Predictors of excess birth weight in Brazil: a systematic review Please cite this article as: Czarnobay SA, Kroll C, Schultz LF, Malinovski J, Mastroeni SS, Mastroeni MF. Predictors of excess birth weight in Brazil: a systematic review. J Pediatr (Rio J). 2019;95:128-54.

Sandra Ana Czarnobay Caroline Kroll Lidiane F. Schultz Juliana Malinovski Silmara Salete de Barros Silva Mastroeni Marco Fabio Mastroeni About the authors

Abstract

Objective:

To describe the main predictors for excess birth weight in Brazilian children.

Data sources:

Systematic review carried out in the bibliographic databases: PubMed/MEDLINE, Cochrane, Scopus, Web of Science, and LILACS. The research in the gray literature was performed using the Google Scholar database. The bias risk analysis was adapted from the Downs and Black scale, used to evaluate the methodology of the included studies.

Data synthesis:

Using the classifications of fetal macrosomia (>4.000 g or ≥4.000 g) and large for gestational age (above the 90th percentile), 64 risk factors for excess birth weight were found in 33 scientific articles in the five regions of the country. Of the 64 risk factors, 31 were significantly associated with excess birth weight, with excess gestational weight gain, pre-gestational body mass index ≥25 kg/m2, and gestational diabetes mellitus being the most prevalent.

Conclusion:

The main predictors for excess birth weight in Brazil are modifiable risk factors. The implementation of adequate nutritional status in the gestational period and even after childbirth appears to be due to the quality and frequency of the follow-up of the mothers and their children by public health agencies.

KEYWORDS
Newborn; Excess weight; Obesity; Macrosomia; Gestational weight gain; Systematic review

Resumo

Objetivo:

Descrever os principais preditores para o excesso de peso ao nascer em crianças brasileiras.

Fontes dos dados:

Revisão sistemática feita nos bancos de dados bibliográficos: PubMed/Medline, Cochrane, Scopus, Web of Science e Lilacs. A pesquisa na literatura cinzenta foi feita na base de dados Google Acadêmico. A análise do risco de viés foi adaptada da escala de Downs e Black, usada para avaliar a metodologia dos estudos incluídos.

Síntese dos dados:

Com o uso das classificações macrossomia fetal (> 4.000 g ou ≥ 4.000 g) e grande para idade gestacional acima do percentil 90, foram encontrados 64 fatores de risco para excesso de peso ao nascer em 33 artigos científicos nas cinco regiões do país. Dos 64 fatores de risco, 31 foram significativamente associados a excesso de peso ao nascer, os mais prevalentes foram ganho de peso gestacional excessivo, índice de massa corporal pré-gestacional ≥25 kg/m2 e diabetes mellitus gestacional.

Conclusão:

Os principais preditores para o excesso de peso ao nascer no Brasil são fatores de risco modificáveis. O estabelecimento de um estado nutricional adequado no período gestacional e mesmo após o parto parece ser a qualidade e a frequência do acompanhamento dos órgãos de saúde junto às mães e seus filhos.

PALAVRAS-CHAVE
Recém-nascido; Excesso de peso; Obesidade; Macrossomia; Ganho de peso gestacional; Revisão sistemática

Introduction

Birth weight has been extensively investigated since the 1940s,11 Brasil. Ministério da Saúde. Gestões e gestores de políticas públicas de atenção à saúde da criança: 70 anos de história. Brasília, DF: Secretaria de Atenção à Saúde; 2011. mainly because of its intrinsic association with the child's and the mother's health status.22 Barker DJ, Gluckman PD, Godfrey KM, Harding JE, Owens JA, Robinson JS. Fetal nutrition and cardiovascular disease in adult life. Lancet. 1993;341:938-41. Directly associated with the newborn's and the mother's nutritional status,33 Wilcox AJ. Intrauterine growth retardation: beyond birthweight criteria. Early Hum Dev. 1983;8:189-93. birth weight is also associated with socioeconomic conditions and the quality of care received during the prenatal period, in addition to influencing the individual's growth and development throughout his/her life.44 Olmos PR, Borzone GR, Olmos RI, Valencia CN, Bravo FA, Hodgson MI, et al. Gestational diabetes and pre-pregnancy overweight: possible factors involved in newborn macrosomia. J Obstet Gynaecol Res. 2011;38:208-14. Moreover, the fact that the mother is intimately connected to the child through the placenta and the umbilical cord throughout pregnancy causes the nutritional status of the mother-child pair to be potentially influenced by similar factors.55 Catalano P, Hauguel-De Mouzon S. Is it time to reconsultation the pedersen hypothesis in the face of the obesity epidemic?. Am J Obstet Gynecol. 2011;204:479-87.

For a long time, several studies considered low birth weight as the main alteration in the child's nutritional status due to its strong association with infant mortality.66 Palinski W, Napoli C. The fetal origins of atherosclerosis: maternal hypercholesterolemia, and cholesterol-lowering or antioxidant treatment during pregnancy influence in utero programming and postnatal susceptibility to atherogenesis. FASEB J. 2002;16:1348-60. Low birth weight is also a characteristic considered in the assessment of the Human Development Index (HDI) to classify countries regarding the type of development.77 ONU. Organização das Nações Unidas. Programa das Nações Unidas para o Desenvolvimento IDH; 2017. Available from: http://www.br.undp.org/content/brazil/pt/home.html [cited 17.09.17].
http://www.br.undp.org/content/brazil/pt...
Developing countries commonly have high rates of low birth weight and, consequently, low HDI.88 UNICEF-WHO. United Nations Children's Fund and World Health Organization. Low birthweight: country, regional and global estimates. New York: UNICEF; 2004.,99 Ota E, Ganchimeg T, Morisaki N, Vogel JP, Pileggi C, Ortiz-Panozo E, et al. Risk factors and adverse perinatal outcomes among term and preterm infants born small-for-gestational-age: secondary analyses of the WHO Multi-Country Survey on Maternal and Newborn Health. PLOS ONE. 2014;9:e105155. However, with the rapid change in world populations' lifestyles, especially changes in diet and physical activity,1010 Batista-Filho M, Rissin A. A transição nutricional no Brasil: tendências regionais e temporais. Cad Saude Publica. 2003;19:181-91. many studies have shown that excess birth weight is also associated with most of the same risk factors for low birth weight.1111 Martins EB, Carvalho MS. Birth weight and overweight in childhood: a systematic review. Cad Saude Publica. 2006;22:2281-300.

In recent years, studies carried out in both developed and developing countries have shown high rates of excess birth weight in their populations.1212 Koyanagi A, Zhang J, Dagvadorj A, Hirayama F, Shibuya K, Souza JP, et al. Macrosomia in 23 developing countries: an analysis of a multicountry, facility-based, cross-sectional survey. Lancet. 2013;381:476-83.

