Monitoring human growth and development: a continuum from the womb to the classroom

A comprehensive set of fully integrated anthropometric measures is needed to evaluate human growth from conception to infancy so that consistent judgments can be made about the appropriateness of fetal and infant growth. At present, there are 2 barriers to this strategy. First, descriptive reference charts, which are derived from local, unselected samples with inadequate methods and poor characterization of their putatively healthy populations, commonly are used rather than prescriptive standards. The use of prescriptive standards is justified by the extensive biologic, genetic, and epidemiologic evidence that skeletal growth is similar from conception to childhood across geographic populations, when health, nutrition, environmental, and health care needs are met. Second, clinicians currently screen fetuses, newborn infants, and infants at all levels of care with a wide range of charts and cutoff points, often with limited appreciation of the underlying population or quality of the study that generated the charts. Adding to the confusion, infants are evaluated after birth with a single prescriptive tool: the World Health Organization Child Growth Standards, which were derived from healthy, breastfed newborn infants, infants, and young children from populations that have been exposed to few growth-restricting factors. The International Fetal and Newborn Growth Consortium for the 21st Century Project addressed these issues by providing international standards for gestational age estimation, first-trimester fetal size, fetal growth, newborn size for gestational age, and postnatal growth of preterm infants, all of which complement the World Health Organization Child Growth Standards conceptually, methodologically, and analytically. Hence, growth and development can now, for the first time, be monitored globally across the vital first 1000 days and all the way to 5 years of age. It is clear that an integrative approach to monitoring growth and development from pregnancy to school age is desirable, scientifically supported, and likely to improve care, referral patterns, and reporting systems. Such integration can be achieved only through the use of international growth standards, especially in increasingly diverse, mixed ancestry populations. Resistance to new scientific developments has been hugely problematic in medicine; however, we are confident that the obstetric and neonatal communities will join their pediatric colleagues worldwide in the adoption of this integrative strategy. A comprehensive set of fully integrated anthropometric measures is needed to evaluate human growth from conception to infancy so that consistent judgments can be made about the appropriateness of fetal and infant growth. At present, there are 2 barriers to this strategy. First, descriptive reference charts, which are derived from local, unselected samples with inadequate methods and poor characterization of their putatively healthy populations, commonly are used rather than prescriptive standards. The use of prescriptive standards is justified by the extensive biologic, genetic, and epidemiologic evidence that skeletal growth is similar from conception to childhood across geographic populations, when health, nutrition, environmental, and health care needs are met. Second, clinicians currently screen fetuses, newborn infants, and infants at all levels of care with a wide range of charts and cutoff points, often with limited appreciation of the underlying population or quality of the study that generated the charts. Adding to the confusion, infants are evaluated after birth with a single prescriptive tool: the World Health Organization Child Growth Standards, which were derived from healthy, breastfed newborn infants, infants, and young children from populations that have been exposed to few growth-restricting factors. The International Fetal and Newborn Growth Consortium for the 21st Century Project addressed these issues by providing international standards for gestational age estimation, first-trimester fetal size, fetal growth, newborn size for gestational age, and postnatal growth of preterm infants, all of which complement the World Health Organization Child Growth Standards conceptually, methodologically, and analytically. Hence, growth and development can now, for the first time, be monitored globally across the vital first 1000 days and all the way to 5 years of age. It is clear that an integrative approach to monitoring growth and development from pregnancy to school age is desirable, scientifically supported, and likely to improve care, referral patterns, and reporting systems. Such integration can be achieved only through the use of international growth standards, especially in increasingly diverse, mixed ancestry populations. Resistance to new scientific developments has been hugely problematic in medicine; however, we are confident that the obstetric and neonatal communities will join their pediatric colleagues worldwide in the adoption of this integrative strategy. Optimizing growth and development from conception to childhood through good nutrition, a clean environment, and adequate holistic health care is essential for the improvement of health and economic development of populations.1Bhutta Z.A. Das J.K. Rizvi A. et al.Evidence-based interventions for improvement of maternal and child nutrition: what can be done and at what cost?.Lancet. 