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Frenquelli R, Ratcliff M, Villar de Onis J, Fernandes M, Barros FC, Hirst JE, Papageorghiou AT, Kennedy SH, Villar J. Complex Perinatal Syndromes Affecting Early Human Growth and Development: Issues to Consider to Understand Their Aetiology and Postnatal Effects. Front Neurosci 2022; 16:856886. [PMID: 35509448 PMCID: PMC9058100 DOI: 10.3389/fnins.2022.856886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Accepted: 03/11/2022] [Indexed: 12/17/2022] Open
Abstract
Complex perinatal syndromes (CPS) affecting pregnancy and childhood, such as preterm birth, and intra- and extra-uterine growth restriction, have multiple, diverse contexts of complexity and interaction that determine the short- and long-term growth, health and development of all human beings. Early in life, genetically-guided somatic and cerebral development occurs alongside a psychism "in statu nascendi," with the neural structures subjected to the effects of the intra- and extra-uterine environments in preparation for optimal postnatal functioning. Different trajectories of fetal cranial and abdominal growth have been identified before 25 weeks' gestation, tracking differential growth and neurodevelopment at 2 years of age. Similarly, critical time-windows exist in the first 5-8 months of postnatal life because of interactions between the newborn and their environment, mother/care-givers and feeding practices. Understanding these complex relational processes requires abandoning classical, linear and mechanistic interpretations that are placed in rigid, artificial biological silos. Instead, we need to conduct longitudinal, interdisciplinary research and integrate the resulting new knowledge into clinical practice. An ecological-systemic approach is required to understand early human growth and development, based on a dynamic multidimensional process from the molecular or genomic level to the socio-economic-environmental context. For this, we need theoretical and methodological tools that permit a global understanding of CPS, delineating temporal trajectories and their conditioning factors, updated by the incorporation of new scientific discoveries. The potential to optimize human growth and development across chronological age and geographical locations - by implementing interventions or "treatments" during periods of greatest instability or vulnerability - should be recognized. Hence, it is imperative to take a holistic view of reproductive and perinatal issues, acknowledging at all levels the complexity and interactions of CPS and their sensitive periods, laying the foundations for further improvements in growth and development of populations, to maximize global human potential. We discuss here conceptual issues that should be considered for the development and implementation of such a strategy aimed at addressing the perinatal health problems of the new millenium.
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Affiliation(s)
- Roberto Frenquelli
- Master Program in Child Psychoanalysis and Neuropsychological, Developmental Psychology Unit, Faculty of Psychology, National University of Rosario, Rosario, Argentina
| | - Marc Ratcliff
- Faculty of Psychology and Educational Science, Centre Jean Piaget, University of Geneva, Geneva, Switzerland
| | - Jimena Villar de Onis
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
- Geneva Foundation for Medical Education and Research, Geneva, Switzerland
| | - Michelle Fernandes
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
- MRC Lifecourse Epidemiology Centre, Human Development and Health Academic Unit, Department of Paediatrics, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Fernando C. Barros
- Post Graduate Course on Health in the Vital Cycle, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Jane E. Hirst
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Aris T. Papageorghiou
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Stephen H. Kennedy
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - Jose Villar
- Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
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González-Alzaga B, Hernández AF, Kim Pack L, Iavicoli I, Tolonen H, Santonen T, Vinceti M, Filippini T, Moshammer H, Probst-Hensch N, Kolossa-Gehring M, Lacasaña M. The questionnaire design process in the European Human Biomonitoring Initiative (HBM4EU). ENVIRONMENT INTERNATIONAL 2022; 160:107071. [PMID: 34979351 DOI: 10.1016/j.envint.2021.107071] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 11/17/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
BACKGROUND Designing questionnaires is a key point of epidemiological studies assessing human exposure to chemicals. The lack of validated questionnaires can lead to the use of previously developed and sub-optimally adapted questionnaires, which may result in information biases that affect the study's validity. On this ground, a multidisciplinary group of researchers developed a series of tools to support data collection within the HBM4EU initiative. The objective of this paper is to share the process of developing HBM4EU questionnaires, as well as to provide researchers with harmonized procedures that could help them to design future questionnaires to assess environmental exposures. METHODS In the frame of the work package on survey design and fieldwork of the HBM4EU, researchers carried out procedures necessary for the development of quality questionnaires and related data collection tools. These procedures consisted of a systematic search to identify questionnaires used in previous human biomonitoring (HBM) studies, as well as the development of a checklist and evaluation sheet to assess the questionnaires identified. The results of these evaluations were taken into consideration for the development of the final questionnaires. RESULTS The main points covered by each of the sections included in HBM4EU questionnaires are described and discussed in detail. Additional tools developed for data collection in the HBM4EU (e.g. non-responder questionnaire, satisfaction questionnaire, matrix-specific questionnaire) are also addressed. Special attention is paid to the limitations faced and hurdles overcome during the process of questionnaire development. CONCLUSIONS Designing questionnaires for use in HBM studies requires substantial effort by a multidisciplinary team to guarantee that the quality of the information collected meets the study's objectives. The process of questionnaire development described herein will contribute to improve the harmonization of HBM studies within the social and environmental context of the EU countries.
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Affiliation(s)
- Beatriz González-Alzaga
- Andalusian School of Public Health (EASP), Spain; Instituto de Investigación Biosanitaria, ibs.GRANADA. Granada, Spain
| | - Antonio F Hernández
- Andalusian School of Public Health (EASP), Spain; Instituto de Investigación Biosanitaria, ibs.GRANADA. Granada, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain; Department of Legal Medicine and Toxicology, University of Granada (UGR) School of Medicine, Spain
| | - L Kim Pack
- German Environment Agency (UBA), Germany
| | - Ivo Iavicoli
- Section of Occupational Medicine, Department of Public Health (DPH), University of Naples Federico II, Italy
| | - Hanna Tolonen
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Tiina Santonen
- Finnish Institute of Occupational Health (FIOH), Helsinki, Finland
| | - Marco Vinceti
- Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy; Department of Epidemiology, Boston University School of Public Health, Boston, MA, USA
| | - Tommaso Filippini
- Section of Public Health, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Hanns Moshammer
- Department of Environmental Health, Centre for Public Health, Medical University Vienna (MUW), Vienna, Austria
| | - Nicole Probst-Hensch
- Swiss Tropical and Public Health Institute (Swiss TPH), Basel, Switzerland; University of Basel, Switzerland
| | | | - Marina Lacasaña
- Andalusian School of Public Health (EASP), Spain; Instituto de Investigación Biosanitaria, ibs.GRANADA. Granada, Spain; CIBER of Epidemiology and Public Health (CIBERESP), Spain; Andalusian Health and Environment Observatory (OSMAN), Granada, Spain.
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Zierold KM, Sears CG, Hagemeyer AN, Brock GN, Polivka BJ, Zhang CH, Sears L. Protocol for measuring indoor exposure to coal fly ash and heavy metals, and neurobehavioural symptoms in children aged 6 to 14 years old. BMJ Open 2020; 10:e038960. [PMID: 33234632 PMCID: PMC7684807 DOI: 10.1136/bmjopen-2020-038960] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 10/12/2020] [Accepted: 10/25/2020] [Indexed: 02/02/2023] Open
Abstract
INTRODUCTION Fly ash is a waste product generated from burning coal for electricity. It is comprised of spherical particles ranging in size from 0.1 µm to over 100 µm in diameter that contain trace levels of heavy metals. Large countries such as China and India generate over 100 million tons per year while smaller countries like Italy and France generate 2 to 3 million tons per year. The USA generates over 36 million tons of ash, making it one of the largest industrial waste streams in the nation. Fly ash is stored in landfills and surface impoundments exposing communities to fugitive dust and heavy metals that leach into the groundwater. Limited information exists on the health impact of exposure to fly ash. This protocol represents the first research to assess children's exposure to coal fly ash and neurobehavioural outcomes. METHODS We measure indoor exposure to fly ash and heavy metals, and neurobehavioural symptoms in children aged 6 to 14 years old. Using air pollution samplers and lift tape samples, we collect particulate matter ≤10 µm that is analysed for fly ash and heavy metals. Toenails and fingernails are collected to assess body burden for 72 chemical elements. Using the Behavioural Assessment and Research System and the Child Behaviour Checklist, we collect information on neurobehavioural outcomes. Data collection began in September 2015 and will continue until February 2021. ETHICS AND DISSEMINATION This study was approved by the Institutional Review Boards of the University of Louisville (#14.1069) and the University of Alabama at Birmingham (#300003807). We have collected data from 267 children who live within 10 miles of two power plants. Children are at a greater risk for environmental exposure which justifies the rationale for this study. Results of this study will be distributed at conferences, in peer-reviewed journals and to the participants of the study.
