International versus national growth charts for identifying small and large-for-gestational age newborns: A population-based study in 15 European countries

Persistent Uninterpretable or Failed Prenatal Cell-Free DNA Screening Indicates a High-Risk Pregnancy and is Associated With Biological Factors Interfering With cfDNA-Analysis: A Prospective Cohort Study

OBJECTIVE

To investigate maternal characteristics, underlying factors and perinatal outcome in pregnancies with persistent uninterpretable prenatal cfDNA screening in a general obstetric population (GOP).

METHODS

This study included pregnant individuals with persistent uninterpretable prenatal cfDNA screening results from December 2020 to December 2022. Prenatal cfDNA screening results were classified as uninterpretable due to low quality score (LQS) or low fetal fraction (LFF). Maternal autoimmune screening and a third prenatal cfDNA screening were performed later in pregnancy. Data on maternal characteristics and perinatal outcome were analyzed.

RESULTS

Among 123 pregnant individuals with failed prenatal cfDNA screening, 68% were due to LFF and 32% to LQS. Obesity and autoimmune diseases were significantly overrepresented. A third prenatal cfDNA screening at 24 weeks was informative in 77.1% cases, with a higher success-rate in the LFF group (87.8%). Maternal autoimmune screening revealed unknown triple positivity for antiphospholipid antibodies in 2.4%. Abnormal perinatal outcome was registered in 69.9% of patients, with higher rates of adverse perinatal outcome in the LFF group.

CONCLUSION

Persistent uninterpretable prenatal cfDNA screening indicates a higher risk for adverse perinatal outcomes, especially in cases with LFF. Maternal autoimmune screening should be considered to identify high-risk pregnancies. A third prenatal cfDNA screening later in pregnancy can help stratify truly high-risk pregnancies and allows patients with initially uninterpretable results to make an informed decision about diagnostic testing.

The Korea Infant Physical Growth Examination Survey (KIPGroS): a study protocol

Growth charts are important tools used to evaluate the growth status of children and estimate the nutritional and health status of the general population. In Korea, the national standardized growth charts were updated in 2017. However, the growth charts developed by the World Health Organization (WHO) are being adopted for children under 3 years of age despite a lack of evidence for their applicability to Koreans. Here we aimed to collect accurate physical measurement data, develop growth charts for infants and toddlers under 3 years of age based on breastfeeding, and evaluate the feasibility of adopting WHO growth standards as a reference in Korea. Beginning April 2020, 6 general and local hospitals were selected nationwide. Mothers and newborns without growth restriction-related factors were enrolled at birth, and they were followed up monthly until 12 months and every 3 months until 36 months. Data were collected on physical measurements; eating habits; childhood morbidity; perinatal factors; and socioeconomic, demographic, and environmental characteristics. All participating hospitals used the same standard equipment. The Korea Infant Physical Growth Examination Survey evaluated the suitability of the WHO growth charts and contributed to the next revision of the Korean growth charts. The results of this study provide a basis for developing health-related strategies for treating children in South Korea.

Cognitive and academic outcomes of large-for-gestational-age babies born at early term: A systematic review and meta-analysis

INTRODUCTION

Early induction of labor (37+0-38+6 gestational weeks) in large-for-gestational-age infants may reduce perinatal risks such as shoulder dystocia, but it may also increase the long-term risks of reduced cognitive abilities. This systematic review aimed to evaluate the cognitive and academic outcomes of large-for-gestational-age children born early term vs full term (combined or independent exposures).

MATERIAL AND METHODS

The protocol was registered in the PROSPERO database under the registration no. CRD42024528626. Five databases were searched from their inception until March 27, 2024, without language restrictions. Studies reporting childhood cognitive or academic outcomes after early term or large-for-gestational-age births were included. Two reviewers independently screened the selected studies. One reviewer extracted the data, and the other double-checked the data. The risk of bias was assessed using the Newcastle-Ottawa Quality Assessment Scale. In addition to narrative synthesis, meta-analyses were conducted where possible.

RESULTS

Of the 2505 identified articles, no study investigated early-term delivery in large-for-gestational-age babies. Seventy-six studies involving 11 460 016 children investigated the effects of either early-term delivery or large-for-gestational-age. Children born at 37 weeks of gestation (standard mean difference, -0.13; 95% confidence interval, -0.21 to -0.05), but not at 38 weeks (standard mean difference, -0.04; 95% confidence interval, -0.08 to 0.002), had lower cognitive scores than those born at 40 weeks. Large-for-gestational-age children had slightly higher cognitive scores than appropriate-for-gestational-age children (standard mean difference, 0.06; 95% confidence interval, 0.01-0.11). Similar results were obtained using the outcomes of either cognitive impairment or academic performance.

CONCLUSIONS

No study has investigated the combined effect of early-term delivery on cognitive scores in large-for-gestational-age babies. Early-term delivery may have a very small detrimental effect on cognitive scores, whereas being large for gestational age may have a very small benefit. However, evidence from randomized controlled trials or observational studies is required.

Maternal genomic profile, gestational diabetes control, and Mediterranean diet to prevent low birth weight

Low birth weight (LBW) is associated to poor health outcomes. Its causes include maternal lifestyle, obstetric factors, and fetal (epi)genetic abnormalities. This study aims to increase the knowledge regarding the genetic background of LBW by analyzing its association with a set of 110 maternal variants related to gestational diabetes mellitus, in the setting of a nutritional intervention with Mediterranean diet. The analysis follows a multifactorial approach, including maternal genetic information of 1,642 pregnant women, along with their anthropometric and metabolic characteristics. Binary logistic regression models provided 33 discovery variants associated with LBW that underwent a functional enrichment process to obtain a protein/gene interaction network and 126 enriched terms. Overall, our analysis proves that genetic variants form proximity clusters, grouped into subsets statistically associated with underlying biological processes or other maternal characteristics, which, on their part, allow early prevention of the eventual risk of LBW.

Association between risk of infant death and birth-weight z scores according to gestational age: A nationwide study using the Finnish Medical Birth Register

OBJECTIVE

To investigate the association between infant mortality and birth weight using estimated fetal weight (EFW) versus birth-weight charts, by gestational age (GA).

METHODS

This nationwide population-based study used data from the Finnish Medical Birth Register from 2006 to 2016 on non-malformed singleton live births at 24-41+6 weeks of gestation (N = 563 630). The outcome was death in the first year of life. Mortality risks by birth-weight z score, defined as a continuous variable using Maršál's EFW and Sankilampi's birth-weight charts, were assessed using generalized additive models by GA (24-27+6, 28-31+6, 32-36+6, 37-38+6, 39-41+6 weeks). We calculated z score thresholds associated with a two- and three-fold increased risk of infant death compared with newborns with a birth weight between 0 and 0.675 standard deviations.

RESULTS

The z score thresholds (with corresponding centiles in parentheses) associated with a two-fold increase in infant mortality were: -3.43 (<0.1) at 24-27+6 weeks, -3.46 (<0.1) at 28-31+6 weeks, -1.29 (9.9) at 32-36+6 weeks, -1.18 (11.9) at 37-38+6 weeks, and - 1.34 (9.0) at 39-41+6 weeks according to the EFW chart. These values were - 2.43 (0.8), -2.62 (0.4), -1.34 (9.0), -1.37 (8.5), and - 1.43 (7.6) according to the birth-weight chart.

CONCLUSION

The association between birth weight and infant mortality varies by GA whichever chart is used, suggesting that different thresholds for the screening of growth anomalies could be used across GA to identify high-risk newborns.

Early respiratory features of small for gestational age very preterm children

The short-term respiratory consequences of small for gestational (SGA) are only partially known. Our aim was to compare the early respiratory features between SGA and appropriate for gestational age (AGA) in very preterm infants. We conducted a secondary analysis of the French prospective EPIPAGE-2 cohort. Eligible children were those born alive before 32 weeks' gestation. The exposed group consisted of children with SGA. The unexposed group consisted of AGA children. SGA and AGA children were randomly matched in a ratio of 1:1 on the same gestational age and sex. Primary outcomes were age at final extubation and age at weaning from any respiratory support. Among 3.964 very preterm from the EPIPAGE2 cohort, 1123 SGA and 1123 AGA very preterm children were included in the study. The median gestational age was 30.0 weeks (interquartile range 28.0-31.0) in both groups. The median birthweight was 1440 g (1138-1680) in the AGA group and 1000 g (780-1184) in the SGA group. Invasive mechanical ventilation was less common in the SGA than in the AGA group: 68.6% (770/1123) versus 72.0% (808/1062), odds ratio 0.85 (95% CI [0.72-1.00]). In cases of mechanical ventilation, median age at final extubation was 4 days (1-23) and 2 days (1-9) in the SGA and AGA groups. Median postmenstrual age at weaning from any respiratory support was 33.4 weeks (31.7-35.9) in the SGA group and 32.4 weeks (31.4-34.3) in the AGA group.

CONCLUSION

SGA is associated with delayed extubation and respiratory support weaning.

WHAT IS KNOWN

• Small for gestational age concerns more than 30% of very preterm children. • The condition is strongly associated with increased neonatal mortality and morbidity, including bronchopulmonary dysplasia.

WHAT IS NEW

• Small for gestational age is associated with delayed extubation and respiratory support weaning in very preterm children. • Shortening invasive mechanical ventilation as much as possible is a crucial issue in this population to try to reduce the risk of bronchopulmonary dysplasia.

