|Year : 2016 | Volume
| Issue : 2 | Page : 63-67
Identification of a surrogate anthropometric measurement to birth weight in high-risk low birth weight newborns in a developing country
Bindu T Nair1, Uma Raju2, RN Mehrishi3
1 Department of Paediatrics, Army College of Medical Sciences, New Delhi, India
2 Department of Neonatology, Nice Hospital, Hyderabad, Telangana, India
3 Department of Pediatrics, Ex-Army Hospital (Research and Referral), New Delhi, India
|Date of Web Publication||15-May-2017|
Bindu T Nair
Department of Paediatrics, Army College of Medical Sciences, Delhi Cantt., New Delhi - 110 010
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background: The study of anthropometric measurements of newborns at birth allows rapid evaluation of the neonate who has suffered abnormal intrauterine growth. Thus, neonates at increased risk of postnatal complications can be followed-up and given greater care.
Objective: The aim of our study was to identify a simple anthropometric measurement which can act as a surrogate to birth weight (BW) in a resource-poor country like India where the weight of majority of the newborns is not taken.
Materials and Methods: We studied all consecutive singleton newborns with gestational age between 28 weeks and 42 weeks delivered at a large hospital in North India between January 2015 and December 2015. The total number of new-borns included in the study was 3000. All data were entered and analyzed using Statistical Package for Social Sciences version 15.0 (SPSS Inc., Chicago, IL, USA).
Results: The mean BW of 3000 neonates was 2387 g (standard deviation - 560). The mean crown heel length, head circumference, chest circumference (CC), mid-upper arm circumference, mid-calf circumference, and mid-thigh circumference were 45.9 ± 3.4 cm, 32.6.5 ± 2.3 cm, 29.5 ± 2.7 cm, 10.1 ± 1.3 cm, 10.5 ± 1.3, and 14.1 ± 1.2 cm, respectively. There was a positive correlation of BW to all such anthropometric measurements with the highest correlation coefficient for CC (r = 0.73). The optimal cutoff points for CC and arm circumference to identify low BW (LBW) newborns were ≥29.5 cm and ≥10.1 cm, respectively.
Conclusion: Measurement of CC is a simple, easy, cheap, and reliable method for identification of LBW. Hence, it can be easily made use of identifying high-risk newborns by our health-care workers in rural settings of developing countries like India.
Keywords: Anthropometric measurements, chest circumference, high-risk newborns, low birth weight
|How to cite this article:|
Nair BT, Raju U, Mehrishi R N. Identification of a surrogate anthropometric measurement to birth weight in high-risk low birth weight newborns in a developing country. Ann Nigerian Med 2016;10:63-7
|How to cite this URL:|
Nair BT, Raju U, Mehrishi R N. Identification of a surrogate anthropometric measurement to birth weight in high-risk low birth weight newborns in a developing country. Ann Nigerian Med [serial online] 2016 [cited 2020 Aug 10];10:63-7. Available from: http://www.anmjournal.com/text.asp?2016/10/2/63/206212
| Introduction|| |
A healthy newborn of today is the healthy child of tomorrow. Birth weight (BW) is a reliable and sensitive indicator for predicting sequelae-both immediate and late of a neonate. Various anthropometric measurements taken at birth have a high correlation with BW.
In view of the appalling infant mortality in our country, it is interesting to know with what background of prenatal growth, our newborns start their independent existence. Low BW (LBW) is considered the single most important underlying risk factor for neonatal deaths., Unfortunately, in developing countries like India, only about half of the newborns are weighed at birth. The gestational age is known only in a small proportion of these newborns. Low birth weight (LBW – weight <2500 g) account for more than 50% of perinatal deaths in our country. The perinatal mortality among LBW babies is about eight times higher than that in the infants weighing more than 2500 g.
The goal of our study was to identify a simple anthropometric measurement which can act as a surrogate to BW in a resource-poor country like India. This simple measurement could best replace weight measurement and identify newborns who are LBW and are at high risk for developing postnatal complications. This can be used suitably in a developing country like India where the majority of our deliveries happen in rural setting. This anthropometric measurement can be used to guide community health workers and unskilled delivery attendants to identify LBW babies.
| Materials and Methods|| |
We conducted an observational study that used a cross-sectional analytical design to study 3000 newborns delivered at a large hospital in North India between January 2015 and December 2015.
The study group consisted of all consecutive singleton newborns with gestational age of between 28 weeks and 41 weeks and 6 days as estimated by maternal last menstrual period (LMP) date. This was confirmed by first-trimester ultrasonography provided that the gestational age difference from that by LMP was not more than 1 week. Newborns aged <48 h were considered.
