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World Health Organization (1995):
Physical status: the use and interpretation of anthropometry. WHO Technical Report Series
854. World Health Organization: Geneva.
The association between IUGR and increased mortality extends into the postneonatal period, but the slope of the relationship between birthweight and mortality is steeper in the neonatal period than later. At least in part, this reflects different causes of death in the two periods; in the neonatal period complications of delivery and congenital abnormalities predominate, whereas infections are more frequent later.
When examining effects of body proportionality at birth on morbidity and mortality one has to take account of the fact that definitions of proportionality and disproportionality, for instance cutoffs in ponderal index, differ among studies.
Differences in body proportionality of IUGR babies at birth are generally assumed to be a reflection of the timing, duration and severity of fetal growth retardation. A widely held assumption is that symmetrically small babies must reflect the influence of a growth inhibiting factor active over a longer period of time and primarily early in pregnancy, whereas asymmetrically small babies were exposed to a growth inhibiting influence over a shorter period of time and mainly towards the end of pregnancy. In developed countries, like Canada, proportionality tends to be highly confounded with severity of growth retardation in the sense that most of the proportionally growth retarded newborns are mildly growth retarded and have a good prognosis, whereas the disproportionally growth retarded babies are more severely growth retarded and their prognosis is less favorable. Severity of growth retardation in turn has a greater effect on morbidity and mortality measures than symmetry. In developing countries other etiologic factors may lead to symmetric and/or asymmetric growth retardation, and the risks implied by these indicators may therefore be different. In Guatemala, for instance, IUGR infants with an adequate ponderal index had higher diarrheal rates during the first few months of life than IUGR infants with low ponderal index, but the risk of morbidity was increased also in infants with low ponderal index, even if their birthweight was > 2500 g.
The etiology of IUGR is certainly an important determinant of risk and prognosis, but unfortunately it is difficult to ascertain in most cases. Different etiologies of growth retardation can result in great variability in risk among newborns that look alike. Bakketeig mentioned that there are mothers who, for no obvious reasons, tend to give birth to small babies repeatedly. The babies of such mothers are at much lower risk than babies who have the same size and appearance for other reasons, e.g., because their mothers are smokers. There are situations in which being born with IUGR even appears to be an advantage; e.g. IUGR infants born to hypertensive mothers seem to have a lower risk of mortality than infants of adequate birth weight born to hypertensive mothers. Knowing the etiology of IUGR is therefore extremely useful, not only for predicting outcome (including chronic noncommunicable disease risk in adulthood), but also for deciding on the most appropriate intervention.
Smoking reduces birthweight by 100
to 400 g and increases the risk of having; an IUGR baby by about 2.5. Smoking is not yet
very common in women in developing countries, but many of them are exposed to smoke in
their house or kitchen; it would be interesting to know what risk this entails and whether
IUGR in smokers is primarily due to nicotine, low oxygen concentration or other factors.