JOURNAL OF PHARMACEUTICAL AND BIOMEDICAL SCIENCES

Kamalammal R, Parameaswari PJ, Ibrahim A, R Soorya Rao. A Study on Anthropometric Surrogates to predict Low Birth Weight Babies. J

Pharm Biomed Sci 2014;04(05):443-447.

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Journal of Pharmaceutical and Biomedical Sciences (J Pharm Biomed Sci.), Member journal. Committee of Publication ethics (COPE) and Journal donation project (JDP).

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A Study on Anthropometric Surrogates to predict Low Birth Weight Babies

Rugmini Kamalammal

1,*, P.J.Parameaswari

2,Afeed Ibrahim

3,Soorya Rao R

4.

Affiliation:-

1Associate Professor,Department of pediatrics,Sree Balaji Medical College and Hospital,Bharath University,Chrompet, Chennai,India 2Assistant Professor,Department of Community Medicine, Sree Balaji Medical College and Hospital,Bharath University,Chrompet,Chennai,India 3Fellow in neonatology,Craft Hospital and Research Center, Kodungalur, Kerala, India 4D-97, Sunnyvale Apartments, 351,Konnur High road, Ayanavaram , Chennai,India The name of the department(s) and institution(s) to which the work should be attributed: Department of pediatrics, Sree Balaji Medical College and Hospital, Bharath University, Chrompet, Chennai, India Department of Community Medicine, Sree Balaji Medical College and Hospital, Bharath University, Chrompet, Chennai, India

*To whom it corresponds:- Dr. Rugmini Kamalammal DNB (Pediatrics) D-97, Sunnyvale Apartments, 351, Konnur High road, Ayanavaram , Chennai -23,India Email id:rugminirao@yahoo.com

Abstract It is found that various anthropometric surrogates of birth weight in newborn can be used in the community and they correlate each other positively. The aim of this study was to find out the most effective anthropometric parameter in the newborn to assess birth weight. A cross sectional study was conducted in a tertiary care hospital in Chennai. Moderate Positive correlation was observed between birth weight & Mid Arm Circumference(r=+0.56(P=0.000)) & next with Length(r=+0.558(P=0.000)).There was a statistically significant association between chest circumference and Birth weight with an odds ratio of 10.9 (5.29 to 22.7) in identifying the LBW babies. Cut-off values of the aforesaid measurements had good sensitivity and specificity for identifying LBW babies. Conclusion: Length and Mid Arm Circumference are the best surrogates to predict birth weight.

Keywords: Anthropometric surrogates; birth

weight.

Article citation:

Kamalammal R,Parameaswari PJ,Ibrahim A,R Soorya Rao. A Study on anthropometric surrogates to predict low birth weight babies.J Pharm Biomed Sci 2014;04(05):443-447. Available at www.jpbms.info.

INTRODUCTION

ow Birth Weight is the single most important risk factor for neonatal death1.Only about half of children are weighed at birth1. This is

more important in developing countries where most newborns are born at home and are cared by traditional birth attendants. In India 3/5th of all births takes place at home2. Less than half of births happen with assistance from a health professional, and more than one-third were delivered by a traditional birth attendant. The remaining 16 percent were delivered by a relative or other untrained person2. Incidence of low birth weight in developing countries (16.5%) is more than double the level in developed regions i.e. 7%3. In

these situations, weighing facility might not exist due to some logistic problems. As Low birth weight babies have very high mortality and morbidity it is essential to identify them at birth. Even though birth weight is sensitive predictor of health, its reliability is reduced outside hospital setup. A suitable surrogate is needed that must be highly correlated with birth weight; be easily measurable using a simple measuring instrument, and should be consistently accurate over the first few days of life since it may be possible that contact with the health care providers happens only after the baby is a few days old.

