342 16.1639 18.31431 21.10948 22.98428 24.45111 26.99756 28.94971
14 −0.8892 18.98 0.20253 13.67167 14.1767 15.02697 16.68413 18.97991 21.95556 23.94398 25.49473 28.17519 30.21912
15 −0.8478 19.666 0.20714 14.04488 14.57897 15.47866 17.23341 19.66593 22.81892 24.92463 26.56565 29.39888 31.55593
16 −0.8615 20.334 0.21081 14.45751 15.01265 15.94931 17.78165 20.33412 23.66469 25.90323 27.65583 30.69856 33.02959
17 −0.9132 20.943 0.21387 14.86774 15.43648 16.39831 18.28857 20.94259 24.4459 26.82817 28.70968 32.01193 34.57371
18 −0.9786 21.486 0.21658 15.25003 15.82811 16.80817 18.74401 21.4863 25.15499 27.68465 29.704 33.29661 36.1284
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Figure 1.

Figure 1

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Weight-for-age percentiles for boys, 5 to 18 years.

Figure 2.

Figure 2

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Height-for-age percentiles for boys, 5 to 18 years.

Figure 3.

Figure 3

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Body mass index-for-age percentiles for boys, 5 to 18 year

Table 4.

L, M, and S parameters and percentiles for weight for age: girls 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 90th 95th 97th
5 −0.938951 16.42919 0.1685386 12.4482 12.84134 13.49605 14.74714 16.42919 18.52782 20.9147 22.65023 23.93477
6 −0.9157015 18.45433 0.178501 13.77099 14.2287 14.99332 16.46255 18.45433 20.96522 23.85503 25.97861 27.56234
7 −0.8899531 20.6649 0.1893735 15.16592 15.69748 16.58836 18.31021 20.6649 23.66574 27.16288 29.76165 31.71543
8 −0.8623634 23.17324 0.1999672 16.73087 17.34735 18.38368 20.39738 23.17324 26.74599 30.95694 34.11781 36.51143
9 −0.8322223 25.97128 0.2097031 18.4657 19.17783 20.37801 22.72062 25.97128 30.18894 35.205 39 41.88993
10 −0.7994724 29.38699 0.2178778 20.61651 21.44358 22.84008 25.57478 29.38699 34.35965 40.30696 44.82735 48.28041
11 −0.7663324 33.57265 0.2237808 23.31085 24.27543 25.90588 29.10424 33.57265 39.41382 46.41186 51.73588 55.8042
12 −0.7413344 38.38703 0.2270551 26.48859 27.60592 29.49531 33.20366 38.38703 45.16304 53.27594 59.44133 64.14745
13 −0.731925 43.22614 0.2279888 29.77024 31.03381 33.17061 37.36462 43.22614 50.88586 60.05038 67.00912 72.31693
14 −0.7383584 47.25764 0.2272233 32.59572 33.97274 36.30124 40.87108 47.25764 55.60431 65.59375 73.18195 78.97207
15 −0.7550535 50.08248 0.2255488 34.66291 36.11118 38.55988 43.36541 50.08248 58.86646 69.39174 77.39851 83.51566
16 −0.777939 52.04097 0.2236553 36.16599 37.65651 40.17663 45.12304 52.04097 61.09903 71.97591 80.2705 86.62072
17 −0.80327 53.22288 0.2218783 37.13643 38.64573 41.19784 46.20867 53.22288 62.42283 73.50063 81.97466 88.47912
18 −0.8281887 53.68508 0.2202955 37.59686 39.10506 41.65562 46.66542 53.68508 62.90914 74.04828 82.59687 89.17638
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Table 5.

L, M, and S parameters and percentiles for height for age: girls 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 90th 95th 97th
5 0.9887214 107.8352 5.39E-02 96.89977 98.27086 100.3825 103.912 107.8352 111.7599 115.2937 117.4091 118.7831
6 1.021588 113.0171 5.28E-02 101.7718 103.1839 105.3575 108.9872 113.0171 117.0439 120.6655 122.8318 124.2382
7 1.047814 118.522 0.051654 106.9798 108.4309 110.6634 114.3892 118.522 122.6479 126.3557 128.5722 130.0106
8 1.046376 123.8421 5.05E-02 112.0533 113.5352 115.8153 119.6207 123.8421 128.0569 131.8449 134.1094 135.5791
9 1.01275 129.1633 4.94E-02 117.1632 118.6694 120.9882 124.8615 129.1633 133.4632 137.3318 139.6463 141.1491
10 0.9565817 134.6863 4.82E-02 122.4892 124.0165 126.3698 130.3064 134.6863 139.0724 143.0252 145.393 146.9317
11 0.8806756 140.31 0.0471158 127.9437 129.4875 131.8689 135.8596 140.31 144.7774 148.8122 151.2332 152.8079
12 0.7635555 145.5699 4.60E-02 133.1145 134.6625 137.0543 141.0729 145.5699 150.0999 154.2049 156.6741 158.2826
13 0.5740123 149.8175 0.0449087 137.392 138.9255 141.3011 145.3088 149.8175 154.3848 158.5453 161.0578 162.6984
14 0.286931 152.6869 4.41E-02 140.3951 141.8969 144.2317 148.1941 152.6869 157.2761 161.4898 164.0497 165.7275
15 −0.1007422 154.3053 4.37E-02 142.1866 143.6478 145.93 149.8333 154.3053 158.9247 163.2127 165.8397 167.5707
16 −0.5813157 155.1001 4.37E-02 143.1323 144.5521 146.7822 150.632 155.1001 159.7814 164.1887 166.919 168.7308
17 −1.140942 155.5257 4.42E-02 143.6594 145.041 147.2248 151.0356 155.5257 160.3117 164.8976 167.7792 169.7091
18 −1.765896 155.8763 4.49E-02 144.071 145.417 147.5594 151.3422 155.8763 160.8071 165.6338 168.7209 170.813
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Table 6.

