Should Fetal Growth Charts Be References or Standards?
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ABSTRACT:
Methods: We summarized estimated fetal weight (EFW) distributions from a hospital's routine 32-week ultrasound in all nonanomalous singleton fetuses (reference) and in those without maternal-fetal conditions affecting fetal growth (standard). We calculated EFWs for the 3rd, 5th, 10th, and 50th percentiles, and the proportion of fetuses each chart classified as small for gestational age.
Results: Of 2309 fetuses in our reference, 690 (30%) met the standard's inclusion criteria. There were no meaningful differences between the EFW distributions of the reference and standard curves (50th percentile: 1989?g reference vs. 1968?g standard; 10th percentile: 1711?g reference vs. 1710?g standard), or the proportion of small for gestational age fetuses (both 9.9%).
Conclusions: In our study, there was little practical difference between a fetal growth reference and standard for detecting small infants.
SUBMITTER: Hutcheon JA
PROVIDER: S-EPMC7707154 | biostudies-literature | 2021 Jan
REPOSITORIES: biostudies-literature
Publications
Should Fetal Growth Charts Be References or Standards?
Hutcheon Jennifer A JA Liauw Jessica J
Epidemiology (Cambridge, Mass.) 20210101 1
<h4>Background</h4>Fetal growth standards (prescriptive charts derived from low-risk pregnancies) are theoretically better tools to monitor fetal growth than conventional references. We examined how modifying chart inclusion criteria influenced the resulting curves.<h4>Methods</h4>We summarized estimated fetal weight (EFW) distributions from a hospital's routine 32-week ultrasound in all nonanomalous singleton fetuses (reference) and in those without maternal-fetal conditions affecting fetal gro ...[more]
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Project description:BackgroundAccurate assessment of fetal size is essential in providing optimal prenatal care. National Institute of Child Health and Human Development (NICHD) study from 2015 demonstrated that estimated fetal weight (EFW) differed significantly by race/ethnicity after 20 weeks. There is a large Somali population residing in Minnesota, many of whom are cared for at our maternal fetal medicine practice at the University of Minnesota. Anecdotally, we noticed an increased proportion of small-for-gestational age diagnoses within this population. We sought to use our ultrasound data to create a reference standard specific for this population and compare to currently applied references.PurposeWe aimed to model fetal growth standards within a healthy Somali population between 16 and 40 weeks gestation, and address possible differences in the growth patterns compared with standards for non-Hispanic White, non-Hispanic Black, Hispanic, and Asian singleton fetuses published by the NICHD in the Fetal Growth Study.Materials and methodsThis is a retrospective cohort study using ultrasound data from 527 low risk pregnancies of Somali ethnicity at single tertiary care center between 2011 and 2017. A total of 1107 scans were identified for these pregnancies and maternal and obstetrical data were reviewed. Women 18-40 years of age with low-risk pregnancies and established dating consistent with first trimester ultrasound scan were included. Exclusion criteria were any maternal, fetal or obstetrical conditions known to affect fetal growth.ResultsEstimated fetal weight among Somali pregnancies differed significantly at some time points from the NICHD four ethnic groups, but generally the EFW graph curves crossed over at most time points between the study groups. At week 18, EFW was significantly larger than all other four ethnic groups (all p<.001), it was also significantly larger from the Hispanic, Black, and Asian ethnic groups at some time points between 18 and 27 weeks gestation (p < .05). Additionally, EFW among Somali pregnancies was significantly smaller than the Black and Asian ethnicity at 32 and 35-36 weeks and smaller than the White ethnicity at 30 and 38-39 weeks (p < .05). Abdominal circumference (AC) for the Somali population was significantly smaller than the other ethnic groups, especially than the White ethnicity at various time points across 16-40 weeks (p < .05). Femur and humerus length were significantly longer when compared to all other ethnic groups at most time points from 16 to 40 weeks of gestation (p < .05). Biparietal diameter (BPD) was significantly smaller than all other ethnic groups specifically at time of fetal survey (18 weeks) and at time of fetal growth assessment (32 weeks) (p < .05).ConclusionsSignificant differences in fetal growth standards were found between the Somali ethnicity and other ethnic groups (White, Black, Asian, and Hispanic) at various time points from 16 to 40 weeks of gestation. Racial/ethnic-specific standards improve the precision for evaluating fetal growth and may decrease the proportion of fetuses of Somali ethnicity labeled as small-for-gestational age.