13 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.

14 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.
-1515 Goldstein RF, Abell SK, Ranasinha S, Misso M, Boyle JA, Black MH, et al. Association of gestational weight gain with maternal and infant outcomes: a systematic review and meta-analysis. JAMA. 2017;317:2207-25. In Norway, a country with more than five million inhabitants1616 CIA. Central Intelligence Agency. The world factbook; 2017. Available from: https://www.cia.gov/library/publications/the-world-factbook/geos/no.html [cited 25.11.17].
https://www.cia.gov/library/publications...
and an HDI of 0.944,1717 UNDP. United Nations Development Programme. Ranking IDH global; 2014, 2015. Available from: http://www.br.undp.org/content/brazil/pt/home/idh0/rankings/idh-global.html [cited 25.11.17].
http://www.br.undp.org/content/brazil/pt...
the rate of excess birth weight in 2006 was 20.5%.1818 Krogsgaard S, Gudmundsdottir SL, Nilsen TI. Prepregnancy physical activity in relation to offspring birth weight: a prospective population-based study in Norway - the HUNT study. J Pregnancy. 2013;2013:780180. In the United States, with an HDI of 0.9151717 UNDP. United Nations Development Programme. Ranking IDH global; 2014, 2015. Available from: http://www.br.undp.org/content/brazil/pt/home/idh0/rankings/idh-global.html [cited 25.11.17].
http://www.br.undp.org/content/brazil/pt...
and 326.425 million inhabitants,1919 USCB. United States Census Bureau. U.S. and world population clock. [cited November 2017] the rate of excess birth weight in 2016 was 13.2%.2020 Baugh N, Harris DE, Aboueissa AM, Sarton C, Lichter E. The impact of maternal obesity and excess gestational weight gain on maternal and infant outcomes in Maine: analysis of pregnancy risk assessment monitoring system results from 2000 to 2010. J Pregnancy. 2016;2016:5871313. Studies carried out in France, Canada, and Spain reported values of excess birth weight of 15.3%, 25.8%, and 16.7%, respectively.2121 OECD. Organization for economic co-operation development. Obesity update 2017; 2017. Available from: https://www.oecd.org/els/health-systems/Obesity-Update-2017.pdf [cited 12.11.17].
https://www.oecd.org/els/health-systems/...
These same countries had HDIs of 0.888, 0.913, and 0.876 in 2015,1717 UNDP. United Nations Development Programme. Ranking IDH global; 2014, 2015. Available from: http://www.br.undp.org/content/brazil/pt/home/idh0/rankings/idh-global.html [cited 25.11.17].
http://www.br.undp.org/content/brazil/pt...
respectively.

In Brazil, a developing country with more than 200 million inhabitants and an HDI of 0.755,1717 UNDP. United Nations Development Programme. Ranking IDH global; 2014, 2015. Available from: http://www.br.undp.org/content/brazil/pt/home/idh0/rankings/idh-global.html [cited 25.11.17].
http://www.br.undp.org/content/brazil/pt...
the rates of excess birth weight vary between 4.1 and 30.1%, depending on the classification criteria used,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2222 Kac G, Velásquez-Meléndez G. Gestational weight gain and macrosomia in a cohort of mothers and their children. J Pediatr (Rio J). 2005;81:47-53.

23 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.

24 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.

25 Madi SR, Garcia RM, Souza VC, Rombaldi RL, Araujo BF, Madi JM. Effect of obesity on gestational and perinatal outcomes. Rev Bras Ginecol Obstet. 2017;39:330-6.

26 Schmidt MI, Duncan BB, Reichelt AJ, Branchtein L, Matos MC, Costa e Forti A, et al. Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care. 2001;24:1151-5.

27 Baggenstoss R, Petzhold SV, Willemann IKM, Pabis FS, Gimenes P, De Souza BV, et al. Study of polymorphism G54D of MBL2 gene in gestational diabetes mellitus. Arq Bras Endocrinol Metabol. 2014;58:900-5.

28 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.
-2929 Melo AS, Assunção PL, Gondim SS, Carvalho DF, Amorim MM, Benicio MH, et al. Estado nutricional materno, ganho de peso gestacional e peso ao nascer. Rev Bras Epidemiol. 2007;10:249-57. and differs considerably depending on the region where the study was carried out.

Currently, excess birth weight has reached alarming levels. The global prevalence of excess birth weight is between 0.5% in India and 14.5% in Algeria.1212 Koyanagi A, Zhang J, Dagvadorj A, Hirayama F, Shibuya K, Souza JP, et al. Macrosomia in 23 developing countries: an analysis of a multicountry, facility-based, cross-sectional survey. Lancet. 2013;381:476-83. The estimate for 2025 is that the world will have 70 million children born with excess weight, an outcome which is already considered by many authors as a serious public health problem.3030 WHO. World Health Organization. Commission on Ending Childhood Obesity. Facts and figures on childhood obesity; 2017. Available from: http://www.who.int/end-childhood-obesity/facts/en/ [cited 25.11.17].
http://www.who.int/end-childhood-obesity...

The different rates of excess birth weight prevalence, commonly found in countries with high socioeconomic, demographic, and cultural diversity, among others, such as Brazil, highlight the importance for each country to identify the main factors associated with this clinical condition.3131 Wang Y, Lim H. The global childhood obesity epidemic and the association between socio-economic status and childhood obesity. Int Rev Psychiatry. 2012;24:176-88. Although several factors associated with excess birth weight are also found in different countries, some factors may be associated with the country's characteristics, and thus cannot be used to explain the same clinical condition in other countries.3131 Wang Y, Lim H. The global childhood obesity epidemic and the association between socio-economic status and childhood obesity. Int Rev Psychiatry. 2012;24:176-88.

Some studies have shown that excess birth weight is mainly associated with pre-gestational maternal excess weight gain, excess weight gain during pregnancy, diabetes mellitus, hypercholesterolemia, advanced age, and multiparity.44 Olmos PR, Borzone GR, Olmos RI, Valencia CN, Bravo FA, Hodgson MI, et al. Gestational diabetes and pre-pregnancy overweight: possible factors involved in newborn macrosomia. J Obstet Gynaecol Res. 2011;38:208-14.,3232 Lizo CL, Azevedo-Lizo Z, Aronson E, Segre CA. Relação entre ganho de peso materno e peso do recém-nascido. J Pediatr (Rio J). 1998;74:114-8.

