A LONGITUDINAL STUDY OF THE GROWTH OF LOW BIRTH WEIGHT INFANTS

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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 for

assess-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

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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)

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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

(4)

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.

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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

(6)

RESULTS

Data relating to mean velocity growth are recorded in Tables I

(

female

)

and II

(

male

)

. The most rapid growth occurred

from 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 I

and 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

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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 at

birth 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,

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1973;51;620

Pediatrics

Mary O. Cruise

INFANTS: I. Velocity and Distance Growth, Birth to 3 Years

A LONGITUDINAL STUDY OF THE GROWTH OF LOW BIRTH WEIGHT

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1973;51;620

Pediatrics

Mary O. Cruise

INFANTS: I. Velocity and Distance Growth, Birth to 3 Years

A LONGITUDINAL STUDY OF THE GROWTH OF LOW BIRTH WEIGHT

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