Geographic altitude and prevalence of underweight, stunting and wasting in newborns with the INTERGROWTH-21st standard

Martínez, Jorge Ivan; Román, Estela M.; Alfaro, Emma L.; Grandi, Carlos; Dipierri, José E.

doi:10.1016/j.jped.2018.03.007

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Original articles • J. Pediatr. (Rio J.) 95 (3) • May-Jun 2019 • https://doi.org/10.1016/j.jped.2018.03.007 copy

Geographic altitude and prevalence of underweight, stunting and wasting in newborns with the INTERGROWTH-21st standard^☆ ☆ Please cite this article as: Martínez JI, Román EM, Alfaro EL, Grandi C, Dipierri JE. Geographic altitude and prevalence of underweight, stunting and wasting in newborns with the INTERGROWTH-21st standard. J Pediatr (Rio J). 2019;95:366 -73.

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective:

To assess the prevalence and risks of underweight, stunting and wasting by gestational age in newborns of the Jujuy Province, Argentina at different altitude levels.

Methods:

Live newborns (n = 48,656) born from 2009–2014 in public facilities with a gestational age between 24⁺⁰ to 42⁺⁶ weeks. Phenotypes of underweight (<P3 weight/age), stunting (<P3 length/age) and wasting (<P3 body mass index/age) were calculated using Intergrowth-21st standards. Risk factors were maternal age, education, body mass index, parity, diabetes, hypertension, preeclampsia, tuberculosis, prematurity, and congenital malformations. Data were grouped by the geographic altitude: ≥2.000 or <2.000 m.a.s.l. Chi-squared test and a multivariate logistic regression analysis were performed to estimate the risk of the phenotypes associated with an altitudinal level ≥2.000 m.a.s.l.

Results:

The prevalence of underweight, stunting and wasting were 1.27%, 3.39% and 4.68%, respectively, and significantly higher at >2.000 m.a.s.l. Maternal age, body mass index >35 kg/m², hypertension, congenital malformations, and prematurity were more strongly associated with underweight rather than stunting or wasting at ≥2.000 m.a.s.l.

Conclusions:

Underweight, stunting, and wasting risks were higher at a higher altitude, and were associated with recognized maternal and fetal conditions. The use of those three phenotypes will help prioritize preventive interventions and focus the management of fetal undernutrition.

KEYWORDS
Fetal growth retardation; Newborn; Birth weight; Prematurity; Malformations

Variable		LA (n = 40,442)			HA (n = 8214)			AOR (95% CI)^a a AOR, adjusted OR for all variables of the table.
		Total^b b There were some missing values.	n	%	Total^b b There were some missing values.	n	%
Maternal educational level (ys)	<8	1744	30	1.7	305	10	3.3	1.61 (0.97 -2.67)
	8 -11	1022	16	1.5	466	10	2.1	1.19 (0.64 -2.23)
	≥12	37,172	458	1.2	7443	175	2.4	1 (Reference)
Maternal BMI (kg/m²)	<18.5	1831	23	1.2	276	12	4.3	1.53^c c p < 0.001. (1.02 -2.30)
	18.5 -24.9	19,327	241	1.2	3747	82	2.2	1 (Reference)
	25 -29.9	7608	77	1.0	1242	30	2.4	0.69^c c p < 0.001. (0.50 -0.94)
	30 -34.9	2549	23	0.9	286	5	1.7	0.51^c c p < 0.001. (0.29 -0.92)
	≥35	8623	140	1.6	2663	66	2.5	1.16 (0.62 -2.18)
Maternal age (ys)	<20	9006	129	1.4	1981	54	2.7	0.91 (0.61 -1.34)
	20 -24	11,974	128	1.1	2411	63	2.6	1.04 (0.73 -1.47)
	25 -29	8896	96	1.1	1812	26	1.4	1 (Reference)
	30 -34	6176	79	1.3	1163	34	2.9	1.31 (0.86 -1.98)
	≥35	3859	72	1.8	844	18	2.1	1.78^c c p < 0.001. (1.13 -2.81)
Parity	0	13,616	216	1.6	2851	89	3.1	1.72^c c p < 0.001. (1.15 -2.56)
	1	10,451	98	0.9	2039	40	2.0	0.98 (0.65 -1.46)
	2	6586	65	1.0	1267	19	1.5	0.88 (0.57 -1.36)
	≥3	9285	125	1.3	2057	47	2.3	1 (Reference)
TBC	No	39,240	485	1.2	8046	193	2.4	1 (Reference)
TBC	Yes	209	3	1.4	12	0	0.0	0.70 (0.17 -9.64)
Diabetes	No	39,207	478	1.2	8062	192	2.4	1 (Reference)
Diabetes	Yes	128	3	2.3	14	0	0	1.29 (0.95 -5.21)
Hypertension	No	38,839	472	1.2	8066	192	2.4	1 (Reference)
Hypertension	Yes	574	15	2.6	31	1	3.2	2.54^c c p < 0.001. (1.14 -5.68)
Preeclampsia	No	38,974	476	1.2	8037	189	2.4	1 (Reference)
Preeclampsia	Yes	385	9	2.3	45	2	4.4	1.10 (0.33 -3.66)
Male	No	19,591	224	1.2	4024	88	2.1	1 (Reference)
Male	Yes	20,347	260	1.3	3995	107	2.6	1.05 (0.84 -1.32)
Congenital malformations	No	29,213	261	0.8	6434	124	1.9	1 (Reference)
Congenital malformations	Yes	366	27	7.3	35	6	17.4	7.66^c c p < 0.001. (4.83 -12.14)
Prematurity	No	37,953	404	0.2	7640	171	0.6	1 (Reference)
Prematurity	Yes	2489	100	16.1	574	24	25.6	1.54^c c p < 0.001. (1.07 -2.22)

