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