2013; 382: 452-477Abstract Full Text Full Text PDF PubMed Scopus (1776) Google Scholar, 2Black R.E. Victora C.G. Walker S.P. et al.Maternal and child undernutrition and overweight in low-income and middle-income countries.Lancet. 2013; 382: 427-451Abstract Full Text Full Text PDF PubMed Scopus (4734) Google Scholar Throughout this critical period, growth, which is a continuous process, must be monitored routinely with the use of congruent screening tools and criteria. Focusing conceptually on only 1 specific phase or a single summary value (eg, late fetal growth or estimated fetal weight) has limited biologic basis and lessens the chances for timely and appropriate interventions. Growth monitoring (GM) is an integral and undisputed component of evidence-based antenatal and newborn care worldwide, as it is for infants and children. However, to be effective, GM requires a comprehensive set of anthropometric standards that enable skeletal growth (eg, fetal head circumference or postnatal length) and fat-related markers (eg, fetal abdominal circumference or postnatal weight) to be assessed longitudinally so that judgments can be made about the appropriateness of growth patterns and deviations (eg, whether the fetus/newborn/infant is wasted, stunted, or overweight/obese).3Victora C.G. Villar J. Barros F.C. et al.Anthropometric characterization of impaired fetal growth: risk factors for and prognosis of newborns with stunting or wasting.JAMA Pediatr. 2015; 169: e151431Crossref PubMed Scopus (47) Google Scholar These tools have been available to evaluate term infants’ postnatal growth, but not fetal growth, newborn size, or the postnatal growth of preterm newborn infants. Two barriers thwart the implementation of the missing perinatal component of the GM strategy. First, unlike in most other fields of medicine, descriptive reference charts, rather than prescriptive standards, are used in obstetric and neonatal practice. Standards are preferable because they describe aspirational, biologic norms that are achieved by healthy populations and individuals throughout the world. References, on the other hand, describe the distribution of variables that are observed in unselected samples at a given time and place, often decades ago.4Bertino E. Milani S. Fabris C. De Curtis M. Neonatal anthropometric charts: what they are, what they are not.Arch Dis Child Fetal Neonatal Ed. 2007; 92: F7-F10Crossref PubMed Scopus (69) Google Scholar They provide information that is of limited value today for clinicians, parents, and families because the criteria used to select subjects and define their health were often ill-defined. This applies, for example, to the Hadlock charts of estimated fetal weight, which are presently used worldwide, evaluated in 109 fetuses from a hospital in Texas in the 1980s.5Hadlock F.P. Harrist R.B. Sharman R.S. Deter R.L. Park S.K. Estimation of fetal weight with the use of head, body, and femur measurements-a prospective study.Am J Obstet Gynecol. 1985; 151: 333-337Abstract Full Text PDF PubMed Scopus (688) Google Scholar The second barrier is the large number and limited methodologic quality of the charts that are available to obstetricians and neonatologists. In a series of systematic reviews, we showed that there are (1) 29 published charts for estimating gestational age that use crown rump length, of which only 4 satisfied minimum quality criteria6Napolitano R. Dhami J. Ohuma E.O. et al.Pregnancy dating by fetal crown-rump length: a systematic review of charts.BJOG. 2014; 121: 556-565Crossref PubMed Scopus (75) Google Scholar; (2) 83 published fetal size charts for monitoring growth by ultrasound scanning, of which only 12 used a reliable dating method7Ioannou C. Talbot K. Ohuma E. et al.Systematic review of methodology used in ultrasound studies aimed at creating charts of fetal size.BJOG. 2012; 119: 1425-1439Crossref PubMed Scopus (115) Google Scholar; (3) 102 published charts of birthweight for gestational age, of which only 8 satisfied minimum quality criteria,8Giuliani F. Spada E. Ohuma E. et al.Systematic review of the methodological quality of studies designed to create neonatal anthropometric charts.Acta Paediatr. 