Based upon our previous study [4], the stretched penile length was found to vary not only between different ethnic groups but also between different regions of similar race and ethnicity. In addition to possible methodological differences, role of other factors (genetic or local environmental) cannot be ruled out. Even with the availability of a very sensitive measuring device as in the current study, measuring less than 3 mm in newborns in routine practice may have its own logistic difficulties. Kutlu, et al. [5] attempted to determine the regional reference standards for clitoral length and suggested a cut-off length of 4.69 mm below which the clitoris is covered by the labia majora when the child was held in a frog-leg like position. This definition has some practical significance as the availability of the digital calipers or other highly sensitive measuring instruments may be questionable in a resource constrained setting like India, more so in the primary health care set-ups. Further, this kind of very simple observation may act like a basic screening, and prompt the neonatal team for further investigation only in a subset of babies.

Interestingly, normative values for AGD and AGR in this study did not show any correlation with gestational age, and was in line with other Western studies [3]. This again would be useful in individualizing the endocrinological evaluation. Further, in cases of suspected maternal androgen exposure as a cause of virilization in the baby, AGD and AGR may help in timing of the exposure.

A recent multi-centric study conducted by the Indian Council of Medical Research (ICMR) has revealed that CAH is not uncommon, especially in South India with a reported prevalence of a little over 1 in 2000 [6]. With newborn screening for congenital hypothyroidism yet to pick up in a big way in India, screening for CAH with standardized 17-hydroxy-progesterone assay still has a long way to go. The basic idea of newborn screening for CAH is to identify the male baby with salt losing CAH as they do not have any genital ambiguity and cannot be picked up clinically. However, female babies with CAH may provide an opportunity for clinical diagnosis as the genitalia may reveal some degree of virilization. This again stresses the importance of clinical examination of the genitalia and early identification of clitoromegaly which seems to be the pragmatic approach to pre-screen for CAH in our setting.

In summary, there is a need for more studies from different parts of India on clitoral length and anogenital distance. Neonatologists and Pediatric endocrinologists should be aware of local and regional references before subjecting the patients to detailed hormonal evaluation in otherwise asymptomatic newborns with suspected genital abnormalities.

Funding: None; Competing interest: None stated.

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3. Mondal R, Chatterjee K, Samanta M, Hazra A, Ray S, Sabui TK, et al. Clitoral Length and anogenital ratio in Indian newborn girls. Indian Pediatr. 2016;53:299-303.

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