33 Siega-Riz AM. Prepregnancy obesity: determinants, consequences, and solutions. Adv Nutr. 2012;3:105-7.
-3434 Santos EM, Amorim LP, Costa OL, Oliveira N, Guimarães AC. Profile of gestational and metabolic risk in the prenatal care service of a public maternity in the Brazilian Northeast. Rev Bras Ginecol Obstet. 2012;34:102-6. However, there is no consensus regarding the main predictors for excess weight at birth specifically for Brazilian children.

It is essential that each country design its public management model based on research data developed with its own population. In this sense, this study aims to identify the main predictors of excess birth weight specifically originating from studies conducted with the Brazilian population.

Methods

This systematic review followed the criteria of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Checklist (PRISMA).3535 Moher D, Liberati A, Tetzlaff J, Altmane DG, Group PRISMA. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Int J Surg. 2010;8:336-41. The protocol of this systematic review was registered in the CRD's (Centre for Reviews and Dissemination) international prospective register of systematic reviews (PROSPERO) under number CRD 42017070505.

Eligibility criteria

Studies that evaluated the risk factors for excess birth weight in Brazil were considered eligible, without restriction or limitation of year of publication and language. The classification criteria for excess birth weight were: large for gestational age (LGA), or larger than the 90th percentile,3636 Lubchenco LO, Hansman C, Dressler M, Boyd E. Intrauterine growth as estimated from liveborn birth-weight data at 24 to 42 weeks of gestation. Pediatrics. 1963;32:793-800. and fetal macrosomia (FM; >4000 g or ≥4000 g),3737 ACOG. American College of Obstetricians and Gynecologists Committee on Practice Bulletins - Obstetrics. Clinical management guidelines for obstetrician-gynecologists. Number 30, September 2001 (replaces Technical Bulletin Number 200, December 1994). Gestational diabetes. Obstet Gynecol. 2001;98:525-38. regardless of whether there was a reference for the classification.

Regarding the study types, this review included cohort, cross-sectional, and case-control studies, with data originating from primary or secondary sources. The exclusion criteria were as follows: (1) did not consider excess birth weight, (2) did not show data for the classification of FM and LGA, (3) had insufficient data to assess the risk factors associated with excess birth weight, (4) did not assess association, and (5) the full-text article was not available. Review articles, editorials, letters, book chapters, personal opinions, comments, and conference or congress summaries were not considered in this study.

Sources of information and research strategies

Detailed and individualized search strategies were carried out in the following databases: PubMed/MEDLINE, Cochrane, Scopus, Web of Science, and LILACS (Appendix 1). For the search of the first 100 articles in the gray literature, the Google Scholar database was used. The list of references of the included studies was manually revised to evaluate the need to include additional references. The search for the descriptors was performed on June 28, 2017. Duplicate references were removed, and the complete reference list was built using EndNote software, version X7.5.1.1 (Thomson Reuters - Philadelphia, PA, United States).

Study selection

Article screening followed two selection steps. In the first stage, article selection was carried out individually by three researchers (S.A.C., L.F.S., J.M.) following the inclusion criteria and according to titles and abstracts of all references. Concomitantly, a reviewer (C.K.) analyzed and checked the criteria needed to select the studies.

In the second stage, the same authors read the full-text articles and excluded those that did not meet the inclusion criteria. Two other authors (M.F.M., S.S.B.S.M.) participated in the selection when there were disagreements between the four reviewers.

Data collection process

Three authors (S.A.C., L.F.S., J.M.) collected information on the selected articles, such as: author and year of publication, place of data collection, type of institution, study objective, type of study, number of participants, maternal and fetal risk factors, criteria for the classification of excess birth weight, prevalence of excess weight in newborns, and main results of the study (Table 1). After compiling the data and findings from the studies, these were checked by a fourth author (C.K.), aiming to organize the findings of the selected articles. To eliminate doubts, a fifth reviewer (M.F.M.) contributed to define possible disagreements.

Table 1
Characteristics of the studies included in this systematic review, according to the region of the country.

Risk of bias in individual studies

Two authors (L.F.S. and J.M.) were in charge of reviewing the methodological quality and the risks of bias according to the scale adapted from Downs and Black3838 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52:377-84. (Table 2), considering only the studies that fit the inclusion criteria. A third author (C.K.) evaluated and defined any disagreements. The Downs and Black scale aims to evaluate studies not related to randomized clinical trials; it comprises 27 applicable questions/items to assess the quality and biases of articles.3838 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52:377-84. These criteria assess the quality of data, internal validity (biases and confounding factors), external validity, and the ability of the study to detect a significant effect.

Table 2
Risk of bias assessment adapted from Downs and Black.3838 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52:377-84.

To assess the risk of bias using the Downs and Black criteria,3838 Downs SH, Black N. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Commun Health. 1998;52:377-84. the articles of this systematic review were grouped into three different categories, each with a specific score: (a) first category: articles involving prevalence-type cross-sectional studies, with a maximum score of 12; (b) second category: articles with a cross-sectional and cohort methodological design, with a maximum score of 22; (c) third category: articles involving case-control studies, with intervention and maximum score of 28. To guarantee the proportion of results between the categories, the score obtained from each article was divided by the maximum possible score for each of the three established categories (Table 2).

Association measures used

This review considered only studies that performed the chi-squared test of proportions or Fischer's exact test to determine the association between excess birth weight and the risk factors. In case of doubt regarding the analysis used in the study, the authors were contacted by e-mail to check if the data were correct. Additionally, the measures of odds ratio, relative risk, and prevalence ratio (PR) were also considered to assess the effect of risk factors and excess birth weight. When a study did not report the p-value for its analyses, the confidence intervals were used to describe whether there was statistical significance. Only categorical variables were considered in this study.

Synthesis of results

It was decided not to include meta-analyses in this systematic review due to the heterogeneity of the data between the considered studies, and the different statistical methods used to assess risk in the studies.

Risk of publication bias

To reduce the risk of bias in the study, the selected articles were assessed by considering each risk factor individually, according to the reference category of excess birth weight (>4000 g, ≥4000 g, >90th percentile or ≥90th percentile).

Results

Study selection

Using the selected databases to search for the articles, 2046 articles were identified on the topic of interest. After the removal of 420 duplicated articles, 1626 articles in English, Portuguese, and Spanish were obtained for the analysis. A comprehensive title and abstract analysis eliminated 1565 articles, resulting in 61 articles in the first stage of the study. Based on the analysis of the first 100 results of Google Scholar, five new articles were added, and another 11 articles were added from the references of previously selected articles, totaling 77 articles eligible for the second stage of the review.