Effects of maternal modafinil treatment on fetal development and neonatal growth parameters - a multicenter case series of the European Network of Teratology Information Services (ENTIS)

OBJECTIVE

In recent years, safety concerns about modafinil exposure during pregnancy have emerged. In particular, increased risks for major congenital anomalies (MCA) and impaired fetal growth were reported, although study results were conflicting. Our investigation aims to examine previously reported safety signals.

METHOD

Multicenter case series based on data from 18 Teratology Information Services from 12 countries. Modafinil exposed pregnancies with an estimated date of birth before August 2019 were included in this study. For prospectively ascertained pregnancies, cumulative incidences of pregnancy outcomes, rate of nonchromosomal MCA in first trimester exposed pregnancies and percentiles of neonatal/infant weight and head circumference (HC) were calculated. Potential dose-dependent effects on fetal growth were explored by linear regression models. Retrospectively ascertained cases were screened for pattern of MCA and other adverse events.

RESULTS

One hundred and seventy-five prospectively ascertained cases were included, of which 173 were exposed at least during the first trimester. Cumulative incidences for live birth, spontaneous abortion and elective termination of pregnancy were 76.9% (95% CI, 68.0%-84.8%), 9.3% (95% CI, 5.0%-16.9%), and 13.9% (95% CI, 8.1%-23.1%), respectively. Nonchromosomal MCA was present in 3/150 live births, corresponding to an MCA rate of 2.0% (95%CI, 0.6%-6.1%), none were reported in pregnancy losses. Compared to reference standards, birth weight (BW) tended to be lower and neonatal HC to be smaller in exposed newborns (data available for 144 and 73 of 153 live births, respectively). In nonadjusted linear regression models, each 100 mg increase of average dosage per pregnancy day was associated with a decrease in standard deviation score (SDS) of -0.28 SDS (95% CI, -0.45 to -0.10) for BW and of -0.28 SDS (95% CI, -0.56 to 0.01) for HC. Screening of 22 retrospectively reported cases did not reveal any specific pattern of MCA or other adverse outcomes.

CONCLUSION

The results do not indicate an increased risk of MCA after in utero exposure to modafinil, but a tendency toward lower BW and reduced neonatal HC. However, these findings should be regarded as preliminary. Until further studies allow for a definite conclusion, modafinil should not be used during pregnancy.

Implementing telemedicine for the care of women with gestational diabetes mellitus in a rural hospital: an observational retrospective study

INTRODUCTION

Gestational diabetes mellitus (GDM) can adversely impact pregnancy outcomes. LGA is a common complication of GDM. Telemedicine is increasingly used for the follow-up of chronic diseases. The objective of this study was to evaluate if implementing a telemedicine solution for GDM could decrease the frequency of large for gestational age (LGA) newborns in a rural hospital.

METHODS

This retrospective interrupted-time-series study was conducted in a rural French hospital. An LGA newborn was defined as a newborn with weight ≥ 90th percentile. The intervention period was defined as starting 45 days after the initial introduction of the telemedicine solution. The two timeframes were: 1 January 2015 to 28 April 2017 (baseline period) and 12 June 2017 to 31 December 2021 (intervention period).

RESULTS

Between 2015 and 2021, 14,382 single births were registered in the hospital and 1,981 births from women with GDM were included. The mean age of mothers was 31.71 ± 5.54 and 32.30 ± 5.14 in women with newborns with birthweights lower and higher than the 90th percentile respectively (p=0.09). LGA births were reduced from 76/533 (14.3%) in the baseline period to 170/1,448 (11.7%) in the intervention period. This reduction became statistically significant in the multivariate analysis (protective OR: 0.541, 95%CI [0.311 to 0.930],p=0.13). Obesity was associated with LGA (OR: 1.877, 95%CI [1.394 to 2.558]).

CONCLUSIONS

The implementation of a telemedicine solution for GDM care in a rural general hospital was associated with a decrease in the adjusted odds of LGA births.

Birthweight charts customised for maternal height optimises the classification of small and large-for-gestational age newborns

AIM

To construct birthweight charts customised for maternal height and evaluate the effect of customization on SGA and LGA classification.

METHODS

Data were extracted (n = 21 350) from the MiCaS project in the Netherlands (2012-2020). We constructed the MiCaS-birthweight chart customised for maternal height using Hadlock's method. We defined seven 5-centimetre height categories from 153 to 157 cm until 183-187 cm and calculated SGA and LGA prevalences for each category, using MiCaS and current Dutch birthweight charts.

RESULTS

The MiCaS-chart showed substantially higher birthweight values between identical percentiles with increasing maternal height. In the Dutch birthweight chart, not customised for maternal height, the prevalence of SGA (p90) increased with increasing height category, from 1.4% in the lowest height category to 21.8% in the highest category (range 20.4%). In the MiCaS-birthweight chart, SGA and LGA prevalences were more constant across maternal heights, similar to overall prevalences (SGA range 3.3% and LGA range 1.7%).

CONCLUSION

Compared to the current Dutch birthweight chart, the MiCaS-birthweight chart customised for maternal height shows a more even distribution of SGA and LGA prevalences across maternal heights.

Comparison of SGA and Severe SGA rates using six size standards - Is there a difference?

BACKGROUND

Small for gestational age (SGA) neonates are known to be at an elevated risk for neonatal morbidity. Despite this, there is a growing array of proposed size standards for identifying SGA fetuses. Given the inherent differences in design, acquisition methods, and the characteristics of the populations they represent, the generalizability of these standards to diverse populations remains uncertain.

INTRODUCTION

This study aimed to assess variations in rates of SGA and severe SGA using six distinct size standards: Hadlock, Fetal Medicine Foundation (FMF), World Health Organization (WHO), Intergrowth-21 (IG-21), and two locally derived population-based size standards. The objective was to examine the differences in SGA and severe SGA rates among these size standards.

METHODS

A retrospective cohort study was conducted, encompassing all singleton deliveries in two tertiary referral hospital campuses with an annual birth count exceeding 10,000, from January 2019 to July 2022. SGA and severe SGA were defined as birthweights below the 10th or 3rd percentile, respectively, based on each growth standard. The study design included details on the setting, subjects (singleton deliveries), and the chosen size standards. Comparative analyses were performed to assess variations in SGA and severe SGA rates among these size standards.

RESULTS

Our study analyzed 32,912 singleton deliveries. We found that the choice of growth standard significantly impacted the rates of both SGA and severe SGA infants. Notably, the WHO criteria identified 5,548 (16.9 %) fetuses as SGA, compared to only 1,716 (5.2 %) using the INTERGROWTH-21 standard (p < 0.001). Similarly, for severe SGA, the FMF charts classified 2098 (6.37 %) infants, significantly higher than the 320 (1 %) identified by Dolberg's local population-based charts (p < 0.001).

CONCLUSION

Our study demonstrates a significant variety of SGA and severe SGA rates using different size standards. Therefore, the decision on the size standards in use is critical given the significant influence on clinical management.

SYNOPSIS

There are significant variations in SGA and Severe SGA rates depending on the chosen size standard.

The Negative Impact of Maternal HIV Infection on Birth Outcomes-Myth or Reality?

Human Immunodeficiency Virus (HIV) infection during pregnancy poses significant risks to both maternal and child health, with potential adverse effects on perinatal outcomes. This study aimed to compare perinatal outcomes, including birth weight, length, Apgar scores, and prematurity rates, between HIV-exposed, uninfected (HEU) children and HIV-unexposed, uninfected (HUU) children. A total of 204 neonates were included in the study, comprising 102 born to HIV-positive mothers and 102 born to uninfected mothers. Our findings revealed significant differences in birth weight (p < 0.001), length (p < 0.001), and Apgar scores at both 1 min (p = 0.003) and 5 min (p < 0.001) between HIV-exposed and -unexposed children. The HIV-exposed group exhibited lower birth weights and lengths, along with lower Apgar scores, indicating potential neonatal health challenges. No significant disparities were observed in the prematurity risk between the two groups (OR = 2.58, p = 0.126), but the risk of being born small for gestational age (SGA) in the case of HEU newborns was significantly high (OR = 17.41, p < 0.001). The significant differences in birth weight, length, and Apgar scores underscore the need for tailored healthcare interventions and support for neonates born to HIV-positive mothers. These findings contribute to our understanding of the complex interplay between maternal HIV infection and perinatal outcomes, guiding healthcare professionals in delivering targeted care for this vulnerable population.

Selecting a birth weight standard for an indigenous population in a LMIC: A prospective comparative study

OBJECTIVES

The aim of the present study was to compare birth weight (BW) distribution and proportion of BWs below or above specified percentiles in low-risk singleton pregnancies in healthy South African (SA) women of mixed ancestry with expected values according to four BW references and to determine the physiological factors affecting BW.

METHODS

This was an ancillary study of a prospective multinational cohort study, involving 7060 women recruited between August 2007 and January 2015 in two townships of Cape Town, characterized by low socioeconomic status, and high levels of drinking and smoking. Detailed information about maternal and pregnancy characteristics, including harmful exposures, was gathered prospectively, allowing us to select healthy women with uncomplicated pregnancies without any known harmful exposures. In this cohort we compared the median BW and the proportion of BWs P90, 95 and 97 according to four reference standards (INTERGROWTH-21st, customized according to the method described by Mickolajczyk, Fetal Medicine Foundation and revised Fenton reference) with expected values. Appropriate parametric and nonparametric tests were used, and sensitivity analysis was performed for infant sex, first trimester bookings and women of normal body mass index (BMI). Multiple regression was used to explore effects of confounders. Written consent and ethics approval was obtained.

