One Size Does Not Fit All: Differences in Newborn Weight Among Mothers of Philippine and Other East Asian Origin

ObjectiveTo determine the likelihood that infants born to Filipina, other East Asian, and Canadian-born women may be misclassified as small for gestational age when using conventional Canadian birth weight curves rather than those specific to their world region.MethodsWe conducted a population-based study of 548 418 singleton live births in Ontario between 2002 and 2007. Smoothed birth weight percentile curves were generated for males and females born to women from Canada, the Philippines, and the rest of East Asia/Pacific. We determined the likelihood of misclassifying an infant as small for gestational age (SGA < 10th percentile weight) or large for gestational age (LGA ≥ 90th percentile weight) on a Canadian-born birth weight curve vs. a curve specific to the other two world regions.ResultsFor gestation-specific 10th and 50th percentiles, term infants born to women from the Philippines often had significantly lower birth weights than infants of Canadian-born mothers. Controlling for maternal age and parity, approximately 88 per 1000 male newborns (95% CI 82 to 95) and 72 per 1000 female newborns (95% CI 54 to 60) of mothers from the Philippines were at risk of being misclassified as SGA. LGA would be missed in approximately 54 per 1000 male newborns (95% CI 49 to 59) and 49 per 1000 female newborns (95% CI 44 to 54) of Filipina mothers. Misclassification of both SGA and LGA was more pronounced among infants of Filipina mothers than of mothers from other East Asian origin.ConclusionsInfants of mothers born in the Philippines weigh significantly less than those of Canadian-born women or mothers emigrating from other East Asian countries. Those who use birth weight curves should consider these differences.     

Intrauterine growth restriction increases morbidity and mortality among premature neonates

OBJECTIVE: Intrauterine growth restriction (IUGR) is an important reason for premature delivery and has been reported to be associated with increased mortality, but in some studies paradoxically, improved morbidities. Data on neonatal outcomes for infants with IUGR at each viable gestational age at birth from large numbers of deliveries are lacking. More particularly, data on perinatal outcome related to an antenatal diagnosis of IUGR compared with a neonatal diagnosis are particularly deficient. Therefore, by using a large contemporary database, we evaluated the outcomes of neonates with IUGR and the gestational age-specific associations between growth restriction, morbidity, and mortality. STUDY DESIGN: With the use of a database formed from a computer-assisted tool that generates clinical progress notes and discharge summaries on neonatal intensive care unit (NICU) admissions, we reviewed data on neonates discharged from 124 NICUs between January 1, 1997, and December 31, 2001. We evaluated singleton, inborn neonates who delivered between 23 and 34 weeks, excluding major congenital anomalies. We compared 3 measures of IUGR: antenatally diagnosed IUGR; a birth weight below the 10th percentile (small for gestational age [SGA]), and newborn infants with either or both of these diagnoses against a control group of gestational age-matched infants meeting none of these criteria whose birth weights were no greater than the 90th percentile. RESULTS: Our sample included 29,916 prematurely born neonates; 1,451 (4.8%) with IUGR, 2,936 (9.8%) who were SGA, and 3,708 (12.3%) had at least 1 of these 2 markers. There were 22,798 (76%) normally grown control neonates. Within each gestational age group from 25 to 32 weeks, each marker of IUGR was associated with increased mortality, necrotizing enterocolitis, need for respiratory support at 28 days of age, and retinopathy of the premature. When corrected for gestational age, exposure to antenatal steroids, gender, and mode of delivery, these associations remained significant. CONCLUSION: IUGR remains a serious problem that is associated with increased morbidity and mortality among prematurely born neonates, regardless of the definition used or whether the diagnosis is made antenatally or after birth. These results are important for obstetric counseling and decision making and for the anticipation and treatment of premature newborn infants.     

Neurologic sequelae in infants with intrauterine growth retardation.

The literature on neurologic sequelae in infants with intrauterine growth retardation (IUGR) is reviewed. In many studies this term is used for only those infants who have a birthweight (BW) below the 10th percentile and are labeled small for gestational age (SGA). The etiology of IUGR can often be correlated with a characteristic pattern of in utero growth and a subsequently predictable pattern of postnatal growth and/or developmental outcome. The concept that certain premature infants who are appropriately grown for gestational age (AGA) but whose birth weights fall below the 50th percentile may have IUGR is supported by the analysis of data from this study. In attempting to predict the neurologic outcome, it may be more helpful to recognize etiologic factors such as sleep disturbances than to analyze infants by birth weight gestational age groups.     

