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Letters to the Editor Indian Pediatrics 2002; 39:1064-1067 |
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We have read the letter by Zubair(1) with great interest, where the author has drawn attention towards Low Birth Weight (LBW) from two perspectives, (i) LBW (<2500 g) as an indicator of maternal health, nutritional status and antenatal care, (ii) Maturity status in terms of gestational age, rather than LBW alone as a more specific and more sensitive indicator of neonatal outcome or simply stated, "Who needs special care"? Sick babies irrespective of birth weight or gestation would constitute High-risk babies and would indicate the need for special care. The survival of sick versus non-sick is different and needs no authentication. LBW has been a time tested and traditionally used indicator of adverse neonatal and infant outcome. The question remaining unanswered may be what is Low birth weight, < 2500 g or < 2000g or < 1800 g? The mortality rates are different in babies < 2500 g as compared to babies > 2500 g. Similarly, the survival of babies > 1800 g is better than those with birth weight < 1800g and so on. However, if the figure of 2500 g has to be taken as a cut off for hospitalization and referral, the numbers would be unmanagable for any health delivery system to take that load. Many Indian neonatologists have debated on this issue without reaching at a final figure though the consensus emerging is for <1800 g. What ever the final magic number may be, it is quite evident that birth weight is an important determinant of neonatal survival (Table I)(2). It may also indicate social and economic development of the locality (3-5). Table I- Mortality by birth weight (NNPD)(2)
Patterns of LBW vary widely; it being lower in developed countries(6) and urban areas(8). Global trends from developed and developing countries show that the rate of LBW has weakly declined, whereas infant mortality and neonatal mortality rates have fallen rapidly(6). In developed countries this static nature has been attributed to rising prematurity rates, rising cesarean section, etc(4). In developing countries like southern Asian countries, LBW is reported between 25-36% in the past decade as compared with developed countries <10%(4-7). However, the causes of LBW are multifactorial and often are attributable in only 50% of LBW babies and hence are treatable only to that extent. Birth weights are often genetically determined and hence standards of weight would be different for Indians, Africans and Caucasian subjects. That also explains the regional differences in the incidence of LBW in Asian and African babies with birth weight <2500g incidence staying around 35% in India while it is lower in Africa. Persistent or non declining LBW rates, despite slight improvement in maternal nutritional status and antenatal care can neither be equated to inadequacy of LBW as an indicator of antenatal visits and maternal nutrition, nor can it be concluded that saturation point in all antenatal intervention modalities has been attained, leaving no scope for action for further reducing the incidence of LBW. LBW can be expected to decline only with simultaneous comprehensive improvements in all fronts namely, social, educational, economic grounds. The study by SEARCH(8) is a true illustration to the above fact, where a 20% decline in LBW was possible due to intervention aiming at health education of mother and grand mothers about care of pregnant women and of neonates. Who needs special care? In developed countries birth weight of 2500 g is used as the cut off point for LBW. In India this would constitute 29-46% of all newborns and therefore a large number for special care to be practically feasible. It has been noted that babies with birth weight of 2000-2500 g are mostly term babies (though small) and do not differ significantly in morbidity and mortality when compared with babies weighing more than 2500 g (2). Moreover if 2000 g is taken as the cut off point for LBW, more manageable 10% infants would require special care. Therefore, most Indian workers recommend the use of 2000 g as the limit for identifying LBW(9). At the other extreme of the birth weight spectrum are the extremely small (£1500 g) babies who comprise 3%(2-10) of all births, but need tertiary care available only at larger institutions. This group has very high mortality rates and survivors have increased risk of psychomotor retardation and a poorer school performance(13). In view of the above greater efforts should be concentrated on infants in the weight group 1500-2000 g as they could be easily salvaged with smaller inputs(9). If we consider maturity (gestational age) as an indicator of assessing neonatal outcome, many disadvantages are noted: (a) Difference in prematurity rate between developed and developing countries may not be that different; (b) Non-availability of data on gestation in the cohort of LBW babies in the developing nations; (c) Non-availability of simple tools to assess gestational age of babies at birth, quickly and accurately by non-skilled workers; (d) Percentage decline in LBW was more when compared with percentage decline in prematurity(6). Thus LBW continues to be widely used as a useful composite indicator of maternal, neonatal, social, educational and development status in both developed and developing countries. As a matter of fact, <2 kg rather than <2.5 kg has been chosen for providing institutional based care for neonates in Reproductive and Child Health program adopted by Government of India in 1997(12). Anil Narang, P.S. Sandesh Kiran, Neonatal Unit, Department of Pediatrics, Advanced Pediatric Center, PGIMER, Sector 12, Chandigarh 160 012, India. | |||||||||||||||||||||||||||||||||||
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