Supported by NIH grant PH 43-68-6. (Received March 22; revision accepted for publication I)ecember 17, 1972.)
ADDRESS FOR REPRINTS: (M.O.C.) Cl ildren’s Hospital of Buffalo, 219 Bryant Street, Buffalo, New York 14222.
A LONGITUDINAL
STUDY
OF THE GROWTH
OF
LOW
BIRTH
WEIGHT
INFANTS
I. Velocity
and
Distance
Growth,
Birth to 3 Years
Mary 0. Cruise, M.D.
From the Department of Pediatrics, State University of New York at Buffalo
and from the Children’s Hospital, Buffalo, New York
ABSTRAC’F. Physicians may need to consider the growth of children-especially those of unusual size
for age-from two different viewpoints. Most
pedia-tricians are used to thinking of what may be called
distance growth: how “normal” is a child’s actual length at 2 years? The other aspect, velocity growth,
expresses the rate or speed at which the child has
grown. This ma’ be equal for children of
corre-sponding ages, whereas their distance growth may
vary greatly. Failure of growth at a normal rate in
one child should be investigated whereas another
child with horizontal growth measurement outside ± 2 SD, but with normal velocity growth may re-qtiire no investigation.
Data from this study provide not only mean
measurements for weight, length, and head circum-ference of low birth weight infants who are grouped sex and gestational age, but also provide velocity
growth from birth through 3 years of age. Preterm
infants (gestational age < 37 weeks) had greater
velocity growth rates than small-for-date infants (full-term, low birth weight). At 1, 2, and 3 years
the SFD infants had the sniallest mean
measure-ments of all the study groups of low birth weight
infants. Coniparative full-term infants were larger
than low birth weight infants froni birth through 3 years of age.
Pediatrics-, 51:620, 1973, GROWTH, VELOCITY
GROWTH, HEAD CIRCUMFERENCE, SMALL-FOR-DATE INFANTS, PREMATURE INFANTS.
N
o entirely satisfactory norms forassess-nient of velocity growth of low birth weight infants of varying gestational ages
have been available. A prospective
longitu-dinal study was initiated to accumulate
data relating to (1) distance growth, (2)
velocity growth, (3) skeletal maturation, and (4) development. Data are restricted
in this discussion to growth of the children
during the first three years of life. Emphasis
is placed on velocity growth.
The study group being reported
con-sisted of 202 single birth, Caucasian,
healthy, low birth weight infants. Each of
the 115 females and 87 males weighed less
than 2,500 gm at birth. Neonates of each
sex were divided into three groups by ges-tational age as follows:
Group I -28-32 weeks of gestation
Group II -33-36 weeks of gestation
Group 111-37-42 weeks of gestation
Groups I and II are preterm infants but
have normal measurements for gestational
age. Group III are term infants but small
for gestational age (SFD).
Length of gestation was calculated to the
nearest week from the first day of the last
menstrual period. Behn and Treloar1 and
Treloar et a!.2 demonstrated the reliability
of recorded menstrual histories. Obstetrical
records and physical examinations of the
neonates were used to substantiate the
cal-culated gestational age.
CASE SELECTION
Study infants were enrolled during the
period of 1961 to 1967. The 202 low birth
weight infants were born in the obstetrical
service of the Buffalo Children’s Hospital or
were admitted to the Premature Nursery at less than 72 hours of age from neighboring
hospitals. A comparative group consisted of 113 full-term, single birth, Caucasian, healthy infants weighing > 2,500 gm at birth. There were 53 females and 60 males.
They were born in the Maternity Unit of
the Buffalo Children’s Hospital and are
participants in the Collaborative Study of
Cerebral Palsy, Mental Retardation, and
other Neurological and Sensory Disorders
of Infancy and Childhood.#{176} All infants who
depriva-ARTICLES
*SF1) = Small for Date Infants.
t C=Comparative group of infants, birth weight >2,500 gm. tion. Mothers had received antenatal
medi-cal care from obstetricians in private
prac-tice. None of the infants had recognizable
congenital anomalies, severe or prolonged
respiratory distress, or evidence of sepsis.
STUDY PROTOCOL
Infants were examined within the first 72
hours after birth, at 13 weeks ± 4 days, 26
weeks ± 1 week, 39 weeks ± 1 week, 52
weeks ± 1 week, 104 weeks. ± 2 weeks,
156 weeks ± 4 weeks, and thereafter at
yearly intervals ± 4 weeks. Measurements
made outside of these time intervals are
not included in the statistical analyses.