Severity of Hypertension in Pregnancy and Morbidity in the Newborn

A prospective study on the effect of severity of hypertension in pregnancy on peri- and neonatal morbidity was conducted over a 22 month period in 1984 - 1986 at Kuoplo University Central Hospital. Five hundred and fifty-four babies without major anomalies were born alive to hypertensive and 3212 to normotenslve mothers. The Incidence of prematurity was highest (22%) among babies with maternal pre-eclampsia, Intrauterine growth retardation (IUGR) being the most frequent (42%) among preterms from this group.

All preterm babies born at 28 - 36 gestational weeks were included for analysis of peri- and neonatal morbidity, 36 “in the pre-eclampsia group, 17 in the pregnancy-induced hypertension group, 11 in the chronic hypertension group and 162” in the normotenslve control group. The respective numbers of babies “in the full-term sample were 49, 74 and 51″ in the hypertension subgroups and 220” in the normotenslve control group.

Among preterm babies maternal pre-eclampsia was associated with the highest neonatal morbidity and birth asphyxia, expressed as reduced optimality scores, and with the lowest birth weight and length. Among full-term babies those with chronic maternal hypertension had the highest neonatal morbidity and birth asphyxia even though babies with maternal pre-eclampsia had the lowest birth weight. When appropriate for gestational age (AGA) and small for gestational age (SGA) children were examined separately, the differences described between the hypertension subgroups and their controls were found mostly between AGA children. Maternal hypertension explained 22% of the between-group differences” in preterm children, mostly via Increased IUGR, and 12%” in full-term children, mostly via increased neonatal morbidity.     

Intrauterine growth restriction – part 2

Small for gestational age (SGA) infants have been classically defined as having birth weight less than two standard deviations below the mean or less than the 10th percentile of a population-specific birth weight for specific gestational age, whereas intrauterine growth restriction (IUGR) has been defined as a rate of foetal growth that is less than normal for the population and for the growth potential of a specific infant. SGA infants have more frequent problems such as perinatal asphyxia, hypothermia, hypoglycaemia, polycythaemia and many more when compared with their appropriate for gestational age counterpart. They too have growth retardation and various major and subtle neurodevelopmental handicaps, with higher rates of perinatal and neonatal mortality. With the advent of newer technologies, even though the perinatal diagnosis of these SGA/IUGR foetuses has increased, but still perinatal morbidity and mortality rates are higher than normal foetuses and infants. In this part, we have covered neonatal IUGR classification, postnatal diagnosis, short-term and long-term complications faced by these IUGR infants.     

Association between maternal panic disorders and pregnancy complications and delivery outcomes

BACKGROUND: The objective of the study was to evaluate the possible association between panic disorders during pregnancy and pregnancy complications, as well as birth outcomes: gestational age and birth weight, as well as preterm birth/low birthweight in newborns. METHODOLOGY: Comparison of newborn infants (without any defects) born to mothers with or without panic disorder in the population-based large data set of the Hungarian Case-Control Surveillance System of Congenital Abnormalities. Main outcome measures were medically recorded pregnancy complications, as well as gestational age and birth weight, proportion of preterm birth and low birthweight. PRINCIPAL FINDINGS: Of 38,151 controls, 187 (0.5%) had mothers with panic disorders during pregnancy. Among pregnancy complications, anemia and polyhydramnion showed a higher prevalence in women with panic disorder. There was a higher proportion of males among newborn infants born to mothers with panic diseases compared to newborn infants of mothers without panic disorders. Pregnant women with panic disorders had a shorter (0.4 week) gestational age (adjusted t = 2.3; p = 0.02) and a larger proportion of preterm births (17.1% versus 9.1%) (adjusted POR with 95% CI = 1.9, 1.3-2.8). However, there was no significant difference in the mean birth weight and rate of low birthweight between the two study groups. CONCLUSION: Panic disorders during pregnancy were associated with anemia, a shorter gestational age and a larger proportion of preterm birth. Further studies are needed to confirm and explain or disprove the male excess among newborn infants born to mothers with panic disorders.     