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Affiliation(s)
- Kristina M Zierold
- Environmental Health Sciences, School of Public Health, The University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Clara G Sears
- Epidemiology, Brown University, Providence, Rhode Island, USA
| | - Abby N Hagemeyer
- Epidemiology and Population Health, University of Louisville, Louisville, Kentucky, USA
| | - Guy N Brock
- Bioinformatics and the Center for Biostatistics, The Ohio State University, Columbus, Ohio, USA
| | - Barbara J Polivka
- School of Nursing, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Charlie H Zhang
- Department of Geography and Geosciences, College of Arts and Sciences, University of Louisville, Louisville, Kentucky, USA
| | - Lonnie Sears
- Department of Pediatrics, Health Sciences Center, University of Louisville, Louisville, Kentucky, USA
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Zachek CM, Schwartz JM, Glasser M, DeMicco E, Woodruff TJ. A screening questionnaire for occupational and hobby exposures during pregnancy. Occup Med (Lond) 2020; 69:428-435. [PMID: 31247109 DOI: 10.1093/occmed/kqz094] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Occupational and environmental exposures during the prenatal period may be associated with adverse pregnancy outcomes and lifelong health effects. Yet, identification and evaluation of these potential hazards is lacking in routine obstetric care. AIMS To assess the feasibility of incorporating a self-administered occupational and environmental exposure questionnaire into obstetric clinics. METHODS A cross-sectional survey assessed prenatal clinic patients at a public hospital who were currently employed and <20 weeks gestation. Questionnaires evaluated job characteristics, workplace and hobby exposures, protective equipment use and symptoms during pregnancy. RESULTS Of 69 participants (96% response rate), 46% were predominantly Spanish-speaking. Primary occupations were caregiver (16%), cleaner (14%) and administrative assistant (14%). Overall, 93% were exposed to a workplace hazard, with most participants reporting physical stressors (82%) or organic solvent exposure (78%). Most women (74%) used some personal protective equipment. Nearly half (54%) reported at least one non-pregnancy symptom, and 52% were referred for follow-up with an occupational medicine practitioner. Household and hobby-related chemical exposures were common in our sample (91%). We observed moderate consistency between job task and chemical use responses: 67-99% of intentionally redundant questions were fully or partially matched. Closed- compared to open-ended activity questions identified a higher proportion of physical stressors (82% versus 12%) and cleaning product (76% versus 30%) exposures. CONCLUSIONS A self-administered questionnaire is an effective screening tool for identifying women with occupational and hobby-related exposures during pregnancy. Consistent incorporation of exposure assessment into prenatal care can improve clinical communications and early interventions for at-risk pregnant women.
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Affiliation(s)
- C M Zachek
- School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - J M Schwartz
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Program on Reproductive Health and the Environment, University of California San Francisco, San Francisco, CA, USA
| | - M Glasser
- Department of Anesthesiology, University of California San Diego, San Diego, CA, USA
| | - E DeMicco
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Program on Reproductive Health and the Environment, University of California San Francisco, San Francisco, CA, USA
| | - T J Woodruff
- Department of Obstetrics, Gynecology, and Reproductive Sciences, Program on Reproductive Health and the Environment, University of California San Francisco, San Francisco, CA, USA
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Joubert BR, Berhane K, Chevrier J, Collman G, Eskenazi B, Fobil J, Hoyo C, John CC, Kumie A, Nicol M, Ramsay M, Smith J, Steyn A, Tshala-Katumbay D, McAllister K. Integrating environmental health and genomics research in Africa: challenges and opportunities identified during a Human Heredity and Health in Africa (H3Africa) Consortium workshop. AAS Open Res 2019; 2:159. [PMID: 32382703 PMCID: PMC7194141 DOI: 10.12688/aasopenres.12983.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2019] [Indexed: 12/12/2022] Open
Abstract
Individuals with African ancestry have extensive genomic diversity but have been underrepresented in genomic research. There is also extensive global diversity in the exposome (the totality of human environmental exposures from conception onwards) which should be considered for integrative genomic and environmental health research in Africa. To address current research gaps, we organized a workshop on environmental health research in Africa in conjunction with the H3Africa Consortium and the African Society of Human Genetics meetings in Kigali, Rwanda. The workshop was open to all researchers with an interest in environmental health in Africa and involved presentations from experts within and outside of the Consortium. This workshop highlighted innovative research occurring on the African continent related to environmental health and the interplay between the environment and the human genome. Stories of success, challenges, and collaborative opportunities were discussed through presentations, breakout sessions, poster presentations, and a panel discussion. The workshop informed participants about environmental risk factors that can be incorporated into current or future epidemiology studies and addressed research design considerations, biospecimen collection and storage, biomarkers for measuring chemical exposures, laboratory strategies, and statistical methodologies. Inclusion of environmental exposure measurements with genomic data, including but not limited to H3Africa projects, can offer a strong platform for building gene-environment (G x E) research in Africa. Opportunities to leverage existing resources and add environmental exposure data for ongoing and planned studies were discussed. Future directions include expanding the measurement of both genomic and exposomic risk factors and incorporating sophisticated statistical approaches for analyzing high dimensional G x E data. A better understanding of how environmental and genomic factors interact with nutrition and infection is also needed. Considering that the environment represents many modifiable risk factors, these research findings can inform intervention and prevention efforts towards improving global health.
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Affiliation(s)
- Bonnie R Joubert
- National Institute of Environmental Health Sciences, National Institutes of Health, Durham, NC, USA
| | - Kiros Berhane
- Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | | | - Gwen Collman
- National Institute of Environmental Health Sciences, National Institutes of Health, Durham, NC, USA
| | | | | | | | - Chandy C John
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Abera Kumie
- Addis Abada University, Addis Abada, Ethiopia
| | - Mark Nicol
- University of Cape Town, Cape Town, South Africa
| | - Michèle Ramsay
- Sydney Brenner Institute for Molecular Bioscience, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | - Adrie Steyn
- Africa Health Research Institute, Durban, South Africa
| | | | - Kimberly McAllister
- National Institute of Environmental Health Sciences, National Institutes of Health, Durham, NC, USA
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Gupta V, Saxena R, Walia GK, Agarwal T, Vats H, Dunn W, Relton C, Sovio U, Papageorghiou A, Davey Smith G, Khadgawat R, Sachdeva MP. Gestational route to healthy birth (GaRBH): protocol for an Indian prospective cohort study. BMJ Open 2019; 9:e025395. [PMID: 31048433 PMCID: PMC6501957 DOI: 10.1136/bmjopen-2018-025395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2018] [Revised: 10/17/2018] [Accepted: 03/12/2019] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Pregnancy is characterised by a high rate of metabolic shifts from early to late phases of gestation in order to meet the raised physiological and metabolic needs. This change in levels of metabolites is influenced by gestational weight gain (GWG), which is an important characteristic of healthy pregnancy. Inadequate/excessive GWG has short-term and long-term implications on maternal and child health. Exploration of gestational metabolism is required for understanding the quantitative changes in metabolite levels during the course of pregnancy. Therefore, our aim is to study trimester-specific variation in levels of metabolites in relation to GWG and its influence on fetal growth and newborn anthropometric traits at birth. METHODS AND ANALYSIS A prospective longitudinal study is planned (start date: February 2018; end date: March 2023) on pregnant women that are being recruited in the first trimester and followed in subsequent trimesters and at the time of delivery (total 3 follow-ups). The study is being conducted in a hospital located in Bikaner district (66% rural population), Rajasthan, India. The estimated sample size is of 1000 mother-offspring pairs. Information on gynaecological and obstetric history, socioeconomic position, diet, physical activity, tobacco and alcohol consumption, depression, anthropometric measurements and blood samples is being collected for metabolic assays in each trimester using standardised methods. Mixed effects regression models will be used to assess the role of gestational weight in influencing metabolite levels in each trimester. The association of maternal levels of metabolites with fetal growth, offspring's weight and body composition at birth will be investigated using regression modelling. ETHICS AND DISSEMINATION The study has been approved by the ethics committees of the Department of Anthropology, University of Delhi and Sardar Patel Medical College, Rajasthan. We are taking written informed consent after discussing the various aspects of the study with the participants in the local language.