Of the 202 low birth weight infants 181 (89.9%) returned at 1 year, 166 (82.2%)
at 2 years and 160 (79.9%) at 3 years of
age. Failures for examinations at times
stated in the protocol were due to (1) geo-graphic moves, (2) absence for vacation, or
(3) illness. There were no deaths.
TABLE I
VELOCITY GROWTH OF Low- BIRTH WEIGHT AND OF COMPARATIVE INFANTS AT I)ESIGNATED INTERVALS,
GROUI’ED BY GESTATIONAL AGE: FEMALE
Age Interval
Mean
Increments
±
Gestational Ag e In Weeks
28-32
i’
.3.3-36
III (SFD)
.37-42 37-42
Weight(kg) 2.4±0.5 2.7±0.5 2.5±0.6 Nodata
Birth-lSwk Length(cm)
Head Circumference (cm)
N 11.7±1.8 9.3±1.5 22 11.0±1.1 7.6±1.1 34 10.9±1.4 6.6±1.1 32 13-26wk Weight Length HeadCircumference N 2.1±0.4 9.1±1.5 4.0±0.7 18 2.1±0.6 7.9±1.4 3.4±0.7 34 1.8±0.4 6.9±1.3 3.1±0.7 28 Nodata 26-39wk Weight Length Head Circumference N 1.4±0.3 5.9±1.5 2.2±0.5 16 1.4±0.3 4.9±1.0 2.2±0.5 32 1.2±0.4 4.9±0.5 2.1±0.5 26 Nodata 39-52wk Weight Length Head Circumference N 1.2±0.4 4.6±1.0 1.7±0.6 18 0.9±0.4 4.8±1.4 1.5±0.5 28 1.0±0.4 3.8±1.0 1.3±0.4 27 Nodata Birth-lyr Weight(kg) Length(cm)
TABLE II
VELOCITY GROWTH OF Low BIRTH WEIGHT AND OF C0MI’ARATIVE INFANTS AT DESIGNATED INTERVALS,
GROUPED BY GESTATIONAL AGE: MALE
Age Interval
Mean
Increments
Gestational Ag e In Weeks
28-32 33-36
III (SFD)*
37-42 37-42
Weight (kg) 2.9±0.6 2.9±0.6 2.9±0.5 No data
Birth-lSwk Length(cm)
Head Circumference (cm)
N
12.4±1.7
9.3± 1.6
17
12.2±1.6
8.2±1.3
28
11.0±1.3
7.1±0.9
22
13-26wk
Weight Length
Head Circumference N
2.3±0.6
9.7±1.5
4.5 ±0.8
17
2.2±0.5
8.6±1.3
3.8 ±0.7
25
2.1±0.7
7.5±2.3
3.3 ±0.9
19
Nodata
26-39wk
Weight Length HeadCircumference
N
1.4±0.5 6.4±0.9 2.4±0.5
17
1.5±0.5 5.6±1.4 2.2±0.6 26
1.3±0.4 5.7±1.3 2.2±0.6 17
Nodata
39-5wk
Weight
Length
Head Circumference N
1.1±0.4
4.1±1.4 1.4±0.5 17
1.0±0.4
4.5±1.1 1.4±0.6 28
0.8±0.3
4.0±1.0 1.2±0.5 17
Nodata
Birth-lyr
Weight(kg) Length(cm)
HeadCircumference(cm) N
7.7±1.2 32.2±2.9
17.8±1.7 20
7.6±1.1 30.4±2.5
15.6±1.6 36
7.0±1.3 27.9±3.0 13.6±1.5
25
6.9±1.1 26.3±2.0 12.6±1.1
37
1-2yr
Weight Length
Head Circumference N
2.2±0.5 11.9±1.9 2.8±0.6 16
2.1±0.6 11.9±1.7
2.5±0.6
34
2.1±0.9 11.6±2.1
2.4±0.7
23
2.4±0.9 12.2±1.7
2.3±0.9
10
2-Syr
Weight Length HeadCircumference N
2.0±0.5 8.3±1.5 1.2±0.5 13
1.8±0.6 7.7±1.7 1.1±0.4 32
2.0±1.2 8.1±1.2 1.2±0.5 21
1.6±0.4 7.7±2.0 1.1±0.3 7
* SFD=Small for Date Infants.
t C=Comparative group of infants, birth weight >2,500 gm.
TECHNIQUES
All examinations were performed by
trained examiners using standardized tech-niques. The chief investigator performed
94% of the total examinations of low birth
weight infants.