Research Article

L

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Previous studies have been done in various parts of the world as this is an important hypothesis which should be tested further before advising the health workers use these surrogates. WHO had undertaken a study in 22 different centers throughout the world for three main measurements birth weight, mid-arm circumference, and chest circumference. In India, the recent by Kaur and Bansal5, gives optimum cut off point for identifying low birth weight newborns for length was 47.45cm, 32.52cm for head circumference, 29.16cm for chest circumference, 8.44cm for mid arm circumference, 11.63cm for thigh circumference. Observation of cut off values in another study by Kadam Y R6 showed that TC of <=15.29 cm. and <=12.97 cm. and CC of <=30.16 cm and <=27.3 cm. had the better sensitivity, specificity & predictive value for identifying infants weighing <=2500 gms. & <=2000gm respectively. The optimal cut-points for head circumference and chest circumference to identify LBW newborns were ≥ 33.5cm and ≥ 30.8 cm respectively in the study by C T Sreeramareddy7. Two other studies8,9 in India gave a cut off value of mid-arm circumference as 9 cm. Present study aims to provide a cut off value of best correlating surrogate which can be used in home deliveries to identify LBW babies and can be used as early referral criteria.

MATERIAL AND METHODS This study was carried out in a teaching hospital in Chennai. All consecutive full-term, singleton, live born babies born of deliveries (n=339) that took place from June 2013 to Feb 2014 were included in the study. To avoid inter-observer bias one of the investigators weighed all the newborns and carried out anthropometric measurements within 24 hours after birth. Examination of the neonate was carried out to rule out any exclusion criteria and also to assess the gestational age which was confirmed by obtaining data from the mother regarding last menstrual period and regularity of cycles. Only those who are greater than 37 weeks of gestational age and those without any exclusion criteria were enrolled in the study. The newborns with congenital anomalies/dysmorphic features were excluded. Anthropometric measurements in respect to newborns were Birth weight (BW) Length Mid arm circumference (MAC) Maximum thigh circumference (TC)

Chest circumference (CC) Head circumference (HC) All the newborns were weighed naked on a spring type of weighing scale to the nearest 50 grams. The weighing machine was checked daily by known standard weight before weighing. The length, in centimeters, was obtained with the newborn in the supine position, on a rigid surface, using an Infantometer. The measurement was done with the aid of another person to hold the infant. Other measurements were made with a non-stretch plastic measuring tape. Mid-upper Arm circumference (MAC) was measured at the midpoint between the tip of Acromion process and Olecranon process of the left upper arm. Head Circumference (HC) was measured between Glabella and the most prominent point of Occiput posteriorly. Chest Circumference (CHC) was measured at the level of nipple at the end phase of expiration. Thigh Circumference (TC) was measured at the lowest furrow of gluteal region. The institutional research ethics committee of the institution approved this study.

RESULTS In the present study of 339 newborns, 178 (52.5%) were males and 161 (47.5%) females. 20 (5.9%) had a BMI £ 9 and 319 (94.1%) greater than 9 with a Mean ±SE (Mean) to be 11.7±0.09. Their Length was ranging between 34cm to 54cm and Birth Weight was ranging from 1.5kg to 3.9kg with mean birth weight 2.9 ± 0.02 kg. Table 1 shows descriptive statistics for the anthropometric measurements and Table 2 shows respective statistically significant Bivariate correlations. The Chest Circumference ranged between 27cm to 37cm showing a statistically significant positive moderate correlation with Mid Arm Circumference, ranging from 8cm to 13cm. The correlation was found to be statistically insignificant for the rest of the Bivariate anthropometric measurements. Table 1. Descriptive statistics for Anthropometric measurements.

Head Circumference(cm) N(%)

33 117 (34.5) 33 – 36.5 220 (64.9)

36.5 2 (0.6)

Mid Arm Circumference(cm)

9 98 (28.9)

9 241 (71.1)

Chest Circumference(cm)

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30.5 52 (15.3)

30.5 287 (84.7)

Mid Thigh circumference(cm)

12 24 (7.1)

12 – 17 297 (87.6)

17 18 (5.3)

Length (cm)

47 37 (10.9)

47 – 52.5 291(85.8)

52.5 11 (3.2)

Birth Weight

2.5 40 (11.8)

2.5 299 (88.2)

Table 2. Karl Pearson’s Coefficient of Correlation for Anthropometric measurements.