RESULTS

The cohort included 739 infants. The INTERGROWTH-21st standard was closest for the actual BW-distribution and categories. Below-expected BW was associated with boys, younger, shorter, leaner women, lower parity and gravidity. Actual BW was significantly influenced by maternal weight, BMI, parity and gestational age.

CONCLUSION

Of the four references assessed in this study, the INTERGROWTH-21st standard was closest for the actual BW distribution. Maternal variables significantly influence BW.

Trimester-specific association between fetal growth and physical activity in pregnant women: total physical activity vs moderate-to-vigorous exercise

OBJECTIVE

To investigate the trimester-specific associations between maternal total physical activity level vs moderate-to-vigorous exercise and fetal growth disorders.

METHODS

We analyzed 2062 mother-neonate pairs participating in the longitudinal China Medical University Birth Cohort Study. The Pregnancy Physical Activity Questionnaire was used to assess the physical activity level of women during the three trimesters. A higher level of total physical activity was defined as meeting or exceeding the cohort-specific 75th percentile, and a higher level of exercise was defined according to the Physical Activity Guidelines for Americans. Fetal growth disorder was defined as small-for-gestational age (SGA) or large-for-gestational age (LGA) at birth.

RESULTS

Of the neonates included in this study, 7.1% were SGA and 15.5% were LGA. A higher level of total physical activity during the first trimester (adjusted relative risk (aRR), 0.62 (95% CI, 0.42-0.91)) and second trimester (aRR, 0.62 (95% CI, 0.41-0.95)) was associated with a lower risk of SGA, and a higher level of total physical activity during the third trimester was associated with a lower risk of LGA (aRR, 0.73 (95% CI, 0.54-0.97)). When analyzing physical activity by subtype, a higher level of occupational physical activity during the first and second trimesters was associated negatively with SGA risk, and higher levels of occupational and low-intensity physical activity during the first trimester were associated negatively with LGA risk. No significant association was found between maternal adherence to the Physical Activity Guidelines for Americans and risk of fetal growth disorders.

CONCLUSIONS

A higher total physical activity level during the first and second trimesters was associated with a decreased risk of SGA, whereas a higher total physical activity level in the third trimester was associated with a decreased risk of LGA. Pregnant women should be advised to increase their total physical activity levels instead of focusing on engaging in only moderate-to-vigorous exercise. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.

Intrauterine exposure to maternal opioid maintenance treatment and associated risk factors may impair child growth

AIM

How maternal opioid maintenance treatment (OMT) affects children is under-researched. This population-based registry study investigated child growth and somatic health following intrauterine exposure to this treatment.

METHODS

Children born between 1 March 2011 and 30 May 2021 to mothers who used buprenorphine, buprenorphine-naloxone, or methadone throughout their pregnancies were followed for 2 years at the Helsinki University Hospital, Finland. Appropriate statistical tests were used to compare the treatment groups.

RESULTS

Of the 67 neonates, 52% were male, 96% were born full-term and 63% were treated for neonatal opioid withdrawal syndrome. Otherwise, the children were predominantly healthy, although relatively small: 22% were small for gestational age, the methadone group children being the smallest. Foetal exposure to maternal methadone treatment, illicit drugs, hepatitis C and smoking were associated with small for gestational age; the former two were also associated with later slower growth, especially head growth and weight gain (p < 0.001). However, 29% were overweight at 2 years.

CONCLUSION

Using child growth as the outcome, we found that buprenorphine-naloxone and buprenorphine-monotherapy had equal effects as forms of maternal OMT. Exposure to multiple risk factors may harm foetal and subsequent growth. We recommend long-term follow-up of children exposed to maternal OMT.

Trajectory of gestational weight gain is related to birthweight: The TAWS cohort study in China

Few studies have reported the timing and amount of gestational weight gain (GWG) to prevent large-for-gestational-age (LGA) or small-for-gestational-age (SGA). This study aimed to evaluate the association of GWG velocity in each trimester with LGA or SGA based on data from the Taicang and Wuqiang cohort study (TAWS, n = 2008). We used a linear mixed model to evaluate the association of trimester-specific GWG velocity with birthweight categories and stratified by prepregnancy body mass index category and parity. For normal-weight pregnant women, mothers with LGA births had higher GWG velocities than mothers with appropriate-for-gestational-age (AGA) births in the first trimester (0.108 vs. 0.031 kg/week, p < 0.01), second trimester (0.755 vs. 0.631 kg/week, p < 0.01) and third trimester (0.664 vs. 0.594 kg/week, p < 0.01); in contrast, mothers with SGA births had lower GWG velocities than mothers with AGA births in the second trimester (0.528 vs. 0.631 kg/week, p < 0.01) and third trimester (0.541 vs. 0.594 kg/week, p < 0.01). For normal-weight pregnant women with AGA births, multiparous women had lower GWG velocities than primiparous women in the second (0.602 vs. 0.643 kg/week, p < 0.01) and third trimesters (0.553 vs. 0.606 kg/week, p < 0.01). Therefore, for normal-weight women, LGA prevention would begin in early pregnancy and continue until delivery and the second and third trimesters may be critical periods for preventing SGA; in addition, among normal-weight pregnant women with AGA births, multiparous women tend to have lower weight gain velocities than primiparous women.

Disease activity and neonatal outcomes after exposure to natalizumab throughout pregnancy

BACKGROUND

After natalizumab discontinuation severe relapses can occur despite pregnancy, but third trimester exposure is associated with neonatal haematological abnormalities (HA). The best time point for stopping natalizumab during pregnancy is unclear.

METHODS

Prospective, observational cohort with 350 natalizumab exposed pregnancies from the German Multiple Sclerosis and Pregnancy Registry. Clinical disease activity and neonatal outcomes are compared between women with natalizumab discontinuation during (1st Trim-group) versus after the first trimester (maintaining-group) and for subgroup analysis before (<30-subgroup) or after (≥30-subgroup) the 30th gestational week (gw).

RESULTS

Baseline characteristics did not significantly differ between the 1st Trim-group (n=179; median exposure duration: 2.60 gw, IQR 1.30-3.60) and the maintaining-group (n=171; median exposure duration: 30.9 gw, IQR 26.9-33.3). Fewer relapses occurred during pregnancy and the postpartum year in the maintaining-group (25.7%) compared with the 1st Trim-group (62.6%; p<0.001). Women in ≥30-subgroup had a significantly lower relapse risk in the first 6 months postpartum (relapse rate ratio: 0.36, 95% CI: 0.15 to 0.84). In total, 7.5% retained meaningful disability 12 months postpartum. No significant effect on neonatal outcomes were observed, but anaemia (OR: 2.62, 95% CI: 1.12 to 6.52) and thrombocytopaenia (OR: 2.64, 95% CI: 1.15 to 6.46) were significantly more common in the ≥30-subgroup. 21.8% of all neonates were born small for gestational age, independent of the timing of natalizumab discontinuation.

CONCLUSION

Continuing natalizumab during pregnancy after gw 30 decreases the relapse risk postpartum going along with a higher risk for HA in the newborns. These results add relevant knowledge as a basis for informed risk-benefit discussion.

The Approach to a Child with Dysmorphic Features: What the Pediatrician Should Know

The advancement of genetic knowledge and the discovery of an increasing number of genetic disorders has made the role of the geneticist progressively more complex and fundamental. However, most genetic disorders present during childhood; thus, their early recognition is a challenge for the pediatrician, who will be also involved in the follow-up of these children, often establishing a close relationship with them and their families and becoming a referral figure. In this review, we aim to provide the pediatrician with a general knowledge of the approach to treating a child with a genetic syndrome associated with dysmorphic features. We will discuss the red flags, the most common manifestations, the analytic collection of the family and personal medical history, and the signs that should alert the pediatrician during the physical examination. We will offer an overview of the physical malformations most commonly associated with genetic defects and the way to describe dysmorphic facial features. We will provide hints about some tools that can support the pediatrician in clinical practice and that also represent a useful educational resource, either online or through apps downloaded on a smartphone. Eventually, we will offer an overview of genetic testing, the ethical considerations, the consequences of incidental findings, and the main indications and limitations of the principal technologies.

Italian neonatal birthweight charts derived from INeS not separated by birth order

BACKGROUND

Identifying high-risk neonates with abnormal fetal growth is crucial for health risk prediction and early intervention. Small for gestational age (SGA) and large for gestational age (LGA) classifications highlight neonates having a higher risk for postnatal diseases. Accurate diagnosis depends on precise anthropometric measurements and appropriate reference data. In 2010, specific neonatal charts for Italian singletons (INeS charts) were published, tracing separately for first- and later-born neonates due to a 3% birth weight difference. We present INeS charts for birth weight non-separated by first- and later-born babies useful when information on parity is unavailable or unreliable, or for better comparisons with other neonatal charts that are not separated by birth-order.

METHODS

INeS charts were traced using a parametric function. Starting with the parameters estimates published in a different paper, INeS charts not separated by birth order were traced for the gestational age range of 23 to 42 weeks. In a second step the charts were parametrized as Cole and Green Lambda Mu and Sigma (LMS) model, allowing computation of standard deviation scores.