2015; ([Epub ahead of print] DOI: http://dx.doi.org/10.1111/apa.13112.)PubMed Google Scholar and (4) 61 published postnatal growth charts for preterm infants with considerable shortcomings in the quality of anthropometric evaluation, gestational age estimation, length of follow-up evaluation, and reportage of postnatal care, feeding regimes, and morbidities. In addition, the choice of a particular reference chart is too often based on clinicians’ preferences or on the default chart offered in the ultrasound machine’s software, which can lead to different references being used even within the same medical practice. Finally, there is considerable variability in the definition of intrauterine growth restriction (IUGR) with the use of combinations of ultrasound measures. Consequently, clinicians currently monitor fetuses and newborn infants at different levels of care and institutions with a wide range of charts. Variable cut-off points (3rd, 5th, 10th, 90th, 95th, or 97th percentiles) are used to define “normality,” macrosomia, and IUGR. Often there is little appreciation of the underlying population or quality of the study that generated the chart being used. Consequently, fetuses can be classified as growth-restricted or overgrown in 1 part of a city or country and as healthy in another. For example, Salomon et al9Salomon L.J. Bernard J.P. Duyme M. Buvat I. Ville Y. The impact of choice of reference charts and equations on the assessment of fetal biometry.Ultrasound Obstet Gynecol. 2005; 25: 559-565Crossref PubMed Scopus (94) Google Scholar showed that the proportion of fetuses who were classified as having a biparietal diameter below the 5th percentile at 20-24 weeks of gestation can range from 6.6–23.7% with the use of 3 different popular ultrasound reference charts. More confusing still is that, only 1 month after birth, infants are evaluated by pediatricians with the use of a single, prescriptive tool, the World Health Organization (WHO) Child Growth Standards, that was derived from healthy newborn infants from populations with few growth-restricting factors whose mothers followed breastfeeding recomendations.10De Onis M. Garza C. Onyango A.W. Martorell R. WHO child growth standards.Acta Paediatr Suppl. 2006; 450: 1-101Google Scholar This situation must result inevitably in diagnostic inaccuracies, confusion for parents, and inappropriate interventions. In an era of evidence-based medicine, supporting an approach in which different tools and criteria are used depending on whether the babies are inside the womb, newly born, or aged ≥1 month is difficult to justify scientifically and to parents. The fact that the WHO Child Growth Standards have been adopted in >125 countries, including the United States, United Kingdom, and Norway,11De Onis M. Onyango A. Borghi E. et al.Worldwide implementation of the WHO child growth standards.Public Health Nutr. 2012; 15: 1603-1610Crossref PubMed Scopus (303) Google Scholar demonstrates that standardization of care is feasible and acceptable across vastly different countries and medical systems. The International Fetal and Newborn Growth Consortium for the 21st Century (INTERGROWTH-21st) Project has produced an integrated set of standards for gestational age estimation,12Papageorghiou A.T. Kennedy S.H. Salomon L.J. et al.International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester of pregnancy.Ultrasound Obstet Gynecol. 2014; 44: 641-648Crossref PubMed Scopus (147) Google Scholar first-trimester fetal size,12Papageorghiou A.T. Kennedy S.H. Salomon L.J. et al.International standards for early fetal size and pregnancy dating based on ultrasound measurement of crown-rump length in the first trimester of pregnancy.Ultrasound Obstet Gynecol. 2014; 44: 641-648Crossref PubMed Scopus (147) Google Scholar fetal growth13Papageorghiou A.T. Ohuma E.O. Altman D.G. et al.International standards for fetal growth based on serial ultrasound measurements: the fetal growth longitudinal study of the INTERGROWTH-21st Project.Lancet. 2014; 384: 869-879Abstract Full Text Full Text PDF PubMed Scopus (597) Google Scholar (to be supported by fetal growth velocity and estimated fetal weight standards in 2016), newborn size for gestational age,14Villar J. Cheikh Ismail L. Victora C.G. et al.International standards for newborn weight, length, and head circumference by gestational age and sex: the newborn cross-sectional study of the INTERGROWTH-21st Project.Lancet. 2014; 384: 857-868Abstract Full Text Full Text PDF PubMed Google Scholar postnatal growth of preterm infants,15Villar J. Giuliani F. Bhutta Z.A. et al.Postnatal growth standards for infants born preterm: the preterm postnatal follow-up study of the INTERGROWTH-21st Project.Lancet Global Health. 2015; ([Accepted for publication])Google Scholar and, in 2016, infant development at 2 years old.16Fernandes M. Stein A. Newton C.R. et al.The INTERGROWTH-21st Project neurodevelopment package: a novel method for the multi-dimensional assessment of neurodevelopment in pre-school age children.PLoS One. 2014; 9: e113360Crossref PubMed Scopus (59) Google Scholar The percentiles of the INTERGROWTH-21st newborn standards are remarkably similar at term to those of the WHO Child Growth Standards (Figure 1), which is not surprising because the 2 studies adopted the same conceptual, methodologic, and analytic approaches. This means that growth and development, for the first time, can be monitored with the same high-quality tools across the vital first 1000 days and up to the age of 5 years. The INTERGROWTH-21st standards were developed from a prospective, population-based project that selected 8 urban areas across 5 continents. Most inhabitants were healthy, adequately nourished, and educated with minimal environmental constraints on growth.17Eskenazi B. Bradman A. et assessment of environmental to