背景:小于胎龄(SGA)定义为出生体重低于出生体重百分位数阈值,通常是第10个百分位数,第3或第5百分位数用于识别严重的SGA。SGA被用作新生儿生长限制的代理,但是SGA新生儿在生理上可以小而健康。该定义还排除了体重高于第10百分位数的生长受限新生儿。为了解决这些限制,一项Delphi研究根据新生儿人体测量和临床参数制定了新生儿生长受限的新共识定义,但尚未评估。
目的:根据Delphi共识定义评估新生儿生长受限的患病率,并使用出生体重百分位数阈值调查与SGA定义相比相关的发病风险。
方法:数据来自2016年和2021年法国国家围产期调查,其中包括法国所有产妇单位在一周内出生≥22周和/或出生体重≥500克的所有婴儿。数据是从医疗记录和分娩后与母亲的访谈中收集的。研究人群包括23,897例单胎出生。Delphi对生长限制的共识定义是出生体重<3百分位数或以下至少3个标准:出生体重,头围或长度<10%,产前诊断为生长受限或母体高血压。新生儿出生时的复合发病率,定义为五分钟Apgar评分<7,脐带动脉pH<7.10,复苏和/或新生儿入院,使用Delphi定义和通常的出生体重百分位数阈值进行比较,以使用以下出生体重百分位数组定义SGA:<3rd,第3-4和第5-9百分位数。针对母亲特征(年龄,奇偶校验,身体质量指数,吸烟,教育水平,预先存在的高血压和糖尿病,和研究年份),然后是共识定义和出生体重百分位数群体。通过链式方程的多重填补被用来填补缺失的数据。对整个样本以及足月和早产新生儿分别进行了分析。
结果:4.9%(95%置信区间(CI):4.6-5.2)的新生儿被确定为生长受限,其中29.7%经历过发病率,与无生长限制的新生儿相比,aRR为2.5(95%CI:2.2-2.7)。与出生体重≥10百分位数相比,低出生体重百分位数的发病率风险较高(<3rdaRR=3.3(95CI:3.0-3.7),第三至第四RR=1.4(95CI:1.1-1.7),第5-9年RR=1.4,(95CI:1.2-1.6))。在调整后的模型中,包括生长限制和出生体重百分位数组的定义,并排除出生体重<3百分位数,包含在两个定义中,出生体重在第3-4百分位数(aRR=1.4,95%CI:1.1-1.7)和第5-9百分位数(aRR=1.4,95CI:1.2-1.6)的发病率风险仍然较高,但不适用于Delphi定义的增长限制(ARR=0.9,95CI:0.7-1.2)。足月和早产新生儿也发现了类似的模式。
结论:Delphi对生长限制的共识定义没有比基于出生体重百分位数的SGA定义更多的新生儿发病率。这些发现说明了在临床实践中采用Delphi共识研究之前评估其结果的重要性。
BACKGROUND: Small for gestational age is defined as a birthweight below a birthweight percentile threshold, usually the 10th percentile, with the third or fifth percentile used to identify severe small for gestational age. Small for gestational age is used as a proxy for growth restriction in the newborn, but small-for-gestational-age newborns can be physiologically small and healthy. In addition, this definition excludes growth-restricted newborns who have weights more than the 10th percentile. To address these limits, a Delphi study developed a new
consensus definition of growth restriction in newborns on the basis of neonatal anthropometric and clinical parameters, but it has not been evaluated.
OBJECTIVE: To assess the prevalence of growth restriction in the newborn according to the Delphi consensus definition and to investigate associated morbidity risks compared with definitions of Small for gestational age using birthweight percentile thresholds.
METHODS: Data come from the 2016 and 2021 French National Perinatal Surveys, which include all births ≥22 weeks and/or with birthweights ≥500 g in all maternity units in France over 1 week. Data are collected from medical records and interviews with mothers after the delivery. The study population included 23,897 liveborn singleton births. The Delphi
consensus definition of growth restriction was birthweight less than third percentile or at least 3 of the following criteria: birthweight, head circumference or length <10th percentile, antenatal diagnosis of growth restriction, or maternal hypertension. A composite of neonatal
morbidity at birth, defined as 5-minute Apgar score <7, cord arterial pH <7.10, resuscitation and/or neonatal admission, was compared using the Delphi definition and usual birthweight percentile thresholds for defining small for gestational age using the following birthweight percentile groups: less than a third, third to fourth, and fifth to ninth percentiles. Relative risks were adjusted for maternal characteristics (age, parity, body mass index, smoking, educational level, preexisting hypertension and diabetes, and study year) and then for the consensus definition and birthweight percentile groups. Multiple imputation by chained equations was used to impute missing data. Analyses were carried out in the overall sample and among term and preterm newborns separately.
RESULTS: We identified that 4.9% (95% confidence intervals, 4.6-5.2) of newborns had growth restriction. Of these infants, 29.7% experienced morbidity, yielding an adjusted relative risk of 2.5 (95% confidence intervals, 2.2-2.7) compared with newborns without growth restriction. Compared with birthweight ≥10th percentile, morbidity risks were higher for low birthweight percentiles (less than third percentile: adjusted relative risk, 3.3 [95% confidence intervals, 3.0-3.7]; third to fourth percentile: relative risk, 1.4 [95% confidence intervals, 1.1-1.7]; fifth to ninth percentile: relative risk, 1.4 [95% confidence intervals, 1.2-1.6]). In adjusted models including the definition of growth restriction and birthweight percentile groups and excluding birthweights less than third percentile, which are included in both definitions, morbidity risks remained higher for birthweights at the third to fourth percentile (adjusted relative risk, 1.4 [95% confidence intervals, 1.1-1.7]) and fifth to ninth percentile (adjusted relative risk, 1.4 [95% confidence intervals, 1.2-1.6]), but not for the Delphi definition of growth restriction (adjusted relative risk, 0.9 [95% confidence intervals, 0.7-1.2]). Similar patterns were found for term and preterm newborns.
CONCLUSIONS: The Delphi consensus definition of growth restriction did not identify more newborns with
morbidity than definitions of small for gestational age on the basis of birthweight percentiles. These findings illustrate the importance of evaluating the results of Delphi
consensus studies before their adoption in clinical practice.