Effect of preeclampsia on blood pressure in newborn very low birth weight infants.

OBJECTIVE: To test the hypothesis that very low birth infants born to mothers with preeclampsia have higher blood pressure over the first week of life than infants whose mothers did not have preeclampsia. METHOD: Infants born at<1,350 g who survived at least one week were stratified by gestational age ( or= 29 completed weeks) and grouped by the presence or absence of preeclampsia. Highest and lowest systolic and mean and diastolic blood pressures were recorded for each of the first seven days of life. Serial blood pressures were analyzed by repeated measures ANOVA. The presence of hypertension (defined as >or= 3 days with the highest systolic blood pressure>90th percentile for gestational age stratum and day-specific range) was analyzed by binary logistic regression. RESULTS. Infants >or= 29 weeks gestational age born to mothers with preeclampsia had higher blood pressures than did controls. Infants or= 29 weeks gestation. The long-term significance of this finding is not known.     

Massage therapy and sleep behaviour in infants born with low birth weight

This study attempts to evaluate the impact of massage therapy on sleep behaviour in infants born with low birth weight (LBW) in St. Petersburg, Russia. Fifty infants (22 boys, 28 girls) who were born in St. Petersburg between 2000 and 2002 and defined as LBW babies (<2500g at birth) were enrolled onto the study at the age of 2 months. Of these, 41 (19 boys, 22 girls) were light and pre-term infants (gestational age < or =36 weeks), and 9 (3 boys, 6 girls) born light at term. The control group consisted of 50 healthy infants born with LBW who were cross-matched with an experimental group of babies and controlled for gender, gestational age, weight and date of birth. The groups were also matched for proximal geographical distribution in the city. Babies in the experimental group were assigned massage intervention therapy that include gentle rubbing, stroking, passive movements of the limbs and other means of kinaesthetic stimulation performed by professionals until the infant is 8 months old. The findings suggest that 8-month-old LBW infants who received massage intervention were less likely to snore during sleep, required less feeding on waking-up at night, and appeared more alert during the day. These apparent correlations remained significant after adjustment was made for major potential confounders. No statistically significant difference was found in sleep behaviour between LBW infants exposed to massage therapy who were either born pre-term or at term. It is suggested that massage may be a valuable approach to improve quality of sleep and reduce sleep-disordered breathing in infants born with LBW. It is acknowledged that whilst this study does not represent a large sample, it is felt that the findings suggest further investigation and offer an insight into an area previously relatively unexplored.     

Intrauterine growth retardation--a prospective study of the diagnostic value of real-time sonography combined with umbilical artery flow velocimetry

This study was undertaken to evaluate the role of umbilical artery flow velocimetry combined with sonographic estimation of fetal weight, head circumference to abdominal circumference ratio, femur length to abdominal circumference ratio, and qualitative determination of amniotic fluid volume as a comprehensive test for the detection of intrauterine growth retardation (IUGR). The following cutoff values were used to indicate abnormal test results: 1) umbilical artery peak systolic to end-diastolic ratio (S/D) above 3, 2) estimated fetal weight below the tenth percentile for gestational age, 3) head circumference to abdominal circumference ratio more than 2 SD above the mean for gestational age, 4) femur length to abdominal circumference ratio above 23.5%, and 5) qualitative amniotic fluid volume less than 2 cm. The study population consisted of 127 patients referred with a clinical suspicion of IUGR. Forty-five infants (35%) were small for gestational age. None of these five tests were uniformly successful in identifying growth-retarded infants. Overall, the best predictor appeared to be estimated fetal weight below the tenth percentile for gestational age, which correctly identified 39 of the 45 IUGR infants (sensitivity 87%, specificity 87%). The sensitivity of this test was nearly twice that of any other test. All indices performed similarly in predicting the non-IUGR infant (range of specificities 87-98%).     

The relationship between mean abdominal diameter and femur length in normal and impaired fetal growth

The relationship of fetal mean abdominal diameter (MAD) to fetal femur length (FL) in clinically normal pregnancies and 37 cases of intrauterine growth retardation (IUGR) was studied. The normal relationship of FL to MAD is closely described by the equation: log (MAD) = 3.326 + (0.185 X FL). r = .953, P less than .001. In the growth retarded infants, 59% of the abdominal measurements fell below the lower 75% confidence limit. Of the abdominal measurements derived from infants with birthweight greater than 2 SD below the mean for gestational age, 86% fell below the lower 75% confidence limit. These data show the MAD is selectively depressed in many, but not all cases of IUGR and particularly in the more severely affected infant, but the technique is not sufficiently discriminant to be used by itself for the detection of IUGR. Detection of an anomaly of this relationship would be strong supportive evidence of IUGR independent of gestational age and possibly identifies infants growth retarded specifically due to chronic deprivation.     