All multiple born babies, babies with gross congenital anomalies, babies born to mothers with conditions likely to influence fetal growth such as hypertensive disorders of pregnancy, gestational diabetes mellitus, chronic infections, and illnesses were excluded from the study. Newborns with birth injuries such as scalp swellings and limb fractures, those who were <1.0 kg and very sick requiring oxygen therapy were also excluded from the study.
The gestational age of neonates was calculated from the first day of LMP and confirmed by clinical assessment using New Ballard score. Four pediatric residents who were trained to measure BW, length, head circumference (HC), chest circumference (CC), mid-upper arm circumference (MUAC), thigh circumference (ThC), calf circumference, and foot length took the measurements. Two pediatricians supervised the research. Study participants were recruited from the postnatal wards of the hospital.
Newborns were subjected to the following anthropometric measurements within 48 h of birth by standard techniques. BW with naked neonate in the supine position was obtained soon after birth by digital scale with 10 g subdivision. All other anthropometric variables including chest (CC), head (occipitofrontal circumference [OFC]), MUAC, mid-calf circumference (MCC), and mid-ThC (MThC) were measured by nonextendable measuring tape, with a width of 1.0 cm and subdivisions of 0.1 cm. and birth crown-heel length (CHL) was measured with infantometer.
HC was obtained by placing tape along the largest occipitofrontal diameter along over the occiput and eyebrow. The CC was measured by placing measuring tape along the point of nipples. The MUAC was obtained of the left arm at the midpoint between acromion and olecranon, with the newborn in dorsal decubitus position and with arm lying laterally to the trunk. CHL was recorded to the nearest 0.1 cm on an infantometer with the baby supine, knees fully extended, and soles of feet held firmly against the foot board and head touching the fixed board. A total of three consecutive measurements were taken for each variable, and the mean values were recorded.
Continuous variables such as the BW and anthropometric measurements were reported using mean and standard deviation (SD) if not skewed. All anthropometric measurements were measured three times, and their means were used in further analysis after being cleaned of abnormal values. Gender comparisons of continuous variables were performed using independent sample t-test. Pearson's correlation coefficient was determined between the various anthropometric measurements.
The study was approved by the Ethics Committee of the institution. Consent of the parents or guardian was obtained before enrolling the baby for the study. It was also explained to parents/guardians that participating in the study was voluntary, and they had the right to discontinue at any time without any consequences to their newborns or themselves.
| Results|| |
The observations in the present study reveal that out of 3000 newborns, 1491 (49.7%) were of LBW. Females, 1614 (53.8%), outnumbered males, 1386 (46.2%). Thirty-five percent of newborns were in the BW range of 2500–2999 g. However, in newborns weighing <2500 g, maximum number (37% of total) was in 2000–2499 g group. This group of newborns need only level 1 care which can be given at home/Primary Health Centre (PHC) level by mother under guidance of accredited social health activist worker, auxiliary nurse midwife, or lady health worker. Only 195 newborns (6.5% of total) fell in the category of weight <1500 g needing level 2/3 neonatal care.
The mean BW of 3000 neonates was 2387 g (SD - 560). The mean CHL, HC, CC, MUAC, MCC, and MThC were 45.9 ± 3.4 cm, 32.6.5 ± 2.3 cm, 29.5 ± 2.7 cm, 10.1 ± 1.3 cm, 10.5 ± 1.3, and 14.1 ± 1.2 cm, respectively. There is no significant difference in anthropometric measurements of male and female newborns [Table 1].
There is increase in all the anthropometric parameters with increasing gestational age up to 39–40 weeks, after which it started declining. All the anthropometric parameters measured were correlated well to gestational age (P < 0.0001). Maximum correlation was found with CC (r = 0.73). The mean and SD of all the anthropometric measurements studied were comparable with other Indian studies but were lower than the Western studies.,,,
Pairwise correlation between BW and anthropometric measurements were done. BW correlated significantly with all the anthropometric measurements. Among LBW newborns, the highest correlations with BW were CC (r = 0.73), MUAC (r = 0.69), MCC (r = 0.65), and MThC (r = 0.64), OFC (r = 0.59), CHL (r = 0.53) [Table 2].
|Table 2: Pairwise correlation between birth weight groups and various anthropometric measurements|
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The sensitivity and specificity, for classifying infants into LBW status was shown in [Table 3]. An optimum cutoff point identifying LBW were 29.5 cm for CC, 10.1 cm for mid-arm circumference, 32.6 cm for HC, 45.9 cm for length, 10.5 cm for MCC, 14.1 cm for MThC, and 0.302 for mid arm to HC ratio [Table 3].
|Table 3: Sensitivity and specificity of optimum cutoff points of anthropometric measurements|
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| Discussion|| |
In India, most of our newborns are delivered at home by untrained or semi-trained birth attendants, relatives, or neighbors. Therefore, BW of these babies is not known. Only a small fraction of the population of India and other developing countries have an institutional delivery, and these babies are weighed at birth.
