Orofacial anthropometric measures in full-term newborns Medidas antropométricas orofaciais em recém-nascidos a termo

Accepted: April 04, 2019 Study conducted at Maternidade Nossa Senhora de Lourdes Aracaju (SE), Brasil and at Universidade Federal de Sergipe São Cristóvão (SE), Brasil. 1 Departamento de Fonoaudiologia, Universidade Federal de Sergipe São Cristóvão (SE), Brasil. 2 Departamento de Medicina, Universidade Federal de Sergipe São Cristóvão (SE), Brasil. 3 Maternidade Nossa Senhora de Lourdes Aracaju (SE), Brasil. 4 Maternidade Santa Helena Aracaju (SE), Brasil. 5 Departamento de Estatística e Informática, Universidade Federal Rural de Pernambuco – Recife (PE), Brasil. 6 Centro de Especialização em Fonoaudiologia Clínica, Saúde e Educação – São Paulo (SP), Brasil. Financial support: Fundação de Apoio à Pesquisa e Inovação Tecnológica do Estado de Sergipe (FAPITEC/SE): 01 Scientific Initiation Scholarship remunerated PIBIC (Notice FAPITEC/SE/FUNTEC/CAPES No 07/2016). Coordenação de Pesquisa (COPES/UFS): 01 Scientific Initiation Scholarship voluntary PIBIC (Notice 02/2016/COPES/POSGRAP/UFS). Coordenação de Aperfeiçoamento de Pessoal de Nível Superior Brasil (CAPES): 01 Ph.D. scholarship (funding code 001). CNPq – 01 Scholarship (PDS) – CNPq Brazil (No. Process 113984/2018-9). Conflict of interests: nothing to declare. ABSTRACT

Although the cranium anthropometric study is widely used in the neonatal medical clinic, including the regional pattern influenced by the various ethnic groups (13) , facial anthropometric measurements and their proportions (1,(14)(15)(16)(17) are still used shyly by health professionals, in particular by the speech therapist working in the field of Orofacial Motricity.
Anthropometry adds objectivity to assessment and provides data for differential and complementary diagnosis of changes, therapeutic planning, and prognostic visualization (14,15,18,19) . Measurement of craniofacial measurements can be done by direct anthropometry (use of calipers and / or tape on the patient's face) or indirect (cephalometric measurements or photographs) (2,4,20,21) .
In general, the works (9,22) focus on the anthropometry of the newborn's cranium (NB). One of the highlights is a study (13) performed in the Northeast region of Brazil, which obtained head circumference, biauricular and anteroposterior distance measurements, cephalic index and fontanelle measurements of 450 NB at term.
Regarding orofacial measurements and proportions, the study of different populations has been justified by the great variability, according to age, geographic, sex (3) and race (1,9,14,23) , focusing on the adolescent population (2) and adult (3,23,24) . Specifically in Brazil, there are studies in different groups, such as: healthy children (1) ; children (15) and adults (25) with mouth breathing syndrome; Japanese-Brazilian population (14) ; young people from the state of Rio de Janeiro (2) ; and children with malnutrition (18) .
However, we highlight the gap in studies addressing healthy NBs, which could bring knowledge about orofacial morphology in this population, as it is known that orofacial functions are intrinsically related to this aspect of the stomatognathic system (1)(2)(3)(4) . Thus, we highlight the importance of the speech therapist to have references of orofacial anthropometric measurements and proportions in NBs, aiming at the objective and detailed evaluation of the orofacial morphology and monitoring the orofacial motricity of this population.
This study aimed to describe and compare the anthropometric measurements and orofacial proportions of NBs healthy term, according to sex in a public hospital in the state of Sergipe, northeastern Brazil.

