THE NORMAL ANTHROPOMETRIC MEASUREMENTS FOR HEALTHY FULL TERM NEWBORNS IN NAJAF CITY.

Received: 07 March 2018 Final Accepted: 09 April 2018 Published: May 2018 Background:-Determination of newborn growth parameters is necessary in each population from different locations for planning their subsequent children growth charts and thus detecting disease by recognizing overt deviation from normal patterns. Objectives:-To establish the normal anthropometric measurements ( Wt, L, OFC, CC, MAC and MTC) for appropriately grown full term newborns in Najaf city-Iraq. Patients & Method:A study was carried out enrolling 500 singleton healthy full term neonates (268 males and 232 females), (325 urban and 175 rural), (166 primipara and 334 multipara), (290 VD and 210 CS), (205 regular ANC and 295 irregular ANC) who completed 37 weeks of gestation and were delivered in Al-Zahraa maternity and children teaching hospital during the period between 1st April to 30th of October 2010. The data and measurements were done during the 1st day of life with exclusion of newborns of mothers with high risk, complicated pregnancies and labors. The included measurements were Wt, L, OFC, CC, MAC and MTC. Wt was measured by electronic scale, L by hard plastic platform (stadiometer), other measurements by flexible non-stretchable plastic tape measure. The studied variables were gender, residence, parity of the mother, mode of delivery and antenatal care. The data analyzed by SPSS (version 17) program for mean, standard deviation, range, p-value and correlation coefficient. Results:Males had a significantly higher CC than females with no significant difference in OFC, Wt, L, MAC and MTC. There was a highly significant difference in Wt between urban and rural neonates( Urban were higher). A significantly higher OFC in rural than urban neonates with no significant difference in L, CC, MAC and MTC. There was a highly significant difference in OFC between multipara and primipara women neonates (multipara were higher). Multipara women neonates were significantly higher in Wt than primipara women neonates. There was no significant difference in L, CC, MAC and MTC. There was no significant difference in OFC, Wt, L, CC, MAC and MTC regarding the mode of delivery whether it was VD or CS.A significantly higher OFC and Wt in neonates of mothers with irregular ANC than neonates of mothers with regular ANC. Conclusions:-This study established local normal values for anthropometric measurements (Wt, L, OFC, CC, MAC and MTC) for

