Beruflich Dokumente
Kultur Dokumente
http://jn.nutrition.org/content/suppl/2015/09/30/jn.115.21637
4.DCSupplemental.html
The Journal of Nutrition
Nutritional Epidemiology
Abstract
Background: Small-for-gestational-age (SGA) and preterm births are associated with adverse health consequences,
including neonatal and infant mortality, childhood undernutrition, and adulthood chronic disease.
Objectives: The specific aims of this study were to estimate the association between short maternal stature and
outcomes of SGA alone, preterm birth alone, or both, and to calculate the population attributable fraction of SGA and
preterm birth associated with short maternal stature.
Methods: We conducted an individual participant data meta-analysis with the use of data sets from 12 population-based
cohort studies and the WHO Global Survey on Maternal and Perinatal Health (13 of 24 available data sets used) from low-
and middle-income countries (LMIC). We included those with weight taken within 72 h of birth, gestational age, and
maternal height data (n = 177,000). For each of these studies, we individually calculated RRs between height exposure
categories of <145 cm, 145 to <150 cm, and 150 to <155 cm (reference: $155 cm) and outcomes of SGA, preterm birth,
and their combination categories. SGA was defined with the use of both the International Fetal and Newborn Growth
Consortium for the 21st Century (INTERGROWTH-21st) birth weight standard and the 1991 US birth weight reference.
The associations were then meta-analyzed.
Results: All short stature categories were statistically significantly associated with term SGA, preterm appropriate-for-
gestational-age (AGA), and preterm SGA births (reference: term AGA). When using the INTERGROWTH-21st standard to
define SGA, women <145 cm had the highest adjusted risk ratios (aRRs) (term SGA—aRR: 2.03; 95% CI: 1.76, 2.35;
Keywords: small-for-gestational-age, chronic malnutrition, neonatal health, maternal health, maternal height
Introduction
intervals) (12, 13). Several studies have also reported maternal
The WHO recently declared a global target of reducing the chronic protein-energy malnutrition as being associated with
number of infants born at a low birth weight (LBW)31 (<2500 g) these adverse newborn outcomes (10, 14). If chronic malnutrition
by 30% by the year 2025 (1). A total of 20 million LBW infants is indeed associated with these 2 neonatal outcomes, the afore-
are born each year, a large majority of those births occurring in mentioned goal of reducing LBW births will go hand in hand with
low- and middle-income countries (LMIC) (2). LBW babies another WHO goal of reducing the number of stunted children
comprise those who did not grow properly (intrauterine growth <5 y of age by 40% between 2010 and 2025 (1).
Primary study Population Original cohort, Analyzed cohort,2 Facility Method of gestational Women with height Timing of
Study Setting design represented n n NMR LBW Preterm SGA delivery age assessment ,145 cm height measurement
Asia
Nepal Rural Sarlahi, Nepal Cluster RCT of multiple Recruitment of all pregnant 4130 3169 42 39 22 56 6 LMP 15.8 First or early
(1999) (25) micronutrient women in study area second trimester
supplementation
Nepal Dhanusha, Nepal RCT of antenatal Antenatal clinic-based 1106 1050 25 22 7 53 53 Ultrasound 13.5 ,20 wk gestation
(2003) (28) micronutrient recruitment of pregnant
supplementation women in study area
Philippines Urban Cebu, Longitudinal health/nutritional Population-based random 3080 2757 14 11 18 25 34 LMP; Ballard to confirm 12.8 6th–7th month of
(1983) (26) Phillipines survey of infant cluster sample of census pregnancy
feeding patterns
Thailand Bangkok, Thailand Prospective follow-up of Longitudinal birth cohort of 4245 3814 5 8 9 22 99 Best obstetric estimate 3.2 28 wk gestation
(2001) (27) birth cohort all births in 4 districts (LMP, ultrasound, or
clinical assessment)
Africa
Burkina Faso Hounde, Burkina Faso RCT of multiple micronutrient Prospective community-based 1373 1049 21 17 16 35 77 Ultrasound 0.2 First or early second
(2004) (30) supplementation cohort trimester
Burkina Faso Hounde, Burkina Faso RCT of maternal Prospective community-based 1316 1061 20 16 18 29 84 Ultrasound 0.1 First or early second
(2006) (29) fortified food cohort trimester