Anthropometric measurements of weight, length, and head circumference were based
on techniques standardized by FaIkner.3’
The measuring board used was described
by Hindley.5 Under 3 years of age supine
length was obtained. The average of three
readings was taken for each of the
anthro-pometric measurements.
X-rays, anteroposterior views, were made
of the left lower extremity. Table top
tech-nique was used. The tube-to-film distance
Length of the left fibula was measured from birth through one year of age by the
teleoradiographic technique described by
Day and Silverman.6 The Caliper used was designed by Tanner and Whitehouse.7
STATISTICAL ANALYSIS
All computations were made in the Com-puter Center of the State University of New
York at Buffalo.f Students’ t-test, based on the hypothesis that the population means
are equal and the population standard er-rors are unequal,8 was used to determine
the significance of the difference between
two means. P was determined from the
f
Supported in part by NIH grant FR-00126 and NSF grant GP-5675.TABLE III
DISTANCE GROWTH OF Low BIRTH WEIGHT AND OF COMPARATIVE INFANTS AT DE.SIGNATED AGES,
GROUPED BY GESTATIONAL AGE: FEMALE
A (weeks)
Mean
Gestalional Ag eIn iJ7eeks
I 28-32 II 33-36 III (SFD)* 37-42 C 37-42
Weight(kg) 1.4±0.3 2.0±0.2 2.2±0.3 3.3±0.4
Birth Length (cm)
Head Circumference (cm) N
39.5±2.4 27.4 ± 1 .5
28
43.6±1.9 30.2±1 .1
48
44.7±2.3 31 .3±1 .5
44 49.5±1.9 33.8±1 .2 53 13±4days Weight Length HeadCircumference N 3.8±0.7 51.0±2.7 36.5±1.2 22 4.7±0.6 54.8±2.3 37.8±1.4 33 4.7±0.7 55.5±2.9 37.9±1.6 32 Nodata 26±1 wk Weight Length Head Circumference N 5.7±0.8 59.8±2.2 40.6 ±0.8 23 6.7±0.9 62.6±2.9 41.2±1.4 41 6.4±0.9 62.4±2.9 41.0±1.6 38 Nodata 39±1 wk Weight Length Head Circumference N 7.5±1.0 66.2±2.5 42.9 ± 1 .0
19 8.0±1.0 67.4±2.9 43.3±1 .5 32 7.8±1.3 67.4±3.7
43.0 ± 1 .8 30 Nodata 52±lwk Weight(kg) Length(cm) HeadCircumference(cm) N 8.7±1.2 71.0±2.6 44.7±1.3 23 9.2±1.2 72.7±3.3 44.8±1.7 37 8.6±1.3 71.3±3.3 44.4±1.7 40 10.0±1.2 75.4±2.8 46.0±1.2 39 104±2wk Weight Length HeadCircumference N 11.1±1.4 88.4±3.6 47.2±1.4 21 11.7±1.4 85.4±3.3 47.6±1.6 35 10.6±1.5 83.1±3.9 46.7±1.8 36 12.4±1.3 86.9±3.0 47.6±1.3 8 156±4wk Weight Length HeadCircumference N 13.4±1.9 92.6±4.1 48.8±1.2 22 13.8±1.7 93.8±4.0 48.9±1.6 30 12.6±2.1 91.1±4.3 47.8±1.8 38 14.9±2.4 97.2±3.9 49.5±1.4 45
* SFD = Small for Date Infants.