L, M, and S parameters and percentiles for body mass index for age: girls 5 to 18 years.

Age (y) L M S 3rd 5th 10th 25th 50th 75th 85th 90th 95th 97th
5 −1.312917 14.32989 0.1244782 11.68381 11.95329 12.39768 13.23284 14.32989 15.66306 16.50564 17.13892 18.18902 18.95529
6 −1.2939 14.48028 0.1335916 11.64918 11.93405 12.40551 13.29727 14.48028 15.93621 16.86706 17.57226 18.75246 19.62239
7 −1.27238 14.74155 0.1436224 11.68709 11.99053 12.4946 13.45457 14.74155 16.34713 17.3866 18.18098 19.52405 20.52522
8 −1.246668 15.17908 0.1536925 11.85864 12.18451 12.72778 13.76909 15.17908 16.96106 18.12861 19.02841 20.56485 21.72278
9 −1.214775 15.69607 0.1634513 12.08774 12.43806 13.02391 14.15329 15.69607 17.6683 18.97423 19.98816 21.73473 23.06392
10 −1.17507 16.35505 0.1724243 12.42587 12.80402 13.43804 14.66594 16.35505 18.53366 19.98798 21.12348 23.09243 24.60179
11 −1.129133 17.17908 0.1801299 12.89472 13.30453 13.99292 15.33042 17.17908 19.57733 21.1863 22.44677 24.64075 26.32944
12 −1.085184 18.14618 0.186309 13.48377 13.92795 14.67501 16.12963 18.14618 20.77105 22.53679 23.92236 26.33827 28.20093
13 −1.050285 19.2067 0.1910618 14.15941 14.6389 15.44607 17.02012 19.2067 22.05912 23.98107 25.49064 28.12516 30.158
14 −1.02617 20.1722 0.1946503 14.78322 15.29402 16.15452 17.83455 20.1722 23.22719 25.28849 26.90886 29.73912 31.92471
15 −1.01184 20.89756 0.1974603 15.24643 15.78093 16.68194 18.44307 20.89756 24.11151 26.28365 27.99302 30.98236 33.29374
16 −1.006032 21.50933 0.1999027 15.63638 16.1905 17.12522 18.95463 21.50933 24.86311 27.13513 28.92606 32.06425 34.49603
17 −1.002935 21.91292 0.2022514 15.87659 16.44464 17.40358 19.28292 21.91292 25.37526 27.72699 29.58424 32.84599 35.37991
18 −0.998486 22.05139 0.2046199 15.92218 16.49753 17.4695 19.37684 22.05139 25.58162 27.98535 29.88696 33.23357 35.83947
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Figure 4.

Figure 4

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Weight-for-age percentiles for girls, 5 to 18 years.

Figure 5.

Figure 5

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Height-for-age percentiles for girls, 5 to 18 years.

Figure 6.

Figure 6

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Body mass index-for-age percentiles for girls, 5 to 18 years

DISCUSSION

Worldwide variations of human growth are well known, suggesting that the use of growth references from another population is potentially risky.13 Previous studies from Saudi Arabia demonstrated marked differences in growth between Saudi children and their American counterparts.14–16 More recently reported differences between Saudi and both CDC 2000 and WHO growth charts confirm previous studies.17,18 The implication of these differences are considerable with the potential of overestimation of prevalence of short stature and malnutrition potentially resulting in unnecessary referrals and patient and parent anxiety.

The percentile system is commonly used in clinics and hospitals for the assessment of growth and nutrition in clinical setting.19 The percentile ranks of individuals define the nutritional and growth status in comparison with peers of the same age and gender. Children and adolescents are growing subjects and regular evaluation of their growth and nutritional status is mandatory. This is especially true for those affected by chronic medical conditions potentially affecting growth and nutrition. In addition, the LMS parameters and tables of percentiles allow the incorporation of growth charts in electronic hospital and clinic records.

The L, M, and S parameters and growth percentile reference has recently been reported in Saudi preschool children.20 However, to our knowledge, no reference has been reported for Saudi school-age children and adolescents. In this report, growth indicators (weight for age, height for age, and BMI for age) are presented, allowing more accurate assessment of growth and nutritional status. Regular follow up of growth parameter percentiles at different ages helps detection and definition of malnutrition. For example, a flat growth line crossing more than one percentile curve in a weight for age or below the 3rd percentile define failure to grow, also called failure to thrive. Similarly, height for age dropping below the 3rd percentile is a sign of short stature. In addition, the BMI is increasingly used to define thinness (BMI < 5th percentile), overweight (BMI > 85th percentile) and obesity (BMI > 95th percentile).21

In conclusion, the availability of L, M, and S parameters, percentiles tables, and reference charts for height for age, BMI for age and to lesser extent weight for age for school-age children and adolescents is important for research and health care.

Acknowledgment

The authors extend their appreciations to the Deanship of Scientific Research at King Saud University for funding this work through Research Group No. RGP-1436-007.

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