RESULTS

The centiles of non-separated INeS charts follow between first- and later-born charts. Distances varied due to changing first-born proportions with gestational age, Max differences of about 100g with later born and 70g with first-born were observed at term. S and L functions have a similar shape for boys and girls. S function shows a pick at about 29 weeks, L function has positive values in all the range of gestational age with a pick at 39 weeks.

CONCLUSIONS

The study presents non-separated Birth Weight INeS charts, bridging the gap when parity information is unavailable. Differences with separated charts were generally small, making them reliable for neonatal health assessment. Insights from L and S parameters contribute to standardized birth weight and adjust it by sex and Gestational Age, useful for defining SGA or LGA neonates. The paper enhances neonatal care tools, showcasing INeS chart flexibility in different clinical scenarios and supporting neonatology research.

Mortality Risk in US Neonatal Intensive Care Unit Infants by Birth Size Classifications Comparing Three Growth Curves

INTRODUCTION

Three widely referenced growth curves classify infant birth anthropometric measurements as small (SGA), appropriate (AGA), or large (LGA) for gestational age (GA) differently. We assessed how these differences in assignment affect the identification and prediction of neonatal intensive care unit (NICU) mortality risk in US preterm infants.

METHODS

Birth data of infants admitted to NICUs from the Pediatrix Clinical Data Warehouse (2013-2018) were analyzed. Birth weight, length, and head circumference of 46,724 singleton infants (24-32 weeks GA) were classified as SGA, AGA, or LGA using the Olsen, Fenton, and INTERGROWTH-21st curves. NICU mortality risk based on birth size classification was analyzed using unadjusted and adjusted logistic regression stratified by GA.

RESULTS

Odds of mortality were increased with SGA classification at all GAs, size measurements, and curve sets, compared with AGA infants. LGA classification for weight was associated with lower mortality risk at 24 weeks GA and higher risk at 30 weeks GA. Odds of mortality did not differ significantly across curve sets. Classification of size at birth alone had relatively low predictive ability to identify mortality risk, with unadjusted AUCs near 0.5 for all analyses.

CONCLUSION

There were no significant differences across curve sets in predicting mortality. Classification of size at birth is a relatively imprecise method to identify infants at risk for NICU mortality.

The clinical performance and population health impact of birthweight-for-gestational age indices at term gestation

BACKGROUND

The assessment of birthweight for gestational age and the identification of small- and large-for-gestational age (SGA and LGA) infants remain contentious, despite the recent creation of the Intergrowth 21st Project and World Health Organisation (WHO) birthweight-for-gestational age standards.

OBJECTIVE

We carried out a study to identify birthweight-for-gestational age cut-offs, and corresponding population-based, Intergrowth 21st and WHO centiles associated with higher risks of adverse neonatal outcomes, and to evaluate their ability to predict serious neonatal morbidity and neonatal mortality (SNMM) at term gestation.

METHODS

The study population was based on non-anomalous, singleton live births between 37 and 41 weeks' gestation in the United States from 2003 to 2017. SNMM included 5-min Apgar score <4, neonatal seizures, need for assisted ventilation, and neonatal death. Birthweight-specific SNMM was modelled by gestational week using penalised B-splines. The birthweights at which SNMM odds were minimised (and higher by 10%, 50% and 100%) were estimated, and the corresponding population, Intergrowth 21st, and WHO centiles were identified. The clinical performance and population impact of these cut-offs for predicting SNMM were evaluated.

RESULTS

The study included 40,179,663 live births and 991,486 SNMM cases. Among female singletons at 39 weeks' gestation, SNMM odds was lowest at 3203 g birthweight, and 10% higher at 2835 g and 3685 g (population centiles 11th and 82nd, Intergrowth centiles 17th and 88th and WHO centiles 15th and 85th). Birthweight cut-offs were poor predictors of SNMM, for example, the cut-offs associated with 10% and 50% higher odds of SNMM among female singletons at 39 weeks' gestation resulted in a sensitivity, specificity, and population attributable fraction of 12.5%, 89.4%, and 2.1%, and 2.9%, 98.4% and 1.3%, respectively.

CONCLUSIONS

Reference- and standard-based birthweight-for-gestational age indices and centiles perform poorly for predicting adverse neonatal outcomes in individual infants, and their associated population impact is also small.

Neonatal mortality risk of large-for-gestational-age and macrosomic live births in 15 countries, including 115.6 million nationwide linked records, 2000-2020

OBJECTIVE

We aimed to compare the prevalence and neonatal mortality associated with large for gestational age (LGA) and macrosomia among 115.6 million live births in 15 countries, between 2000 and 2020.

DESIGN

Population-based, multi-country study.

SETTING

National healthcare systems.

POPULATION

Liveborn infants.

METHODS

We used individual-level data identified for the Vulnerable Newborn Measurement Collaboration. We calculated the prevalence and relative risk (RR) of neonatal mortality among live births born at term + LGA (>90th centile, and also >95th and >97th centiles when the data were available) versus term + appropriate for gestational age (AGA, 10th-90th centiles) and macrosomic (≥4000, ≥4500 and ≥5000 g, regardless of gestational age) versus 2500-3999 g. INTERGROWTH 21st served as the reference population.

MAIN OUTCOME MEASURES

Prevalence and neonatal mortality risks.

RESULTS

Large for gestational age was common (median prevalence 18.2%; interquartile range, IQR, 13.5%-22.0%), and overall was associated with a lower neonatal mortality risk compared with AGA (RR 0.83, 95% CI 0.77-0.89). Around one in ten babies were ≥4000 g (median prevalence 9.6% (IQR 6.4%-13.3%), with 1.2% (IQR 0.7%-2.0%) ≥4500 g and with 0.2% (IQR 0.1%-0.2%) ≥5000 g). Overall, macrosomia of ≥4000 g was not associated with increased neonatal mortality risk (RR 0.80, 95% CI 0.69-0.94); however, a higher risk was observed for birthweights of ≥4500 g (RR 1.52, 95% CI 1.10-2.11) and ≥5000 g (RR 4.54, 95% CI 2.58-7.99), compared with birthweights of 2500-3999 g, with the highest risk observed in the first 7 days of life.

CONCLUSIONS

In this population, birthweight of ≥4500 g was the most useful marker for early mortality risk in big babies and could be used to guide clinical management decisions.

Quantitative Proteomics of Maternal Blood Plasma in Isolated Intrauterine Growth Restriction

Intrauterine growth restriction (IUGR) remains a significant concern in modern obstetrics, linked to high neonatal health problems and even death, as well as childhood disability, affecting adult quality of life. The role of maternal and fetus adaptation during adverse pregnancy is still not completely understood. This study aimed to investigate the disturbance in biological processes associated with isolated IUGR via blood plasma proteomics. The levels of 125 maternal plasma proteins were quantified by liquid chromatography-multiple reaction monitoring mass spectrometry (LC-MRM MS) with corresponding stable isotope-labeled peptide standards (SIS). Thirteen potential markers of IUGR (Gelsolin, Alpha-2-macroglobulin, Apolipoprotein A-IV, Apolipoprotein B-100, Apolipoprotein(a), Adiponectin, Complement C5, Apolipoprotein D, Alpha-1B-glycoprotein, Serum albumin, Fibronectin, Glutathione peroxidase 3, Lipopolysaccharide-binding protein) were found to be inter-connected in a protein-protein network. These proteins are involved in plasma lipoprotein assembly, remodeling, and clearance; lipid metabolism, especially cholesterol and phospholipids; hemostasis, including platelet degranulation; and immune system regulation. Additionally, 18 proteins were specific to a particular type of IUGR (early or late). Distinct patterns in the coagulation and fibrinolysis systems were observed between isolated early- and late-onset IUGR. Our findings highlight the complex interplay of immune and coagulation factors in IUGR and the differences between early- and late-onset IUGR and other placenta-related conditions like PE. Understanding these mechanisms is crucial for developing targeted interventions and improving outcomes for pregnancies affected by IUGR.

What helps define outcomes in persistent uninterpretable non-invasive prenatal testing: Maternal factors, fetal fraction or quality scores?

OBJECTIVES

To assess maternal characteristics and comorbidities in patients with persistent uninterpretable non-invasive prenatal testing (NIPT) and to evaluate the association with adverse pregnancy outcome in a general risk population.

METHODS

A retrospective cohort study (July 2017-December 2020) was conducted of patients with persistent uninterpretable NIPT samples. Maternal characteristics and pregnancy outcomes were compared with the general Belgian obstetric population.

RESULTS

Of the 148 patients with persistent uninterpretable NIPT, 37 cases were due to a low fetal fraction (LFF) and 111 due to a low quality score (LQS). Both groups (LFF, LQS) showed more obesity (60.6%, 42.4%), multiple pregnancies (18.9%, 4.5%) and more obstetrical complications. In the LQS group, a high rate of maternal auto-immune disorders (30.6%) was seen and hypertensive complications (17.6%), preterm birth (17.6%) and neonatal intensive care unit (NICU) admission (22%) were significantly increased. In the LFF group hypertensive complications (21.6%), gestational diabetes (20.6%), preterm birth (27%), SGA (25.6%), major congenital malformations (11.4%), c-section rate (51.4%) and NICU admission (34.9%) were significantly increased. Chromosomal abnormalities were not increased in both groups.

CONCLUSIONS

Patients with persistent uninterpretable NIPT have significantly more maternal obesity, comorbidities and adverse pregnancy outcome than the general population and should receive high-risk pregnancy care. Distinguishing between LFF and LQS optimizes counseling because maternal characteristics and pregnancy outcome differ between these groups.