Mean ± SE r-value (P-value)

Measurements Mean ± SE r-value (P-value)

Birth weight Length

2.9 ± 0.08 49.3 ± 0.12

+0.558 (P=0.000)*

Head Circumference Chest Circumference

33.0 ± 0.07 31.8 ± 0.09

+0.499 (P=0.000)*

Birth weight

Mid Arm Circumference

2.9 ± 0.08

9.9 ± 0.05

+0.560 (P=0.028)*

Head Circumference Mid Arm Circumference

33.0 ± 0.07 9.9 ± 0.05

+0.399

(P=0.000)*

Length Head Circumference

49.3 ± 0.12 33.0 ± 0.07

+0.454 (P=0.000)*

Head Circumference Mid Thigh Circumference

33.0 ± 0.07 14.6 ± 0.54

+0.242 (P=0.000)*

Length Chest Circumference

49.3 ± 0.12 31.8 ± 0.09

+0.399 (P=0.000)*

Chest Circumference Mid Arm Circumference

31.8 ± 0.09 9.9 ± 0.05

+0.556 (P=0.000)*

Length

Mid Arm Circumference

49.3 ± 0.12 9.9 ± 0.05

+0.390 (P=0.000)*

Chest Circumference Mid Thigh Circumference

31.8 ± 0.07

14.6 ±0.54

+0.143 (P=0.008)*

Birth weight

Head Circumference

2.9 ± 0.08 33.0 ± 0.07

+0.466 (P=0.000)*

Birth weight Chest Circumference

2.9 ± 0.08 31.8 ± 0.09

+0.390 (P=0.008)*

*Statistically Significant

Fig. 1 shows the variation in the anthropometric measurements (95% CI) for the different birth weight group of newborns.

Figure 1. Bar Diagram with 95% CI for Anthropometric measurements.

The Chi Square values showed statistically significant association for all the parameters - Length, HC, CC, MAC and TC with the Birth weight groups. Further the two parameters, Chest Circumference £ 30.5cm showed 10.9 times i.e. [Odds Ratio=10.9 ; (5.29 to 22.7)] and the Mid Arm Circumference £ 9 cm had 10.19 times i.e. [Odds Ratio =10.19 ; (4.74 to 21.9)] the chance of identifying the LBW babies based on the cutoff points mentioned in earlier references4-9. Fig. 2

presents the ROC (Receiver Operator Characteristic) curve for these three parameters. We observed that Mid Arm circumference with a cutoff point of 7cm had statistically significant maximum area with good Sensitivity-99.3%, Specificity-95% compared to Chest Circumference with a cutoff point of 26cm and Length with a cutoff point of 44.5cm.

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Figure 2. Receiver Operator Characteristic Curves for Length, CC & MAC.

The main findings of our study are 1. Chest Circumference (cm) had statistically significant positive mild correlation with Birth Weight 2. Length (cm) and Mid Arm Circumference (cm) had statistically significant positive moderate correlation with Birth weight 3. Chest Circumference £ 30.5cm showed 10.9 times chance and Mid Arm Circumference £ 9 cm had 10.19 times chance of identifying the LBW babies

4. Mid Arm Circumference £ 8.55cm as a cutoff point with Sensitivity –70 % Specificity – 95.3% will be an indicator for LBW babies.