In the second stage, all 77 articles were read in full and 44 were excluded from the analysis; 23 of them due to lack of data for the nutritional status classification, three because the articles assessed another outcome, six because they did not provide enough data to assess the risk factors, seven because they did not evaluate the association between the outcome and the predictors, and five because the full-text article was not found (Appendix 2). The flow chart showing the process of identification, inclusion, and exclusion of studies is shown in Fig. 1.

Figure 1
Diagram of bibliographic search adapted from PRISMA 2.

Study characteristics

The studies used in this review were published in the last four decades (1981-2017) and were carried out in the five regions of Brazil. Most of the studies were carried out in the Southeast (55.0%) and South (39.0%) regions. The total sample included 105,826 newborns, with most of them (60.6%) from cross-sectional studies, and 36.4% from cohort studies. Most of the studies used the scores of FM ≥4000 g (42.5%) or LGA >90th percentile (42.5%) to assess the newborns' nutritional status. The prevalence of fetal macrosomia varied between 1.74%3939 Siqueira AA, Areno FB, Almeida PA, Tanaka AC. The relationship among infant birth weight and sex, and type of delivery. Rev Saude Publica. 1981;15:283-90. and 17.8%,4040 Silva DG, Macedo NB. Association between gestational weight gain and pregnancy outcome. Sci Med. 2014;24:229-36. whereas the prevalence of LGA varied between 3.5%4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12. and 30.1%.4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7. The characteristics of the studies included in this review are shown in Table 1.

Risk of bias in the studies

The assessment of the methodological quality and risk of bias is shown in Table 2. Of the 33 articles evaluated, a mean score of 79.6% was obtained, with a maximum score of 100.0% and a minimum score of 59.1%. Twenty articles showed values below the mean score and, therefore, were considered as having risk of bias and reduced methodological quality.

Synthesis of results

Table 3 shows the risk factors and their association with the assessed outcome. There were 67 risk factors found for excess birth weight in the five regions of the country. Of these, 31 risk factors were significantly associated with the outcome (Table 3). Risk factors were grouped according to five main characteristics: (a) biological, (b) socioeconomic, (c) other risk factors, (d) risk factors not associated with excess birth weight, and (e) region of the country (South, Southeast, North, Northeast, and Midwest).

Table 3
Risk factors associated with excess birth weight in Brazil.

Biological characteristics

Gestational weight gain (GWG)

Of the 15 studies that assessed excess GWG as a risk factor for excess birth weight,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,3232 Lizo CL, Azevedo-Lizo Z, Aronson E, Segre CA. Relação entre ganho de peso materno e peso do recém-nascido. J Pediatr (Rio J). 1998;74:114-8.,3434 Santos EM, Amorim LP, Costa OL, Oliveira N, Guimarães AC. Profile of gestational and metabolic risk in the prenatal care service of a public maternity in the Brazilian Northeast. Rev Bras Ginecol Obstet. 2012;34:102-6.,4040 Silva DG, Macedo NB. Association between gestational weight gain and pregnancy outcome. Sci Med. 2014;24:229-36.,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.

43 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.

44 Rodrigues PL, Oliveira CL, Brito AD, Kac G. Determinant factors of insufficient and excess gestational weight gain and maternal-child adverse outcomes. Nutrition. 2010;26:617-23.

45 Gonçalves CV, Mendoza-Sassi RA, Cesar JA, Castro NB, Bortolomedi AP. Body mass index and gestational weight gain as factors predicting complications and pregnancy outcome. Rev Bras Ginecol Obstet. 2012;34:304-9.

46 Costa BM, Paulinelli RR, Barbosa MA. Association between maternal and fetal weight gain: cohort study. Sao Paulo Med J. 2012;130:242-7.

47 da Fonseca MR, Laurenti R, Marin CR, Traldi MC. Ganho de peso gestacional e peso ao nascer do concepto: estudo transversal na região de Jundiaí, São Paulo, Brasil. Cienc Saude Colet. 2014;19:1401-7.

48 Drehmer M, Duncan BB, Kac G, Schmidt MI. Association of second and third trimester weight gain in pregnancy with maternal and fetal outcomes. PLOS ONE. 2013;8:e54704.

49 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7.
-5050 Padilha C, Barros DC, Campos AB, Ayeta AC, Queiroz JA, Saunders C. Performance of an anthropometric assessment method as a predictor of low birthweight and being small for gestational age. J Hum Nutr Diet. 2014;28:292-9. only three showed that excess GWG was not associated with excess birth weight.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,4747 da Fonseca MR, Laurenti R, Marin CR, Traldi MC. Ganho de peso gestacional e peso ao nascer do concepto: estudo transversal na região de Jundiaí, São Paulo, Brasil. Cienc Saude Colet. 2014;19:1401-7.,5050 Padilha C, Barros DC, Campos AB, Ayeta AC, Queiroz JA, Saunders C. Performance of an anthropometric assessment method as a predictor of low birthweight and being small for gestational age. J Hum Nutr Diet. 2014;28:292-9.

Pre-gestational BMI

Twelve studies investigated pre-gestational BMI as a risk factor for excess birth weight.1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2525 Madi SR, Garcia RM, Souza VC, Rombaldi RL, Araujo BF, Madi JM. Effect of obesity on gestational and perinatal outcomes. Rev Bras Ginecol Obstet. 2017;39:330-6.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.

42 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.
-4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,4545 Gonçalves CV, Mendoza-Sassi RA, Cesar JA, Castro NB, Bortolomedi AP. Body mass index and gestational weight gain as factors predicting complications and pregnancy outcome. Rev Bras Ginecol Obstet. 2012;34:304-9.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7.,5151 Nucci LB, Schmidt MI, Duncan BB, Fuchs SC, Fleck ET, Britto MM. Nutritional status of pregnant women: prevalence and associated pregnancy outcomes. Rev Saude Publica. 2001;35:502-7.,5252 Vernini JM, Moreli JB, Magalhães CG, Costa RA, Rudge MV, Calderon IM. Maternal and fetal outcomes in pregnancies complicated by overweight and obesity. Reprod Health. 2016;13:100. Of these, two studies did not find a significant association with the evaluated outcome.1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893. Additionally, excess weight at the last consultation,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8. excess weight during pregancy,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6.,5454 Carniello LV, Guarnieri GU, Venâncio JA, Cruz FL, Rodrigues EC, Augusto CC, et al. Resultado perinatal dos recém-nascidos em relação ao índice de massa corpórea (IMC) materno no momento do parto em um hospital terciário da Baixada Santista. Rev UNILUS Ensino Pesqui. 2015;12:79-85. obesity at delivery,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12. excess weight at the start of pregnancy,4747 da Fonseca MR, Laurenti R, Marin CR, Traldi MC. Ganho de peso gestacional e peso ao nascer do concepto: estudo transversal na região de Jundiaí, São Paulo, Brasil. Cienc Saude Colet. 2014;19:1401-7. and the association between pre-gestational overweight and excess GWG1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14. also demonstrated association with excess birth weight.