supplementation
Tanzania Urban Dar es Salaam, RCT of mutivitamin Facility-based antenatal 7752 6846 28 8 17 20 97 LMP 3.5 12–27 wk gestation
(2001) (32) Tanzania supplementation clinics
Tanzania Korogwe, Tanzania Observational malaria Facility-based recruitment, 915 795 33 11 5 22 88 Ultrasound 0.5 #24 wk gestation
(2008) (31) study ANC clinics, community follow-up
Americas
Brazil Urban Pelotas city, Longitudinal birth cohort Population-based; all births 5914 5808 11 7 6 17 100 LMP 2.2 Immediately after
(1982) (34) Rio Grande do Sul, survey in Pelotas hospitals delivery
Southern Brazil (100% facility delivery)
Brazil Urban Pelotas city, Longitudinal birth cohort Population-based; all 5279 5203 7 9 11 19 100 LMP and Dubowitz 0.8 Immediately after
(1993) (35) Rio Grande do Sul, survey births in Pelotas hospitals delivery
Southern Brazil (100% facility delivery)
Brazil Urban Pelotas city, Longitudinal birth cohort Population-based; all births 4287 4287 10 11 16 15 100 LMP and ultrasound, 0.6 3 mo postpartum
(2004) (33) Rio Grande do Sul, survey in Pelotas hospitals if available; Dubowitz
Southern Brazil (100% facility delivery)
Peru Urban shantytown, RCT of maternal Facility-based 978 964 0 4 5 11 100 LMP, clinical indications, 11.6 10–24 wk gestation
(1995) (36) Lima, Peru zinc supplementation and ultrasound,
if available
1
All values are percentages except NMR (which is number of neonatal deaths per 1000 live births). Details of the WHO data are available in Supplemental Table 2. ANC, antenatal care; LBW, low birth weight; LMP, (date of) last menstrual period;
NMR, neonatal mortality rate; RCT, randomized controlled trial; SGA, small-for-gestational-age.
2
With data on maternal height, gestational age, and birth weight taken within 72 h of birth.
The numbers of observations (n) were rounded to the closest 100, but PAFs were calculated before rounding. AGA, appropriate-for-gestational-age; LMIC, low- and middle-income countries; MDG, Millennium Development Goal; PAF, population
14.8 (12.2, 17.2)
(19.5, 26.4)
(19.7, 26.4)
(13.7, 18.9)
exclusive combination categories of preterm and/or SGA,
(9.4, 13.1)
% (95% CI)
(6.3, 9.5)
2.8 (1.9, 3.7)
(4.4, 6.8)
(5.9, 9.6)
allowing us to differentiate maternal statureÕs associations
PAF,
with each of these outcomes. We found that short stature has a
23.2
23.3
8.0
16.5
5.6
11.3
7.8
stronger association with SGA birth than with preterm birth.
Although the exposure and outcome definitions were not
exactly comparable, our associations were similar to those
(226,400, 304,000)
(380,600, 526,900)
maternal short stature,
(65,300, 88,300)
(39,800, 60,300)
21,200 (16,200, 25,900)
28,700 (23,800, 33,300)
birth attributed to
(6500, 10,400)
of Maternal Anthropometry and Pregnancy Outcomes meta-
(1800, 2900)
Preterm SGA
(400, 570)
analysis reported a pooled crude OR of 1.9 (95% CI: 1.8, 2.0)
for SGA birth [with the use of a different US standard
Number and percentage of small-for-gestational-age and preterm births attributable to short maternal stature, US population as counterfactual1
77,500
267,600
50,300
8,500
457,500
(95% CI: 1.1, 1.2) for preterm birth, comparing the lowest to
highest quartile of height in each data set (10). The meta-
analysis in that study did not use adjusted associations, and
Preterm SGA
its use of quartile cutoffs for height did not allow for PAF
4400
33,800
281,400
194,100
41,700
334,000
632,000
108,800
1,150,300
2,780,500
birth, n
2.3)
4.1)
9.9)
3.3)
3.1)
6.6)
(0.9,
(1.6,
(5.1,
(5.3,
(1.4,
(1.0,
(3.3,
(360,400, 719,200)
short stature, n (95% CI)
(59,500, 115,500)
(47,200, 108,300)
21,100 (11,200, 30,100)
34,000 (22,200, 44,600)
(1900, 5000)
Preterm AGA
(250, 630)
8000
89,200
314,800
79,100
550,800
980,800
735,300
217,500
15,200
379,400
1,163,400
4,008,800
3,304,700
10,922,600
birth, n
(12.2, 14.1)
(22.7, 25.5)
(22.8, 25.7)
(17.4, 19.7)
(6.0, 7.0)
(7.9, 9.1)
(7.9, 9.3)
(5,169,600, 5,844,200)
(530,300, 596,700)
(593,000, 684,800)
maternal short stature,
(17,700, 20,700)
(75,500, 88,800)
Term SGA births
attributed to
(6200, 7200)
n (95% CI)
564,100
640,100
82,200
3,939,700
5,513,900
207,000
900,900
295,900
51,000
958,200
1,180,000
2,336,400
16,213,600
7,525,300
29,668,300
births, n
Southeast Asia
Central Asia
Caucasus and
Western Asia
Eastern Asia
South Asia
subregion
Total LMIC
Oceania