From Bariatric Surgery to Conception: The Ideal Timing to Optimize Fetal Weight

PURPOSE

Bariatric surgery (BS) increases the risk of small for gestational age (SGA) neonates. Guidelines recommend postponing pregnancy for 12-24 months, but optimal surgery-to-conception interval (BSCI) remains uncertain. We aimed to evaluate the impact of BSCI on birth weight and SGA.

MATERIALS AND METHODS

Retrospective cohort study of 42 pregnancies following BS, including Roux-en-Y gastric bypass, gastric sleeve, adjustable gastric banding and biliopancreatic diversion. Neonates were classified as SGA if birth weight < 10th percentile. Optimal BSCI was obtained from the analysis of ROC curves, and pregnancies were compared by that cut-off.

RESULTS

There was a linear association between BSCI and birth weight and an inverse association with SGA, with each additional month of BSCI translating into additional 4.5 g (95%CI: 2.0-7.0) on birth weight and -6% risk of SGA (95%CI: 0.90-0.99). We established a cut-off of 24.5 months of BSCI for lower risk of SGA. Pregnancies conceived in the first 24 months had a more than tenfold increased risk of SGA (OR 12.6, 95%CI: 2.4-66.0), even when adjusted for maternal age, gestational diabetes and inadequate gestational weight gain.

CONCLUSION

BSCI was associated with birth weight and SGA. Our results are in line with the recommendations of BSCI of at least 24 months to reduce the risk of SGA.

Pregnancy after kidney transplantation: an observational study on maternal, graft and offspring outcomes in view of current literature

Introduction

Pregnancy after kidney transplantation (KTx) is considered to have a high risk of non-negligible complications for the mother, the allograft, and the offspring. With an increased incidence of these pregnancies over the past decades, transplant nephrologists and specialized obstetricians face increasing challenges, with scarce literature regarding long-term outcomes.

Methods

We retrospectively collected data from all women with at least one live birth pregnancy after KTx who were followed at our tertiary hospital between 2000 and 2021 to study maternal, graft and fetal outcomes.

Results

Ten patients underwent 14 live birth pregnancies after KTx. Preponderant maternal complications were stage 1 acute kidney injury (43%), urinary tract infections (UTI, 43%), progression of proteinuria without diagnostic criteria for preeclampsia (29%), and preeclampsia (14%). Median baseline serum creatinine at conception was 126.5 µmol/L [median estimated glomerular filtration rate (eGFR) 49 mL/min/1.73m2], and eGFR tended to be lower than baseline at follow-ups. Overall, there was no increase in preexisting or occurrence of de novo donor-specific antibodies. No graft loss was documented within the 2-year follow-up. There were nine premature births (64%), with a median gestational age of 35.7 weeks. The median birth weight, height, and head circumference were 2,560 g, 45.5 cm, and 32.1 cm, respectively. These measurements tended to improve over time, reaching a higher percentile than at birth, especially in terms of height, but on average remained under the 50th percentile curve.

Discussion

Overall, pregnancies after KTx came with a range of risks for the mother, with a high prevalence of cesarean sections, emergency deliveries, UTI, and preeclampsia, and for the child, with a high proportion of prematurity, lower measurements at birth, and a tendency to stay under the 50th percentile in growth charts. The short- and long-term impact on the allograft seemed reassuring; however, there was a trend toward lower eGFR after pregnancy. With these data, we emphasize the need for a careful examination of individual risks via specialized pre-conception consultations and regular monitoring by a transplant nephrologist and a specialist in maternal-fetal medicine during pregnancy. More data about the long-term development of children are required to fully apprehend the impact of KTx on offspring.

Trend of pregnancy outcomes in type 1 diabetes compared to control women: a register-based analysis in 1996-2018

Introduction

In 1989, the St Vincent declaration aimed to approximate pregnancy outcomes of diabetes to that of healthy pregnancies. We aimed to compare frequency and trends of outcomes of pregnancies affected by type 1 diabetes and controls in 1996-2018.

Methods

We used anonymized records of a mandatory nation-wide registry of all deliveries between gestational weeks 24 and 42 in Hungary. We included all singleton births (4,091 type 1 diabetes, 1,879,183 controls) between 1996 and 2018. We compared frequency and trends of pregnancy outcomes between type 1 diabetes and control pregnancies using hierarchical Poisson regression.

Results

The frequency of stillbirth, perinatal mortality, large for gestational age, caesarean section, admission to neonatal intensive care unit (NICU), and low Appearance, Pulse, Grimace, Activity, and Respiration (APGAR) score was 2-4 times higher in type 1 diabetes compared to controls, while the risk of congenital malformations was increased by 51% and SGA was decreased by 42% (all p<0.05). These observations remained significant after adjustment for confounders except for low APGAR scores. We found decreasing rate ratios comparing cases and controls over time for caesarean sections, low APGAR scores (p<0.05), and for NICU admissions (p=0.052) in adjusted models. The difference between cases and controls became non-significant after 2009. No linear trends were observed for the other outcomes.

Conclusions

Although we found that the rates of SGA, NICU care, and low APGAR score improved in pregnancies complicated by type 1 diabetes, the target of the St Vincent Declaration was only achieved for the occurrence of low APGAR scores.

Intrauterine growth restriction, prematurity, and low birth weight: risk phenotypes of neonatal death, Rio de Janeiro State, Brazil

Intrauterine growth restriction and prematurity determine low birth weight. The combination of the three conditions results in different neonatal phenotypes that interfere with child survival. Neonatal prevalence, survival and mortality were estimated according to neonatal phenotypes in the cohort of live births in 2021 in the state of Rio de Janeiro, Brazil. In this study, live births of multiple pregnancies, with congenital anomalies and inconsistencies in the information of weight and gestational age were excluded. The Intergrowth curve was used to classify weight adequacy. Mortality (< 24 hours, 1-6 and 7-27 days) and survival (Kaplan-Meier) were estimated. In total, 6.8%, 5.5%, and 9.5% of the 174,399 live births were low birth weight, small for gestational age (SGA), and premature, respectively. Considering low birth weight live births, 39.7% were SGA and 70% were premature. The neonatal phenotypes were heterogeneous according to maternal, delivery, pregnancy, and newborn characteristics. The mortality rate per 1,000 live births was high for low birth weight premature newborns, both SGA (78.1) and AGA (adequate for gestational age: 61.1), at all specific ages. Reductions in the survival rate were observed when comparing non-low birth weight and AGA term live births. The estimated prevalence values were lower than those of other studies, partly due to the exclusion criteria adopted. The neonatal phenotypes identified children who were more vulnerable and at higher risk of death. Prematurity contributed more to mortality than SGA, and its prevention is necessary to reduce neonatal mortality in the state of Rio de Janeiro.

Regional references vs. international standards for assessing weight and length by gestational age in Lithuanian neonates

Introduction

There is no global consensus as to which standards are the most appropriate for the assessment of birth weight and length. The study aimed to compare the applicability of regional and global standards to the Lithuanian newborn population by sex and gestational age, based on the prevalence of small or large for gestational age (SGA/LGA).

Materials and Methods

Analysis was performed on neonatal length and weight data obtained from the Lithuanian Medical Birth Register from 1995 to 2015 (618,235 newborns of 24-42 gestational weeks). Their distributions by gestation and sex were estimated using generalized additive models for location, scale, and shape (GAMLSS), and the results were compared with the INTERGROWTH-21st (IG-21) standard to evaluate the prevalence of SGA/LGA (10th/90th centile) at different gestational ages.

Results

The difference in median length at term between the local reference and IG-21 was 3 cm-4 cm, while median weight at term differed by 200 g. The Lithuanian median weight at term was higher than in IG-21 by a full centile channel width, while the median length at term was higher by two channel widths. Based on the regional reference, the prevalence rates of SGA/LGA were 9.7%/10.1% for boys and 10.1%/9.9% for girls, close to the nominal 10%. Conversely, based on IG-21, the prevalence of SGA in boys/girls was less than half (4.1%/4.4%), while the prevalence of LGA was double (20.7%/19.1%).

Discussion

Regional population-based neonatal references represent Lithuanian neonatal weight and length much more accurately than the global standard IG-21 which provides the prevalence rates for SGA/LGA that differ from the true values by a factor of two.

Vulnerable newborn types: Analysis of population-based registries for 165 million births in 23 countries, 2000-2021

OBJECTIVE

To examine the prevalence of novel newborn types among 165 million live births in 23 countries from 2000 to 2021.

DESIGN

Population-based, multi-country analysis.

SETTING

National data systems in 23 middle- and high-income countries.

POPULATION

Liveborn infants.

METHODS

Country teams with high-quality data were invited to be part of the Vulnerable Newborn Measurement Collaboration. We classified live births by six newborn types based on gestational age information (preterm <37 weeks versus term ≥37 weeks) and size for gestational age defined as small (SGA, <10th centile), appropriate (10th-90th centiles), or large (LGA, >90th centile) for gestational age, according to INTERGROWTH-21st standards. We considered small newborn types of any combination of preterm or SGA, and term + LGA was considered large. Time trends were analysed using 3-year moving averages for small and large types.

MAIN OUTCOME MEASURES

Prevalence of six newborn types.

RESULTS

We analysed 165 017 419 live births and the median prevalence of small types was 11.7% - highest in Malaysia (26%) and Qatar (15.7%). Overall, 18.1% of newborns were large (term + LGA) and was highest in Estonia 28.8% and Denmark 25.9%. Time trends of small and large infants were relatively stable in most countries.

