Improving Birth Outcomes Meeting the Challenge in the Developing World (2003) / Chapter Skim
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6. The Problem of Low Birth Weight
6. The Problem of Low Birth Weight
Pages 203-235
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PART IV Additional Causes of Neonatal Morlality and Morbiclity
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Moreover, LBW neonates who survive infancy are at increased risk for health, growth, and developmental problems, and those who are small for their gestational age may be predisposed to developing chronic adult disorders such as hypertension, type 2 diabetes, and heart disease. This chapter reviews the prevalence, causes, and consequences of intrauterine growth restriction (IUGR)
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Currently, WHO recommends the use of chest circumference; newborns with chest circumferences iSGA is defined by WHO as a birth weight below the tenth percentile for gestational age based on the sex-specific reference by Williams et al.
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Important causes of preterm delivery include genitourinary infection, multiple pregnancy, pregnancy-induced hypertension, low prepregnancy BMI, incompetent cervix, history of prior preterm birth, cigarette smoking (where prevalent) , and 2BMI is a measure of nutritional status and is calculated as (wt in kg)
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remains relatively unexplored in such settings. Maternal undernutrition (characterized by low energy intake, low gestational weight gain, low prepregnancy BMI, and short stature)
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Perhaps the most dramatic evidence for this comes from the pregnancy experiences of women during the Dutch famine of 1944-1945. When energy rations were reduced from 1700 to 700 kcal/day for women in the third trimester of pregnancy, mean birth weight decreased by more than 300 g; there was no change in the mean length of gestation (Stein et al., 1975; Susser and Stein, 1994~.
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found a positive association between both gestational age and birth weight (among female newborns only) and a longer maternal stay in a maternity rest home; however, this result could also reflect the simple fact that women who delivered later stayed longer in the rest home.
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Further study of the effects of lower levels of alcohol intake on fetal growth is needed (Lundsberg et al., 1997~. Malaria is a major cause of anemia and has been associated with reduced birth weight and with an elevated risk of IUGR in primiparous women, who make up 30-50 percent of pregnant women.
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, rather than its role in preterm birth. The maternal environment plays a far larger role in fetal growth than do genetic factors (Walton and Hammond, 1938; Brooks et al., 1995)
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In Bangladesh, on the other hand, a 1993-1996 study reported an infant mortality rate of 107.3 per 1,000, and IUGR and preterm birth rates of 69.2 and 17.1 percent, respectively (Arifeen, 1997~. In the latter setting, the relative risks of infant death associated with IUGR and preterm birth were only 1.2 and 1.6, respectively.
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Finally, IUGR in girls increases the risk of IUGR in the girls' own offspring, and several generations may be required to achieve optimal fetal growth (Ramakrishnan et al., 1999~. A recent study reports that Filipino infants with low gestational age-adjusted birth weight had later menarche, on average, whereas those with lower birth length (adjusted for both birth weight and gestational age)
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A study of Guatemalan infants born in 1984-1986 revealed an increased risk of severe neonatal morbidity in disproportionate IUGR infants, however, even after controlling for their lower birth weight (Villar et al., 1990~. In recent years, researchers have identified an additional area of concern regarding the adverse consequences of IUGR: the fetal origins of adult disease (Barker, 1992; Leon, 1998~.
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In India, for example, the rise in obesity coupled with deficits in fetal growth may be contributing to the current "epidemic" of insulin resistance and type 2 diabetes in that country (Yajnik, 2001~. Nonetheless, conventional adult risk factors appear to explain most of the variation in prevalence of coronary heart disease among developing countries (Li et al., 1994~.
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The non-RCT evidence reviewed here was identified from a computerized search of MEDLINE (with restriction to publications in English or French) based on the following medical subject headings and logic: infant, premature; infant, LBW; birth weight; infant, small-for-gestational age; fetal growth retardation; and labor, premature.
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Energy/Protein Supplementation During Pregnancy Controlled clinical trials providing food supplements to pregnant women have yielded only modest effects in enhancing fetal growth and in reducing IUGR (de Onis et al., 1998b; Rush, 2001~. A Cochrane systematic review examines 13 of these trials, including studies from Colombia, Indonesia, Taiwan, and the Gambia, as well as studies among undernourished women in several developed countries (Kramer, 2002a)
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revealed a significant increase in mean birth weight (147g, 95 percent CI 51-244 g) , although no data were reported on preterm birth or IUGR (Mahomed and Gulmezoglu, 2002~.
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among poorly nourished HIV-positive women in Tanzania who were not receiving antiretroviral therapy (Fawzi et al., 1998~. Treatment of Genitourinary Infection The Cochrane systematic review on treatment of asymptomatic bacteriuria reports a cooled relative risk of 0.64 (95 percent CI = 0.50-0.82)
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suggests that the effect of antimalarial prophylaxis is restricted to improving fetal growth, presumably by reducing placental parasitemia. One small nonrandomized trial showed that a two-dose regimen of sulfadoxine-pyrimethane was associated with a nonsignificantly higher mean birth weight (2,864 versus 2,748 g)
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The type of antenatal care received may be more important than early initiation or frequent visits, but no definitive conclusions are possible based on the available evidence. In Latin America, for example, 2,235 women at higher-thanaverage risk for delivering an LBW infant were given psychosocial support and health education through four home visits between weeks 22 and 34 of gestation, but such care clici not reduce the incidence of IUGR or preterm delivery (Villar et al., 1992~.
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Strategies for reducing neonatal and infant mortality among LBW infants that do not depend on neonatal intensive care or other expensive technologies would be of particular benefit to the least-developed countries. Breastieeding and/or use of expressed breast milk represent one such "lowtech" strategy, which can reduce infection (and perhaps mortality due to infection)
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There is good evidence from systematic reviews of randomized trials that increasing food intake during pregnancy can increase fetal growth and reduce the risk of IUGR. However, no evidence is available that public health programs in poor countries have suc
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1997. Birth weight, intrauterine growth retardation and prematurity: a prospective study of infant growth and survival in the slums of Dhaka, Bangladesh.
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Varner M, National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units.2000. Metronidazole to prevent preterm delivery in pregnant women with asymptomatic bacterial vaginosis.
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1994. Rey-Martinez kangaroo program: an alternative way of caring for low birth weight infants.
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1974. Familial trends in low birth weight.
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1987. Influence of maternal birth weight on rate of fetal growth and duration of gestation.
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2001. Low birth weight and perinatal mortality.
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2002. Fish oil and other prostaglandin precursor supplementation during pregnancy for reducing pre-eclampsia, preterm birth, low birth weight and intrauterine growth restriction [protocol]
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2001. Term infants with fetal growth restriction are not at increased risk for low intelligence scores at age 17 years.
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1992. Neonatal morbidity according to gestational age and birth weight from five tertiary care centers in the United States, 1983 through 1986.
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1982. The relative contribution of prematurity and fetal growth retardation to low birth weight in developing and developed societies.
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1995. Maternal anthropometry and pregnancy outcomes: WHO Collaborative Study.
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