| S-EPMC7085970 | biostudies-literature
Project description:The use of appropriate growth standards/references is of significant clinical importance in assessing the height of children with short stature as it may determine eligibility for appropriate therapy. The aim of this study was to determine the impact of using World Health Organization (WHO) instead of national growth standards/references on height assessment in short children. Data were collected from routine clinical practice (1998-2014) from nine European countries that have available national growth references and were enrolled in NordiNet® International Outcome Study (IOS) (NCT00960128), a large-scale, non-interventional, multinational study. The patient cohort consisted of 5996 short pediatric patients diagnosed with growth hormone deficiency (GHD), Turner syndrome (TS) or born small for gestational age (SGA). The proportions of children with baseline height standard deviation score (SDS) below clinical cut-off values (-2 SDS for GHD and TS; -2.5 SDS for SGA) based on national growth references and WHO growth standards/references were compared for children aged <5 years and children aged ≥5 years. In seven of the countries evaluated, significantly fewer children aged ≥5 years with GHD (22%; P<0.0001), TS (21%; P<0.0001) or born SGA (32%; P<0.0001) had height below clinical cut-off values using WHO growth references vs. national references. Likewise, among children aged <5 years in the pooled analysis of the same seven countries, a significantly lower proportion of children with GHD (8%; P<0.0001), TS (12%; P = 0.0003) or born SGA (12%; P<0.0001) had height below clinical cut-off values using WHO growth standards vs. national references. In conclusion, in NordiNet® IOS the number of patients misclassified using WHO growth standards/references was significantly higher than with national references. This study highlights that, although no growth reference has 100% sensitivity for identifying growth disorders, the most recent national or regional growth charts may offer the most appropriate tool for monitoring childhood growth in Europe.
| S-EPMC4900602 | biostudies-literature
Project description:BackgroundThe common use of singleton fetal growth standard to access twin growth might lead to over-monitoring and treatment. We aimed to develop fetal growth standards for Chinese twins based on ultrasound measurements, and compare it with Zhang's and other twin fetal growth charts.MethodsA cohort of uncomplicated twin pregnancies were prospectively followed in 2014-2017. Smoothed estimates of fetal growth percentiles for both monochorionic (MC) and dichorionic (DC) twins were obtained using a linear mixed model. We also created growth charts for twins using a model-based approach proposed by Zhang et al. Our twin standards were compared with Hadlock's (singleton) in predicting adverse perinatal outcomes.ResultsA total of 398 twin pregnancies were included, with 214 MC and 582 DC live-born twins. The MC twins were slightly lighter than the DC twins, with small differences throughout the gestation. Our ultrasound-based fetal weight standards were comparable to that using Zhang's method. Compared with previous references/standards from the US, Brazil, Italy and UK, our twins had very similar 50th percentiles, but narrower ranges between the 5th and 95th or 10th and 90th percentiles. Compared with the Hadlock's standard, the risks of neonatal death and adverse perinatal outcomes for small for gestational age (SGA) versus non-SGA were substantially elevated using our standards.ConclusionsA normal fetal growth standard for Chinese twins was created. The differences between MC and DC twins were clinically insignificant. The 50th weight percentiles of the Chinese twins were identical to those in other races/ethnicities but the ranges were markedly narrower. Our standard performed much better than the Hadlock's in predicting low birth weight infants associated with adverse perinatal outcomes in twin pregnancies. The present study also indicated that Zhang's method is applicable to Chinese twins, and other areas may use Zhang's method to generate their own curves for twins if deemed necessary.