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Affiliation(s)
- Vipin Gupta
- Department of Anthropology, University of Delhi, Delhi, India
| | - Ruchi Saxena
- Department of Obstetrics and Gynaecology, Sardar Patel Medical College, Bikaner, Rajasthan, India
| | | | | | - Harsh Vats
- Department of Anthropology, University of Delhi, Delhi, India
| | - Warwick Dunn
- School of Biosciences, Phenome Centre Birmingham and Institute of Metabolism and Systems Research, University of Birmingham, Birmingham, UK
| | - Caroline Relton
- MRC Integrative Epidemiology Unit and Bristol Medical School, University of Bristol, Bristol, UK
| | - Ulla Sovio
- Obstetrics and Gyneacology, University of Cambridge, Cambridge, UK
| | - Aris Papageorghiou
- Nuffield Department of Women’s & Reproductive Health, University of Oxford, Oxford, United Kingdom
| | - George Davey Smith
- MRC Integrative Epidemiology Unit and Bristol Medical School, University of Bristol, Bristol, UK
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Iwai-Shimada M, Nakayama SF, Isobe T, Michikawa T, Yamazaki S, Nitta H, Takeuchi A, Kobayashi Y, Tamura K, Suda E, Ono M, Yonemoto J, Kawamoto T. Questionnaire results on exposure characteristics of pregnant women participating in the Japan Environment and Children Study (JECS). Environ Health Prev Med 2018; 23:45. [PMID: 30219031 PMCID: PMC6138908 DOI: 10.1186/s12199-018-0733-0] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Accepted: 08/21/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Japan Environment and Children's Study (JECS) is a nation-wide birth cohort study investigating environmental effects on children's health and development. In this study, the exposure characteristics of the JECS participating mothers were summarized using two questionnaires administered during pregnancy. METHODS Women were recruited during the early period of their pregnancy. We intended to administer the questionnaire during the first trimester (MT1) and the second/third trimester (MT2). The total number of registered pregnancies was 103,099. RESULTS The response rates of the MT1 and MT2 questionnaires were 96.8% and 95.1%, respectively. The mean gestational ages (SDs) at the time of the MT1 and MT2 questionnaire responses were 16.4 (8.0) and 27.9 (6.5) weeks, respectively. The frequency of participants who reported "lifting something weighing more than 20 kg" during pregnancy was 5.3% for MT1 and 3.9% for MT2. The Cohen kappa scores ranged from 0.07 to 0.54 (median 0.31) about the occupational chemical use between MT1 and MT2 questionnaires. Most of the participants (80%) lived in either wooden detached houses or steel-frame collective housing. More than half of the questionnaire respondents answered that they had "mold growing somewhere in the house". Insect repellents and insecticides were used widely in households: about 60% used "moth repellent for clothes in the closet," whereas 32% applied "spray insecticide indoors" or "mosquito coil or an electric mosquito repellent mat." CONCLUSIONS We summarized the exposure characteristics of the JECS participants using two maternal questionnaires during pregnancy.
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Affiliation(s)
- Miyuki Iwai-Shimada
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Shoji F Nakayama
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan.
| | - Tomohiko Isobe
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Takehiro Michikawa
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Shin Yamazaki
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Hiroshi Nitta
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Ayano Takeuchi
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan.,Department of Preventive Medicine and Public Health, Keio University, 35 Shinanomachi, Shinjuku-ku, Tokyo, 1608582, Japan
| | - Yayoi Kobayashi
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Kenji Tamura
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Eiko Suda
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Masaji Ono
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Junzo Yonemoto
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan
| | - Toshihiro Kawamoto
- Japan Environment and Children's Study Programme Office, National Institute for Environmental Studies, 16-2 Onogawa, Tsukuba, 305-8506, Japan.,Department of Environmental Health, University of Occupational and Environmental Health, 1-1 Iseigaoka, Yahatanishi-ku, Kitakyushu, 807-8555, Japan
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Papageorghiou AT, Kennedy SH, Salomon LJ, Altman DG, Ohuma EO, Stones W, Gravett MG, Barros FC, Victora C, Purwar M, Jaffer Y, Noble JA, Bertino E, Pang R, Cheikh Ismail L, Lambert A, Bhutta ZA, Villar J. The INTERGROWTH-21 st fetal growth standards: toward the global integration of pregnancy and pediatric care. Am J Obstet Gynecol 2018; 218:S630-S640. [PMID: 29422205 DOI: 10.1016/j.ajog.2018.01.011] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Revised: 01/04/2018] [Accepted: 01/05/2018] [Indexed: 10/18/2022]
Abstract
The purpose of the INTERGROWTH-21st project was to develop international, prescriptive standards for fetal growth assessed by ultrasound and fundal height, preterm postnatal growth, newborn size and body composition, maternal weight gain, and infant development at the age of 2 years. Hence, we have produced, based on World Health Organization recommendations, the first comprehensive set of international standards of optimal fetal and newborn growth that perfectly match the existing World Health Organization child growth standards. Uniquely, the same population was followed up longitudinally from 9 weeks of fetal life to 2 years of age, with growth, health, and nutritional status assessment at 2 years supporting the appropriateness of the population for construction of growth standards. The resulting package of clinical tools allows, for the first time, growth and development to be monitored from early pregnancy to infancy. The INTERGROWTH-21st fetal growth standards, which are based on observing >4500 healthy pregnancies, nested in a study of >59,000 pregnancies from populations with low rates of adverse perinatal outcomes, show how fetuses should grow-rather than the more limited objective of past references, which describe how they have grown at specific times and locations. Our work has confirmed the fundamental biological principle that variation in human growth across different populations is mostly dependent on environmental, nutritional, and socioeconomic factors. We found that when mothers' nutritional and health needs are met and there are few environmental constraints on growth, <3.5% of the total variability of skeletal growth was due to differences between populations. We propose that not recognizing the concept of optimal growth could deprive the most vulnerable mothers and their babies of optimal care, because local growth charts normalize those at highest risk for growth restriction and overweight, and can be valuable for policymakers to ensure rigorous evaluation and effective resource allocation. We strongly encourage colleagues to join efforts to provide integrated, evidence-based growth monitoring to pregnant women and their infants worldwide. Presently, there are 23.3 million infants born small for gestational age in low- to middle-income countries according to the INTERGROWTH-21st newborn size standards. We suggest that misclassification of these infants by using local charts could affect the delivery of optimal health care.
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Villar J, Cheikh Ismail L, Staines Urias E, Giuliani F, Ohuma EO, Victora CG, Papageorghiou AT, Altman DG, Garza C, Barros FC, Puglia F, Ochieng R, Jaffer YA, Noble JA, Bertino E, Purwar M, Pang R, Lambert A, Chumlea C, Stein A, Fernandes M, Bhutta ZA, Kennedy SH. The satisfactory growth and development at 2 years of age of the INTERGROWTH-21 st Fetal Growth Standards cohort support its appropriateness for constructing international standards. Am J Obstet Gynecol 2018; 218:S841-S854.e2. [PMID: 29273309 PMCID: PMC5807090 DOI: 10.1016/j.ajog.2017.11.564] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 11/07/2017] [Accepted: 11/08/2017] [Indexed: 11/30/2022]
Abstract
Background The World Health Organization recommends that human growth should be monitored with the use of international standards. However, in obstetric practice, we continue to monitor fetal growth using numerous local charts or equations that are based on different populations for each body structure. Consistent with World Health Organization recommendations, the INTERGROWTH-21st Project has produced the first set of international standards to date pregnancies; to monitor fetal growth, estimated fetal weight, Doppler measures, and brain structures; to measure uterine growth, maternal nutrition, newborn infant size, and body composition; and to assess the postnatal growth of preterm babies. All these standards are based on the same healthy pregnancy cohort. Recognizing the importance of demonstrating that, postnatally, this cohort still adhered to the World Health Organization prescriptive approach, we followed their growth and development to the key milestone of 2 years of age. Objective The purpose of this study was to determine whether the babies in the INTERGROWTH-21st Project maintained optimal growth and development in childhood. Study Design In the Infant Follow-up Study of the INTERGROWTH-21st Project, we evaluated postnatal growth, nutrition, morbidity, and motor development up to 2 years of age in the children who contributed data to the construction of the international fetal growth, newborn infant size and body composition at birth, and preterm postnatal growth standards. Clinical care, feeding practices, anthropometric measures, and assessment of morbidity were standardized across study sites and documented at 1 and 2 years of age. Weight, length, and head circumference age- and sex-specific z-scores and percentiles and motor development milestones were estimated with the use of the World Health Organization Child Growth Standards and World Health Organization milestone distributions, respectively. For the preterm infants, corrected age was used. Variance components analysis was used to estimate the percentage variability among individuals within a study site compared with that among study sites. Results There were 3711 eligible singleton live births; 3042 children (82%) were evaluated at 2 years of age. There were no substantive differences between the included group and the lost-to-follow up group. Infant mortality rate was 3 per 1000; neonatal mortality rate was 1.6 per 1000. At the 2-year visit, the children included in the INTERGROWTH-21st Fetal Growth Standards were at the 49th percentile for length, 50th percentile for head circumference, and 58th percentile for weight of the World Health Organization Child Growth Standards. Similar results were seen for the preterm subgroup that was included in the INTERGROWTH-21st Preterm Postnatal Growth Standards. The cohort overlapped between the 3rd and 97th percentiles of the World Health Organization motor development milestones. We estimated that the variance among study sites explains only 5.5% of the total variability in the length of the children between birth and 2 years of age, although the variance among individuals within a study site explains 42.9% (ie, 8 times the amount explained by the variation among sites). An increase of 8.9 cm in adult height over mean parental height is estimated to occur in the cohort from low-middle income countries, provided that children continue to have adequate health, environmental, and nutritional conditions. Conclusion The cohort enrolled in the INTERGROWTH-21st standards remained healthy with adequate growth and motor development up to 2 years of age, which supports its appropriateness for the construction of international fetal and preterm postnatal growth standards.