CONCLUSIONS

The distribution of newborn types varies across the 23 middle- and high-income countries. Small newborn types were highest in west Asian countries and large types were highest in Europe. To better understand the global patterns of these novel newborn types, more information is needed, especially from low- and middle-income countries.

Population-based references for waist and hip circumferences, waist-to-hip and waist-to-height ratios for children and adolescents, and evaluation of their predictive ability

Childhood obesity is a public health problem globally as well as in Poland. This paper aimed to provide age- and sex-specific waist circumference, hip circumference, waist-to-height ratio and waist-to-hip ratio normative values for Polish children and adolescents aged 3 - 18 years for more precise monitoring of abdominal fat accumulation. The waist circumference, hip circumference, waist-to-height ratio and waist-to-hip ratio references were constructed with the lambda-mu-sigma (LMS) method using data from two nationally representative health surveys: the OLA study and the OLAF study, the largest available paediatric surveys in Poland which provided measured height, weight, waist, hip and blood pressure for 22,370 children and adolescents aged 3 - 18 years. The predictive ability of newly established references for overweight/obesity as defined by the International Obesity Task Force criteria and elevated blood pressure was tested with receiver operating characteristic. Abdominal obesity cut-offs linked to adult cardiometabolic cut-offs were established. Reference values for waist circumference, hip circumference, waist-to-height ratio and waist-to-hip ratio are presented, as well as waist circumference, waist-to-height ratio and waist-to-hip ratio cut-off values linked to adult's cut-offs of cardiometabolic risk. The predictive value for overweight and obesity of population-based waist, hip and waist-to-height ratio references was outstanding-area under the receiver operating characteristic curve > 0.95 in both sexes, whereas with regard to the elevated blood pressure predictive ability was low-area under the receiver operating characteristic curve < 0.65.   Conclusion: This paper presents the first waist, hip, waist-to-height ratio and waist-to-hip ratio references for Polish children and adolescents aged 3-18 years. The 90th and 95th percentile and cut-offs linked to adult thresholds for cardiometabolic risk are proposed as cut-offs for abdominal obesity. What is Known: • Waist circumference, waist-to-height ratio and waist-to-hip ratio are used to assess abdominal obesity in children and adults. • In Poland, there is no abdominal obesity and hip circumference references for children and adolescents from 3 to 18 years of age. What is New: • Population-based references of central obesity indices and hip references for children and youth aged 3-18 years and cardiometabolic risk thresholds for children and adolescents linked to adult's cut-offs were established.

[Review of the literature on intrauterine and birthweight charts]

OBJECTIVES

To describe the main intrauterine and birthweight charts and review the studies comparing their performance for the identification of infants at risk of adverse perinatal outcomes.

METHODS

We carried out a literature search using Medline and selected the charts most frequently cited in the literature, French charts and those recently published.

RESULTS

Current knowledge on the association between mortality and morbidity and growth anomalies (small and large for gestational age) mostly relies on the use of descriptive charts which describe the weight distribution in unselected populations. Prescriptive charts, which describe ideal growth in low risk populations, have been constructed more recently. Few studies have evaluated whether the thresholds used to identify infants at risk with descriptive charts (such as the 3^rd or the 10^th percentile) are applicable to prescriptive charts. There is a large variability in the percentage of fetuses or newborns identified as being at risk by each chart, with from 3 to 25% having with a weight under the 10^th percentile, regardless of whether descriptive or prescriptive charts are used. The sensitivity and specificity of antenatal screening for small or large for gestational age newborns depends on the chart used to derive estimated fetal weight percentiles.

CONCLUSION

There is marked variability between intrauterine growth charts that can influence the percentage of infants identified as having abnormal growth. These results show that before the adoption of a growth chart, it is essential to evaluate whether it adequately describes the population and its performance for identifying of infants at risk because of growth anomalies.

Circulating biomarkers associated with placental dysfunction and their utility for predicting fetal growth restriction

Fetal growth restriction (FGR) leading to low birth weight (LBW) is a major cause of neonatal morbidity and mortality worldwide. Normal placental development involves a series of highly regulated processes involving a multitude of hormones, transcription factors, and cell lineages. Failure to achieve this leads to placental dysfunction and related placental diseases such as pre-clampsia and FGR. Early recognition of at-risk pregnancies is important because careful maternal and fetal surveillance can potentially prevent adverse maternal and perinatal outcomes by judicious pregnancy surveillance and careful timing of birth. Given the association between a variety of circulating maternal biomarkers, adverse pregnancy, and perinatal outcomes, screening tests based on these biomarkers, incorporating maternal characteristics, fetal biophysical or circulatory variables have been developed. However, their clinical utility has yet to be proven. Of the current biomarkers, placental growth factor and soluble fms-like tyrosine kinase 1 appear to have the most promise for placental dysfunction and predictive utility for FGR.

The accuracy of international and national fetal growth charts in detecting small-for-gestational-age infants using the Lambda-Mu-Sigma method

Objective

To construct a national fetal growth chart using retrospective data and compared its diagnostic accuracy in predicting SGA at birth with existing international growth charts.

Method

This is a retrospective study where datasets from May 2011 to Apr 2020 were extracted to construct the fetal growth chart using the Lambda-Mu-Sigma method. SGA is defined as birth weight <10th centile. The local growth chart's diagnostic accuracy in detecting SGA at birth was evaluated using datasets from May 2020 to Apr 2021 and was compared with the WHO, Hadlock, and INTERGROWTH-21st charts. Balanced accuracy, sensitivity, and specificity were reported.

Results

A total of 68,897 scans were collected and five biometric growth charts were constructed. Our national growth chart achieved an accuracy of 69% and a sensitivity of 42% in identifying SGA at birth. The WHO chart showed similar diagnostic performance as our national growth chart, followed by the Hadlock (67% accuracy and 38% sensitivity) and INTERGROWTH-21st (57% accuracy and 19% sensitivity). The specificities for all charts were 95-96%. All growth charts showed higher accuracy in the third trimester, with an improvement of 8-16%, as compared to that in the second trimester.

Conclusion

Using the Hadlock and INTERGROWTH-21st chart in the Malaysian population may results in misdiagnose of SGA. Our population local chart has slightly higher accuracy in predicting preterm SGA in the second trimester which can enable earlier intervention for babies who are detected as SGA. All growth charts' diagnostic accuracies were poor in the second trimester, suggesting the need of improvising alternative techniques for early detection of SGA to improve fetus outcomes.

International Consensus Guideline on Small for Gestational Age (SGA): Etiology and Management from Infancy to Early Adulthood

This International Consensus Guideline was developed by experts in the field of SGA of 10 pediatric endocrine societies worldwide. A consensus meeting was held and 1300 articles formed the basis for discussions. All experts voted about the strengths of the recommendations. The guideline gives new and clinically relevant insights into the etiology of short stature after SGA birth, including novel knowledge about (epi)genetic causes. Besides, it presents long-term consequences of SGA birth and new treatment options, including treatment with gonadotropin-releasing hormone agonist (GnRHa) in addition to growth hormone (GH) treatment, and the metabolic and cardiovascular health of young adults born SGA after cessation of childhood-GH-treatment in comparison with appropriate control groups. To diagnose SGA, accurate anthropometry and use of national growth charts are recommended. Follow-up in early life is warranted and neurodevelopment evaluation in those at risk. Excessive postnatal weight gain should be avoided, as this is associated with an unfavorable cardio-metabolic health profile in adulthood. Children born SGA with persistent short stature < -2.5 SDS at age 2 years or < -2 SDS at age of 3-4 years, should be referred for diagnostic work-up. In case of dysmorphic features, major malformations, microcephaly, developmental delay, intellectual disability and/or signs of skeletal dysplasia, genetic testing should be considered. Treatment with 0.033-0.067 mg GH/kg/day is recommended in case of persistent short stature at age of 3-4 years. Adding GnRHa treatment could be considered when short adult height is expected at pubertal onset. All young adults born SGA require counseling to adopt a healthy lifestyle.

Implications for quantifying early life growth trajectories of term-born infants using INTERGROWTH-21st newborn size standards at birth in conjunction with World Health Organization child growth standards in the postnatal period

BACKGROUND

The INTERGROWTH-21st sex and gestational age (GA) specific newborn size standards (IG-NS) are intended to complement the World Health Organization Child Growth Standards (WHO-GS), which are not GA-specific. We examined the implications of using IG-NS at birth and WHO-GS at postnatal ages in longitudinal epidemiologic studies.

OBJECTIVES

The aim of this study was to quantify the extent to which standardised measures of newborn size and growth are affected when using WHO-GS versus IG-NS at birth among term-born infants.

METHODS

Data from two prenatal trials in Bangladesh (n = 755) and The Gambia (n = 522) were used to estimate and compare size at birth and growth from birth to 3 months when using WHO-GS only ('WHO-GS') versus IG-NS at birth and WHO-GS postnatally ('IG-NS'). Mean length-for-age (LAZ), weight-for-age (WAZ) and head circumference-for-age (HCAZ), and the prevalence of undernutrition (stunting: LAZ < -2SD; underweight: WAZ < -2SD; and microcephaly: HCAZ < -2SD) were estimated overall and by GA strata [early-term (370/7 -386/7 ), full-term (390/7 -406/7 ) and late-term (410/7 -430/7 )]. We used Bland-Altman plots to compare continuous indices and Kappa statistic to compare categorical indicators.