METHODS
A descriptive and analytical randomized study conducted in a public maternity hospital in the city of Aracaju (SE), which established, based on gestational age and sex, the orofacial measurements of healthy NBs. The Research Ethics Committee (REC) of Universidade Federal de Sergipe approved it under nº CAAE 53611316.0.0000.5546.
The study included 46 NBs who were admitted to the maternity hospital between August 2016 and February 2017. The study involved minimal risk to participants, related to possible embarrassment. All participants' guardians signed a free and informed consent form.
Inclusion criteria were: full-term NBs, appropriate for gestational age (AGA) according to physical examination, clinically stable and admitted to the maternity hospital in which the study was conducted. Exclusion criteria were: the presence of craniofacial anomalies, severe complications at birth (APGAR within 1 min <5 and 5 min <7) and has been alternatively orally fed (nasogastric tube and / or orogastric tube).
In the maternity accommodation, the daily census of the sector was observed and the NBs who were eligible for the study were randomly selected from the draw (meeting the inclusion and exclusion criteria).
Soon after collecting the authorizations by the guardians, hand washing procedures by the researchers, and having the hands put on latex gloves, the orofacial anthropometric measurements of the NBs were taken, being preferably in sleep, positioned in the cradle or bed, in a position supine, with lips occluded.
The measurement procedure was performed by four researchers previously trained by the author (26) of the Data Collection Protocol. The measurements, which were taken in millimeters (mm), had their arithmetic mean calculated for each measured structure. All of them were transcribed in the adapted protocol, whose header was expanded to the neonatal population, and the item "other orofacial measures" was excluded (Annex 1).
The orofacial points were marked with Make B  black eye pencil. After the procedure, the markings were removed with water-moistened soft cotton.
A stainless steel Stainless Hardened  digital caliper was used, with a liquid crystal display and unit system indication in mm, with a resolution of 0.01mm and an accuracy of +/-0.03 mm / 0.001mm. The tip of the instrument was coated with adhesive as a safety, not to hurt the NB. Once this was done, the caliper was reset, ensuring the initial reference point for the measurements, eliminating any interference with the use of the adhesive.
The procedure for obtaining the measurements was performed twice with each NB, by the same observer, with the help of a second researcher to contain the head and avoid risks to the NB. After each procedure, the caliper was sanitized with 70º INPM hydrated ethyl alcohol and cotton, rubbing five times on the instrument stems.
Considering the nature of the subject (neonate), there was a potential risk of waking him or the sudden movement that would cause injury if there was too much manipulation in the procedure of taking measures. Thus, each subject was measured only twice. Due to these limitations, inherent to the characteristics of the studied population, no measures were discarded.
However, due to the absence of thresholds in the literature for a technical error of measurement in orofacial measurements, we chose to use the Bland-Altman graph (27) to evaluate possible discrepancies. However, it was observed that of the analyzed variables, the discards were justified on 1 or 2 occasions in each variable, resulting in at least 95.6% of the observations with reliability.
The points that served as reference for the anthropometric measurements are represented in Figure 1, they are: trichion (tr), which is the point located at the insertion of the hair in the midline of the forehead (in NB without hair, the tr was considered as a point corresponding to what would be the insertion of the hair in the midline of the forehead); the glabella (g), which is the most prominent point on the midline between the eyebrows; the subnasale (sn), which is situated medially in the meeting of the inferior border of the nasal septum with the surface of the superior lip; the upper lip (labiale superius -ls), which is located medially at the redness line of the upper lip; the stomion (sto), which is an imaginary point situated in the medial region of the intercession between the median vertical line of the face and the horizontal line of the mouth rhyme, when the lips are closed and the teeth are occluded; the gnathion (gn), which is the point located in the lower region of the lower jaw edge; the outer corner of the eye (exocanthion -ex), which is medially situated on the outer edge of the eye, with reference to the hard tissue; e the cheilion (ch), which is the point located on the lip commissure (1,(14)(15)(16)(17) (Figure 1).
The following anthropometric measurements were taken: upper third of the face (tr-g); middle third of face (g-sn); lower third of face (sn-gn); distance between the outer corner of the eye and the cheilion (ex-ch) right and left; filter height (sn-ls); upper lip height (sn-sto) and lower lip height (sto-gn) (17) (Figure 2).
After the measurements were taken, the orofacial proportions were calculated: upper lip divided by lower lip (sn-sto / sto-gn); upper third divided by lower third (tr-g / g-sn); and middle third divided by the lower third (g-sn / sn-gn) (17) .
The collected data were tabulated in a Microsoft Excel 2016  spreadsheet and treated with a significance level of 5% (p<0,05).
Data were described using simple frequencies and percentages when categorical, as well as mean and standard deviation when continuous. Mean differences were assessed using the Mann-Whitney test, and associations using Fisher's exact test. Agreement between measurements was calculated by Pearson correlation.