in the INTERGROWTH-21st 2013; PubMed Scopus Google Scholar of these study in a second at risk of were J. Altman D.G. M. et al.The and implementation of the INTERGROWTH-21st 2013; PubMed Scopus Google Scholar of a reliable of gestational age by ultrasound The ultrasound was used at all to of A novel which the review of and A. I. C. et methodology used to the fetal growth standards in the INTERGROWTH-21st 2013; PubMed Scopus Google Scholar, I. C. Ohuma E. et and quality of ultrasound in the INTERGROWTH-21st 2013; PubMed Scopus Google Scholar Newborn infants were with the same methods and quality as in the WHO Child Growth Standards Ismail L. Ohuma E. et al.Anthropometric and quality for the of fetal and newborn growth the INTERGROWTH-21st 2013; PubMed Scopus Google Scholar with a follow-up study of their growth, and M. Stein A. Newton C.R. et al.The INTERGROWTH-21st Project neurodevelopment package: a novel method for the multi-dimensional assessment of neurodevelopment in pre-school age children.PLoS One. 2014; 9: e113360Crossref PubMed Scopus (59) Google Scholar 2 years of age from which a of and will be the growth and development at 1 of age of term and preterm newborn infants the WHO Child Growth A.T. Ohuma E.O. Altman D.G. et al.International standards for fetal growth based on serial ultrasound measurements: the fetal growth longitudinal study of the INTERGROWTH-21st Project.Lancet. 2014; 384: 869-879Abstract Full Text Full Text PDF PubMed Scopus (597) Google Scholar, J. Giuliani F. Bhutta Z.A. et al.Postnatal growth standards for infants born preterm: the preterm postnatal follow-up study of the INTERGROWTH-21st Project.Lancet Global Health. 2015; ([Accepted for publication])Google Scholar we have with commonly used (eg, and 97th as is the for infant and child growth Onis M. Garza C. Onyango A.W. Martorell R. WHO child growth standards.Acta Paediatr Suppl. 2006; 450: 1-101Google Scholar we presently are to which cutoff points perinatal and postnatal J. Cheikh Ismail L. Victora C.G. et al.International standards for newborn weight, length, and head circumference by gestational age and sex: the newborn cross-sectional study of the INTERGROWTH-21st Project.Lancet. 2014; 384: 857-868Abstract Full Text Full Text PDF PubMed Google Scholar for in an evidence-based for perinatal It be that the observed geographic and in fetal growth across populations the use of international standards. These are difficult to given the use in of based on that are from healthy subjects and their use for across populations. an example, that the definition of be for in international the of be cutoff GM of the and child up to 5 years be done in the same International standards are justified by the evidence that skeletal and growth in is similar from conception to childhood across geographic populations, when health, nutrition, and health care needs are met. These that only of the variability in growth and size at birth, and childhood can be to populations, as to variability individuals within the same population Onis M. Garza C. Onyango A.W. Martorell R. WHO child growth standards.Acta Paediatr Suppl. 2006; 450: 1-101Google Scholar, J. A.T. R. et al.The of fetal growth and newborn size across populations in the INTERGROWTH-21st the fetal growth longitudinal study and newborn cross-sectional 2014; Full Text Full Text PDF Scopus Google Scholar, J.P. Martorell R. C. R.E. and weight standards for children. are in growth PubMed Scopus Google component for fetal newborn infant and child skeletal growth and ultrasound J. A.T. R. et al.The of fetal growth and newborn size across populations in the INTERGROWTH-21st the fetal growth longitudinal study and newborn cross-sectional 2014; Full Text Full Text PDF Scopus Google preterm infant J. Giuliani F. Bhutta Z.A. et al.Postnatal growth standards for infants born preterm: the preterm postnatal follow-up study of the INTERGROWTH-21st Project.Lancet Global Health. 2015; ([Accepted for publication])Google and infant Onis M. Garza C. Onyango A.W. Martorell R. WHO child growth standards.Acta Paediatr Suppl. 2006; 450: 1-101Google child J.P. Martorell R. C. R.E. and weight standards for children. are in growth PubMed Scopus Google crown-rump J. A.T. R. et al.The of fetal growth and newborn size across populations in the INTERGROWTH-21st the fetal growth longitudinal study and newborn cross-sectional 2014; Full Text Full Text PDF Scopus Google head J. A.T. R. et al.The of fetal growth and newborn size across populations in the INTERGROWTH-21st the fetal growth longitudinal study and newborn cross-sectional 2014; Full Text Full Text PDF Scopus Google study individuals within a individuals for these measures be estimated because they were from cross-sectional human growth and J Obstet in a new individuals for these measures be estimated because they were from cross-sectional human growth and J Obstet The the use of charts based on unselected and health First, fetuses and newborn infants are evaluated in a the of or age by will be to in all populations, of the of or which is For example, it was estimated that the of age in countries is at J. 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