Diabetes mellitus

Of the six studies1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.

42 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.
-4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,5555 Madi JM, Rombaldi RL, Araújo BF, Zatti H, Oliveira-Filho PF, Madi SR. Fatores maternos e perinatais relacionados à macrossomia fetal. Rev Bras Ginecol Obstet. 2006;28:232-7. that investigated the association between DM and the nutritional status of newborns, three studies showed a significant association between the presence of DM and excess birth weight.4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,4545 Gonçalves CV, Mendoza-Sassi RA, Cesar JA, Castro NB, Bortolomedi AP. Body mass index and gestational weight gain as factors predicting complications and pregnancy outcome. Rev Bras Ginecol Obstet. 2012;34:304-9. In relation to gestational DM (GDM), three2626 Schmidt MI, Duncan BB, Reichelt AJ, Branchtein L, Matos MC, Costa e Forti A, et al. Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care. 2001;24:1151-5.,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,5656 Trujillo J, Vigo A, Duncan BB, Falavigna M, Wendland EM, Campos MA, et al. Impact of the International Association of Diabetes and Pregnancy Study Groups criteria for gestational diabetes. Diabetes Res Clin Pract. 2015;108:288-95. of five studies2626 Schmidt MI, Duncan BB, Reichelt AJ, Branchtein L, Matos MC, Costa e Forti A, et al. Gestational diabetes mellitus diagnosed with a 2-h 75-g oral glucose tolerance test and adverse pregnancy outcomes. Diabetes Care. 2001;24:1151-5.,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,5656 Trujillo J, Vigo A, Duncan BB, Falavigna M, Wendland EM, Campos MA, et al. Impact of the International Association of Diabetes and Pregnancy Study Groups criteria for gestational diabetes. Diabetes Res Clin Pract. 2015;108:288-95.,5757 Leal RC, Santos CN, Lima MJ, Moura SK, Pedrosa AO, Costa AC. Maternal-perinatal complications in high risk pregnancy. J Nurs UFPE on line. 2017;11:1641-9. showed a significant association between the presence of GDM and excess birth weight. Only one study showed a significant association between the risk factors: (1) family history and obstetric history of DM, (2) glycemic index (total glycemic mean ≥120 mg/dL and postprandial blood glucose ≥130 mg/dL), and (3) Rudge classification (IB or IIA + IIB) with excess birth weight.4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.

Maternal age

Thirteen studies assessed the association between maternal age and nutritional status at birth.1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7.,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6.,5858 Santos JB, Silva JB, Silva MG, Lopes MN, Dantas PN, Lopes CM. Newborn birth weight, maternal age group and delivery method. Rev Bras Enferm. 2001;54:517-27.

59 Araujo SG, Sant'Ana DM. Relação entre a idade materna e o peso ao nascer: um estudo da gravidez na adolescência no município de Umuarama, PR, Brasil em 2001. Ciênc Cuid Saúde. 2003;2:155-60.
-6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. Of these, three showed that maternal age was significantly associated with excess birth weight: ≥20 years,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74. 20-30 years,5858 Santos JB, Silva JB, Silva MG, Lopes MN, Dantas PN, Lopes CM. Newborn birth weight, maternal age group and delivery method. Rev Bras Enferm. 2001;54:517-27. and >30 years.5858 Santos JB, Silva JB, Silva MG, Lopes MN, Dantas PN, Lopes CM. Newborn birth weight, maternal age group and delivery method. Rev Bras Enferm. 2001;54:517-27.,5959 Araujo SG, Sant'Ana DM. Relação entre a idade materna e o peso ao nascer: um estudo da gravidez na adolescência no município de Umuarama, PR, Brasil em 2001. Ciênc Cuid Saúde. 2003;2:155-60.

Parity

Eight studies investigated the association between parity and nutritional status,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.

42 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.
-4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. and only one showed that mothers who had more than two children were significantly associated with excess birth weight.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.

Child's gender

Six studies1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,3939 Siqueira AA, Areno FB, Almeida PA, Tanaka AC. The relationship among infant birth weight and sex, and type of delivery. Rev Saude Publica. 1981;15:283-90.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. investigated the association between gender and nutritional status at birth. Of these, two studies showed that male gender and excess birth weight were significantly associated.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,3939 Siqueira AA, Areno FB, Almeida PA, Tanaka AC. The relationship among infant birth weight and sex, and type of delivery. Rev Saude Publica. 1981;15:283-90.

Maternal height

Only one6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. of the two studies2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. that investigated maternal height and nutritional status showed that women with height >1.5 m were significantly associated with excess birth weight.

History of fetal macrosomia

Two studies showed a significant association between history of fetal macrosomia and excess birth weight.4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6.

Arterial hypertension (AH)

Four studies assessed the association between AH and nutritional status,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6.,5757 Leal RC, Santos CN, Lima MJ, Moura SK, Pedrosa AO, Costa AC. Maternal-perinatal complications in high risk pregnancy. J Nurs UFPE on line. 2017;11:1641-9. and only one study showed a significant association between the presence of AH and excess birth weight.4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8.

Type of delivery

Three studies2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12. investigated the association between type of delivery and nutritional status at birth, and two studies showed that the cesarean section and excess birth weight were significantly associated.2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.

Socioeconomic characteristics

Marital status

Six studies1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. evaluated the association between marital status and nutritional status at birth. Two studies showed that excess birth weight was significantly associated with married2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93. and single/widowed/divorced2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74. marital status.

Family income

Only one4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. of four studies1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. showed that an increase in family income was significantly associated with excess birth weight.

Prenatal consultations

Of three studies1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. involving the number of prenatal consultations, only one study2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74. showed that having at least seven prenatal consultations was significantly associated with excess birth weight.

Other characteristics associated with excess birth weight

The characteristics: social security affiliation_National Institute of Social Security/Institute of Social Security of Santa Catarina (INPS/IPESC),6161 Souza ML, Tanaka ACA, Siqueira AA, Santana RM. Live births at maternity hospitals. 1. Birth weight, sex, delivery type and the mother's health insurance. Rev Saude Publica. 1988;22:489-93. age at first delivery <20 years,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14. presence of anemia during pregnancy,4545 Gonçalves CV, Mendoza-Sassi RA, Cesar JA, Castro NB, Bortolomedi AP. Body mass index and gestational weight gain as factors predicting complications and pregnancy outcome. Rev Bras Ginecol Obstet. 2012;34:304-9. newborns carrying the wild genotype ("GG") of the LEP-rs7799039 polymorphism,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893. total cholesterol levels between 183.5 and 466.7 mg/dL4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. and low levels of HDL-c and high levels of maternal leptin1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84. were significantly associated with excess birth weight.