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Affiliation(s)
- José Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
| | - Leila Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK; Clinical Nutrition and Dietetics Department, University of Sharjah, Sharjah, United Arab Emirates
| | - Eleonora Staines Urias
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Francesca Giuliani
- Azienda Ospedaliera OIRM Sant'Anna Citta della Salute e della Scienza di Torino, Torino, Italy
| | - Eric O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cesar G Victora
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotasl, Pelotas, Brazil
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Cutberto Garza
- Division of Nutritional Sciences, Cornell University, Ithaca, NY
| | - Fernando C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotasl, Pelotas, Brazil; Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Fabien Puglia
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | | | - Yasmin A Jaffer
- Department of Family & Community Health, Ministry of Health, Muscat, Sultanate of Oman
| | - Julia A Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Enrico Bertino
- Dipartimento di Scienze Pediatriche e dell' Adolescenza, SCDU Neonatologia, Universita di Torino, Torino, Italy
| | - Manorama Purwar
- Nagpur INTERGROWTH-21(st) Research Centre, Ketkar Hospital, Nagpur, India
| | - Ruyan Pang
- School of Public Health, Peking University, Beijing, China
| | - Ann Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Cameron Chumlea
- Lifespan Health Research Center, Boonshoft School of Medicine, Wright State University, Dayton, Ohio
| | - Alan Stein
- Department of Psychiatry, University of Oxford, Oxford, UK
| | - Michelle Fernandes
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Hirst JE, Villar J, Victora CG, Papageorghiou AT, Finkton D, Barros FC, Gravett MG, Giuliani F, Purwar M, Frederick IO, Pang R, Cheikh Ismail L, Lambert A, Stones W, Jaffer YA, Altman DG, Noble JA, Ohuma EO, Kennedy SH, Bhutta ZA. The antepartum stillbirth syndrome: risk factors and pregnancy conditions identified from the INTERGROWTH-21 st Project. BJOG 2016; 125:1145-1153. [PMID: 28029221 PMCID: PMC6055673 DOI: 10.1111/1471-0528.14463] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To identify risk factors for antepartum stillbirth, including fetal growth restriction, among women with well-dated pregnancies and access to antenatal care. DESIGN Population-based, prospective, observational study. SETTING Eight international urban populations. POPULATION Pregnant women and their babies enrolled in the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. METHODS Cox proportional hazard models were used to compare risks among antepartum stillborn and liveborn babies. MAIN OUTCOME MEASURES Antepartum stillbirth was defined as any fetal death after 16 weeks' gestation before the onset of labour. RESULTS Of 60 121 babies, 553 were stillborn (9.2 per 1000 births), of which 445 were antepartum deaths (7.4 per 1000 births). After adjustment for site, risk factors were low socio-economic status, hazard ratio (HR): 1.6 (95% CI, 1.2-2.1); single marital status, HR 2.0 (95% CI, 1.4-2.8); age ≥40 years, HR 2.2 (95% CI, 1.4-3.7); essential hypertension, HR 4.0 (95% CI, 2.7-5.9); HIV/AIDS, HR 4.3 (95% CI, 2.0-9.1); pre-eclampsia, HR 1.6 (95% CI, 1.1-3.8); multiple pregnancy, HR 3.3 (95% CI, 2.0-5.6); and antepartum haemorrhage, HR 3.3 (95% CI, 2.5-4.5). Birth weight <3rd centile was associated with antepartum stillbirth [HR, 4.6 (95% CI, 3.4-6.2)]. The greatest risk was seen in babies not suspected to have been growth restricted antenatally, with an HR of 5.0 (95% CI, 3.6-7.0). The population-attributable risk of antepartum death associated with small-for-gestational-age neonates diagnosed at birth was 11%. CONCLUSIONS Antepartum stillbirth is a complex syndrome associated with several risk factors. Although small babies are at higher risk, current growth restriction detection strategies only modestly reduced the rate of stillbirth. TWEETABLE ABSTRACT International stillbirth study finds individual risks poor predictors of death but combinations promising.
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Affiliation(s)
- J E Hirst
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - J Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - C G Victora
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil
| | - A T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - D Finkton
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - F C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil.,Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - M G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle, WA, USA
| | - F Giuliani
- Dipartimento di Scienze della Sanità Pubblica e Pediatriche, Università degli Studi di Torino, Torino, Italy
| | - M Purwar
- Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India
| | - I O Frederick
- Center for Perinatal Studies, Swedish Medical Center, Seattle, WA, USA
| | - R Pang
- School of Public Health, Peking University, Beijing, China
| | - L Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - A Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - W Stones
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Y A Jaffer
- Department of Family & Community Health, Ministry of Health, Muscat, Oman
| | - D G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - J A Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - E O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.,Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - S H Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Z A Bhutta
- Division of Women & Child Health, The Aga Khan University, Karachi, Pakistan.,Center for Global Health for Sick Children, Toronto, ON, Canada
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Papageorghiou AT, Kemp B, Stones W, Ohuma EO, Kennedy SH, Purwar M, Salomon LJ, Altman DG, Noble JA, Bertino E, Gravett MG, Pang R, Cheikh Ismail L, Barros FC, Lambert A, Jaffer YA, Victora CG, Bhutta ZA, Villar J. Ultrasound-based gestational-age estimation in late pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 48:719-726. [PMID: 26924421 PMCID: PMC6680349 DOI: 10.1002/uog.15894] [Citation(s) in RCA: 103] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 02/12/2016] [Accepted: 02/18/2016] [Indexed: 05/04/2023]
Abstract
OBJECTIVE Accurate gestational-age (GA) estimation, preferably by ultrasound measurement of fetal crown-rump length before 14 weeks' gestation, is an important component of high-quality antenatal care. The objective of this study was to determine how GA can best be estimated by fetal ultrasound for women who present for the first time late in pregnancy with uncertain or unknown menstrual dates. METHODS INTERGROWTH-21st was a large, prospective, multicenter, population-based project performed in eight geographically defined urban populations. One of its principal components, the Fetal Growth Longitudinal Study, aimed to develop international fetal growth standards. Each participant had their certain menstrual dates confirmed by first-trimester ultrasound examination. Fetal head circumference (HC), biparietal diameter (BPD), occipitofrontal diameter (OFD), abdominal circumference (AC) and femur length (FL) were measured every 5 weeks from 14 weeks' gestation until delivery. For each participant, a single, randomly selected ultrasound examination was used to explore all candidate biometric variables and permutations to build models to predict GA. Regression equations were ranked based upon minimization of the mean prediction error, goodness of fit and model complexity. An automated machine learning algorithm, the Genetic Algorithm, was adapted to evaluate > 64 000 potential polynomial equations as predictors. RESULTS Of the 4607 eligible women, 4321 (94%) had a pregnancy without major complications and delivered a live singleton without congenital malformations. After other exclusions (missing measurements in GA window and outliers), the final sample comprised 4229 women. Two skeletal measures, HC and FL, produced the best GA prediction, given by the equation loge (GA) = 0.03243 × (loge (HC))2 + 0.001644 × FL × loge (HC) + 3.813. When FL was not available, the best equation based on HC alone was loge (GA) = 0.05970 × (loge (HC))2 + 0.000000006409 × (HC)3 + 3.3258. The estimated uncertainty of GA prediction (half width 95% interval) was 6-7 days at 14 weeks' gestation, 12-14 days at 26 weeks' gestation and > 14 days in the third trimester. The addition of FL to the HC model led to improved prediction intervals compared with using HC alone, but no further improvement in prediction was afforded by adding AC, BPD or OFD. Equations that included other measurements (BPD, OFD and AC) did not perform better. CONCLUSIONS Among women initiating antenatal care late in pregnancy, a single set of ultrasound measurements combining HC and FL in the second trimester can be used to estimate GA with reasonable accuracy. We recommend this tool for underserved populations but considerable efforts should be implemented to improve early initiation of antenatal care worldwide. © 2016 Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A. T. Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
| | - B. Kemp
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
| | - W. Stones
- Faculty of Health SciencesAga Khan UniversityNairobiKenya
- School of MedicineUniversity of St AndrewsSt AndrewsScotland
| | - E. O. Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
- Centre for Statistics in Medicine, Botnar Research CentreUniversity of OxfordOxfordUK
| | - S. H. Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
| | - M. Purwar
- Nagpur INTERGROWTH‐21 Research CentreKetkar HospitalNagpurIndia
| | - L. J. Salomon
- Maternité Necker‐Enfants Malades, AP‐HPUniversité Paris DescartesParisFrance
| | - D. G. Altman
- Center for Statistics in Medicine, Nuffield Department of OrthopaedicsRheumatology and Musculoskeletal Sciences, University of OxfordOxfordUK
| | - J. A. Noble
- Department of Engineering ScienceUniversity of OxfordOxfordUK
| | - E. Bertino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, Cattedra di NeonatologiaUniversità degli Studi di TorinoTurinItaly
| | - M. G. Gravett
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS)SeattleWAUSA
| | - R. Pang
- School of Public HealthPeking UniversityBeijingChina
| | - L. Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
| | - F. C. Barros
- Programa de Pós‐Graduação em Saúde e ComportamentoUniversidade Católica de PelotasPelotasRSBrazil
- Programa de Pós‐Graduação em EpidemiologiaUniversidade Federal de PelotasPelotasRSBrazil
| | - A. Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
| | - Y. A. Jaffer
- Department of Family & Community HealthMinistry of HealthMuscatSultanate of Oman
| | - C. G. Victora
- Programa de Pós‐Graduação em EpidemiologiaUniversidade Federal de PelotasPelotasRSBrazil
| | - Z. A. Bhutta
- Division of Women & Child HealthThe Aga Khan UniversityKarachiPakistan
- Center for Global HealthHospital for Sick ChildrenTorontoONCanada
| | - J. Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton CollegeUniversity of OxfordOxfordUK
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Postnatal growth standards for preterm infants: the Preterm Postnatal Follow-up Study of the INTERGROWTH-21(st) Project. LANCET GLOBAL HEALTH 2016; 3:e681-91. [PMID: 26475015 DOI: 10.1016/s2214-109x(15)00163-1] [Citation(s) in RCA: 206] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/23/2015] [Accepted: 07/27/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Charts of size at birth are used to assess the postnatal growth of preterm babies on the assumption that extrauterine growth should mimic that in the uterus. METHODS The INTERGROWTH-21(st) Project assessed fetal, newborn, and postnatal growth in eight geographically defined populations, in which maternal health care and nutritional needs were met. From these populations, the Fetal Growth Longitudinal Study selected low-risk women starting antenatal care before 14 weeks' gestation and monitored fetal growth by ultrasonography. All preterm births from this cohort were eligible for the Preterm Postnatal Follow-up Study, which included standardised anthropometric measurements, feeding practices based on breastfeeding, and data on morbidity, treatments, and development. To construct the preterm postnatal growth standards, we selected all live singletons born between 26 and before 37 weeks' gestation without congenital malformations, fetal growth restriction, or severe postnatal morbidity. We did analyses with second-degree fractional polynomial regression models in a multilevel framework accounting for repeated measures. Fetal and neonatal data were pooled from study sites and stratified by postmenstrual age. For neonates, boys and girls were assessed separately. FINDINGS From 4607 women enrolled in the study, there were 224 preterm singleton births, of which 201 (90%) were enrolled in the Preterm Postnatal Follow-up Study. Variance component analysis showed that only 0·2% and 4·0% of the total variability in postnatal length and head circumference, respectively, could be attributed to between-site differences, justifying pooling the data from all study sites. Preterm growth patterns differed from those for babies in the INTERGROWTH-21(st) Newborn Size Standards. They overlapped with the WHO Child Growth Standards for term babies by 64 weeks' postmenstrual age. INTERPRETATION Our data have yielded standards for postnatal growth in preterm infants. These standards should be used for the assessment of preterm infants until 64 weeks' postmenstrual age, after which the WHO Child Growth Standards are appropriate. Size-at-birth charts should not be used to measure postnatal growth of preterm infants. FUNDING Bill & Melinda Gates Foundation.