RESULTS

At birth, mean LAZ, WAZ and HCAZ, and the prevalence of undernutrition were most similar among newborns between 39 and 40 weeks of GA when using WHO-GS versus IG-NS. However, anthropometric indices were systematically lower among early-term infants and higher among late-term infants when using WHO-GS versus IG-NS. Early-term and late-term infants demonstrated relatively faster and slower growth, respectively, when using WHO-GS versus IG-NS, with the direction and magnitude of differences varying between anthropometric indices. Individual-level differences in attained size and growth, when using WHO-GS versus IG-NS, were greater than 0.2 SD in magnitude for >60% of infants across all anthropometric indices.

CONCLUSIONS

Using IG-NS at birth with WHO-GS postnatally is acceptable for full-term infants but may give a misleading interpretation of growth trajectories among early- and late-term infants.

The choice of reference chart affects the strength of the association between malaria in pregnancy and small for gestational age: an individual participant data meta-analysis comparing the Intergrowth-21 with a Tanzanian birthweight chart

BACKGROUND

The prevalence of small for gestational age (SGA) may vary depending on the chosen weight-for-gestational-age reference chart. An individual participant data meta-analysis was conducted to assess the implications of using a local reference (STOPPAM) instead of a universal reference (Intergrowth-21) on the association between malaria in pregnancy and SGA.

METHODS

Individual participant data of 6,236 newborns were pooled from seven conveniently identified studies conducted in Tanzania and Malawi from 2003-2018 with data on malaria in pregnancy, birthweight, and ultrasound estimated gestational age. Mixed-effects regression models were used to compare the association between malaria in pregnancy and SGA when using the STOPPAM and the Intergrowth-21 references, respectively.

RESULTS

The 10th percentile for birthweights-for-gestational age was lower for STOPPAM than for Intergrowth-21, leading to a prevalence of SGA_STOPPAM of 14.2% and SGA_IG21 of 18.0%, p < 0.001. The association between malaria in pregnancy and SGA was stronger for STOPPAM (adjusted odds ratio (aOR) 1.30 [1.09-1.56], p < 0.01) than for Intergrowth-21 (aOR 1.19 [1.00-1.40], p = 0.04), particularly among paucigravidae (SGA_STOPPAM aOR 1.36 [1.09-1.71], p < 0.01 vs SGA_IG21 aOR 1.21 [0.97-1.50], p = 0.08).

CONCLUSIONS

The prevalence of SGA may be overestimated and the impact of malaria in pregnancy underestimated when using Intergrowth-21. Comparing local reference charts to global references when assessing and interpreting the impact of malaria in pregnancy may be appropriate.

Birth weight for gestational age: standard growth charts for the Polish population

Introduction. Birth weight is one of the most important factors determining neonatal well-being. From an epidemiological viewpoint, a neonatal reference chart provides a picture of the health status of a population. Global customized growth charts seem to be the most practical in multicultural settings, allowing adjustment for ethnicity. However, regional charts might be a valuable contribution to reliable growth assessment. Our study aims to establish a reference tool for growth assessment and visualize the local potential, by creating standard charts based on the data from the tertiary center with the highest number of deliveries per year in Poland. Material and Methods. We retrospectively analysed  31,353 records from the electronic database of singleton births from a five-year period from a tertiary hospital in Poznań, Poland. We excluded pre-term deliveries and high-risk pregnancies basing on well-known factors influencing fetal growth, bringing the number of records to  21,379. The data were processed separately by gender (females n=10,312, 48.2% and males n=11,067, 51.8%). Percentiles were calculated for each week of gestational age. Means and standard deviations were determined. Results. Standard growth charts (including 3rd, 10th, 25th, 50th, 75th, 90th and 97th percentiles) are presented. Descriptive data of population distribution are shown. Conclusions. In conclusion, obtaining standard growth charts for mature newborns has created the opportunity for a more actual and adequate assessment of the Polish neonatal population. It should allow for the implementation of new standards in future research on perinatal care.

[Ante- and postnatal growth charts in France - guidelines for clinical practice from the Collège national des gynécologues et obstétriciens français (CNGOF) and from the Société française de néonatologie (SFN)]

OBJECTIVE

To recommend the most appropriate biometric charts for the detection of antenatal growth abnormalities and postnatal growth surveillance.

METHODS

Elaboration of specific questions and selection of experts by the organizing committee to answer these questions; analysis of the literature by experts and drafting conclusions by assigning a recommendation (strong or weak) and a quality of evidence (high, moderate, low, very low) and for each question; all these recommendations have been subject to multidisciplinary external review (obstetrician gynecologists, pediatricians). The objective for the reviewers was to verify the completeness of the literature review, to verify the levels of evidence established and the consistency and applicability of the resulting recommendations. The overall review of the literature, quality of evidence and recommendations were revised to take into consideration comments from external reviewers.

RESULTS

Antenatally, it is recommended to use all WHO fetal growth charts for EFW and common ultrasound biometric measurements (strong recommendation; low quality of evidence). Indeed, in comparison with other prescriptive curves and descriptive curves, the WHO prescriptive charts show better performance for the screening of SGA (Small for Gestational Age) and LGA (Large for Gestational Age) with adequate proportions of fetuses screened at extreme percentiles in the French population. It also has the advantages of having EFW charts by sex and biometric parameters obtained from the same perspective cohort of women screened by qualified sonographers who measured the biometric parameters according to international standards. Postnatally, it is recommended to use the updated Fenton charts for the assessment of birth measurements and for growth monitoring in preterm infants (strong recommendation; moderate quality of evidence) and for the assessment of birth measurements in term newborn (expert opinion).

CONCLUSION

It is recommended to use WHO fetal growth charts for antenatal growth monitoring and Fenton charts for the newborn.

Evaluating the Growth Assessment Protocol for stillbirth prevention: progress and challenges

Many stillbirths are associated with fetal growth restriction, and are hence potentially avoidable. The Growth Assessment Protocol (GAP) is a multidisciplinary program with an evidence based care pathway, training in risk assessment, fetal growth surveillance with customised charts and rolling audit. Antenatal detection of small for gestational age (SGA) has become an indicator of quality of care. Evaluation is essential to understand the impact of such a prevention program. Randomised trials will not be effective if they cannot ensure proper implementation before assessment. Observational studies have allowed realistic evaluation in practice, with other factors excluded that may have influenced the outcome. An award winning 10 year study of stillbirth data in England has been able to assess the effect of GAP in isolation, and found a strong, causal association with improved antenatal detection of SGA babies, and the sustained decline in national stillbirth rates. The challenge now is to apply this program more widely in low and middle income settings where the main global burden of stillbirth is, and to adapt it to local needs and resources.

Automated growth monitoring app (GROWIN): a mobile Health (mHealth) tool to improve the diagnosis and early management of growth and nutritional disorders in childhood

OBJECTIVE

To assess the functionality and feasibility of the GROWIN app for promoting early detection of growth disorders in childhood, supporting early interventions, and improving children's lifestyle by analyzing data collected over 3 years (2018-2020).

METHODS

We retrospectively assessed the growth parameters (height, weight, body mass index [BMI], abdominal circumference) entered by users (caregivers/parents) in the GROWIN app. We also analyzed the potential health problems detected and the messages/recommendations the app showed. Finally, we assessed the possible impact/benefit of the app on the growth of the children.

RESULTS

A total of 21 633 users (Spanish [65%], Latin American [30%], and others [5%]) entered 10.5 ± 8.3 measurements (0-15 y old). 1200 recommendations were for low height and 550 for low weight. 1250 improved their measurements. A specialist review was recommended in 500 patients due to low height. 2567 nutrition tests were run. All children with obesity (n = 855, BMI: 27.8 kg/m2 [2.25 SD]) completed the initial test with a follow-up of ≥1 year. Initial results (score: 8.1) showed poor eating habits (fast food, commercially baked goods, candy, etc.), with >90% not having breakfast. After 3-6 months, BMI decreased ≥1 point, and test scores increased ≥2 points. This benefit was maintained beyond 1 year and was correlated with an improvement in BMI (r = -.65, P = .01).

DISCUSSION/CONCLUSIONS

The GROWIN app represents an innovative automated solution for families to monitor growth. It allows the early detection of abnormal growth indicators during childhood and adolescence, promoting early interventions. Additionally, in children with obesity, an improvement in healthy nutritional habits and a decrease in BMI were observed.

Risk Measurement of Perinatal and Neonatal Morbidity Characteristics and Applicability of GAIA Case Definitions: Results and Lessons Learnt of a Hospital-Based Prospective Cohort Study in the Valencia Region (2019-2020)

Post-marketing safety surveillance of new vaccines aimed to be administered during pregnancy is crucial to orchestrate efficient adverse events evaluation. This is of special relevance in the current landscape of new vaccines being introduced in the pregnant women population, and particularly due to the recent administration of COVID-19 vaccines in pregnant women. This multi-center prospective cohort study, nested within the WHO-Global Vaccine Safety-MCC study, involved two hospitals in the Valencia region. Hereby, the incidence rates of seven perinatal and neonatal outcomes in the Valencia region are presented. The pooled data analysis of the two Valencian hospitals allowed the estimation of incidence rates in the Valencia Region (per 1000 live births): 86.7 for low birth weight, 78.2 for preterm birth, 58.8 for small for gestational age, 13 for congenital microcephaly, 0.4 for stillbirth, 1.2 for neonatal death and 6.5 for neonatal infection. These figures are in line with what is expected from a high-income country and the previously reported rates for Spain and Europe, except for the significantly increased rate for congenital microcephaly. Regarding the data for maternal immunization, the vaccination status was collected for 94.4% of the screened pregnant women, highlighting the high quality of the Valencian Vaccine Registry. The study also assessed the Valencian hospitals’ capacity for identifying and collecting data on maternal immunization status, as well as the applicability of the GAIA definitions to the identified outcomes.