Characteristics not associated with excess birth weight

The following characteristics were not significantly associated with excess birth weight: maternal schooling,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61.per capita income,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. interpregnancy interval,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,6060 Lima GS, Sampaio HA. Influência de fatores obstétricos, socioeconômicos e nutricionais da gestante sobre o peso do recém-nascido: estudo realizado em uma maternidade em Teresina, Piauí. Rev Bras Saude Matern Infant. 2004;4:253-61. family history of DM,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7. maternal history of GDM,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6. family history of fetal macrosomia,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6. smoking before and during pregnancy,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7. alcohol consumption,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. fasting blood glucose,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7.,5353 Rehder PM, Pereira BG, Silva JL. Resultados gestacionais e neonatais em mulheres com rastreamento positivo para diabetes mellitus e teste oral de tolerância à glicose - 100 g normal. Rev Bras Ginecol Obstet. 2011;33:81-6. insulin use,4242 Kerche LT, Abbade JF, Costa RA, Rudge MV. Calderon IdM. Fatores de risco para macrossomia fetal em gestações complicadas por diabete ou por hiperglicemia diária. Rev Bras Ginecol Obstet. 2005;27:580-7. previous miscarriage,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93. gestational age,2323 Paula HA, Salvador BC, Barbosa L, Cotta RM. Peso ao nascer e variáveis maternas no âmbito da promoção da saúde. Rev APS. 2011;14:67-74.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93. skin color,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12.,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. age at menarche,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93. physical activity during and before pregnancy,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84.,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93. preeclampsia,4343 Amorim MM, Leite DF, Gadelha TG, Muniz AG, Mela AS, Rocha AM. Risk factors for macrosomia in newborns at a school-maternity in northeast of Brazil. Rev Bras Ginecol Obstet. 2009;31:241-8. number of pregnancies,1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893. maternal heart disease, premature rupture of membranes and collagenosis,4141 Nomura RM, Paiva LV, Costa VN, Liao AW, Zugaib M. Influência do estado nutricional materno, ganho de peso e consumo energético sobre o crescimento fetal, em gestações de alto risco. Rev Bras Ginecol Obstet. 2012;34:107-12. maternal energy consumption (Kcal), consumption of saturated, monounsaturated, and polyunsaturated fats,4949 Castro MB, Farias DR, Lepsch J, Mendes RH, Ferreira AA, Kac G. High cholesterol dietary intake during pregnancy is associated with large for gestational age in a sample of low-income women of Rio de Janeiro, Brazil. Matern Child Nutr. 2016;13:580-7. maternal G54D, ADIPOQ rs2241766 polymorphisms, and FTO rs9939609 in the newborn,2727 Baggenstoss R, Petzhold SV, Willemann IKM, Pabis FS, Gimenes P, De Souza BV, et al. Study of polymorphism G54D of MBL2 gene in gestational diabetes mellitus. Arq Bras Endocrinol Metabol. 2014;58:900-5.,2828 Kroll C, Mastroeni SS, Veugelers PJ, Mastroeni MF. Association of ADIPOQ, LEP, and FTO gene polymorphisms with large for gestational age infants. Am J Hum Biol. 2017;29:e22893. maternal levels of LDL-c, triglycerides, and adiponectin,1414 Farias DR, Poston L, Franco-Sena AB, Silva AA, Pinto T, Oliveira LC, et al. Maternal lipids and leptin concentrations are associated with large-for-gestational-age births: a prospective cohort study. Sci Rep. 2017;7:84. and urinary tract infection/sexually transmitted diseases.5757 Leal RC, Santos CN, Lima MJ, Moura SK, Pedrosa AO, Costa AC. Maternal-perinatal complications in high risk pregnancy. J Nurs UFPE on line. 2017;11:1641-9.

Region of the country (South, Southeast, North, Northeast, and Midwest)

The 67 described risk factors were reported by studies developed in the five regions of the country. However, the South and Southeast regions showed the highest number of studies (n = 23, 69.7%) and, consequently, a higher number of risk factors associated with excess birth weight. Only one study was conducted in the Midwest region (3.0%), and five studies (15.2%) were carried out in the north/northeast regions. Finally, four (12.1%) of the 33 studies were carried out with databases from four regions: South, Southeast, North, and Northeast.

Discussion

In this pioneering systematic review involving only studies conducted with the Brazilian population, 33 articles were assessed and 67 risk factors for excess birth weight were found, of which 31 were significantly associated with the outcome. The 33 studies were carried out in the five regions of Brazil. Among the biological risk factors, GWG, pre-gestational BMI, and DM were the main predictors of excess birth weight, also corroborating studies carried out in other countries.6262 Henriksen T. The macrosomic fetus: a challenge in current obstetrics. Acta Obstet Gynecol Scand. 2008;87:134-45.

63 Dietz PM, Callaghan WM, Sharma AJ. High pregnancy weight gain and risk of excess fetal growth. Am J Obstet Gynecol. 2009;201, 51.e51-6.
-6464 Cho EH, Hur J, Lee KJ. Early gestational weight gain rate and adverse pregnancy outcomes in Korean women. PLOS ONE. 2015;10:e0140376.

Brazil is a country with continental dimensions, with more than 200 million inhabitants distributed unevenly in the five different geographic regions. The authors believe these characteristics influence the different risk factors for the birth of children with excess body weight. These factors include cultural characteristics, distribution of federal/state government resources, availability of healthy foods, access to health care (public/private), income, and schooling. Notably, all these factors have been more prominent in the South and Southeast regions, the two richest regions of the country.6565 Brasil. Ministério da Saúde. O sistema público de saúde brasileiro. Coordenação-Geral de Documentação e Informação/SAA/SE. Procedimentos para normalização de publicações do Ministério da Saúde/Ministério da Saúde, Coordenação-Geral de Documentação e Informação. Brasília, DF: Ministério da Saúde; 2002.,6666 IBGE. Instituto Brasileiro de Geografia e Estatística. Pesquisa de Orçamentos Familiares 2008-2009. Despesas, rendimentos e condições de vida. Ministério do Planejamento, Orçamento e Gestão. Diretoria de Pesquisas. Coordenação de Trabalho e Rendimento. Rio de Janeiro (RJ); 2010. Although in this study it was not possible to establish the effect of the region on excess birth weight development, GWG was the only risk factor identified in all five regions of the country. Regarding pre-gestational BMI and DM, they were identified in all regions except the Midwest.