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Andersen ZJ, Sram RJ, Ščasný M, Gurzau ES, Fucic A, Gribaldo L, Rossner P, Rossnerova A, Kohlová MB, Máca V, Zvěřinová I, Gajdosova D, Moshammer H, Rudnai P, Knudsen LE. Newborns health in the Danube Region: Environment, biomonitoring, interventions and economic benefits in a large prospective birth cohort study. ENVIRONMENT INTERNATIONAL 2016; 88:112-122. [PMID: 26735349 DOI: 10.1016/j.envint.2015.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 12/07/2015] [Accepted: 12/10/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND The EU strategy for the Danube Region addresses numerous challenges including environment, health and socioeconomic disparities. Many old environmental burdens and heavily polluted areas in Europe are located in the Danube Region, consisting of 14 countries, with over 100 million people. Estimating the burden of environmental exposures on early-life health is a growing research area in Europe which has major public health implications, but the data from the Danube Region are largely missing. AIM This review presents an inventory of current environmental challenges, related early-life health risks, and knowledge gaps in the Danube Region, based on publicly available databases, registers, and literature, as a rationale and incentive for a new integrated project. The review also proposes the concept for the project aiming to characterize in utero exposures to multiple environmental factors and estimate their effect on early-life health, evaluate economic impact, as well as identify interventions with a potential to harness social norms to reduce emissions, exposures and health risks in the Danube Region. METHODS Experts in environmental epidemiology, human biomonitoring and social science in collaboration with clinicians propose to establish a new large multi-center birth cohort of mother-child pairs from Danube countries, measure biomarkers of exposure and health in biological samples at birth, collect centrally measured climate, air and water pollution data, conduct pre- and postnatal surveys on lifestyle, indoor exposures, noise, occupation, socio-economic status, risk-averting behavior, and preferences; and undertake clinical examinations of children at and after birth. Birth cohort will include at least 2000 newborns per site, and a subset of at least 200 mother-child pairs per site for biomonitoring. Novel biomarkers of exposure, susceptibility, and effect will be applied, to gain better mechanistic insight. Effects of multiple environmental exposures on fetal and child growth, respiratory, allergic, immunologic, and neurodevelopmental health outcomes will be estimated. Parent's willingness to pay for reducing health risks in children will be elicited by survey, while values of cost-of-illness will be gathered from literature and national statistics. Effects of risk reducing interventions will be examined. CONCLUSIONS The proposed project would provide novel estimates of the burden of early childhood diseases attributable to environmental exposures and assess health impacts of different intervention scenarios in the Danube Region, in an integrated approach combining human biomonitoring, epidemiological and social science research.
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Affiliation(s)
- Zorana J Andersen
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark.
| | - Radim J Sram
- Institute of Experimental Medicine, AS CR Videnska 1083, 142 20 Prague 4, Czech Republic.
| | - Milan Ščasný
- Charles University in Prague, Environment Center, Jose Martiho 2, 162 00 Prague 6, Czech Republic.
| | - Eugen S Gurzau
- The Environmental Health Center, Busuiocului 58, 400240 Cluj Napoca, Romania.
| | - Aleksandra Fucic
- Institute for Medical Research and Occupational Health, Ksaverska c 2, 10000 Zagreb, Croatia.
| | - Laura Gribaldo
- EC DG Joint Research Centre, Institute for Health and Consumer Protection, TP 260, Via E. Fermi, 2749 21027 Ispra, Italy.
| | - Pavel Rossner
- Institute of Experimental Medicine, AS CR Videnska 1083, 142 20 Prague 4, Czech Republic.
| | - Andrea Rossnerova
- Institute of Experimental Medicine, AS CR Videnska 1083, 142 20 Prague 4, Czech Republic.
| | - Markéta Braun Kohlová
- Charles University in Prague, Environment Center, Jose Martiho 2, 162 00 Prague 6, Czech Republic.
| | - Vojtěch Máca
- Charles University in Prague, Environment Center, Jose Martiho 2, 162 00 Prague 6, Czech Republic.
| | - Iva Zvěřinová
- Charles University in Prague, Environment Center, Jose Martiho 2, 162 00 Prague 6, Czech Republic.
| | - Dagmar Gajdosova
- Regional Public Health Authority, Ipelska 1, 040 11 Kosice, Slovak Republic.
| | - Hanns Moshammer
- Institut Umwelt-Hygiene, Medical University of Vienna, Kinderspitalgasse 15, 1090 Vienna, Austria.
| | - Peter Rudnai
- National Center for Public Health, Budapest, Hungary.
| | - Lisbeth E Knudsen
- Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, 1014 Copenhagen, Denmark.
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Cheikh Ismail L, Bishop DC, Pang R, Ohuma EO, Kac G, Abrams B, Rasmussen K, Barros FC, Hirst JE, Lambert A, Papageorghiou AT, Stones W, Jaffer YA, Altman DG, Noble JA, Giolito MR, Gravett MG, Purwar M, Kennedy SH, Bhutta ZA, Villar J. Gestational weight gain standards based on women enrolled in the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project: a prospective longitudinal cohort study. BMJ 2016; 352:i555. [PMID: 26926301 PMCID: PMC4770850 DOI: 10.1136/bmj.i555] [Citation(s) in RCA: 112] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
OBJECTIVE To describe patterns in maternal gestational weight gain (GWG) in healthy pregnancies with good maternal and perinatal outcomes. DESIGN Prospective longitudinal observational study. SETTING Eight geographically diverse urban regions in Brazil, China, India, Italy, Kenya, Oman, United Kingdom, and United States, April 2009 to March 2014. PARTICIPANTS Healthy, well nourished, and educated women enrolled in the Fetal Growth Longitudinal Study component of the INTERGROWTH-21(st) Project, who had a body mass index (BMI) of 18.50-24.99 in the first trimester of pregnancy. MAIN OUTCOME MEASURES Maternal weight measured with standardised methods and identical equipment every five weeks (plus/minus one week) from the first antenatal visit (<14 weeks' gestation) to delivery. After confirmation that data from the study sites could be pooled, a multilevel, linear regression analysis accounting for repeated measures, adjusted for gestational age, was applied to produce the GWG values. RESULTS 13,108 pregnant women at <14 weeks' gestation were screened, and 4607 met the eligibility criteria, provided consent, and were enrolled. The variance within sites (59.6%) was six times higher than the variance between sites (9.6%). The mean GWGs were 1.64 kg, 2.86 kg, 2.86 kg, 2.59 kg, and 2.56 kg for the gestational age windows 14-18(+6) weeks, 19-23(+6) weeks, 24-28(+6) weeks, 29-33(+6) weeks, and 34-40(+0) weeks, respectively. Total mean weight gain at 40 weeks' gestation was 13.7 (SD 4.5) kg for 3097 eligible women with a normal BMI in the first trimester. Of all the weight measurements, 71.7% (10,639/14,846) and 94.9% (14,085/14,846) fell within the expected 1 SD and 2 SD thresholds, respectively. Data were used to determine fitted 3rd, 10th, 25th, 50th, 75th, 90th, and 97th smoothed GWG centiles by exact week of gestation, with equations for the mean and standard deviation to calculate any desired centiles according to gestational age in exact weeks. CONCLUSIONS Weight gain in pregnancy is similar across the eight populations studied. Therefore, the standards generated in this study of healthy, well nourished women may be used to guide recommendations on optimal gestational weight gain worldwide.