Variable		LA (n = 40,442)			HA (n = 8214)			AOR (95% CI)^a a Adjusted OR for all variables of the table.
		Total^b b There were some missing values.	n	%	Total^b b There were some missing values.	n	%
Maternal educational level (ys)	<8	1691	40	2.4	289	22	7.6	1.02 (0.71 -1.48)
	8 -11	995	24	2.4	452	20	4.4	1.15 (0.78 -1.69)
	≥12	36,468	789	2.2	7202	413	5.7	1 (Reference)
Maternal BMI (kg/m²)	<18.5	1803	54	3.0	270	21	7.8	1.31^c c p < 0.001. (1.01 -1.70)
	18.5 -24.9	19,008	436	2.3	3628	194	5.3	1 (Reference)
	25 -29.9	7425	130	1.8	1203	57	4.7	0.84 (0.71 -1.00)
	30 -34.9	2493	47	1.9	278	7	2.5	0.71^c c p < 0.001. (0.52 -0.97)
	≥35	8425	186	2.2	2564	176	6.9	1.03 (0.68 -.56)
Maternal Age (ys)	<20	8859	205	2.3	1910	137	7.2	1.02 (0.82 -1.28)
	20 -24	11,750	266	2.3	2339	128	5.5	1 (Reference)
	25 -29	8726	187	2.1	1762	93	5.3	0.93 (0.76 -1.13)
	30 -34	6041	110	1.8	1113	54	4.9	0.85 (0.66 -1.08)
	≥35	3754	84	2.2	816	42	5.1	0.95 (0.72 -1.27)
Parity	0	13,387	327	2.4	2749	169	6.1	1 (Reference)
	1	10,238	211	2.1	1983	109	5.5	1.13 (0.89 -1.14)
	2	6466	147	2.3	1234	68	5.5	0.99 (0.78 -1.25)
	≥3	9063	168	1.9	1977	109	5.5	1.15 (0.91 -1.46)
TBC	No	38,008	820	2.2	7786	447	5.7	1 (Reference)
TBC	Yes	204	5	2.5	12	0	0.0	1.21 (0.44 -3.32)
Diabetes	No	38,375	1212	3.3	7896	536	7.3	1 (Reference)
Diabetes	Yes	121	4		15	1	0	0.50 (0.07 -3.69)
Hypertension	No	37,636	809	2.1	7808	445	5.7	1 (Reference)
Hypertension	Yes	545	18	3.3	29	0	0.0	1.21 (0.65 -2.27)
Preeclampsia	No	37,770	808	2.1	7778	440	5.7	1 (Reference)
Preeclampsia	Yes	362	15	4.1	45	3	6.7	1.30 (0.65 -2.59)
Male	No	18,801	624	3.2	3736	295	7.3	1 (Reference)
Male	Yes	19,500	642	3.2	3752	253	6.3	0.87 (0.76 -1.00)
Congenital malformations	No	28,954	820	2.8	6365	352	5.5	1 (Reference)
Congenital malformations	Yes	355	29	8.1	33	6	18.2	2.60^c c p < 0.001. (1.67 -4.06)
Prematurity	No	37,397	981	2.6	7519	445	5.9	1 (Reference)
Prematurity	Yes	2170	285	13.3	517	103	19.9	1.23 (0.97 -1.58)