The aim of our study was to reaffirm the suggestion given by the WHO of choosing a surrogate anthropometric measurement which could replace measurement of BW in a resource-poor setting of rural areas of a developing country like India. This surrogate anthropometric measurement would be of great help for health personnel in rural setting to detect high-risk neonates. These neonates could thus be provided adequate intervention and care and prevent neonatal morbidity and mortality.
In our study, we found that the BW ranged from 1000 to 3500 g with a mean of 2387 g (SD - 560 g). A study in India showed almost similar mean BW of 2678 ± 454 g. One study in Bangladesh showed mean BW of 2889 ± 468 g  which is higher than our study, but recently, a study in Jhansi (Uttar Pradesh, India) showed a mean BW of 2348 ± 505 g  which matches to our study. There is slight preponderance of females over males in our study comprising 52.7% females and 47.3% males.
A WHO multicenter study reported that the average BW was 2630, 2780, and 3840 for newborns in India, Nepal, and Sri Lanka, respectively. In another study from India, the overall average BW was 2348 ± 505 g  which was something similar to our study. However, another study from Bangladesh showed a mean BW of 3195.4 ± 399.9 g and only 3.8% of the newborns were LBW. In another study in Ghana, the overall mean BW was 2.9 kg with an SD of 0.7. In another Nepalese study also, the mean BW was 3029 ± 438 g, and only 34 (8.5%) newborns were LBW. The mean BW and anthropometry in our study were lower than these previous studies.
It was observed in our study that the difference in the mean BW between male and female newborns is not significant (P > 0.05). This is in conformity with studies by Kadam et al. In a study in Bangladesh, incidence of LBW newborns was 41%. Ganesh Kumar et al. in 2012 reported in their study 55.27% incidence of LBW. Hence, these data are near about the same as ours.
In our study, there was no significant difference in BW and anthropometric measurements between male and female newborns. It may be due to large size of our population with both male and female neonates. However, our data revealed that positive correlation existed between all the studied parameters and BW in our study group.
In a study in Tanzania, foot length and in another study in Nepal, CC was found as best surrogate for identifying LBW newborns. Similarly, there have been several studies attempted to determine a surrogate anthropometric parameter to identify LBW babies in rural settings of resource-poor countries like India. These anthropometric measurements have to be cheap, simple, logistically feasible, and reliable. Hence, we made a comparison of all these varied anthropometric measurements to find the best surrogate.
According to other studies , also, many anthropometric measurements have shown high correlations ranging from 0.60 to 0.95 between BW, arm circumference, and CC. There are other studies,, also suggesting that mid-arm circumference is reliable anthropometric measures for establishing cutoffs for the identification of LBW infants. However, in our study, the maximum correlation with BW was observed for CC (r = 0.73). Therefore, we concluded that CC would be the best surrogate for BW. Thus, CC would be a good surrogate for identifying LBW neonates.
Our study shows that CC at a cutoff limit of 29.5 cm is effective in detecting LBW infant with a sensitivity of 89% and specificity of 82%. Another study  showed cutoff limit 30.5 cm with specificity 83.6% and sensitivity of 83.3%. Yet another study showed cutoff point of 30.8 with sensitivity 94% and specificity of 90%. A WHO collaborative study has recommended that CC of 29 and 30 cm may identify “highly at risk” and “at risk” newborns, respectively. This finding is similar to Dhar et al. study which showed that strongest correlation was present between CC and BW (r = 0.84). We recommend the use of CC as a surrogate for BW for two reasons.
First, it is simpler to measure as identification of the nipple line is easier, making measurement more operationally feasible than that of the mid-arm circumference. Second, it is clearly evident from analysis of our data that CC is the best simple and reliable surrogate parameter that could be used by health-care workers in rural settings of our country where weight measurement is not possible in majority of the babies delivered. This health personnel working in the community can be provided color coded tapes indicating weight <2500 g.
In our study, CC was found to be the best surrogate to predict LBW newborns in rural settings of a developing country like India. The cutoff point of CC can be 29.5 cm which showed highest sensitivity and specificity.
| Conclusion|| |
We conclude that a simple measurement such as CC can simply and practicably identify infants with chances of high risk in rural setting of a developing country. These anthropometric measurements are easy to learn and can conveniently be introduced into the existing system of health care to be used by paramedical workers to detect neonates who are LBW and are at risk. A color coded, measuring tape may be suggested for use by health workers or family members to identify LBW newborns in rural and home setting.
We wish to express gratitude to the postgraduate residents and nursing staff of the postnatal wards for their tremendous cooperation and support to make this study successful.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]