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Affiliation(s)
- Leila Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Deborah C Bishop
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Ruyan Pang
- School of Public Health, Peking University, Beijing, China
| | - Eric O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Gilberto Kac
- Universidade Federal do Rio de Janeiro/Rio de Janeiro Federal University, Instituto de Nutrição Josué de Castro/Nutrition Institute, Departamento de Nutrição Social e Aplicada, Rio de Janeiro, Brazil
| | - Barbara Abrams
- School of Public Health, University of California, Berkeley, CA, USA
| | | | - Fernando C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - Jane E Hirst
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Ann Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - William Stones
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya School of Medicine, University of St Andrews, St Andrews, Scotland, UK
| | - Yasmin A Jaffer
- Department of Family and Community Health, Ministry of Health, Muscat, Sultanate of Oman
| | - Douglas G Altman
- Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - J Alison Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Maria Rosa Giolito
- Direttore SC consultori familiari e pediatria di comunità, Torino, Italy
| | - Michael G Gravett
- Global Alliance to Prevent Prematurity and Stillbirth (GAPPS), Seattle Children's, Seattle, WA, USA
| | - Manorama Purwar
- Nagpur INTERGROWTH-21 Research Centre, Ketkar Hospital, Nagpur, India
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Zulfiqar A Bhutta
- Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan Centre for Global Child Health, Hospital for Sick Children, TN, Canada
| | - José Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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15
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Cheikh Ismail L, Giuliani F, Bhat BA, Bishop D, Papageorghiou AT, Ochieng R, Puglia F, Altman DG, Maia-Schlüssel M, Noble JA, Bertino E, Gravett MG, Purwar M, Yajing L, Mota D, Ohuma E, Lambert A, Kennedy SH, Bhutta ZA, Villar J. Preterm feeding recommendations are achievable in large-scale research studies. BMC Nutr 2016. [DOI: 10.1186/s40795-016-0047-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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16
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Giuliani F, Cheikh Ismail L, Bertino E, Bhutta ZA, Ohuma EO, Rovelli I, Conde-Agudelo A, Villar J, Kennedy SH. Monitoring postnatal growth of preterm infants: present and future. Am J Clin Nutr 2016; 103:635S-47S. [PMID: 26791186 PMCID: PMC6443302 DOI: 10.3945/ajcn.114.106310] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is no consensus with regard to which charts are most suitable for monitoring the postnatal growth of preterm infants. OBJECTIVE We aimed to assess the strategies used to develop existing postnatal growth charts for preterm infants and their methodologic quality. DESIGN A systematic review of observational longitudinal studies, having as their primary objective the creation of postnatal growth charts for preterm infants, was conducted. Thirty-eight items distributed in 3 methodologic domains ("study design," "statistical methods," and "reporting methods") were assessed in each study. Each item was scored as a "low" or "high" risk of bias. Two reviewers independently selected the studies, assessed the risk of bias, and extracted data. A total quality score [(number of "low risk" of bias marks/total number of items assessed) × 100%] was calculated for each study. Median (range, IQR) quality scores for each methodologic domain and for all included studies were computed. RESULTS Sixty-one studies met the inclusion criteria. Twenty-seven (44.3%) of the 61 studies scored ≥50%, of which 10 scored >60% and only 1 scored >66%. The median (range, IQR) quality score for the 61 included studies was 47% (26-75%, 34-56%). The scores for the domains study design, statistical methods, and reporting methods were 44% (19-67%, 33-52%), 25% (0-88%, 13-38%), and 33% (0-100%, 0-33%), respectively. The most common shortcomings were observed in items related to anthropometric measures (the main variable of interest), gestational age estimation, follow-up duration, reporting of postnatal care and morbidities, assessment of outliers, covariates, and chart presentation. CONCLUSIONS The overall methodologic quality of existing longitudinal studies was fair to low. To overcome these problems, the Preterm Postnatal Follow-up Study, 1 of the 3 main components of The International Fetal and Newborn Growth Consortium for the 21st Century Project, was designed to construct preterm postnatal growth standards from a prospective cohort of "healthy" pregnancies and preterm newborns without evidence of fetal growth restriction.
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Affiliation(s)
- Francesca Giuliani
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Leila Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology, and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Enrico Bertino
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Zulfiqar A Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Eric O Ohuma
- Nuffield Department of Obstetrics & Gynaecology, and Centre for Statistics in Medicine, University of Oxford Botnar Research Centre, Oxford, United Kingdom
| | - Ilaria Rovelli
- Department of Public Health and Pediatrics, University of Turin, Turin, Italy
| | - Agustin Conde-Agudelo
- Perinatology Research Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD; National Institutes of Health/Department of Health and Human Services, Detroit, MI
| | - José Villar
- Nuffield Department of Obstetrics & Gynaecology, and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics & Gynaecology, and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom;
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Monitoring human growth and development: a continuum from the womb to the classroom. Am J Obstet Gynecol 2015; 213:494-9. [PMID: 26184778 DOI: 10.1016/j.ajog.2015.07.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Revised: 06/22/2015] [Accepted: 07/06/2015] [Indexed: 11/23/2022]
Abstract
A comprehensive set of fully integrated anthropometric measures is needed to evaluate human growth from conception to infancy so that consistent judgments can be made about the appropriateness of fetal and infant growth. At present, there are 2 barriers to this strategy. First, descriptive reference charts, which are derived from local, unselected samples with inadequate methods and poor characterization of their putatively healthy populations, commonly are used rather than prescriptive standards. The use of prescriptive standards is justified by the extensive biologic, genetic, and epidemiologic evidence that skeletal growth is similar from conception to childhood across geographic populations, when health, nutrition, environmental, and health care needs are met. Second, clinicians currently screen fetuses, newborn infants, and infants at all levels of care with a wide range of charts and cutoff points, often with limited appreciation of the underlying population or quality of the study that generated the charts. Adding to the confusion, infants are evaluated after birth with a single prescriptive tool: the World Health Organization Child Growth Standards, which were derived from healthy, breastfed newborn infants, infants, and young children from populations that have been exposed to few growth-restricting factors. The International Fetal and Newborn Growth Consortium for the 21st Century Project addressed these issues by providing international standards for gestational age estimation, first-trimester fetal size, fetal growth, newborn size for gestational age, and postnatal growth of preterm infants, all of which complement the World Health Organization Child Growth Standards conceptually, methodologically, and analytically. Hence, growth and development can now, for the first time, be monitored globally across the vital first 1000 days and all the way to 5 years of age. It is clear that an integrative approach to monitoring growth and development from pregnancy to school age is desirable, scientifically supported, and likely to improve care, referral patterns, and reporting systems. Such integration can be achieved only through the use of international growth standards, especially in increasingly diverse, mixed ancestry populations. Resistance to new scientific developments has been hugely problematic in medicine; however, we are confident that the obstetric and neonatal communities will join their pediatric colleagues worldwide in the adoption of this integrative strategy.
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Garza C. Fetal, neonatal, infant, and child international growth standards: an unprecedented opportunity for an integrated approach to assess growth and development. Adv Nutr 2015; 6:383-90. [PMID: 26178022 PMCID: PMC4496737 DOI: 10.3945/an.114.008128] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The recent publication of fetal growth and gestational age-specific growth standards by the International Fetal and Newborn Growth Consortium for the 21st Century Project and the previous publication by the WHO of infant and young child growth standards based on the WHO Multicentre Growth Reference Study enable evaluations of growth from ∼9 wk gestation to 5 y. The most important features of these projects are the prescriptive approach used for subject selection and the rigorous testing of the assertion that growth is very similar among geographically and ethnically diverse nonisolated populations when health, nutrition, and other care needs are met and the environment imposes minimal constraints on growth. Both studies documented that with adequate controls, the principal source of variability in growth during gestation and early childhood resides among individuals. Study sites contributed much less to observed variability. The agreement between anthropometric measurements common to both studies also is noteworthy. Jointly, these studies provide for the first time, to my knowledge, a conceptually consistent basis for worldwide and localized assessments and comparisons of growth performance in early life. This is an important contribution to improving the health care of children across key periods of growth and development, especially given the appropriate interest in pursuing "optimal" health in the "first 1000 d," i.e., the period covering fertilization/implantation, gestation, and postnatal life to 2 y of age.