624
TABLE IV
DISTANCE GROWTH OF LOW BIRTH WEIGHT AND OF COMI’ARATIVE INFANTS AT DESIGNATED AGES,
GROUPED BY GESTATIONAL AGE: MALE
(weeks)
Mean
7ts
Gestationa.l Ag eIn Weeks
I 28-32 II 33-36 III (SFD)* 37-42 Ct 37-42
Weight(kg) 1.6±0.3 2.0±0.3 2.1±0.3 3.3±0.4
Birth Length (cm)
Head Circumference (cm) N 40.2±2.7 28.2 ±2.0 21 43.6±1.9 30.5±1.5 40 45.2± 1.4 31.7±1.0 26 50.1±1.8 34.3±1.0 60 13±4 days Weight Length Head Circumference N 4.4±0.8 52.4±3.1
37.4 ± 1.6 17
4.8±0.6 55.6±1.7
38.6 ± 1 .1 29 5.0±0.5 56.1±1.7 38.8±1 .1 22 Nodata 26±1 wk Weight Length HeadCircumference N 6.8±0.9 62.0±3.1 42.2±1.6 21 7.1±0.7 64.1±2.2 42.4±1.1 35 7.1±0.7 63.8±2.3 42.2±1.0 22 Nodata 39±1 wk Weight Length Head Circumference N 8.2±1.3 68.2±3.7
44.4 ± 1 .7 17
8.6±1.0 69.7±2.3
44.6 ± 1 .1 30
8.4±1.0 69.2±2.5
44.4 ± 1 .2 17 Nodata 52±1 wk Weight(kg) Length (cm) IleadCircumference(cm) N 9.3±1.4 72.3±3.7 45.9±1.5 20 9.6±1.1 74.0±2.4 46.0±1.3 36 9.1±1.1 73.0±2.6 45.3±1.6 25 10.2±1.1 76.5±2.6 47.0±1.2 37 104±2 wk Weight Length HeadCircumference N 11.5±1.5 84.4±3.4 48.8±1.5 16 11.7±1.4 85.6±3.4 48.4±1.3 35 11.2±1.8 84.7±4.0 47.4±1.6 23 11.9±1.3 87.2±3.0 48.7±1.4 10 156±4wk Weight Length IleadCircumference N 13.4±1.5 91.9±3.5 49.7±1.8 15 13.6±1.5 93.8±3.6 49.5±1.4 33 13.4±3.0 92.7±4.5 48.7±1.8 22 14.8±1.7 97.4±4.0 50.6±1.2 48
* SFD =SmaH for Date Infants.
t C=Comparative group of infants, birth weight >2,500 gm.
standard table of t. Level of significance in all tests was P = 0.05.
For each group of infants, separated by
gestational age, the mean, standard devia-tion (SD) and standard error of the mean (SE) were determined for each of the
van-ables listed in the protocol.
Jncrcnieiits of growth were obtained by
subtracting the values of the
anthropomet-nc measurements at the earlier age from
the values at the older age. If a child
missed an appointment within the protocol period an increment for that span of time was not included. This explains the
differ-ences in sample sizes for velocity
RESULTS
Data relating to mean velocity growth are recorded in Tables I
(
female)
and II(
male)
. The most rapid growth occurredfrom birth to 13 weeks of age. Growth in
head circumference was the most
impres-sive as the mean rate of gain for each low
birth weight study group was above the
90th percentile on Falkner’s Incremental Growth Charts.9’1#{176} Group I infants of each
sex had a larger increment in head
circum-ference than group III (SFD) infants
(P = <.01) Likewise, group II had a
larger increment than group III infants (P = < .01 for female and P = < .05 for male).
Female and male infants in group I con-tinued to grow significantly more rapidly than group III infants from 13 to 26 weeks of age (P = < .01 for each measurement except for weight of male infants).
The trimonthly mean rate of growth for
each group of infants was slower from 26 to
52 weeks of age and few differences among the study groups were significant
statisti-cally. Mean measurements were above the
median on Falkner’s Incremental Growth
Charts.9’1#{176}
Few infants in comparative groups were seen at tnimonthly intervals. Therefore,
in-cremental data were calculated for the in-terval from birth to 52 weeks of age. Low
birth
weight infants of each sex in groups Iand II had smaller mean measurements at
birth than group III infants (P = <.01) but the former groups of infants grew more rapidly than group III infants during the
first year of life (P = < .01 for each mea-surement except weight of males). Infants
in study groups I and II, because of more rapid growth, exhibited greater distance growth than the group III (SFD) infants by
1 year of age. Distance growth data are
recorded in Tables III and IV.
Low birth weight infants made greater velocity growth during the first year of life than comparative infants, particularly in
head circumference (P. = <.01) and
length (P = < .01) but they did not attain
the distance growth of comparative infants.
The latter infants of each sex were heavier, longer, and had larger head
circumfer-ences than low birth weight infants at 1
year of age (P = < .01).
Infants in study groups I and II, generally continued to grow more rapidly than group
III infants from 1 to 2 years and from 2 to
3 years of age, but few differences in
veloc-ity growth during these intervals of time
were statistically significant. All groups of
low birth weight infants had velocity
growth measurements which corresponded closely to or above the median on Falkner’s
Incremental Growth Charts.9’1#{176} Differences in velocity growth between comparative and low birth weight infants were
statisti-cally nonsignificant for the time intervals of
1 to2and2to3years.