454 the likelihood of abortion, fetal death, IUGR, poor cardiopulmonary or metabolic transitioning at birth, fetal or neonatal disease, or other handicaps [20] . The neonatal period is a highly vulnerable time for an infant. The high neonatal morbidity and mortality rates attest to the fragility of life during this period; in the united states, of all deaths occurring in the first year, two thirds are in the neonatal period [21] . Careful surveillance of the obstetric patient is directed toward the identification of developing problems that may affect the fetus or mother adversely [22] . Improving the quality of obstetric care is an urgent priority in developing countries, where maternal mortality remains high [23] . Absent or delayed onset of prenatal care is associated with increased rate of IUGR infant. However, prenatal care does provide the opportunity to detect (and possibly treat) some of maternal and fetal conditions which can lead to IUGR [24] . ANC is considered regular if first visit is in the first or second trimester or number of visits 4-5 during the whole pregnancy [25] . Mothers in deprived socioeconomic conditions frequently have growth retarded infant. In those setting, primarily from the mothers poor nutrition and health over a long period of time, including during pregnancy, the high prevalence of specific and non specific infections, or from pregnancy complications underpinned by poverty [26] . Some studies indicate fatigue during work or upright posture might diminish uterine blood flow and thus hinder the supply of oxygen and nutrient to the fetus [27] . Maternal parity exert a modest effect on birth, first born infant tend to be smaller and often categorized as IUGR. This effect decreases with successive deliveries and less likely to be seen beyond the third birth [28] . Women ,whose 1 st pregnancy result in growth restricted infant, have been regarded to be with 1 in 4 risk of delivering a second infant below the 10th percentile, while after two pregnancies complicated by IUGR with four fold increase in the risk of subsequent growth restricted infant [29] . The incidence of LBW in teenagers nilliparus are higher [30] .Also, increase in maternal age (> 35 years) show increase incidence of LBW compared with younger age [31] . Advanced maternal age increases the risk of both chromosomal and non chromosomal fetal malformations [20] . Older women also have more unintended pregnancies -itself is a risk factor for low birth weight-than do women in their twenties and early thirties [32] . Maternal infections increase the risk of delivery of LBW [33] . The average term newborn weighs approximately 3.4 Kg, boys are slightly heavier than girls, the average length and head circumference are about 50 cm and 35 cm respectively, in term infants [34] . The birth weight of a newborn is a significant determinant of neonatal and postnatal infant mortality [35] . The birth weight is potentially a useful parameter for measurement of health during the vulnerable periods of life and serves as a useful indicator of health of the community because it is sensitive to environmental and socioeconomic influences [36] .Body length tends to be a better gauge of gestational age than body weight in under grown neonates with chromosomal abnormalities or congenital Rubella [37] . Growth in length reflects the differential growth of the head, trunk, and long bones of the legs . Head size increases most rapidly after 28 weeks of gestation, and growth slows before 2-3 years of life .The trunk increases during the same period but continues to lengthen at a slower rate from 2 years through puberty. The legs grow fastest during the period covering the last 14 weeks of gestation through the first 6 months of life(18 cm/ yr).This rate far exceeds that of leg growth in male puberty(4 cm/yr) [38] . Head size attracts particular attention in infancy, the occipitofrontal circumference of the skull is measured soon after birth, not only to ensure that the baby does not have microcephaly, reflecting poor brain growth in utero, but also to establish a baseline for the first year of life.The head of the newborn infant makes up almost one third of total size compared with the adult proportion of approximately 1:7 [39] . The head circumference of the full term newborn is about (2-3cm) 1 inch greater than the chest circumference which average (30.5-33 cm) 12-13 inch. [40] Normally at birth, head circumference is larger than chest circumference. By the age of four months, the head circumference equals the chest circumference, and later the chest circumference is larger than head circumference except in the presence of malnutrition [41] . Mid-arm circumference is a good indicator of muscle bulk and is very useful in following children with malnutrition on treatment, combined with measurement of skin fold thickness (which measures fat) mid-arm circumference may help determine the proportion of fat to muscle [41] . Several studies have led to the conclusion that the newborns nutritional status is more important than birth weight alone for identifying perinatal risk [42,43] . Perinatal risk assessment by weight percentile criteria has been shown to be insufficient, thus requiring the determination of additional or alter-native indices to improve this evaluation [44,45] . Significant variation exists in mid-arm circumference and mid-thigh circumference values among different populations, these differences may be due to several factors, including genetic characteristics and nutritional status, as well as possible difference in measurements procedures [46] . The periodic measurement of anthropometric variables in different population and regions of a country reflect changes in children nutrition and health status and are a reliable tool to evaluate social health [47] . The main advantages of the measurements described above are practical, simple, non invasive, inexpensive, portable and highly suitable for pediatric use in the ward, clinic or community [48] .

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Aim Of The Study:-1. To determine the normal standards of anthropometric measurements (birth weight , length , head circumference , chest circumference ,mid-arm circumference and mid-thigh circumference) for full term neonates in Najaf city. 2. To compare the above measurements with some national and international studies. 3. To design charts that might be used as a base line for further related studies. 4. To identify an anthropometric surrogate to birth weight during the first 24 hours of life.