| S-EPMC8220745 | biostudies-literature
Project description:BackgroundThis study examined the relationship of infant feeding with anthropometric indices of children during their first six years of life relative to the Korean National Growth Charts (KNGC) and the World Health Organization Child Growth Standards (WHO-CGS).MethodsThe study population consisted of 547,669 Korean infants and children who were 6 months-old to 6 years-old (born in 2008-2009) and participated in the National Health Screening Program for Infants and Children. Data on height, weight, and type of feeding during the first 6 months (exclusively breastfed [BF] vs. mixed- or formula-fed [FF]) were analyzed.ResultsBF boys and girls were significantly shorter and lighter than FF counterparts from the age of 6 months to 4 years, but these differences were not significant after the age of 4 years. BF boys and girls only had significantly lower body mass index at the age of 2 years. Under the age of 2 years 6 months, and especially under the age of 1 year, BF boys and girls were significantly taller and heavier than the 50th percentile values of the 50th percentile value of the WHO-CGS.ConclusionIn this study using large-scaled national data, Korean breastfed children are shorter and lighter by 3 years 6 months-4 years 6 months, but afterward, there is no significant difference from those who had mixed- or formula-feeding. Substantial disparities in the anthropometric indices of Korean infants under the age of 1 compared to KNCG and WHO-CGS were found, regardless of their infantile feeding types. Our results emphasize the importance of constructing a nationwide reference chart based on actual measurements of BF Korean infants.
| S-EPMC8648613 | biostudies-literature
Project description:BackgroundThe fetal growth charts in widest use in China were published by Hadlock >35 years ago and were established on data from several hundred of American pregnant women. After that, >100 fetal growth charts were published around the world. We attempted to assess the impact of applying the long-standing Hadlock charts and other charts in a Chinese population and to compare their ability to predict newborn small for gestational age (SGA).MethodsFor this retrospective observational study, we reviewed all pregnant women ( n = 106,455) who booked prenatal care with ultrasound measurements for fetal biometry at the Shenzhen Maternity and Child Healthcare Hospital between 2012 and 2019. A fractional polynomial regression model was applied to generate Shenzhen fetal growth chart ranges for head circumference (HC), biparietal diameter (BPD), abdominal circumference (AC), and femur length (FL). The differences between Shenzhen charts and published charts were quantified by calculating the Z -score. The impact of applying these published charts was quantified by calculating the proportions of fetuses with biometric measurements below the 3rd centile of these charts. The sensitivity and area under the receiver operating characteristic curves of published charts to predict neonatal SGA (birthweight <10th centile) were assessed.ResultsFollowing selection, 169,980 scans of fetal biometry contributed by 41,032 pregnancies with reliable gestational age were analyzed. When using Hadlock references (<3rd centile), the proportions of small heads and short femurs were as high as 8.9% and 6.6% in late gestation, respectively. The INTERGROWTH-21st standards matched those of our observed curves better than other charts, in particular for fat-free biometry (HC and FL). When using AC<10th centile, all of these references were poor at predicting neonatal SGA.ConclusionsApplying long-standing Hadlock references could misclassify a large proportion of fetuses as SGA. INTERGROWTH-21st standard appears to be a safe option in China. For fat-based biometry, AC, a reference based on the Chinese population is needed. In addition, when applying published charts, particular care should be taken due to the discrepancy of measurement methods.
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Project description:BackgroundThis study focused on comparing the applicability and efficacy of the World Health Organization (WHO) growth standards and the China growth charts in diagnosing malnutrition and indicating nutritional interventions in preterm infants.MethodsSix hundred and eighty-three preterm infants were involved and their anthropometric data were collected. The proportion of weight and head circumference less than the 10th percentile (P10 ), weight less than the 25th percentile (P25 ), and weight for length greater than the 90th percentile (P90 ) identified by the WHO growth standards and the China growth charts were compared.ResultsAt corrected age (CA) 1 ~< 2 months (m), the proportion of head circumference <P10 assessed by the WHO growth standards was higher than that assessed by the China growth charts by approximately 4.4% in boys and 6.6% in girls. During infancy, both boys and girls had lower proportions of weight <P10 and weight <P25 with the WHO growth standards than with the China growth charts: 5.1% and 5.6%, respectively, for weight <P10 and 7.0% and 8.8%, respectively, for weight <P25 . For boys older than CA 1 m and for girls older than CA 3 m, the proportion of weight-for-length >P90 assessed by the WHO growth standards was greater than that assessed by the China growth charts.ConclusionsCompared with the China growth charts, the WHO growth standards can further reduce the number of diagnoses of abnormal physical growth, are more helpful in avoiding overnutrition interventions, and are more sensitive in the early detection of delayed head circumference growth.
