SLHD Guideline Neonatal anthropometry – measurement and reporting of newborn size and growth TRIM Document No SD21/17112 (POL/310) Policy Reference SLHD_GL2021_017 Related MOH Policy N/A Keywords Neonatal; anthropometry; newborn; measurement; growth Applies to All clinical staff who provide newborn care in SCN and NICU in SLHD Clinical Stream Women’s Health, Neonatology and Paediatrics Tier 2 Sign-off Executive Director Medical Services SLHD Clinical Director Women’s Health, Neonatology & Paediatrics Date approved by SLHD Policy Committee 11/03/2021 Author Clinical Associate Professor, Neonatology RPAH Status Active Review Date 11/03/2026 Risk Rating H Replaces N/A Version History Current Version V.1 – 11/03/2021
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SLHD Guideline
Neonatal anthropometry – measurement and reporting of newborn size and growth
Two people using the ‘two leg’ method on a rigid infantometer.
Alternative - the Neorule: Operator 1 holds the head gently with the eyes directly upwards
with the lower margin of the orbit in the same vertical plane as the external auditory meatus
and gently holds the headboard to the vertex. Operator 2 applies gentle traction to extend
the legs without displacing the pelvis and then slides the footplate to meet the heel with just
sufficient pressure to cause the skin to blanche; the CHL is then noted to the nearest mm.
10.2.4 How to measure head circumference?
Use a non-stretchable disposable paper 1–2 cm wide marked in 0.1 cm increments.
To measure the head circumference, securely wrap the tape measure around the widest
possible circumference of the infant’s head (typically 1 to 2 finger-widths above the eyebrow
(supraorbital ridges) on the forehead, above the ears, to the most prominent part of the back
of the head (occiput). Repeat the measurement three times and select the largest
measurement to the nearest 0.1 cm.
Sydney Local Health District Policy No: SLHD_GL2021_017
Date Issued: MARCH 2021
Compliance with this Guideline is Recommended 13
Measuring head circumference: Above image reproduced from reference.
11. Reporting
Numerical methods used to describe weight, length, and head circumference growth velocity
in preterm infants include grams/kilogram/day (g/kg/d), centimetres/week (cm/week), and
change in z scores reported at 28 days and 36 weeks postmenstrual age.
Z scores should be calculated using a validated size at birth chart and growth chart (e.g.
Fenton chart) up to 42 weeks postmenstrual age. Subsequently the INTERGOWTH 21 /
WHO growth chart will be used.
12. Definitions
Excess weight loss: >12% on day 3 and >10% on day 5.
Primary indicators of neonatal malnutrition (Not appropriate for first 2 weeks of life except for
days to regain birth weight)
Mild malnutrition:
Days to regain birth weight 15-18
Decline in weight-for-age z score 0.8-1.2 SD
Weight gain velocity <75% of expected
Moderate malnutrition
Days to regain birth weight 19-21
Decline in weight-for-age z score >1.2-2 SD
Weight gain velocity <50% of expected
Severe malnutrition
Days to regain birth weight >21
Decline in weight-for-age z score >2 SD
Weight gain velocity<25% of expected
Mild stunting
Decline in length-for-age z score 0.8-1.2 SD
Length gain velocity <75% of expected
Sydney Local Health District Policy No: SLHD_GL2021_017
Date Issued: MARCH 2021
Compliance with this Guideline is Recommended 14
Moderate stunting
Decline in length-for-age z score >1.2-2 SD
Length gain velocity <50% of expected
Severe stunting
Decline in length-for-age z score >2 SD
Length gain velocity<25% of expected
Microcephaly: head circumference >2 standard deviations below the mean for age and sex
or <3rd centile for age and sex.
Severe microcephaly: head circumference >3 standard deviations below the mean for age
and sex.
Macrocephaly: occipitofrontal circumference >2 standard deviations above the mean for a
given age and sex.
