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International versus national growth charts for identifying small and large-for-gestational age newborns: A
Alice Hocquette1, Mélanie Durox1, Rachael Wood2
1Université de Paris, CRESS, Obstetrical Perinatal and Pediatric Epidemiology Research Team, EPOPé, INSERM, INRA, F-75004 Paris, France.
Insights
International intrauterine growth charts may misclassify infant growth, potentially leading to underestimating risks for small-for-gestational-age infants and overestimating risks for large-for-gestational-age infants in Europe.
Area of Science:
- Perinatal Medicine
- Public Health
- Neonatalogy
Background:
- Debate exists regarding universal prescriptive vs. national intrauterine growth charts.
- Accurate growth assessment is crucial for identifying infants at risk.
Purpose of the Study:
- To compare perinatal mortality rates for small-for-gestational-age (SGA) and large-for-gestational-age (LGA) infants using international and national growth charts in Europe.
- To evaluate the impact of different chart methodologies on infant classification and mortality risk.
Main Methods:
- Analysis of singleton births (33-42 weeks gestation) from 15 European countries in 2010 and 2014 (N=1,475,457).
- Classification of infants as SGA (<10th percentile) and LGA (>90th percentile) using international Intergrowth-21st standards and national customized charts.
- Calculation of sex-adjusted odds ratios (aOR) for stillbirth, neonatal, and extended perinatal mortality using multilevel models.
Main Results:
- National charts showed consistent SGA/LGA prevalence (~10%), while international charts exhibited north-south gradients.
- Perinatal mortality risk increased for SGA infants by both chart types (aOR=6.1) and those reclassified from SGA to appropriate-for-gestational-age (AGA) by international charts (aOR=2.7).
- Reclassification from AGA to LGA by international charts showed decreased mortality risk (aOR=0.6).
Conclusions:
- Utilizing international growth charts in Europe may lead to misclassification of growth-restricted infants as normal.
- This shift could incorrectly identify infants with low mortality risk as having excessive growth.
- The findings highlight significant discrepancies between international and national growth chart applications in Europe.
Background:
To inform the on-going debate about the use of universal prescriptive versus national intrauterine growth charts, we compared perinatal mortality for small and large-for-gestational-age (SGA/LGA) infants according to international and national charts in Europe.
Methods:
We classified singleton births from 33 to 42 weeks of gestation in 2010 and 2014 from 15 countries (N = 1,475,457) as SGA (birthweight <10th percentile) and LGA (>90th percentile) using the international Intergrowth-21st newborn standards and national charts based on the customised charts methodology. We computed sex-adjusted odds ratios (aOR) for stillbirth, neonatal and extended perinatal mortality by this classification using multilevel models.
Findings:
SGA and LGA prevalence using national charts were near 10% in all countries, but varied according to international charts with a north to south gradient (3.0% to 10.1% and 24.9% to 8.0%, respectively). Compared with appropriate for gestational age (AGA) infants by both charts, risk of perinatal mortality was increased for SGA by both charts (aOR[95% confidence interval (CI)]=6.1 [5.6-6.7]) and infants reclassified by international charts from SGA to AGA (2.7 [2.3-3.1]), but decreased for those reclassified from AGA to LGA (0.6 [0.4-0.7]). Results were similar for stillbirth and neonatal death.
Interpretation:
Using international instead of national charts in Europe could lead to growth restricted infants being reclassified as having normal growth, while infants with low risks of mortality could be reclassified as having excessive growth.
Funding:
InfAct Joint Action, CHAFEA Grant n°801,553 and EU/EFPIA Innovative Medicines Initiative 2 Joint Undertaking ConcePTION grant n°821,520. AH received a PhD grant from EHESP.