Subsequent pregnancy following labor of a very-low-birth-weight infant

During a period of 5 years (1978-1982), 55 mothers with an average age of 27.5 +/- 5.4 years, delivered 59 infants, weighing less than 1500 g. These infants had a mean birth weight of 1160.5 +/- 263 g and a mean gestational age of 28.7 +/- 2.25 weeks (range 25-32 weeks). Subsequently 47 (79.6%) survived and 12 (20.4%) died. There was a statistical difference of both mean gestational age and of mean gestational weight between survivors or infants with neonatal death. Twenty two of 29 mothers who subsequently became pregnant, gave birth to liveborn infants, who subsequently survived (four pregnancies terminated in induced abortion). Mean gestational age was 37 +/- 3 weeks (range 32-41 weeks) (P less than 0.001) and a mean birth weight was 2753.2 +/- 570 g (range 1620-3600 g) (P less than 0.001. All the 22 infants subsequently born weighed more than 1501 g, 7 (31.8%) infants weighed 1501-2500 g and 15 (68.2%) more than 2500 g. Similar data were obtained from a control group of 615 mothers (chosen at random) who delivered a normal infant at term, 202 subsequently became pregnant and 176 gave birth to a normal infant at term. Mean gestational age was 39.54 +/- 1.24 weeks (P less than 0.001) and mean birth weight was 3299.3 +/- 412 g (P less than 0.001). (In the control group 10 pregnancies terminated in induced abortions). The above data could be used in advising for future pregnancy outcome in regard to women with premature births.     

Genetic,metabolic and endocrine aspect of intrauterine growth restriction: an update

Intrauterine growth restriction (IUGR) is defined as growth of fetus below its in-utero growth potential. Small for gestational age (SGA) is defined as newborn with birth weight less than 10th centile as per the gestational age, sex and race. There exists major difference between IUGR and SGA. IUGR infants have multiple short-term and long-term complications and IUGR is a silent cause of various morbidities and mortalities in these infants. IUGR/SGA is usually end results of maternal, placental, fetal and genetic causes. With the advance of molecular biology, the list genetic cause of IUGR is increasing and these genetic causes include maternal, placental and fetal genes. Several metabolic and endocrinal causes are also responsible to cause IUGR. In this review, we will try to cover genetic, metabolic and endocrinal factors that are responsible for IUGR.     

Effect of Preeclampsia on Blood Pressure in Newborn Very Low Birth Weight Infants

Objective. To test the hypothesis that very low birth infants born to mothers with preeclampsia have higher blood pressure over the first week of life than infants whose mothers did not have preeclampsia. Method. Infants born at < 1,350 g who survived at least one week were stratified by gestational age ( ≤ 28 weeks and ≥ 29 completed weeks) and grouped by the presence or absence of preeclampsia. Highest and lowest systolic and mean and diastolic blood pressures were recorded for each of the first seven days of life. Serial blood pressures were analyzed by repeated measures ANOVA. The presence of hypertension (defined as ≥ 3 days with the highest systolic blood pressure > 90th percentile for gestational age stratum and day-specific range) was analyzed by binary logistic regression. Results. Infants ≥ 29 weeks gestational age born to mothers with preeclampsia had higher blood pressures than did controls. Infants ≤ 28 weeks gestational age born to preeclamptic and nonpreeclamptic mothers had similar blood pressures. In the combined cohort, hypertension was not more prevalent among infants born to women with preeclampsia. Conclusions. Preeclampsia is associated with higher blood pressure in very low birth weight neonates who are ≥ 29 weeks gestation. The long-term significance of this finding is not known.     

