Elsevier

The Lancet

Volume 384, Issue 9946, 6–12 September 2014, Pages 857-868
The Lancet

Articles
International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project

https://doi.org/10.1016/S0140-6736(14)60932-6Get rights and content

Summary

Background

In 2006, WHO published international growth standards for children younger than 5 years, which are now accepted worldwide. In the INTERGROWTH-21st Project, our aim was to complement them by developing international standards for fetuses, newborn infants, and the postnatal growth period of preterm infants.

Methods

INTERGROWTH-21st is a population-based project that assessed fetal growth and newborn size in eight geographically defined urban populations. These groups were selected because most of the health and nutrition needs of mothers were met, adequate antenatal care was provided, and there were no major environmental constraints on growth. As part of the Newborn Cross-Sectional Study (NCSS), a component of INTERGROWTH-21st Project, we measured weight, length, and head circumference in all newborn infants, in addition to collecting data prospectively for pregnancy and the perinatal period. To construct the newborn standards, we selected all pregnancies in women meeting (in addition to the underlying population characteristics) strict individual eligibility criteria for a population at low risk of impaired fetal growth (labelled the NCSS prescriptive subpopulation). Women had a reliable ultrasound estimate of gestational age using crown–rump length before 14 weeks of gestation or biparietal diameter if antenatal care started between 14 weeks and 24 weeks or less of gestation. Newborn anthropometric measures were obtained within 12 h of birth by identically trained anthropometric teams using the same equipment at all sites. Fractional polynomials assuming a skewed t distribution were used to estimate the fitted centiles.

Findings

We identified 20 486 (35%) eligible women from the 59 137 pregnant women enrolled in NCSS between May 14, 2009, and Aug 2, 2013. We calculated sex-specific observed and smoothed centiles for weight, length, and head circumference for gestational age at birth. The observed and smoothed centiles were almost identical. We present the 3rd, 10th, 50th, 90th, and 97th centile curves according to gestational age and sex.

Interpretation

We have developed, for routine clinical practice, international anthropometric standards to assess newborn size that are intended to complement the WHO Child Growth Standards and allow comparisons across multiethnic populations.

Funding

Bill & Melinda Gates Foundation.

Introduction

In 1994, the main WHO expert committee on the use and interpretation of anthropometry recommended the use of international standards to assess anthropometric measures.1, 2 To implement these recommendations for infants and children, WHO initiated the Multicentre Growth Reference Study (MGRS).3 In 2006, this study generated WHO Child Growth Standards for children younger than 5 years, which are now accepted worldwide.4, 5 Two characteristics made the WHO MGRS unique and unprecedented: the study included populations from Brazil, Ghana, India, Norway, Oman, and the USA, and it used a prescriptive approach to select the study populations (inclusion of only breast-fed infants from mothers who did not smoke and who had minimum environmental constraints on growth).6

Aiming to complement the WHO MGRS, in 2008 the International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) launched a multicountry project to develop similar prescriptive standards for fetuses, newborn infants, and the postnatal growth of preterm infants. The INTERGROWTH-21st Project was done in eight countries and completed in 2014.7 One of its three main studies (the Newborn Cross-Sectional Study) aimed to produce newborn standards for birthweight, length, and head circumference at birth. The approach for the primary analysis8 was based on that used in the WHO MGRS3 to compare the similarities in skeletal size and growth of fetuses and newborn infants. The results of the two studies concur and strongly support pooling of the eight INTERGROWTH-21st populations to construct new international newborn standards.

The large number of size charts for use at birth available (104 published since 1990) and their substantial methodological heterogeneity and limitations (unpublished data) complicate the clinical assessment of a newborn infant's nutritional status and make comparisons difficult across populations. Available estimates for the prevalence and mortality of small-for-gestational-age babies show that these assessments are a major priority for public health.9, 10, 11 The absence of an international standard has been a major limitation for such estimates because the many references to choose from were derived from individual countries or regions at particular timepoints. Therefore, development of an international standard for newborn infants is important for clinical practice and essential to estimate accurately the prevalence of small-for-gestational-age babies worldwide. In this Article, we present such a set of standards.

Section snippets

Methods

Study design and participants

INTERGROWTH-21st is a multicentre, multiethnic, population-based project done between April 27, 2009, and March 2, 2014, in eight study sites: Pelotas, Brazil; Turin, Italy; Muscat, Oman; Oxford, UK; Seattle WA, USA; Shunyi County in Beijing, China; the central area of Nagpur, India; and the Parklands suburb of Nairobi, Kenya.7 The primary aim of the project was to study growth, health, nutrition, and neurodevelopment from 14 weeks of gestation to age 2 years using

Results

Between May 14, 2009, and Aug 2, 2013, we enrolled 59 137 pregnant women at the eight sites, of whom 6056 did not have a reliable estimate of gestational age and 910 had multiple pregnancies. Of the remaining 52 171 women, 20 486 (35% of the total NCSS population) met the individual clinical and demographic eligibility criteria for the standards presented here, had a reliable ultrasound estimate of gestational age, and delivered one live baby without a congenital malformation. These 20 486

Discussion

The INTERGROWTH-21st Project aimed to produce, for the first time (panel), international standards for newborn size for each gestational age based on data from its NCSS subpopulation, which conformed at population and individual levels to the prescriptive approach used in the WHO MGRS.3 These new standards are considered to be a conceptual and practical link to WHO Child Growth Standards, which have been adopted by more than 125 countries worldwide.40, 41 They will bridge gaps in clinical and

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