Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21st standard: analysis of CHERG datasetsBMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3677 (Published 17 August 2017) Cite this as: BMJ 2017;358:j3677
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Re: Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21st standard: analysis of CHERG datasets
Huge disparity in SGA detection rates
We compliment the researchers for their effort and analysis of this massive CHERG datasets. We would like to comment from our experience about the reported small for gestational age (SGA) rates for India of 36%, and the 2012 neonatal mortality rates of 30/1000 live births.
Neonatal mortality in SGA is dependent on multiple factors, most important being antenatal identification, intrapartum monitoring and neonatal care available. Many public institutionsin India may not have resources for recommended fetal growth assessment, intrapartum monitoring facilities and availability of professional neonatal team to take care after birth. Stillbirths in SGA is a direct end point and a better marker to assess the performance of a centile chart. Over diagnosis of SGA may lead to over interventions which is currently a worrying problem for India. Both customised centiles and our hospital centiles for the newborn give an SGA incidence of 10.3% for our institute with a stillbirth rate of 6/1000 and neonatal mortality rate of 4.6/1000 for the year 2016 (for more than 28 weeks, total of 8642 births).
Gestational age assessment was correlated by ultrasound in six out of 14 data cohorts only. Clinical methods and neonatal examination based gestational age assignment are not known to be very reliable. It would have been more interesting if this analysis was limited to those with ultrasound confirmed gestational age. Low birth weight definition of less than 2500 gm is dependent on the gestational age and not a good marker for fetal growth restriction in comparision to SGA.
The SGA rates of China has been mentioned as 4.6% which may be an underdiagnosis for that population. The scope of prevention of neonatal deaths definitely exists in low / middle income countries, and has to be targetted at SGA detection, management with an appropriately timed delivery and good neonatal care facilities. The extent of decrease would depend on the scale used to differentiate normality from abnormality. Any scale which demarkates 36% of the population as abnormal has to have a rethink.
Competing interests: No competing interests
Formula feed is frequently used for preterm babies in hospital settings in India.1 National Family Health Survey 4 reveals that only 41.6% neonates in India receive breast-milk within first hour of birth.2 That means two-third babies are still missing out on early commencement of breast milk. The practice of manual expression of milk for ensuring exclusive breast feeding is, unfortunately, limited. Similar deviations are also observed in case of caesarean section, although in higher frequency. Post-operative tiredness, anaesthesia, decreased alertness interfere with the initiation of early breast feeding.3 In general, nobody waits for recovery of mother after operation and prelacteal feeding ensues. Sometimes, hospital staffs encourage the relatives for the same.3-5 With increasing trend of caesarean section in the country, it would be difficult to maintain early initiation of breast feeding in future.
Be it preterm delivery or caesarean section, the common undesirable result is deviation from exclusive breast feeding. There are different factors responsible for such tradition. Tendency among higher socio-economic groups to go for formula food is one of them.3 In some cases, feeding the baby with commercially available preparation becomes a status symbol or socially recognized standard in baby care. This becomes more evident when people, including economically weaker sections, rush for readymade food for initiation of complementary food. Administration of ghutti (a popular herbal preparation), honey and other milk has long been the social norm in India. It is another reason stopping exclusive breast feeding from being universal.2
On one hand, we talk about restricting the use of infant milk substitutes and celebrate breastfeeding week every year with new slogans and let prelacteal feeding be our tradition, even in hospital setting, on the other. We need to come out of this double standard.
1. Sethi A, Joshi M, Thukral A, Dalal JS, Deorari AK. A quality improvement initiative: improving exclusive breastfeeding rates of preterm neonates. Indian J Pediatr 2017;84:322-5.
2. International Institute for Population Sciences (IIPS) and Macro International. National Family Health Survey (NFHS-4), India, 2015-16: Mumbai; IIPS: 2017.
3. Patel A, Banerjee A, Kaletwad A. Factors Associated with Prelacteal Feeding and Timely Initiation of Breastfeeding in Hospital-Delivered Infants in India. J Hum Lact. 2013;29:572–578. doi: 10.1177/0890334412474718.
4. Roy MP, Mohan U, Singh SK, Singh VK, Srivastava AK. Determinants of prelacteal feeding in rural Northern India. Int J Prev Med 2014;5:658-63.
5. Khan AM, Kayina P, Agrawal P, Gupta A, Kannan AT. A study on infant and young child feeding practices among mothers attending an urban health center in East Delhi. Indian J Public Health 2012;56:301-4.
Competing interests: No competing interests