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Low Birth Weight: The Indian Perspective
Prof. H.P.S. Sachdev
DEFINITIONSDEFINITIONS
• WHO (1995) - Based on Global Data Perinatal & Neonatal Morbidity & Mortality Later Growth & Development
• LBW - Below 2500 g VLBW - Below 1500 g
• Birth weight crude proxy for fetal growth OnlyOnly measure in Developing Countries
• Focus – Optimal fetal development
Global LBW Prevalence (%)Asia 21Oceania 20Africa 15Latin America 11North America 7USSR 7Europe 6Global 17
Half of Global LBW Burden is in
South Asia
Others South Asia
Presentation Format• Implications
• Epidemiology
• Time Comparison
• Body Composition
• Some Interventions
• Public Health Issues
Implications of LBW
• Morbidity and Mortality
• Subsequent Development
• Long term Growth
• Adult Degenerative Diseases
Growth in Weight in Delhi LBW
Boys
0
5
10
15
20
25
30
35
40
Age ( 0 to 14 Years)
Wei
gh
t (K
g)
LBW Controls
Source: Indian Pediatrics 1995; 32: 963
Epidemiology
LBW Prevalence (%) in South Asia
0
10
20
30
40
50
60
Ba
ng
lad
es
h
Bh
uta
n
Ind
ia
Ma
ldiv
es
Ne
pa
l
Pa
kis
tan
Sri
La
nk
a
Low Oft cited High
Variation in LBW Prevalence
• Inter Regional
• Socio-economic
• Urban Rural
Varies from 10% to 56%
Preterms 7.1% to 22.3%
Multicentric Data
• National Neonatology Forum (1995/ 2002) Institutional Data on 37082 / 66512 Births LBW - 33% / 31.6% VLBW - 3.3% / 3.3% Preterm - 12.3% / 14.7%
• ? Overestimates: Underprivileged and High Risk Population
Multicentric and Other Data• CSSM (1995): 14 District Based Data on
27069 Births - 18.4%, Reliability ??
2.7% - MP, 5.1%-AS, 25%-TN, 40%-OR
• National Family Health Survey(99): 23% (Newborn Weight Recorded in 30% of 32,393 Births; Based on Recall: Bias)
• Community surveys 8% - 19%
Type: Heterogeneous PopulationHeterogeneous Population
• Born Too Small (Intrauterine Growth Retarded or SFD; <2SD)
OR
• Born Too Soon (Preterm <37 Weeks)
LBW Type
• NNF Data• Predominantly Term
IUGR • Contrast: Developed
Overwhelming Preterm
Contribution of Prematurity
67%
33%
Preterm Others
Intrauterine Growth Curves Comparison
Figure 1. Comparison of gestation distribution.
0.00
5.00
10.00
15.00
20.00
25.00
30.00
35.00
40.00
45.00
<29 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 >43
Gestation (weeks)
Per
cen
t
Sheth 1971 Ghosh 1979 Sheth 1972 Bjerkedahl 1973 ICMR 1984
Gestational Distribution
• Preterms India 7.1% to 22.3% (12.3%) Developed - 5%
• At 36 weeks births 2% (West) vs 3-12%
• Maximum Deliveries 40-41 W vs 39-40W
• Variation (Socio-economic)
Time Comparison
Trends in Low Birth Weight
0102030405060
Rourkela(OR)
North Arcot(TN)
North Arcot(TN)
Vellore Mumbai
Current Previous
1962
1986
1969-73
1989-93
1969
1994
1988
1995
74gMean Wt 78g 52g 126g
Mean Gest
?
?Preterm
0.7W21-16%
0.8W20-15%
0.3W14-10%
0
Male Subscapular Trend
2
2.5
3
3.5
4
4.5
36 37 38 39 40 41
PRESENT PURI (1980)
mm
Gestation(Weeks)
P<0.01
Positive Trend in Birth Weight
• Improvement possible in current scenario
• Both intrauterine growth and gestation contributory
Birth Weight Changes in DevelopedPlace Period BW (g) LBW (%)
USA 50-75 - 0
USA 70-80 60 7.4 - 6.3
Omaha 35-85 0 (Term) 0
ICE-Mult 70-84 40 - 100 -
Illinois 50-90 33 (Bl Ma)74 (W Fe)
7 - 613-14
Birth Weight Changes in Developed
• Change in BW Comparable (33-100 g) But Prevalence Less
• Persistence in DifferencesRacial Inter-country (ICE Multi-centric)
Body Composition
Age (years)
302826242220181614121086420
BM
I 'Z
Sco
re'
.4
.3
.2
.1
0.0
-.1
-.2
Population average
Diabetic/IGT
Early Life Origin of Diabetes
Bhargava, Sachdev, et al. N Engl J Med 2004;350:865-75.
FATNESS
Birth Weight and Infant Fat
r=0.62; r2=0.38; p<0.001
-5.0 -2.5 0.0 2.5 5.0-5
-2
1
4
BABY FAT % (Z)
BIRTH WEIGHT (Z)
Fat Indices Comparison
-2
-1.5
-1
-0.5
0
0.5
1
1.5
2
2.5
Fat % (Z Score)
PT SGA AGA LGA LBW
Some Interventions
Adolescent Pregnancy
• Indirect Influence Wt, Ht & Nutrition
• In U.P. LBW- 67% Preterm - 33%
0 5 10 15 20
SriLanka
Bhutan
Maldives
Pakistan
India
Nepal
Bangla
Mean Marriage Age (Yr)
Results of Systematic Reviews on Macronutrient Supplementation & BW
Supplement Outcome: systematic
review
N WMD(Random)
95%CI Source
Balanced protein/energy
13:13 3526 29 –10, 60 Kramer 2000
Isocaloric balanced protein
3:3 966 –64 –124, 3 Kramer 1996
High protein 2:2 529 –58 –146, 30 Kramer 1996
Food Supplement Consumption
3% 12%
10%
75%
Eat >3/4 Eat 1/2-3/4 Eat <1/2 Not Recd ICDS Data Source: Nayar et al. Indian Pediatrics 1997
Results of Systematic Reviews on Micronutrient Supplementation and BW
Supplement Outcome: systematic
review
N WMD(Random)
95%CI Source
Folate 1:21 149 –86 –107, –64 Mahomed 1999
Iron 1:20 197 –30 –90, 150 Mahomed 1999
Zinc 3:7 1136 19 –104, 141 Mahomed 1997
Magnesium 4:7 1482 51 0, 102 Makrides & Crowther 2001
Effect of Smoking Cessation on LBW (Lumley et al 1999)
Public Health Issues
• Does “One Birth Size Fit All” ?
• Realistic Prevalence & Time Trends Surveillance: NNF, Surveys, Sentinel, ICDS
• Mix Sustainable Interventions vs Isolated
• Body Composition esp. Interven Studies
• Predominantly Growth Retarded: Requirements in Exclusively Breast Fed