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Affiliation(s)
- Cutberto Garza
- Boston College, Chestnut Hill, MA; Department of Global Health, George Washington University Milken Institute School of Public Health, Washington, DC; and Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD
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Albouy-Llaty M, Dupuis A, Grignon C, Strezlec S, Pierre F, Rabouan S, Migeot V. Estimating drinking-water ingestion and dermal contact with water in a French population of pregnant women: the EDDS cohort study. JOURNAL OF EXPOSURE SCIENCE & ENVIRONMENTAL EPIDEMIOLOGY 2015; 25:308-16. [PMID: 25073435 DOI: 10.1038/jes.2014.48] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/05/2013] [Revised: 05/20/2014] [Accepted: 05/20/2014] [Indexed: 05/12/2023]
Abstract
The aim of the present study, a part of the Endocrine Disruptor Deux-Sèvres (EDDS) cohort study, was to estimate water-use habits of pregnant French women. The study population consisted of 132 pregnant women living in Deux-Sèvres (France) in 2012-2013, in areas where drinking water is exclusively produced by surface water. Drinking-water data included ingested water (tap, bottled and filtered) and ingestion place (home, work and elsewhere). Dermal contact with water included showering, bathing, swimming, spa use, hand-washing and other water activities. Data were collected through face-to-face interviews at second and third trimesters of pregnancy with a 1-day-recall questionnaire. Intertrimestral differences in water-use habits were assessed. Predictors of water ingestion and duration of dermal contact with water were assessed with multiple linear regressions. At the second trimester of pregnancy, the mean total drinking-water ingestion was 1.8±0.6 l per day (mean and SD), 71% of which was tap water. Total drinking-water ingestion was not different between both trimesters but ingestion place differed. Dermal contact with water estimate was 188±118 and 173±92 min/week at second and third trimesters, respectively. Smoking increased water ingestion 777 ml/day 95% CI (171-1384). Duration of dermal contact in spring was 30 min/week 95% CI (13-48) higher than in winter. Obese women spend 26 min/week 95% CI (2-50) more showering than women with recommended weight. Our estimates of pregnant French women's exposure to water will help researchers to better assess water pollutant risks.
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Affiliation(s)
- Marion Albouy-Llaty
- 1] Department of Analytical Chemistry, Pharmaceutics and Epidemiology, Faculty of Medicine and Pharmacy, University of Poitiers, IC2MP, UMR7285-CNRS, Poitiers Cedex France [2] Poitiers University Hospital, Biology-Pharmacy-Public Health Pole, Poitiers Cedex, France
| | - Antoine Dupuis
- 1] Department of Analytical Chemistry, Pharmaceutics and Epidemiology, Faculty of Medicine and Pharmacy, University of Poitiers, IC2MP, UMR7285-CNRS, Poitiers Cedex France [2] Poitiers University Hospital, Biology-Pharmacy-Public Health Pole, Poitiers Cedex, France
| | - Claire Grignon
- 1] Department of Analytical Chemistry, Pharmaceutics and Epidemiology, Faculty of Medicine and Pharmacy, University of Poitiers, IC2MP, UMR7285-CNRS, Poitiers Cedex France [2] Poitiers University Hospital, Biology-Pharmacy-Public Health Pole, Poitiers Cedex, France
| | - Sylvie Strezlec
- Maternal and Childhood Protection, Conseil general des Deux-Sèvres, Niort, France
| | - Fabrice Pierre
- Poitiers University Hospital, Mother and child Pole, Poitiers Cedex, France
| | - Sylvie Rabouan
- Department of Analytical Chemistry, Pharmaceutics and Epidemiology, Faculty of Medicine and Pharmacy, University of Poitiers, IC2MP, UMR7285-CNRS, Poitiers Cedex France
| | - Virginie Migeot
- 1] Department of Analytical Chemistry, Pharmaceutics and Epidemiology, Faculty of Medicine and Pharmacy, University of Poitiers, IC2MP, UMR7285-CNRS, Poitiers Cedex France [2] Poitiers University Hospital, Biology-Pharmacy-Public Health Pole, Poitiers Cedex, France
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Papageorghiou AT, Kennedy SH, Salomon LJ, Ohuma EO, Cheikh Ismail L, Barros FC, Lambert A, Carvalho M, Jaffer YA, Bertino E, Gravett MG, Altman DG, Purwar M, Noble JA, Pang R, Victora CG, Bhutta ZA, Villar J. International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester of pregnancy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2014; 44:641-8. [PMID: 25044000 PMCID: PMC4286014 DOI: 10.1002/uog.13448] [Citation(s) in RCA: 157] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVES There are no international standards for relating fetal crown-rump length (CRL) to gestational age (GA), and most existing charts have considerable methodological limitations. The INTERGROWTH-21(st) Project aimed to produce the first international standards for early fetal size and ultrasound dating of pregnancy based on CRL measurement. METHODS Urban areas in eight geographically diverse countries that met strict eligibility criteria were selected for the prospective, population-based recruitment, between 9 + 0 and 13 + 6 weeks' gestation, of healthy well-nourished women with singleton pregnancies at low risk of fetal growth impairment. GA was calculated on the basis of a certain last menstrual period, regular menstrual cycle and lack of hormonal medication or breastfeeding in the preceding 2 months. CRL was measured using strict protocols and quality-control measures. All women were followed up throughout pregnancy until delivery and hospital discharge. Cases of neonatal and fetal death, severe pregnancy complications and congenital abnormalities were excluded from the study. RESULTS A total of 4607 women were enrolled in the Fetal Growth Longitudinal Study, one of the three main components of the INTERGROWTH-21(st) Project, of whom 4321 had a live singleton birth in the absence of severe maternal conditions or congenital abnormalities detected by ultrasound or at birth. The CRL was measured in 56 women at < 9 + 0 weeks' gestation; these were excluded, resulting in 4265 women who contributed data to the final analysis. The mean CRL and SD increased with GA almost linearly, and their relationship to GA is given by the following two equations (in which GA is in days and CRL in mm): mean CRL = -50.6562 + (0.815118 × GA) + (0.00535302 × GA(2) ); and SD of CRL = -2.21626 + (0.0984894 × GA). GA estimation is carried out according to the two equations: GA = 40.9041 + (3.21585 × CRL(0.5) ) + (0.348956 × CRL); and SD of GA = 2.39102 + (0.0193474 × CRL). CONCLUSIONS We have produced international prescriptive standards for early fetal linear size and ultrasound dating of pregnancy in the first trimester that can be used throughout the world.
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Affiliation(s)
- A T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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21
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Villar J, Papageorghiou AT, Pang R, Ohuma EO, Cheikh Ismail L, Barros FC, Lambert A, Carvalho M, Jaffer YA, Bertino E, Gravett MG, Altman DG, Purwar M, Frederick IO, Noble JA, Victora CG, Bhutta ZA, Kennedy SH. The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study. Lancet Diabetes Endocrinol 2014; 2:781-92. [PMID: 25009082 DOI: 10.1016/s2213-8587(14)70121-4] [Citation(s) in RCA: 208] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Large differences exist in size at birth and in rates of impaired fetal growth worldwide. The relative effects of nutrition, disease, the environment, and genetics on these differences are often debated. In clinical practice, various references are often used to assess fetal growth and newborn size across populations and ethnic origins, whereas international standards for assessing growth in infants and children have been established. In the INTERGROWTH-21(st) Project, our aim was to assess fetal growth and newborn size in eight geographically defined urban populations in which the health and nutrition needs of mothers were met and adequate antenatal care was provided. METHODS For this study, fetal growth and newborn size were measured in two INTERGROWTH-21(st) component studies using prespecified markers and the same methods, equipment, and selection criteria. In the Fetal Growth Longitudinal Study (FGLS), we studied educated, affluent, healthy women, with adequate nutritional status who were at low risk of intrauterine growth restriction. The primary markers of fetal growth were ultrasound measurements of fetal crown-rump length at less than 14 weeks and 0 days of gestation and fetal head circumference from 14 weeks and 0 days to 40 weeks and 0 days of gestation, and birthlength for newborn size. In the concomitant, population-based Newborn Cross-Sectional Study (NCSS), we measured birthlength in all newborn babies from the eight geographically defined urban populations with the same methods, instruments, and staff as in FGLS. From this large NCSS cohort, we selected an FGLS-like subpopulation to match FGLS with the same eligibility criteria. FINDINGS Between May 14, 2009, and Aug 2, 2013, we enrolled 4607 women in FGLS and 59 137 women in NCSS. From NCSS, 20 486 (34·6%) women met the FGLS eligibility criteria, and constituted the FGLS-like subpopulation. With variance component analysis, only between 1·9% and 3·5% of the total variability in crown-rump length, fetal head circumference, and newborn birthlength could be attributed to between-site differences. With standardised site effect analysis in 16 gestational age windows from 9 weeks and 0 days of gestation to birth for the three measures (128 comparisons), only one was marginally higher than 0·5 SD of the standardised site difference range. Sensitivity analyses, excluding individual populations in turn from the pooling of all-site centiles across gestational ages, showed no noticeable effect on the 3rd, 50th, and 97th centiles derived from the remaining populations. Our populations were consistent at birth with those in the WHO Multicentre Growth Reference Study (MGRS). The mean birthlength for term newborn babies in that study was 49·5 cm (SD 1·9), which was very similar to that in the FGLS cohort (49·4 cm [1·9]) and the NCSS derived FGLS-like subpopulation (49·3 cm [1·8]). INTERPRETATION Fetal growth and newborn length are similar across diverse geographical settings when mothers' nutritional and health needs are met, and environmental constraints on growth are low. The findings for birthlength are in strong agreement with those of the WHO MGRS. These results provide the conceptual frame to create international standards for growth from conception to newborn baby, which will extend the present infant to childhood WHO MGRS standards. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- José Villar
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Ruyan Pang