Regarding the type of health system described in the assessed studies, either public or private, most of them (90.9%) was performed in the public system. However, due to the regional inequality of the articles assessed in this review, it was not possible to perform any analysis about the health system used by the population.

Describing and evaluating the effect of factors that lead to excess birth weight in different cultures and populations is crucial to preventing the potential occurrence of noncommunicable diseases throughout the child's life. Some studies have shown that the negative effects of excess birth weight, both in childhood and adolescence, as well as in adult life, have significantly contributed to the development of several chronic noncommunicable comorbidities, such as morbid obesity, DM, neoplasia, and cardiovascular diseases.6767 Gungor NK. Overweight and obesity in children and adolescents. J Clin Res Pediatr Endocrinol. 2014;6:129-43.,6868 Hruby A, Hu FB. The epidemiology of obesity: a big picture. Pharmacoeconomics. 2015;33:673-89. These results show that maternal follow-up during the gestational period is a mandatory strategy to prevent the development of these diseases.

The establishment of a scenario where the mother has pre-gestational excess weight, excess GWG, and DM seems to be related to difficulties regarding the implementation of public health policies aimed at maternal follow-up before and during pregnancy. It is noteworthy that these factors can be modified before and during the gestational period,6969 Muktabhant B, Lawrie T, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excess weight gain in pregnancy. Cochrane Database Syst Rev. 2015;15:257.,7070 Boulet SL, Alexander GR, Salihu HM, Pass M. Macrosomic births in the United States: determinants, outcomes, and proposed grades of risk. Am J Obstet Gynecol. 2003;188:1372-8. and that they reflect the complex sociodemographic, economic, political, and cultural conditions of each country and between the different regions of each country.3333 Siega-Riz AM. Prepregnancy obesity: determinants, consequences, and solutions. Adv Nutr. 2012;3:105-7.,6565 Brasil. Ministério da Saúde. O sistema público de saúde brasileiro. Coordenação-Geral de Documentação e Informação/SAA/SE. Procedimentos para normalização de publicações do Ministério da Saúde/Ministério da Saúde, Coordenação-Geral de Documentação e Informação. Brasília, DF: Ministério da Saúde; 2002.,7171 Moussa HN, Alrais MA, Leon MG, Abbas EL, Sibai BM. Obesity epidemic: impact from preconception to postpartum. Future Sci OA. 2016;2:FSO137.

Since the 1990s, Brazil has undergone a period of intense nutritional transition, characterized by a reduction in the prevalence of childhood malnutrition and an increase in the prevalence of obesity in different age groups.1010 Batista-Filho M, Rissin A. A transição nutricional no Brasil: tendências regionais e temporais. Cad Saude Publica. 2003;19:181-91.,7272 Conde WL, Monteiro CA. Nutrition transition and double burden of undernutrition and excess of weight in Brazil. Am J Clin Nutr. 2014;100:1617S-22S. Among the main factors causing this nutritional transition is the population's nutritional standard, as a result of changes in the individual diet.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,7373 Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev. 2012;70:3-21. This change in the Brazilian food habits includes the adoption of a diet rich in fats, sugar, and refined foods, and a reduction in the consumption of complex carbohydrates and fibers.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,7474 Popkin BM, Keyou G, Zhai F, Guo X, Ma H, Zohoori N. The nutrition transition in China: a cross-sectional analysis. Eur J Clin Nutr. 1993;47:333-46. Together with the progressive decline in physical activity and stimulated mainly by the excess use of electronic equipment, the predominance of a sedentary lifestyle has substantially contributed to the increase of obesity in the country.2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,7373 Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev. 2012;70:3-21. Additionally, the reduction in family size, the increase in food availability, the greater concentration of individuals in the urban areas, where they spend less energy and have access to numerous types of industrialized foods,2424 Oliveira LC, Pacheco AH, Rodrigues PL, Schlussel MM, Spyrides MH, Kac G. Factors accountable for macrosomia incidence in a study with mothers and progeny attended at a Basic Unity of Health in Rio de Janeiro, Brazil. Rev Bras Ginecol Obstet. 2008;30:486-93.,7575 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brazil 2016: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates of sociodemographic frequency and distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2016; 2017. and the increase in social benefits are aspects that influence the nutritional transition process in Brazil.

Studies carried out in Brazil and in other countries have shown that the constant and adequate multidisciplinary monitoring/intervention for pregnant women and women of reproductive age with excess body weight is a simple preventive measure, specific to primary health care, which is essential to minimize the negative effects of excess birth weight for the mother-child pair.6969 Muktabhant B, Lawrie T, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excess weight gain in pregnancy. Cochrane Database Syst Rev. 2015;15:257.,7676 Brasil. Ministério da Saúde. Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. Gestação de alto risco: manual técnico/Ministério da Saúde, Secretaria de Atenção à Saúde. Departamento de Ações Programáticas Estratégicas. 5. ed. Brasília: Editora do Ministério da Saúde 5; 2012. p. 302. In addition to preventing the birth of macrosomic newborns, favoring natural childbirth and preventing several other problems caused by an LGA newborn, the monitored practice of physical activity and/or diet are possible interventions to be adopted to prevent excess gain during pregnancy.6969 Muktabhant B, Lawrie T, Lumbiganon P, Laopaiboon M. Diet or exercise, or both, for preventing excess weight gain in pregnancy. Cochrane Database Syst Rev. 2015;15:257. However, Brazil does not seem to be able to prevent the spread of overweight/obesity in the country. Data from the Brazilian Institute of Geography and Statistics (Instituto Brasileiro de Geografia e Estatística [IBGE]) show that between 1979 and 2009, the prevalence of overweight and obesity in adult women increased from 28.7% to 48.0%, and from 8.0% to 16.9%, respectively.7777 IBGE. Instituto Brasileiro de Geografia e Estatística. Ministério do Planejamento, Orçamento e Gestão. Pesquisa de orçamentos familiares 2008-2009: antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro, RJ: IBGE; 2010. In the same period, the prevalence of obesity in children aged 5-9 years increased from 2.4% to 14.2%,7777 IBGE. Instituto Brasileiro de Geografia e Estatística. Ministério do Planejamento, Orçamento e Gestão. Pesquisa de orçamentos familiares 2008-2009: antropometria e estado nutricional de crianças, adolescentes e adultos no Brasil. Rio de Janeiro, RJ: IBGE; 2010. disclosing the challenge to prevent the progression of obesogenic conditions among the population.