13. References
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3. Fenton TR, Anderson D, Groh-Wargo S, Hoyos A, Ehrenkranz RA, Senterre T. An Attempt to Standardize the Calculation of Growth Velocity of Preterm Infants-Evaluation of Practical Bedside Methods. J Pediatr. 2018;196:77-83.
4. Bhutta ZA, Giuliani F, Haroon A, Knight HE, Albernaz E, Batra M, Bhat B, Bertino E, McCormick K, Ochieng R, Rajan V, Ruyan P, Cheikh Ismail L, Paul V, International F, Newborn Growth Consortium for the 21st C. Standardisation of neonatal clinical practice. BJOG. 2013;120 Suppl 2:56-63, v.
5. Goldberg DL, Becker PJ, Brigham K, Carlson S, Fleck L, Gollins L, Sandrock M, Fullmer M, Van Poots HA. Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. J Acad Nutr Diet. 2018;118:1571-82.
6. Martinez JI, Roman 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). 2018.
7. Giuliani F, Ohuma E, Spada E, Bertino E, Al Dhaheri AS, Altman DG, Conde-Agudelo A, Kennedy SH, Villar J, Cheikh Ismail L. Systematic review of the methodological quality of studies designed to create neonatal anthropometric charts. Acta Paediatr. 2015;104:987-96.
8. Finken MJJ, van der Steen M, Smeets CCJ, Walenkamp MJE, de Bruin C, Hokken-Koelega ACS, Wit JM. Children Born Small for Gestational Age: Differential Diagnosis, Molecular Genetic Evaluation, and Implications. Endocr Rev. 2018;39:851-94.
9. Lee S, Walker SP. The role of ultrasound in the diagnosis and management of the growth restricted fetus. Australas J Ultrasound Med. 2010;13:31-6.
10. Beune IM, Bloomfield FH, Ganzevoort W, Embleton ND, Rozance PJ, van Wassenaer-Leemhuis AG, Wynia K, Gordijn SJ. Consensus Based Definition of Growth Restriction in the Newborn. J Pediatr. 2018;196:71-6 e1.
11. Fenton TR, Chan HT, Madhu A, Griffin IJ, Hoyos A, Ziegler EE, Groh-Wargo S, Carlson SJ, Senterre T, Anderson D, Ehrenkranz RA. Preterm Infant Growth Velocity Calculations: A Systematic Review. Pediatrics. 2017;139.
12. Clayton PE, Cianfarani S, Czernichow P, Johannsson G, Rapaport R, Rogol A. Management of the child born small for gestational age through to adulthood: a consensus statement of the International Societies of Pediatric Endocrinology and the Growth Hormone Research Society. J Clin Endocrinol Metab. 2007;92:804-10.
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Compliance with this Guideline is Recommended 15
13. de Onis M, Habicht JP. Anthropometric reference data for international use: recommendations from a World Health Organization Expert Committee. Am J Clin Nutr. 1996;64:650-8.
14. American College of O, Gynecologists. ACOG Practice bulletin no. 134: fetal growth restriction. Obstet Gynecol. 2013;121:1122-33.
15. Lee ACC, Kozuki N, Cousens S, Stevens GA, Blencowe H, Silveira MF, Sania A, Rosen HE, Schmiegelow C, Adair LS, Baqui AH, Barros FC, Bhutta ZA, Caulfield LE, Christian P, Clarke SE, Fawzi W, Gonzalez R, Humphrey J, Huybregts L, Kariuki S, Kolsteren P, Lusingu J, Manandhar D, Mongkolchati A, Mullany LC, Ndyomugyenyi R, Nien JK, Roberfroid D, Saville N, Terlouw DJ, Tielsch JM, Victora CG, Velaphi SC, Watson-Jones D, Willey BA, Ezzati M, Lawn JE, Black RE, Katz J. Estimates of burden and consequences of infants born small for gestational age in low and middle income countries with INTERGROWTH-21 st standard: Analysis of CHERG datasets. BMJ (Online). 2017;358 (no pagination).