Group III (SFD) infants had smaller
mean measurements at 2 and 3 years of age than infants in study group II. Females in group II were heavier (P = < .01), taller
(P = <.01), and had larger head
circum-ferences (P = <.02) at 3 years of age than group III females. Group II males likewise were larger than group III males at 2 and 3
years of age but differences were
statisti-cally nonsignificant. Sample sizes were
smaller for males than for females and this may explain the lack of statistical signifi-cance. Comparative infants of each sex con-tinued to maintain larger mean
measure-ments than low birth weight infants
through 3 years of age (P = <.01 except for head circumference of males).
COMMENT
Silverma&I and other investigators1229
have focused attention on the importance
coopera-tion of parents was excellent so that the cx-aminations were performed within the time limits described in the protocol. Thus,
accu-rate velocity growth data could be
ob-tamed. The purpose of this report is to sup-ply tables which may serve as standards for
velocity and distance growth from birth
through 3 years of age of preterm and of
full-term low birth weight, Caucasian, sin-gle birth, healthy infants. Data relating to stem-stature index, radiographic studies, development, psychological tests, postnatal complications as spasticity, and other his-torical facts have been omitted from this re-port.
No explanations are offered as to the
etiology of the growth patterns of the vari-ous study groups. Data have been analyzed for ages and heights of mothers, parity, and
the number of other low birth weight
in-fants in the family. There are no significant differences among the study groups.
The small-for-date infants comprise
about one-third of all infants who weigh less than 2,500 grams at birth.5455 Babson56
and Fitzhardinge and Steven57 have
re-ported longitudinal studies of the post natal growth of SFD infants. This investigator agrees in general with the conclusions of the
above authors. Fitzhardinge and Steven57
reported incremental growth of SFD
in-fants for intervals of six months. This inves-tigator’s data demonstrate that the most rapid growth for all low birth weight in-fants occurred during the first 13 weeks of life. The SFD infants grew less rapidly than the preterni groups of low birth weight
in-fants.
The ability of preterm low birth weight infants to surpass the SFD infants in veloc-ity and distance growth is not limited to the
Caucasian race. A similar trend was demon-strated for Negro infants in Heimer’s58
study and for Japanese children in Tarumo-to’s study. This investigator’s study
con-tained too few noncaucasian infants for
valid statistical analyses. Black infants en-rolled were from socioeconomic families similar to the Caucasian infants and they exhibited the same growth patterns.
SUMMARY
Two hundred and two single birth, Cau-casian, healthy, low birth weight infants and 113 full-term comparative infants, who weighed > 2,500 gm at birth, have been
followed in a prospective longitudinal
study from birth through a minimum of 3
years of age. Infants were grouped by sex
and gestational age. Velocity and distance growth in weight, length and head
circum-ference were analyzed.
The small-for-date infants
(
study group III) had the largest mean measurements atbirth of all the groups of low birth weight infants (P = < .01). However, these SFD infants by 1 year of age had been surpassed in velocity and distance growth by preterm infants (study groups I and II). The SFD infants were smaller than preterm infants at 2 and at 3 years of age. Full-term compara-tive infants remained larger than low birth weight infants from birth through 3 years
of age.
The velocity growth of each study group of infants was greatest during the first 3
months of life. Velocity growth of preterm
low birth weight infants of each se sur-passed that of SFD infants, particularly in head circumference, from birth to 3 months
(P = <.01) and from 3 to 6 months
(P = <.01) Differences in velocity
growth for all measurements were less after
6 months of age but preterm infants had
greater velocity growth than SFD infants
through 3 years of age.
Data in tables may serve as standards
against which the velocity and distance
growth of a low birth weight infant of
known gestational age may be compared.
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Acknowledgment
Supported by NIH research grant A-6036 from
the National Institute of Arthritis and Metabolic
Diseases and NIH grant 5 ROI HD00434 from the
National Institute of Child Health and Human
De-velopment and by a research grant from the
United Health Foundation of Western New York.
Medical Student Summer Research Scholars
were supported by funds from the National Fund
for Medical Education, the Heart Association of
Erie County, the Cancer Training Grant and the
NIH General Research Grant.
The investigator appreciates the advice and
en-couragement of her former Chief, Dr. Mitchell I.
Rubin, the cooperation of Dr. David Weintraub, Director of the Premature Nursery, the support of
pediatricians in private practice, and the interest
and cooperation of the children and their parents
who have sacrificed time to keep their
appoint-ments.
Part of this material was presented at the Tenth
Annual Meeting of the Ambulatory Pediatric Asso-ciation in Atlantic City on April 29, 1970, and part
at the Annual Meeting of the New York State
Medical Society inNew York Cits on February 16,
