Developmental outcomes in small-for-gestational age twins using a singleton vs twin birthweight reference
Jessica L Gleason1, Edwina Yeung1, Rajeshwari Sundaram2
1Epidemiology Branch, Division of Intramural Population Health Research, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD (Drs Gleason, Yeung, Mendola, Vafai, Robinson, Putnick, and Grantz).
Insights
Singleton birthweight references identify more twins at risk for developmental delay than twin-specific references. Using singleton references for small-for-gestational age twins is appropriate for identifying developmental risks.
Area of Science:
- Neonatal development
- Pediatric health outcomes
- Birth cohort studies
Background:
- Limited data exist on developmental delays in appropriately grown twins.
- Twins may have a higher risk of developmental delay compared to singletons.
- Small-for-gestational age (SGA) classification using singleton references may misclassify appropriately grown twins.
Purpose of the Study:
- To assess the risk of developmental delay in twins identified as small-for-gestational age (SGA) using both twin and singleton birthweight references.
- To compare the utility of twin versus singleton references in identifying developmental risks in twins.
Main Methods:
- A birth cohort of 1790 twins and 3829 singletons (2008-2010) was analyzed.
- Parents completed Ages & Stages Questionnaires (ASQ) for child development between 4 and 36 months.
- Adjusted generalized linear mixed-effects models assessed ASQ failure rates, accounting for twin clustering.
Main Results:
- Uncertain SGA twins (SGA by singleton, not twin reference) did not show increased ASQ failure compared to non-SGA twins.
- Both twin-reference SGA and uncertain SGA twins had higher odds of ASQ failure compared to non-SGA singletons.
- Twin-reference SGA twins exhibited the highest risk (aOR 3.14), followed by uncertain SGA twins (aOR 2.35).
Conclusions:
- A singleton birthweight reference may overestimate SGA in twins but appropriately identifies more twins at risk for developmental delay.
- Findings suggest singleton references are suitable for identifying developmental risks in twins, despite potential overestimation of SGA.
- This approach enhances the identification of at-risk twins compared to twin-specific references.
Background:
Limited data exist about the potential developmental delays in appropriately grown twins; furthermore, twins may be at higher risk of developmental delay than singletons. Small-for-gestational age is a risk factor for developmental delay and is based on singleton birthweight references, which may misclassify small-for-gestational age in a subset of appropriately grown twins.
Objective:
This study aimed to evaluate the risk of developmental delay in twins classified as small-for-gestational age according to the twin and singleton birthweight references (<10th percentile).
Study Design:
In a birth cohort (2008-2010) of twins (n=1790) and singletons (n=3829) where parents completed Ages & Stages Questionnaires for child development between 4 and 36 months, we used a US population-based birthweight reference to categorize singletons and twins as small-for-gestational age. Uncertain small-for-gestational age twins were defined as small-for-gestational age by a singleton reference (<10th percentile) and not by a twin reference, and twin-reference small-for-gestational age twins were defined as small-for-gestational age by a twin reference. Adjusted generalized linear mixed-effects models were used to estimate the odds of failure on any Ages & Stages Questionnaires domain and on each of the 5 domains (fine motor, gross motor, communication, personal-social, and problem-solving domains); random intercepts accounted for repeated measures and twin clustering.
Results:
Compared with non-small-for-gestational age twins (>10th percentile), uncertain small-for-gestational age twins did not have higher odds of Ages & Stages Questionnaires failure (adjusted odds ratio, 1.28; 95% confidence interval, 0.91-1.80). Compared with non-small-for-gestational age singletons, both twin-reference and uncertain small-for-gestational age twins had higher odds of Ages & Stages Questionnaires failure, with the highest risk conferred to twin-reference small-for-gestational age twins (twin-reference adjusted odds ratio, 3.14 [95% confidence interval, 1.94-5.10]; uncertain adjusted odds ratio, 2.35 [95% confidence interval, 1.69-3.26]; P<.01 for trend). Results remained consistent when limiting analyses to term births (≥37 weeks' gestation).
Conclusion:
Although a singleton reference may overestimate small-for-gestational age in twins, the findings indicated that a singleton birthweight reference may be appropriate for twins because it identifies more twins at risk of developmental delay than a twin reference.
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