16. Raiten DJ, Steiber AL, Carlson SE, Griffin I, Anderson D, Hay WW, Jr., Robins S, Neu J, Georgieff MK, Groh-Wargo S, Fenton TR, Pre BCWG. Working group reports: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project. Am J Clin Nutr. 2016;103:648S-78S.
17. Rochow N, Raja P, Liu K, Fenton T, Landau-Crangle E, Gottler S, Jahn A, Lee S, Seigel S, Campbell D, Heckmann M, Poschl J, Fusch C. Physiological adjustment to postnatal growth trajectories in healthy preterm infants. Pediatr Res. 2016;79:870-9.
18. Ross E, Munoz FM, Edem B, Nan C, Jehan F, Quinn J, Mallett Moore T, Sesay S, Spiegel H, Fortuna L, Kochhar S, Buttery J, Brighton Collaboration Failure to Thrive Working G. Failure to thrive: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data. Vaccine. 2017;35:6483-91.
19. Rosen H, Shmueli A, Ashwal E, Hiersch L, Yogev Y, Aviram A. Delivery outcomes of large-for-gestational-age newborns stratified by the presence or absence of gestational diabetes mellitus. Int J Gynaecol Obstet. 2018;141:120-5.
20. Araujo Junior E, Peixoto AB, Zamarian AC, Elito Junior J, Tonni G. Macrosomia. Best Pract Res Clin Obstet Gynaecol. 2017;38:83-96.
21. Ye J, Torloni MR, Ota E, Jayaratne K, Pileggi-Castro C, Ortiz-Panozo E, Lumbiganon P, Morisaki N, Laopaiboon M, Mori R, Tuncalp O, Fang F, Yu H, Souza JP, Vogel JP, Zhang J. Searching for the definition of macrosomia through an outcome-based approach in low- and middle-income countries: a secondary analysis of the WHO Global Survey in Africa, Asia and Latin America. BMC Pregnancy Childbirth. 2015;15:324.
23. DeSilva M, Munoz FM, Sell E, Marshall H, Tse Kawai A, Kachikis A, Heath P, Klein NP, Oleske JM, Jehan F, Spiegel H, Nesin M, Tagbo BN, Shrestha A, Cutland CL, Eckert LO, Kochhar S, Bardaji A, Brighton Collaboration Congenital Microcephaly Working G. Congenital microcephaly: Case definition & guidelines for data collection, analysis, and presentation of safety data after maternal immunisation. Vaccine. 2017;35:6472-82.
24. Pavone P, Pratico AD, Rizzo R, Corsello G, Ruggieri M, Parano E, Falsaperla R. A clinical review on megalencephaly: A large brain as a possible sign of cerebral impairment. Medicine (Baltimore). 2017;96:e6814.
25. Tan AP, Mankad K, Goncalves FG, Talenti G, Alexia E. Macrocephaly: Solving the Diagnostic Dilemma. Top Magn Reson Imaging. 2018;27:197-217.
26. Seaver LH, Irons M, American College of Medical Genetics Professional P, Guidelines C. ACMG practice guideline: genetic evaluation of short stature. Genet Med. 2009;11:465-70.
27. Grunauer M, Jorge AAL. Genetic short stature. Growth Hormone & Igf Research. 2018;38:29-33.
28. Grunauer M, Jorge AAL. Genetic short stature. Growth Horm IGF Res. 2018;38:29-33.
29. Hannema SE, Savendahl L. The Evaluation and Management of Tall Stature. Hormone research in paediatrics. 2016;85:347-52.
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Compliance with this Guideline is Recommended 16
30. Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59.
31. Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel BS. New intrauterine growth curves based on United States data. Pediatrics. 2010;125:e214-24.
32. Villar J, Giuliani F, Bhutta ZA, Bertino E, Ohuma EO, Ismail LC, Barros FC, Altman DG, Victora C, Noble JA, Gravett MG, Purwar M, Pang R, Lambert A, Papageorghiou AT, Ochieng R, Jaffer YA, Kennedy SH, International F, Newborn Growth Consortium for the C. Postnatal growth standards for preterm infants: the Preterm Postnatal Follow-up Study of the INTERGROWTH-21(st) Project. Lancet Glob Health. 2015;3:e681-91.