Perinatal outcome in growth retarded pregnancies dated by ultrasound

To analyse the incidence of fetal growth retardation and its impact on perinatal mortality and neonatal morbidity, pregnancies complicated by intra-uterine growth retardation (IUGR) were compared with matched non-IUGR pregnancies. The IUGR group included all infants born in the city of Malm? during the study period and having a birthweight of 2 standard deviations or more below the mean birthweight for gestational age. The gestational age of all pregnancies was assessed with ultrasound in the first half of pregnancy. The IUGR fetuses were more vulnerable during delivery, and emergency cesarean section due to imminent fetal asphyxia was performed more frequently, but Apgar scores were similar in both groups. The frequency of respiratory disorders was lower in the IUGR group than in the non-IUGR group when corticosteroid-treated pregnancies were excluded. The IUGR group required slightly longer care on the neonatal ward than the non-IUGR group, but not more intervention. The IUGR group as a whole had an unexpectedly low neonatal complication rate, such complications as did occur being related to preterm birth rather than to growth retardation.     

Diabetes and pregnancy. Maternal risk factors and neonatal morbidity

BACKGROUND: To verify in our population the incidence of infants of mother with insulin dependent diabetes mellitus (IDDM) or gestational diabetes (GD) and to evaluate the maternal characteristics influencing neonatal outcome. METHODS: The study was retrospectively performed on 6179 infants born between 1995 and 1998 at the Obstetric Clinic of the University of Messina and referred the Division of Neonatology. The following groups have been selected: group A (offsprings of IDDM mothers), group B (offsprings of DG mothers), group C and group D, controls, (2 infants of the same sex and gestational age born before and after the infants of group A and group B, respectively). The parameters analyzed were: diabetic familiarity, age, weight and body mass index (BMI) of the mothers, delivery, gestational age, weight at birth, neonatal outcome. RESULTS: The infants of IDDM mothers were 3% and the infants of GD mothers were 0.8%. Group A and group B present a significantly higher incidence of: diabetic familiarity, cesarean section, macrosomia, hypoglycemia, hypocalcemia, hyperbilirubinemia. The GD mothers had weight and BMI higher than IDDM mothers. The infant weight did not correlate with maternal weight and BMI. CONCLUSIONS: These data suggest that in our population GD is underestimated, metabolic control in pregnancy is insufficient, obstetric practices are too invasive, neonatal outcome is verosimely correlated only to metabolic control.     

The effect of minor degrees of glucose intolerance on the incidence of neonatal macrosomia.

The incidence of neonatal macrosomia in infants of mothers who have only one abnormal value in a 3-hour glucose tolerance test (GTT) is greater than normal. Often, corrections for gestational age have not been used in the analysis, and in the few studies in which corrections were made, the results conflicted. In this study, the birth weights of infants from 157 patients who had only one abnormal GTT value were compared with the birth weights of infants from normal mothers, with and without correction for gestational age. Analysis using three different GTT criteria revealed that the incidence of birth weight greater than 4000 g was 20% or greater in the infants of mothers who had only one abnormal GTT value and only 12.4% in controls. However, when adjusted for gestational age, there were no differences in the birth weights and percentage of large for gestational age (LGA) infants in the study groups versus controls. The mean and gestational age-adjusted birth weights of the greater-than-4000-g neonates born to women with one abnormal GTT value were no different than those of controls. However, at delivery, the gestational ages of patients with one abnormal GTT value tended to be slightly greater than those of controls by 0.1-0.6 weeks, suggesting that minor degrees of abnormal glucose metabolism may prolong pregnancy in some patients. When compared with the literature, the findings of this study suggest that the National Diabetes Data Group criteria may be too high as a screen for LGA infants.     

Doppler umbilical velocimetry in the prediction of adverse outcome in pregnancies at risk for intrauterine growth retardation

Perinatal indicators of fetal compromise were assessed according to the results of continuous-wave Doppler umbilical velocimetry for 172 patients at risk for intrauterine growth retardation (IUGR). Forty-three (25%) of the patients delivered an infant with a birth weight below the tenth percentile for gestational age. The last Doppler study before delivery was abnormal in 48.8% of the growth-retarded infants but in only 13.2% of the infants without evidence of IUGR. Furthermore, in the growth-retarded group, early delivery, reduced birth weight, decreased amniotic fluid at birth, admission to the neonatal intensive care unit, neonatal complications associated with IUGR, and a prolonged hospital stay were observed more frequently in those who had an abnormal ratio than in those with a normal ratio. The sensitivity of the systolic/diastolic ratio for an adverse perinatal outcome (operative delivery for fetal distress, neonatal morbidity associated with IUGR, and/or perinatal death) was significantly better for the infants with IUGR (66.7%) than for the infants without IUGR (27.8%; P less than .05). The predictive value of an abnormal ratio was also higher for the pregnancies complicated with IUGR (57.1%) than for those without IUGR (29.4%), but not to a statistically significant degree. These data suggest that Doppler umbilical velocimetry studies are valuable in identifying those growth-retarded fetuses at increased risk for an adverse perinatal outcome.     