In contrast, some authors have shown promising results regarding the lifestyle changes in the Brazilian population. The increase from 33.0% to 35.2% in the consumption of fruits and vegetables in the period between 2008 and 2016 in adults suggests a potential change in the diet of the Brazilian population.7575 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brazil 2016: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates of sociodemographic frequency and distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2016; 2017. The frequency of the regular consumption of fruits and vegetables in 2016 was higher in women (40.7%) than in men (28.8%).7575 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brazil 2016: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates of sociodemographic frequency and distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2016; 2017. In the same period, in both genders, the regular consumption of fruits and vegetables increased with age and with the level of schooling.7575 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brazil 2016: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates of sociodemographic frequency and distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2016; 2017. Regarding the practice of physical activity during leisure time, there was an increase from 30.3% in 2009 to 37.6% in 2016 in the adult population, also suggesting a possible change in the population's lifestyle.7575 Brasil. Ministério da Saúde. Secretaria de Vigilância em Saúde. Departamento de Vigilância de Doenças e Agravos não Transmissíveis e Promoção da Saúde. Vigitel Brazil 2016: surveillance of risk and protective factors for chronic diseases by telephone survey: estimates of sociodemographic frequency and distribution of risk and protective factors for chronic diseases in the capitals of the 26 Brazilian states and the Federal District in 2016; 2017.

It is imperative that public policies aimed at controlling/monitoring women's health also consider the cultural, sociodemographic, economic, and even regional conditions of the country. Very often, the cultural influence of family and close friends can be a determinant in the nutritional status of the mother-child pair. It is essential to involve family members in the strategies to improve family quality of life, especially regarding the regular practice of adequate physical activity and diet.1313 Mastroeni MF, Czarnobay SA, Kroll C, Figueirêdo KB, Mastroeni SS, Silva JC, et al. The independent importance of pre-pregnancy weight and gestational weight gain for the prevention of large-for gestational age Brazilian newborns. Matern Child Health J. 2017;21:705-14.

From the perspective of public health, it seems evident that primary health care and its constant monitoring should be offered to women before, during, and after the gestational period. Even if the woman starts her pregnancy with excess pre-gestational BMI, interventions to return to the appropriate nutritional status are more effective when performed in the first months of pregnancy, when adherence to regular physical activity and dietary control are more effective. If excess weight gain occurs during pregnancy, specific strategies implemented by a multidisciplinary team make it possible to adjust the woman's weight to prevent the occurrence of potential comorbidities and the birth of macrosomic or LGA newborns. The success of an intervention aimed at improving the nutritional status of the mother at any moment of her pregnancy is directly associated with the involvement of the family, rather than the mother alone.

Among the strengths of this study are the extensive literature review involving five databases, including cross-sectional and longitudinal studies. The review was not limited to language and year of publication, and thus covered four decades worth of studies. Another noteworthy point is related to the organization of data, which were presented aiming to reduce the heterogeneity between the studies and facilitate the analysis. Finally, because this represents the first systematic review to describe several risk factors for excess birth weight in Brazilian children, it will substantially contribute to the creation of public policies aimed at improving the quality of life at birth.

Some limitations regarding this systematic review should be considered. First, the different reference standards7878 Marcondes E. Crescimento normal: tabelas e gráficos. In: Marcondes E, editor. Crescimento normal e deficiente. São Paulo: Savier; 1989. p. 42-69.

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80 Ministério da Saúde. Departamento de Informática do SUS. SINASC-Sistema de Informações de Nascidos Vivos (SINASC). Brasília: Ministério da Saúde; 2008.

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82 WHO. World Health Organization. Physical status: the use and interpretation of anthropometry. Technical Report Series. Geneva: World Health Organization Technical Report Series, 854; 1995. p. 375-409.

83 Alexander GR, Himes JH, Kaufman RB, Mor J, Kogan M. A United States national reference for fetal growth. Obstet Gynecol. 1996;87:163-8.

84 Pedreira CE, Pinto FA, Pereira SP, Costa ES. Birth weight patterns by gestational age in Brazil. An Acad Bras Cienc. 2011;83:619-25.

85 Villar J, Papageorghiou AT, Pang R, Ohuma EO, Ismail LC, Barros FC, et al. The likeness of fetal growth and newborn size across non-isolated populations in the INTERGROWTH-21st Project: the Fetal Growth Longitudinal Study and Newborn Cross-Sectional Study. Lancet Diabetes Endocrinol. 2014;2:781-92.

86 Puffer RR, Serrano CV. Patterns of birth weight, chapter 4 combination of birth weight and length of gestation. Scientific Publication No. 504, Washington DC, USA: Pan American Health Org, WHO; 1987. p. 52-65.
-8787 ADA. American Diabetes Association. Gestational diabetes mellitus. Diabetes Care. 2000;23:S77-9. for excess birth weight used by the studies made it difficult to compare the data, limiting a more robust data analysis, such as meta-analysis. Second, the absence of the reference criterion for the nutritional status classification in some articles made it impossible to exactly identify how many and which definitions were used. This is an important issue, since some countries use their own classification criteria and, therefore, caution should be taken when comparing the studies. Third, the different criteria used to assess the association (chi-squared, RR, PR, OR) between the outcome variables and the study predictors made it difficult to compare the results, since the magnitude of each criterion used is not the same. Fourth, the impossibility of developing a meta-analysis in this study prevented the authors from assessing the effect of the region on the different identified risk factors. Most of the studies included in the review were carried out in the South and Southeast regions, exactly because they are the regions where the distribution of resources for teaching and research remains greater. In this sense, the presented data may not accurately reflect the characteristics of the other regions (North, Northeast, and Midwest). Finally, the absence of a single tool capable of assessing the risk of bias in the different study designs also made it difficult to analyze the bias between studies.

Final considerations

Gestational weight gain, pre-gestational BMI, and DM were the main predictors of excess birth weight in Brazilian children. The determinant factor to ensure the establishment of adequate nutritional status in the gestational period and even after delivery appears to be the quality and frequency of the follow-up of mothers and their children by health care agencies. It should be remembered that the data presented and discussed in this review were based on the 33 identified studies. The disproportionate distribution of these studies according to the region does not allow the generalization of the results to the entire country.

  • Please cite this article as: Czarnobay SA, Kroll C, Schultz LF, Malinovski J, Mastroeni SS, Mastroeni MF. Predictors of excess birth weight in Brazil: a systematic review. J Pediatr (Rio J). 2019;95:128-54.
  • Funding
    Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES); Fundo de Apoio à Pesquisa da Universidade da Região de Joinville.

Appendix A   SUPPLEMENTARY MATERIAL

Supplementary material associated with this article can be found in the online version available at https://doi.org/10.1016/j.rec.2018.03.009.

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Publication Dates

  • Publication in this collection
    11 Apr 2019
  • Date of issue
    Mar-Apr 2019

History

  • Received
    13 Mar 2018
  • Accepted
    2 Apr 2018
  • Published
    19 May 2018
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