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Project description: Not available
| S-EPMC5261648 | biostudies-literature
Project description:Anthropometric measures are commonly converted to age stratified z-scores to examine variation in growth outcomes in mixed-age and sex samples. For many study populations, z-scores will differ if calculated from World Health Organization (WHO) growth standards or within-population references. The specific growth reference used may influence statistical estimates of growth outcomes and their determinants, with implications for biological inference. We examined factors associated with growth outcomes in a sample of 152 Tsimane children aged 0-36 months. The Tsimane are a subsistence-scale population in the Bolivian Amazon with high rates of infectious disease and growth faltering. To examine the influence of growth reference on statistical inferences, we constructed multiple plausible models from available infant, maternal, and household attributes. We then ran identical models for height-for-age (HAZ), weight-for-age (WAZ), and weight-for-height (WHZ), with z-scores alternately calculated from WHO and robust Tsimane Lambda-Mu-Sigma growth curves. The distribution of WHO relative to Tsimane HAZ scores was negatively skewed, reflecting age-related increases in lower HAZ. Standardized coefficients and significance levels generally agreed across WHO and Tsimane models, although the strength and significance of specific terms varied in some models. Age was strongly, negatively associated with HAZ and WAZ in nearly all WHO, but not Tsimane models, resulting in consistently higher R2 estimates. Age and weaning effects were confounded in WHO models. Biased estimates of determinants associated with WHO HAZ may be more extreme in small samples and for variables that are strongly age-patterned. Additional methodological considerations may be warranted when applying WHO standards to within-population studies, particularly for populations with growth patterns known to systematically deviate from those of the WHO reference sample.
| S-EPMC6469771 | biostudies-literature
Project description:Three recently completed longitudinal cohort studies have developed intrauterine fetal growth charts, one in the United States and two international. This expert review compares and contrasts the Eunice Kennedy Shriver National Institute of Child Health and Human Development Fetal Growth Studies, INTERGROWTH-21st and World Health Organization Multicentre Growth Reference Study conclusions in light of differences in aims, sampling frames, and analytical approaches. An area of controversy is whether a single growth reference is representative of growth, regardless of ethnic or country origin. The INTERGROWTH and World Health Organization Fetal studies used a similar approach as the World Health Organization Multicentre Growth Reference Study for infants and children, the aim of which was to create a single international reference for the best physiological growth for children aged 0-5 years. INTERGROWTH made the same assumption (ie, that there would be no differences internationally among countries or racial/ethnic groups in fetal growth when conditions were optimal). INTERGROWTH found differences in crown-rump length and head circumference among countries but interpreted the differences as not meaningful and presented a pooled standard. The World Health Organization Multicentre Growth Reference Study was designed to create a pooled reference, although they evaluated for and presented country differences, along with discussion of the implications. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Study was designed to assess whether racial/ethnic-specific fetal growth standards were needed, in recognition of the fact that fetal size is commonly estimated from dimensions (head circumference, abdominal circumference, and femur length) in which there are known differences in children and adults of differing racial/ethnic groups. A pooled standard would be derived if no racial/ethnic differences were found. Highly statistically significant racial/ethnic differences in fetal growth were found resulting in the publication of racial/ethnic-specific derived standards. Despite all 3 studies including low-risk status women, the percentiles for fetal dimensions and estimated fetal weight varied among the studies. Specifically, at 39 weeks, the 50th percentile for estimated fetal weight was 3502 g for whites, 3330 g for Hispanics, 3263 g for Asians, and 3256 for blacks in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Study, compared with 3186 g for INTERGROWTH and 3403 g for World Health Organization Multicentre Growth Reference Study. When applying these standards to a clinical population, it is important to be aware that different percentages of small- and large-for-gestational-age fetuses will be identified. Also, it may be necessary to use more restrictive cut points, such as the 2.5th or 97.5th, for small-for-gestational-age or large-for-gestational-age fetuses, respectively. Ideally, a comparison of diagnostic accuracy, or misclassification rates, of small-for-gestational-age and large-for-gestational-age fetuses in relation to morbidity and mortality using different criteria is necessary to make recommendations and remains an important data gap. Identification of the appropriate percentile cutoffs in relation to neonatal morbidity and mortality is needed in local populations, depending on which fetal growth chart is used. On a final point, assessment of fetal growth with a one-time measurement remains standard clinical practice, despite recognition that a single measurement can indicate only size. Ultimately, it is knowledge about fetal growth in addition to other factors and clinical judgment that should trigger intervention.
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Project description:[This corrects the article DOI: 10.1371/journal.pmed.1002284.].
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