- School of Public Health, Peking University, Beijing, China
| | - Eric O Ohuma
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Leila Cheikh Ismail
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Fernando C Barros
- Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - Ann Lambert
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Maria Carvalho
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Yasmin A Jaffer
- Department of Family and Community Health, Ministry of Health, Muscat, Sultanate of Oman
| | - Enrico Bertino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, Cattedra di Neonatologia, Università degli Studi di Torino, Torino, Italy
| | | | - Doug G Altman
- Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Manorama Purwar
- Nagpur INTERGROWTH-21st Research Centre, Ketkar Hospital, Nagpur, India
| | | | - Julia A Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Cesar G Victora
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, The Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, Canada
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics & Gynaecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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Papageorghiou AT, Ohuma EO, Altman DG, Todros T, Cheikh Ismail L, Lambert A, Jaffer YA, Bertino E, Gravett MG, Purwar M, Noble JA, Pang R, Victora CG, Barros FC, Carvalho M, Salomon LJ, Bhutta ZA, Kennedy SH, Villar J. International standards for fetal growth based on serial ultrasound measurements: the Fetal Growth Longitudinal Study of the INTERGROWTH-21st Project. Lancet 2014; 384:869-79. [PMID: 25209488 DOI: 10.1016/s0140-6736(14)61490-2] [Citation(s) in RCA: 540] [Impact Index Per Article: 54.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND In 2006, WHO produced international growth standards for infants and children up to age 5 years on the basis of recommendations from a WHO expert committee. Using the same methods and conceptual approach, the Fetal Growth Longitudinal Study (FGLS), part of the INTERGROWTH-21(st) Project, aimed to develop international growth and size standards for fetuses. METHODS The multicentre, population-based FGLS assessed fetal growth in geographically defined urban populations in eight countries, in which most of the health and nutritional needs of mothers were met and adequate antenatal care was provided. We used ultrasound to take fetal anthropometric measurements prospectively from 14 weeks and 0 days of gestation until birth in a cohort of women with adequate health and nutritional status who were at low risk of intrauterine growth restriction. All women had a reliable estimate of gestational age confirmed by ultrasound measurement of fetal crown-rump length in the first trimester. The five primary ultrasound measures of fetal growth--head circumference, biparietal diameter, occipitofrontal diameter, abdominal circumference, and femur length--were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. The best fitting curves for the five measures were selected using second-degree fractional polynomials and further modelled in a multilevel framework to account for the longitudinal design of the study. FINDINGS We screened 13,108 women commencing antenatal care at less than 14 weeks and 0 days of gestation, of whom 4607 (35%) were eligible. 4321 (94%) eligible women had pregnancies without major complications and delivered live singletons without congenital malformations (the analysis population). We documented very low maternal and perinatal mortality and morbidity, confirming that the participants were at low risk of adverse outcomes. For each of the five fetal growth measures, the mean differences between the observed and smoothed centiles for the 3rd, 50th, and 97th centiles, respectively, were small: 2·25 mm (SD 3·0), 0·02 mm (3·0), and -2·69 mm (3·2) for head circumference; 0·83 mm (0·9), -0·05 mm (0·8), and -0·84 mm (1·0) for biparietal diameter; 0·63 mm (1·2), 0·04 mm (1·1), and -1·05 mm (1·3) for occipitofrontal diameter; 2·99 mm (3·1), 0·25 mm (3·2), and -4·22 mm (3·7) for abdominal circumference; and 0·62 mm (0·8), 0·03 mm (0·8), and -0·65 mm (0·8) for femur length. We calculated the 3rd, 5th 10th, 50th, 90th, 95th and 97th centile curves according to gestational age for these ultrasound measures, representing the international standards for fetal growth. INTERPRETATION We recommend these international fetal growth standards for the clinical interpretation of routinely taken ultrasound measurements and for comparisons across populations. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- Aris T Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Eric O Ohuma
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | | | - Leila Cheikh Ismail
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Ann Lambert
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Yasmin A Jaffer
- Department of Family and Community Health, Ministry of Health, Muscat, Oman
| | | | | | - Manorama Purwar
- Nagpur INTERGROWTH-21(st) Research Centre, Ketkar Hospital, Nagpur, India
| | - J Alison Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Ruyan Pang
- School of Public Health, Peking University, Beijing, China
| | - Cesar G Victora
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil
| | - Fernando C Barros
- Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, RS, Brazil; Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, RS, Brazil
| | - Maria Carvalho
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Laurent J Salomon
- Department of Obstetrics and Fetal Medicine, Hôpital Necker Enfants Malades, Université Paris Descartes, Paris, France
| | - Zulfiqar A Bhutta
- Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan; Center for Global Child Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - José Villar
- Nuffield Department of Obstetrics and Gynaecology, and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
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Villar J, Cheikh Ismail L, Victora CG, Ohuma EO, Bertino E, Altman DG, Lambert A, Papageorghiou AT, Carvalho M, Jaffer YA, Gravett MG, Purwar M, Frederick IO, Noble AJ, Pang R, Barros FC, Chumlea C, Bhutta ZA, Kennedy SH. International standards for newborn weight, length, and head circumference by gestational age and sex: the Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet 2014; 384:857-68. [PMID: 25209487 DOI: 10.1016/s0140-6736(14)60932-6] [Citation(s) in RCA: 1353] [Impact Index Per Article: 135.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In 2006, WHO published international growth standards for children younger than 5 years, which are now accepted worldwide. In the INTERGROWTH-21(st) Project, our aim was to complement them by developing international standards for fetuses, newborn infants, and the postnatal growth period of preterm infants. METHODS INTERGROWTH-21(st) is a population-based project that assessed fetal growth and newborn size in eight geographically defined urban populations. These groups were selected because most of the health and nutrition needs of mothers were met, adequate antenatal care was provided, and there were no major environmental constraints on growth. As part of the Newborn Cross-Sectional Study (NCSS), a component of INTERGROWTH-21(st) Project, we measured weight, length, and head circumference in all newborn infants, in addition to collecting data prospectively for pregnancy and the perinatal period. To construct the newborn standards, we selected all pregnancies in women meeting (in addition to the underlying population characteristics) strict individual eligibility criteria for a population at low risk of impaired fetal growth (labelled the NCSS prescriptive subpopulation). Women had a reliable ultrasound estimate of gestational age using crown-rump length before 14 weeks of gestation or biparietal diameter if antenatal care started between 14 weeks and 24 weeks or less of gestation. Newborn anthropometric measures were obtained within 12 h of birth by identically trained anthropometric teams using the same equipment at all sites. Fractional polynomials assuming a skewed t distribution were used to estimate the fitted centiles. FINDINGS We identified 20,486 (35%) eligible women from the 59,137 pregnant women enrolled in NCSS between May 14, 2009, and Aug 2, 2013. We calculated sex-specific observed and smoothed centiles for weight, length, and head circumference for gestational age at birth. The observed and smoothed centiles were almost identical. We present the 3rd, 10th, 50th, 90th, and 97th centile curves according to gestational age and sex. INTERPRETATION We have developed, for routine clinical practice, international anthropometric standards to assess newborn size that are intended to complement the WHO Child Growth Standards and allow comparisons across multiethnic populations. FUNDING Bill & Melinda Gates Foundation.
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Affiliation(s)
- José Villar
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK.
| | - Leila Cheikh Ismail
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Cesar G Victora
- Programa de Pós-Graduaçao em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil
| | - Eric O Ohuma
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK; Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Enrico Bertino
- Dipartimento di Scienze Pediatriche e dell'Adolescenza, Cattedra di Neonatologia, Universita degli Studi di Torino, Torino, Italy
| | - Doug G Altman
- Centre for Statistics in Medicine, Botnar Research Centre, University of Oxford, Oxford, UK
| | - Ann Lambert
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Aris T Papageorghiou
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
| | - Maria Carvalho
- Faculty of Health Sciences, Aga Khan University, Nairobi, Kenya
| | - Yasmin A Jaffer
- Department of Family and Community Health, Ministry of Health, Muscat, Oman
| | | | - Manorama Purwar
- Nagpur INTERGROWTH-21(st) Research Centre, Ketkar Hospital, Nagpur, India
| | | | - Alison J Noble
- Department of Engineering Science, University of Oxford, Oxford, UK
| | - Ruyan Pang
- School of Public Health, Peking University, Beijing, China
| | - Fernando C Barros
- Programa de Pós-Graduaçao em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil; Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, Brazil
| | - Cameron Chumlea
- Lifespan Health Research Center Boonshoft School of Medicine, Wright State University, Dayton, OH, USA
| | - Zulfiqar A Bhutta
- Division of Women and Child Health, The Aga Khan University, Karachi, Pakistan; Center for Global Health, Hospital for Sick Children, Toronto, ON, Canada
| | - Stephen H Kennedy
- Nuffield Department of Obstetrics and Gynaecology and Oxford Maternal and Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, UK
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