DISCUSSION

This study is an attempt to find the surrogate to birth weight which is easy to perform at periphery and also correlates best with Birth Weight. In this study, the data reveals that there is not much difference in anthropometric measurements with sex. This is in accordance with the previous studies6,7. The mean birth weight was 2.96 kg, which is in accordance with the WHO study10. Our study showed a statistically significant correlation between length and birth weight and also Mid Arm Circumference and birth weight. This observation is supported by the previous studies4,5,7-9. Cut off given for Mid Arm Circumference by these studies range from 8.44 cm to 9 cm.. A cut off value of 8.55 cm had a sensitivity of 70 % and specificity of 95.3 % which is a good criteria for a screening tool. Length, as an anthropometric surrogate was not taken into consideration by any of the latest studies to best of our knowledge except a study done in India5. It may be due to the fact that the measure requires an Infantometer and also assistance of another person to hold the infant. This becomes a logistic problem in the periphery. This particular study had a cut off value of 47.44 cm. Our study showed 98.5% sensitivity with 47.5cm as cut off. Hence we as authors would like to avoid recommending length as a surrogate for birth weight to be used in periphery but strongly recommend the same as a surrogate in a set up where logistics is not a problem. To our surprise chest circumference showed a satisfactory significant correlation with birth weight and also an odds ratio of 10. Chest

Circumference showed highest sensitivity (75.4%), specificity (78.4%), and positive predictive value (48.9%) as compared with other anthropometric parameters in a study done in India in a community set up11. It is suggested as best surrogate by other studies also 5,12,13. None of the other studied parameters have shown positive correlation with birth weight Conclusion is that Mid Arm Circumference and Chest Circumference are the two best surrogates which can be used in the periphery by health workers with a simple tool , the measuring tape. Of the two, Chest Circumference is easier as nipple line can be identified easily. A study to see a correlation between the sum of both Mid Arm Circumference and Chest Circumference with Birth Weight is suggested.

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(Punjab) - A hospital based study. Human Biology Review. 2012;1(4):376-386. 6.Kadam Y R, Somaiya P, Kakade S V. A Study of Surrogate Parameters of Birth Weight. Indian J Community Med 2005;30:89-91. 7.Sreeramareddy CT, Chuni N, Patil R, Singh D, Shakya B: . Anthropometric surrogates to identify low birth weight Nepalese newborns: a hospital-based study. BMC Pediatrics. 2008;8(16):1471-2431-8-16. 8.Das JC, Afroze A, Khanam ST, Paul N. Mid-arm circumference: an alternative measure for screening low birth weight babies. Bangladesh Med Res Counc Bull 2005;31:1-6. 9.Nair, R. Bindu, Elizabeth, K. E., Geetha, S., Varghese, Sarath.Mid Arm Circumference (MAC) and Body Mass Index (BMI)–The Two Important Auxologic Parameters in Neonates. Journal of Tropical Pediatrics. 2006; 52(5):341-345. 10.World Health Organization: Multi-centre study on low birth weight and infant mortality in India, Nepal and Sri Lanka. New Delhi: Southeast Asia Regional Office, World Health Organization; 1994:78. (SEARO regional health paper no. 25)

11.Rustagi N, Prasuna JG, Taneja DK. Anthropometric surrogates for screening of low birth weight newborns: a community-based study. Asia Pac J Public Health. 2012 Mar;24(2):343-51. 12.S K Kapoor, G Kumar, and K Anand. Use of mid-arm and chest circumferences to predict birth weight in rural north India. J Epidemiol Community Health. 1996 December; 50(6): 683–686. 13.Zakir Hussain, F Huque. Detection of low birth-weight new born babies by anthropometric measurements in Bangladesh.The Indian Journal of Pediatrics. 1991;58(2):223-231. 14.Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, de Bernis L, Neonatal Survival Steering Team: Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet 2005; 365:977-988. 15.Mullany LC, Darmstadt GL, Caffey P, Waley SK, Leclarq SC, Tielsch JM, A Low Cost, Colour Coded, hand held spring scale accurately categorizes Birth Weight in low resource settings, Arch Dis Child 2006; 91:410-13.

Source of support: None

Competing interest / Conflict of interest The author(s) have no competing interests for financial support, publication of this research, patents and royalties through this collaborative research. All authors were equally involved in discussed research work. There is no financial conflict with the subject matter discussed in the manuscript.

Copyright © 2014 Kamalammal R,Parameaswar PJ,Ibrahim A,R Soorya Rao. This is an open access article distributed under the

Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.