Variable		LA (n = 40,442)			HA (n = 8214)			AOR (95% CI)^a a Adjusted OR for all variables of the table.
		Total^b b There were some missing values.	n	%	Total^b b There were some missing values.	n	%
Maternal educational level (ys)	<8	1677	82	4.9	289	11	3.8	1.03 (0.75 -1.41)
	8 -11	989	40	4.0	447	49	11.0	1.16 (0.85 -1.59)
	≥12	36,165	1493	4.1	7194	687	9.5	1 (Reference)
Maternal BMI (kg/m²)	<18.5	1781	94	5.3	269	34	12.6	1.23 (0.99 -1.53)
	18.5 -24.9	18,907	847	4.5	3636	365	10.0	1 (Reference)
	25 -29.9	7398	247	3.3	1209	89	7.4	0.71^c c p < 0.01. (0.61 -0.83)
	30 -34.9	2480	83	3.3	273	24	8.8	0.76^c c p < 0.01. (0.59 -0.98)
	≥35	8265	344	4.2	2543	235	9.2	0.68 (0.44 -1.03)
Age (ys)	<20	8741	447	5.1	1903	196	10.3	0.91 (0.75 -1.09)
	20 -24	11,669	475	4.1	2342	233	9.9	0.99 (0.84 -1.17)
	25 -29	8703	330	3.8	1754	139	7.9	1 (Reference)
	30 -34	5994	226	3.8	1123	102	9.1	1.02 (0.83 -1.25)
	≥35	3698	137	3.7	805	77	9.6	1.16 (0.91 -1.48)
Parity	0	13,268	728	5.5	2747	320	11.6	1.64^c c p < 0.01. (1.35 -2.01)
	1	10,146	383	3.8	1972	176	8.9	1.24 (0.97 -1.44)
	2	6415	211	3.3	1239	84	6.8	0.18 (0.79 -1.17)
	≥3	9002	293	3.3	1972	167	8.5	0.89 (0.72 -1.11)
TBC	No	37,685	1564	4.2	7774	739	9.5	1 (Reference)
TBC	Yes	204	12	5.9	12	1	8.3	1.74 (0.90 -3.32)
Diabetes	No	37,332	1557	4.2	7797	742	9.5	1 (Reference)
Diabetes	Yes	526	20	3.8	27	1	3.7	0.97 (0.50 -1.85)
Hypertension	No	37,455	1561	4.2	7767	736	9.5	1 (Reference)
Hypertension	Yes	354	11	3.1	44	5	11.4	0.95 (0.46 -1.96)
Preeclampsia	No	18,305	791	4.1	3607	378	9.5	1 (Reference)
Preeclampsia	Yes	18,911	824	4.2	3576	369	9.4	0.95 (0.46 -1.96)
Male	No	18,305	791	4.1	3607	378	9.5	1 (Reference)
Male	Yes	18,911	824	4.2	3576	369	9.4	0.92 (0.83 -1.03)
Congenital malformations	No	28,610	11,457	4.0	6310	654	10.3	1 (Reference)
Congenital malformations	Yes	335	29	8.7	32	8	25	2.52^c c p < 0.01. (1.69 -3.75)
Prematurity	No	37,335	1234	3.3	7505	601	8.1	1 (Reference)
Prematurity	Yes	1496	381	25.4	425	146	34.3	0.64^c c p < 0.01. (0.48 -0.84)

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[1] * Corresponding author. E-mail:jorjom@gmail.com (J.I. Martínez).