Short-term outcome in infants with birth weights less than 1750 g born to mothers with HELLP syndrome.

Premature infants born to mothers with HELLP syndrome were reported to have a less favourable outcome compared to infants with uncomplicated maternal history. We investigated the short term outcome in 21 premature infants with birth weights less than 1750 g born to mothers with HELLP syndrome. Median birth weight was 1050 g (range 420 g-1750 g), corresponding gestational age 29 weeks (range 26-35 weeks). Mechanical ventilation for RDS was necessary in 15 infants. Intracranial hemorrhage was diagnosed in 2 infants, 1 of the surviving infants developed bronchopulmonary dysplasia. Acute renal failure was observed in 3 infants immediately after birth. Mortality was attributed to progressive respiratory failure in 2 patients (b.w. 420 g and 490 g) and persisting acute renal failure in 1 patient (b.w. 520 g) Leucocytopenia (less than 9000/mm3) was observed in 13 infants and thrombocytopenia (less than 115000/mm3) was noted in 4 infants during the first day. Eighteen infants survived. We conclude, that the short term outcome in infants born to mothers with HELLP syndrome is not as poor, as previously reported.     

Growth increments in preterm low risk infants

Thirty five surviving low risk vaginally born preterm infants were followed for four years. Weekly increments for weight, length and head circumference were obtained. The implications relating to growth velocity from gestational age, fetal acidosis and neurodevelopmental disorders as well as sex, feeding habits and mothers' educational level were studied. A significant difference for weight was found between infants with and without a neurodevelopmental disorder during the first 7 months. Infants with fetal acidosis (scalp pH less than 7.2) or a neurodevelopmental disorder have lower increments for weight and head circumference during the first 3 months than infants without fetal acidosis or a neurodevelopmental disorder, but they demonstrated the highest increments for weight between 3-7 months of age. Mean growth increments were high for infants of well educated mothers, but the growth increments for infants of less educated mothers did not differ from the total preterm group. Breastfed infants between birth and 3 months of age show high increments for weight. Boys have a better mean increment for weight than girls between birth and 3 months of age. The opposite was found for length. The group differences are not significant and too small for a definite statement, but they do reveal small differences during early infancy that may prove helpful in the management of infants at risk.     

Pregnant mothers out of the perinatal regionalization's reach.

INTRODUCTION: Birth of very low birth weight (VLBW) infants outside subspecialty perinatal centers increases risk for death and major morbidities. OBJECTIVE: The purpose of this study is to evaluate barriers to utilizing a regional perinatal center for the birth of VLBW infants to mothers not living in the immediate vicinity of the center. METHODS: We conducted a retrospective cohort study of VLBW infants residing in the catchment area of a community level II, Specialty Neonatal Unit (SN) admitted to a Regional Subspecialty Neonatal Intensive Care Unit (RC) between January 1999 and December 31, 2004. Maternal demographics and prenatal care as well as outcomes were compared by place of birth. RESULTS: Out of 98 VLBW infants admitted to the RC, 49 (50%) were delivered outside the RC (out-born) and 49 (50%) were born at the RC (in-born). There was no statistical difference in insurance coverage, race, gestational age, severity of illness or maternal demographic factors between out-born and in-born infants. Less than adequate prenatal care rather than distance of maternal residence from the RC was associated with birth outside the RC. Adjusting for prenatal care, distance of residence from the RC increased the risk for delivering outside the center in the subset of mothers insured by Medicaid. CONCLUSIONS: Mothers of VLBW infants who received less than adequate prenatal care and did not live in the vicinity of a subspecialty center had an increased risk for delivery outside that center compared to those with adequate care. Appropriate place of birth for VLBW infants to low-income mothers may be influenced by the distance of their residence to an RC.