The INTERGROWTH-21^st fetal growth standards: toward the global integration of pregnancy and pediatric care - 28/02/18

Doi : 10.1016/j.ajog.2018.01.011

Aris T. Papageorghiou, MD ^a, Stephen H. Kennedy, MD ^a,^{^{1
These authors contributed equally to this article.}}, Laurent J. Salomon, MD ^e, Douglas G. Altman, DSc ^b, Eric O. Ohuma, DPhil ^a,^c, William Stones, MD ^f, Michael G. Gravett, MD ^g, Fernando C. Barros, MD ^h,ⁱ, Cesar Victora, MD ⁱ, Manorama Purwar, MD ^j, Yasmin Jaffer, MD ^k, Julia A. Noble, DPhil ^d, Enrico Bertino, MD ^l, Ruyan Pang, MD ^m, Leila Cheikh Ismail, PhD ^a,ⁿ, Ann Lambert, PhD ^a, Zulfiqar A. Bhutta, PhD ^o,^p,^q,^{^{1
These authors contributed equally to this article.}}, José Villar, MD ^a,^{^{1
These authors contributed equally to this article.},}^⁎
for the
International Fetal and Newborn Growth Consortium for the 21^st Century (INTERGROWTH-21^st)
^a Nuffield Department of Obstetrics & Gynecology and Oxford Maternal & Perinatal Health Institute, Green Templeton College, University of Oxford, Oxford, United Kingdom
^b Center for Statistics in Medicine, Nuffield Department of Orthopedics, Rheumatology, & Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
^c Center for Tropical Medicine & Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
^d Department of Engineering Science, University of Oxford, Oxford, United Kingdom
^e Department of Obstetrics and Fetal Medicine, Hopital Necker Enfants Malades, Université Paris Descartes, Paris, France
^f Departments of Obstetrics & Gynecology and Public Health, Malawi College of Medicine, Blantyre, Malawi
^g Global Alliance to Prevent Prematurity and Stillbirth, Seattle Children’s, Seattle, WA
^h Programa de Pós-Graduação em Saúde e Comportamento, Universidade Católica de Pelotas, Pelotas, Brazil
ⁱ Programa de Pós-Graduação em Epidemiologia, Universidade Federal de Pelotas, Pelotas, Brazil
^j Nagpur INTERGROWTH-21^st Research Center, Ketkar Hospital, Nagpur, India
^k Department of Family & Community Health, Ministry of Health, Muscat, Sultanate of Oman
^l Divisione di Neonatologia e Terapia Intensiva Neonatale, Dipartimento di Scienze Pediatriche e dell'Adolescenza; Università degli Studi di Torino, Torino Italy
^m School of Public Health, Peking University, Beijing, China
ⁿ Clinical Nutrition and Dietetics Department, University of Sharjah, Sharjah, United Arab Emirates
^o Center of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan
^p Center for Global Child Health, Hospital for Sick Children, Toronto, Ontario, Canada
^q International Pediatric Association, Webster Groves, MO

^∗Corresponding author: José Villar, MD.

Abstract

The purpose of the INTERGROWTH-21^st 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-21^st 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-21^st 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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Key words : abdominal circumference, biparietal diameter, estimated fetal weight, femur length, fetal size, macrosomia, optimal growth, reference chart, skeletal growth, small for gestational age, socioeconomic status, standard, stunting

Plan

Introduction

Methodological issues relevant for the screening of fetal growth abnormalities in the general pregnant population

References vs standards

How were the INTERGROWTH-21^st populations selected?

Why outcome measures should be masked

Which is the most appropriate analytical strategy?

Race/ethnicity is not a biological factor influencing fetal growth

Implications for screening in the general pregnant population: local charts vs international standards

Conclusions

This study was supported by the INTERGROWTH-21^st grant 49038 from the Bill and Melinda Gates Foundation to the University of Oxford. The funder played no role in the study design; collection, analysis, and interpretation of data; the writing of the report; or the decision to submit the article for publication. Dr Papageorghiou is supported by the Oxford Partnership Comprehensive Biomedical Research Center, with funding from the Department of Health’s National Institute for Health Research Biomedical Research Centers funding scheme.

The authors report no conflicts of interest. The INTERGROWTH-21^st project was approved by the Oxfordshire Research Ethics Committee ‘C’ (reference: 08/H0606/139), the research ethics committees of the individual institutions, and the regional health authorities where the project was implemented. Participants provided written consent to be involved in the Fetal Growth Longitudinal Study.

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Vol 218 - N° 2S

P. S630-S640 - février 2018 Retour au numéro

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The INTERGROWTH-21^st fetal growth standards: toward the global integration of pregnancy and pediatric care - 28/02/18

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