RESULTS
The results of this study are presented in Table 1. In all participants, regarding gestational age at birth (GAB), there was no difference between groups, ranging from 36,43 weeks to 42,57 weeks, studied NBs mean age o was 39.24 (SD: 1.51) weeks.
Regarding the average of facial measurements, differences were found for the middle and lower thirds of the face, with higher values in males. There were also differences in the mean upper, lower lip and filter measurements, again higher in males. All observed differences were classified between small and medium magnitude, according to Cohen's criterion.
Regarding the general values found for the orofacial proportions, namely upper lip and lower lip (sn-sto / sto-gn), upper third and middle third (tr-g / g-sn) and middle third and lower third (g-sn / sn-gn), there were no differences between the groups (Table 1).

DISCUSSION
The study of anthropometry in Orofacial Motricity, with the establishment of reference values for several populations, besides bringing advantages to the evaluation, facilitates interdisciplinary communication, since the speech therapist can base his evidence and demonstrate it to other professionals from of objective data (17) .
This research is a pioneer in investigating orofacial measurements and proportions in NBs born in the Northeast region of Brazil. The study showed that it is possible to perform an objective and quantitative facial morphological evaluation in NBs, using parameters from head restraint, preferably during supine sleep behavior, paying attention to safety in the use of caliper.
Since changes in facial morphology impact orofacial functions (1)(2)(3)(4) , It highlights the applicability of the evaluation of measures and anthropometric orofacial proportions at an early age (along with NBs). Conducting research in this area, as the present study aims to add knowledge of orofacial measures in the study population, establishing benchmarks so that you can evaluate possible variables that compromise the development and maturation of orofacial functions.
In view of the objective assessment of facial morphology in NBs proposed here, it is believed that, with early intervention, it will be possible to minimize any morphological interference in orofacial functions, seeking to ensure their proper development in NBs.
The present study showed that in the early period of life, in term and healthy NBs, there are sex differences for some orofacial anthropometric measurements, coinciding with the pattern described in the literature (14,22) on average measurements, always higher in males.
On the adult's face, the literature (29) It has as reference values a height of the upper lip with an average of 19 to 22 mm and a lower lip of 38 to 44 mm, with higher values in males. The present study also corroborates this relationship between NBs, with higher values in males, conferring sexual dimorphism in the population studied for some collected measures.
The results of the present study also meet research that indicates that there are statistical differences in orofacial anthropometric measurements between sexes, but these differences were not found between orofacial proportions (1,15) . Future studies are needed to better understand these variables in the study population, clarifying the clinical impact of these findings.
In neonate population, a study (30) in northern India, the values of 8.85 mm for the NB's filter and 7.75 mm for females were observed, with an average of 8.30 mm, very similar to that found in the population studied here (8.26 mm).
However, the lack of specific studies of orofacial anthropometric measurements in the NB population made it difficult to compare the findings of this study with other studies involving this age group. As a limitation of the present study, inherent to the characteristics of the population, there was, for example, the lack of NB hair, leading to the need to assume about the location of the trichion (tr), which may compromise the accuracy of the data.
Another limitation was the impossibility of multiple measurements of the NB's facial measurements when there was a discrepancy between values, which led to the non-discarding of measurements with a relative agreement, such as the left eye corner. On the other hand, all significant results between the groups referred to measures and proportions that obtained high agreement.
This research contributed to the characterization of anthropometric measurements and orofacial proportions in healthy NBs of a maternity hospital in the state of Sergipe. Given Captions: GAB -gestational age at birth; mm -millimeter; SD -standard-deviation; D -Cohen's size effect; Mann-Whitney test the regional variability, these values cannot be generalized to NBs from other regions, being essential to expand the study in different states.

CONCLUSION
The study established the orofacial measurements and proportions in healthy NBs of maternity in the state of Sergipe, showing the differences between the sexes at birth, always larger in males.
In general, it is possible to point out the presence of sexual dimorphism for the measures of the face at birth, while there is no evidence of this finding when it comes to the orofacial proportions in the studied population. Due to regional variation, it is necessary to expand the study with populations from other locations, through a multicenter study, to create an anthropometric profile of the Brazilian NBs.