ArticlesInternational standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project
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use at birth available (104 published since 1990) and their substantial methodological heterogeneity and limitations (unpublished data) complicate the clinical assessment of a newborn infant's nutritional status and make comparisons difficult across populations.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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