33. de Onis M, Onyango AW, Borghi E, Garza C, Yang H, Group WHOMGRS. Comparison of the World Health Organization (WHO) Child Growth Standards and the National Center for Health Statistics/WHO international growth reference: implications for child health programmes. Public Health Nutr. 2006;9:942-7.
34. WHO. Multicentre Growth Reference Study Group. Enrolment and baseline characteristics in the WHO Multicentre Growth Reference Study. Acta Paediatr Suppl. 2006;450:7-15.
35. Fenton TR, Nasser R, Eliasziw M, Kim JH, Bilan D, Sauve R. Validating the weight gain of preterm infants between the reference growth curve of the fetus and the term infant. BMC Pediatr. 2013;13:92.
36. Cole TJ, Wright CM, Williams AF, Group RGCE. Designing the new UK-WHO growth charts to enhance assessment of growth around birth. Arch Dis Child Fetal Neonatal Ed. 2012;97:F219-22.
37. Reddy KV, Sharma D, Vardhelli V, Bashir T, Deshbotla SK, Murki S. Comparison of Fenton 2013 growth curves and Intergrowth-21 growth standards to assess the incidence of intrauterine growth restriction and extrauterine growth restriction in preterm neonates </=32 weeks. J Matern Fetal Neonatal Med. 2019:1-8.
38. Tuzun F, Yucesoy E, Baysal B, Kumral A, Duman N, Ozkan H. Comparison of INTERGROWTH-21 and Fenton growth standards to assess size at birth and extrauterine growth in very preterm infants. J Matern Fetal Neonatal Med. 2018;31:2252-7.
39. Cartwright RD, Anderson NH, Sadler LC, Harding JE, McCowan LME, McKinlay CJD. Neonatal morbidity and small and large size for gestation: a comparison of birthweight centiles. J Perinatol. 2020;20:20.
40. Landau-Crangle E, Rochow N, Fenton TR, Liu K, Ali A, So HY, Fusch G, Marrin ML, Fusch C. Individualized Postnatal Growth Trajectories for Preterm Infants. JPEN J Parenter Enteral Nutr. 2018;42:1084-92.
41. Schlaudecker EP, Munoz FM, Bardaji A, Boghossian NS, Khalil A, Mousa H, Nesin M, Nisar MI, Pool V, Spiegel HML, Tapia MD, Kochhar S, Black S, Brighton Collaboration Small for Gestational Age Working G. Small for gestational age: Case definition & guidelines for data collection, analysis, and presentation of maternal immunisation safety data. Vaccine. 2017;35:6518-28.
42. World Health Organization. Training Course on Child Growth Assessment. Geneva, WHO. 2008.
43. Cheikh Ismail L, Puglia FA, Ohuma EO, Ash ST, Bishop DC, Carew RM, Al Dhaheri AS, Chumlea WC. Precision of recumbent crown-heel length when using an infantometer. BMC Pediatr. 2016;16:186.
44. Wood AJ, Raynes-Greenow CH, Carberry AE, Jeffery HE. Neonatal length inaccuracies in clinical practice and related percentile discrepancies detected by a simple length-board. J Paediatr Child Health. 2013;49:199-203.
45. Lawn CJ, Chavasse RJ, Booth KA, Angeles M, Weir FJ. The neorule: a new instrument to measure linear growth in preterm infants. Arch Dis Child Fetal Neonatal Ed. 2004;89:F360-3.
Sydney Local Health District Policy No: SLHD_GL2021_017
Date Issued: MARCH 2021
Compliance with this Guideline is Recommended 17
14. Consultation
Enterprise Risk Management System Coordinator SLHD
Neonatology Clinical Nurse Consultant RPAH
SLHD Centre for Education and Workforce Policy Committee
SLHD Maternity Policy Committee
15. National Safety and Quality Standard/s, 2nd ed