Testing the Institute of Medicine (IOM) recommendations on maternal reproductive health and associated neonatal characteristics in a transitional, Mediterranean population

BACKGROUND

High pre-pregnancy body mass index (BMI) and excessive gestational weight gain (GWG) are significant risk factors for maternal and neonatal health.

AIM

To assess pre-pregnancy BMI and GWG during pregnancy and their association with different maternal and neonatal characteristics in the transitional Mediterranean population from the Eastern Adriatic islands.

SUBJECTS AND METHODS

262 mother-child dyads from the CRoatian Islands' Birth Cohort Study (CRIBS) were included in the study. Chi-square test, ANOVA and regression analysis were used to test the association between selected characteristics.

RESULTS

22% of women entered pregnancy with overweight/obesity and 46.6% had excessive GWG. Pre-pregnancy overweight and obesity were significantly associated with elevated triglycerides uric acid levels, and decreased HDL cholesterol in pregnancy. Excessive GWG was associated with elevated fibrinogen and lipoprotein A levels. Women with high pre-pregnancy BMI and GWG values were more likely to give birth to babies that were large for gestational age (LGA), additionally confirmed in the multiple logistic regression model.

CONCLUSION

High maternal pre-pregnancy BMI and excessive GWG were both significantly associated with deviated biochemical parameters and neonatal size. More careful monitoring of maternal nutritional status can lead to better pre- and perinatal maternal health care.

Associations of severe adverse perinatal outcomes among continuous birth weight percentiles on different birth weight charts: a secondary analysis of a cluster randomized trial

Objective

To identify neonatal risk for severe adverse perinatal outcomes across birth weight centiles in two Dutch and one international birth weight chart.

Background

Growth restricted newborns have not reached their intrinsic growth potential in utero and are at risk of perinatal morbidity and mortality. There is no golden standard for the confirmation of the diagnosis of fetal growth restriction after birth. Estimated fetal weight and birth weight below the 10^th percentile are generally used as proxy for growth restriction. The choice of birth weight chart influences the specific cut-off by which birth weight is defined as abnormal, thereby triggering clinical management. Ideally, this cut-off should discriminate appropriately between newborns at low and at high risk of severe adverse perinatal outcomes and consequently correctly inform clinical management.

Methods

This is a secondary analysis of the IUGR Risk Selection (IRIS) study. Newborns (n = 12 953) of women with a low-risk status at the start of pregnancy and that received primary antenatal care in the Netherlands were included.

We examined the distribution of severe adverse perinatal outcomes across birth weight centiles for three birth weight charts (Visser, Hoftiezer and INTERGROWTH) by categorizing birth weight centile groups and comparing the prognostic performance for severe adverse perinatal outcomes.

Severe adverse perinatal outcomes were defined as a composite of one or more of the following: perinatal death, Apgar score < 4 at 5 min, impaired consciousness, asphyxia, seizures, assisted ventilation, septicemia, meningitis, bronchopulmonary dysplasia, intraventricular hemorrhage, periventricular leukomalacia, or necrotizing enterocolitis.

Results

We found the highest rates of severe adverse perinatal outcomes among the smallest newborns (< 3^rd percentile) (6.2% for the Visser reference curve, 8.6% for the Hoftiezer chart and 12.0% for the INTERGROWTH chart). Discriminative abilities of the three birth weight charts across the entire range of birth weight centiles were poor with areas under the curve ranging from 0.57 to 0.61. Sensitivity rates of the various cut-offs were also low.

Conclusions

The clinical utility of all three charts in identifying high risk of severe adverse perinatal outcomes is poor. There is no single cut-off that discriminates clearly between newborns at low or high risk.

Trial Registration

Netherlands Trial Register NTR4367.

Registration date March 20^th, 2014.

Preconception and early-pregnancy risk prediction for birth complications: development of prediction models within a population-based prospective cohort

Background

Suboptimal maternal health already from preconception onwards is strongly linked to an increased risk of birth complications. To enable identification of women at risk of birth complications, we aimed to develop a prediction model for birth complications using maternal preconception socio-demographic, lifestyle, medical history and early-pregnancy clinical characteristics in a general population.

Methods

In a population-based prospective cohort study among 8340 women, we obtained information on 33 maternal characteristics at study enrolment in early-pregnancy. These characteristics covered the preconception period and first half of pregnancy (< 21 weeks gestation). Preterm birth was < 37 weeks gestation. Small-for-gestational-age (SGA) and large-for-gestational-age (LGA) at birth were gestational-age-adjusted birthweight in the lowest or highest decile, respectively. Because of their co-occurrence, preterm birth and SGA were combined into a composite outcome.

Results

The basic preconception model included easy obtainable maternal characteristics in the preconception period including age, ethnicity, parity, body mass index and smoking. This basic preconception model had an area under the receiver operating characteristics curve (AUC) of 0.63 (95% confidence interval (CI) 0.61 to 0.65) and 0.64 (95% CI 0.62 to 0.66) for preterm birth/SGA and LGA, respectively. Further extension to more complex models by adding maternal socio-demographic, lifestyle, medical history and early-pregnancy clinical characteristics led to small, statistically significant improved models. The full model for prediction of preterm birth/SGA had an AUC 0.66 (95% CI 0.64 to 0.67) with a sensitivity of 22% at a 90% specificity. The full model for prediction of LGA had an AUC of 0.67 (95% CI 0.65 to 0.69) with sensitivity of 28% at a 90% specificity. The developed models had a reasonable level of calibration within highly different socio-economic subsets of our population and predictive performance for various secondary maternal, delivery and neonatal complications was better than for primary outcomes.

Conclusions

Prediction of birth complications is limited when using maternal preconception and early-pregnancy characteristics, which can easily be obtained in clinical practice. Further improvement of the developed models and subsequent external validation is needed.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04497-2.

Birth growth curves of neonates in high-altitude areas: A cross-sectional study

BACKGROUND

Since the current commonly used birth growth curves are unsuitable for neonates in high-altitude areas; this study aimed to establish birth growth curves for full-term neonates residing at 2,000-3,000 m.

METHODS

This cross-sectional study retrospectively analyzed the physical measurement data of 1,546 full-term neonates delivered at the Red Cross Hospital of Qinghai province, China, from July 2021 to April 2022. The percentile curves of birth weight, length, and head circumference of neonates of different gestational ages and genders were developed using curve fitting. The newly developed birth-weight percentile reference was compared with the INTERGROWTH-21st Neonatal Growth Curve (International Standard) and the Chinese Neonate Growth Curve (Chinese Standard).

RESULTS

The median birth weight, length, and head circumference of the study population were 3,200 g, 52.0 cm, and 32.8 cm, respectively, except for the group with a gestational age of 37 weeks. The growth indicators of male infants in all groups were higher than those of the female infants (P < 0.05). We found differences between the newly developed birth-weight percentile curves in the high-altitude areas and the International and Chinese Standards.

CONCLUSION

Establishing birth growth curves corresponding to altitude may be more suitable than the existing standards for local medical staff to conduct health assessments of neonates.

Comparison of the performance of estimated fetal weight charts for the detection of small- and large-for-gestational age newborns with adverse outcomes: a French population-based study

OBJECTIVE

To compare the performance of estimated fetal weight (EFW) charts at the third trimester ultrasound for detecting small- and large-for-gestational age (SGA/LGA) newborns with adverse outcomes.

DESIGN

Nationally representative observational study.

SETTING

French maternity units in 2016.

POPULATION

9940 singleton live births with an ultrasound between 30 and 35 weeks of gestation.

METHODS

We compared three prescriptive charts (INTERGROWTH-21st, World Health Organization (WHO), Eunice Kennedy Shriver National Institute of Child Health and Human Development [NICHD]), four descriptive charts (Hadlock, Fetal Medicine Foundation, two French charts) and a French customised growth model (Epopé).

MAIN OUTCOME MEASURES

SGA and LGA (birthweights <10th and >90th percentiles) associated with adverse outcomes (low Apgar score, delivery-room resuscitation, neonatal unit admission).

RESULTS

2.1% and 1.1% of infants had SGA and LGA and adverse outcomes, respectively. The sensitivity and specificity for detecting these infants with an EFW <10th and >90th percentile varied from 29-65% and 84-96% for descriptive charts versus 27-60% and 83-96% for prescriptive charts. WHO and French charts were closest to the EFW distribution, yielding a balance between sensitivity and specificity for SGA and LGA births. INTERGROWTH-21st and Epopé had low sensitivity for SGA with high sensitivity for LGA. Areas under the receiving operator characteristics curve ranged from 0.62 to 0.74, showing low to moderate predictive ability, and diagnostic odds ratios varied from 7 to 16.

CONCLUSION

Marked differences in the performance of descriptive as well as prescriptive EFW charts highlight the importance of evaluating them for their ability to detect high-risk fetuses.

TWEETABLE ABSTRACT

Choice of growth chart strongly affected identification of high-risk fetuses at the third trimester ultrasound.