Patients And Methods:-
Five hundred normal singleton full term neonates (268 males and 232 females), (325 urban and 175 rural), (166 primipara and 334 multipara), (290 VD and 210 CS), (205 regular ANC and 295 irregular ANC) who completed 37 weeks of gestation and were delivered in Al-Zahraa maternity and children teaching hospital at Al-Najaf city -Iraq during the period between 1st April to 30th of October 2010. The exclusion criteria include: 1. Neonates of high risk or complicated pregnancies by medical illness as hypertension, diabetes mellitus, infection, autoimmune disease, heart disease and smoking. 2. Neonates with visible congenital anomalies. 3. Neonates who had caput succedaneum and cephalhematoma. 4. Neonates who were delivered before 37 weeks of gestation.
The above four criteria were excluded by history and clinical examination, the data collection were taken by direct interview with the mothers and measurements were taken for their newborns by the researcher during the first 24 hours of life.
The studied variables were gender, residence (urban and rural), parity of the mother (primipara and multipara), mode of delivery (vaginal delivery and caesarean section), ANC (regular and irregular).
The studied measurements included: Wt, L,OFC,CC, MAC and MTC. The Wt was measured in kilograms on naked neonates by an accurate electronic scale (SECA, Germany made, maximum Wt was 16 kg).
A stadiometer (SECA, Germany made, maximum length was 99cm) is a hard plastic platform was used for measuring the L in centimeters by laying the baby supine on it with fully extended lower limbs, straight back and feet together with a head board placed against the baby's head and a movable foot board was pressed gently against the feet.
The OFC was determined in centimeters by using a flexible, non stretchable plastic tape measure ( Butterfly brand, China made) which was run one inch above the glabella to the occipital prominence, 3 measurements obtained and their mean was recorded.
The CC was determined at the level of nipples by a flexible, non stretchable tape measure during inspiration. The MAC was measured over the left triceps muscle in a point midway between the tip of the acromian process and the tip of olecranon process, with the arm hanging on the side of the body. The MTC was measured by putting the baby on his right side and measure the circumference on the point over the left quadriceps muscle midway between the hip and knee joints.Regarding parity, a primipara is a woman who has been delivered only once of a fetus or fetuses born alive or dead with an estimated length of gestation of 20 weeks or more, multipara is a woman who has completed 2 or more pregnancies to 20 weeks or more [52] .The ANC was considered regular if first visit is in the first or second trimester, or number of visits 4-5 during the whole pregnancy. [24] The gestational age included in this study (37-41 completed weeks) was determined by last menstrual period, early ultrasound and the new Ballard score system (for both physical and neuromuscular criteria).The data processing was done using the statistical package for the social sciences SPSS (version 17).
Statistical analyses were performed to estimate the arithmetic mean, range, standard deviation and p-value.A significant statistical difference of variables was considered when p-value ≤ 0.05. The 2-tailed t-test was used to compare all variables.A correlation matrix was built in order to test associations between the studied measurements. The curves were drawn by using Microsoft office Excel and Microsoft office Word 2007.

Results:-
A total number of (500) healthy full term neonates were examined during the first day of life for Wt (kg), L (cm), OFC (cm) , CC (cm) , MAC (cm) and MTC (cm). The OFC for boys was 24.43±1.03 cm, while for girls it was 34.22±1.00 cm, with a non-significant difference between males and females (p-value > 0.05). For birth Wt of boys it was 3.25±0.44 kg, while for girls it was 3.15±0.47 kg, with no significant difference (p-value > 0.05). Regarding L it was 49.94±1.64 cm for males and 49.63±1.84 cm for females, with no significant difference(p-value > 0.05). The CC was 32.77±2.54 cm and 32.35±1.41 cm for males and females respectively with significantly higher CC in males than in females(p-value < 0.05). Regarding MAC, for boys it was 11.21±1.08 cm, while for girls it was 11.18±1.10 cm with a non-significant difference in MAC between girls and boys(p-value > 0.05). The MTC was 13.79±1.25 cm for boys and 13.64±1.28 cm for girls with no significant difference (p-value > 0.05). Regarding residency, Urban neonates were (325), (65%) and Rural neonates were (175), (35%). The OFC was 34.27±0.97 cm for urban group ,while it was 34.44±1.10 cm for the rural group with a statistically significant difference (p-value < 0.05), Rural higher than Urban. The birth Wt of urban neonates was 3.21±0.41 kg, while that of rural neonates was 3.19±0.53 kg, with a statistically highly significant difference (p-value < 0.001), Urban higher than Rural. The L for urban group was 49.77±1.75 cm, while for rural group it was 49.85±1.74 cm with a non-significant difference (p-value > 0.05). Regarding CC for urban neonates it was 32.55±1.99 cm and that of rural one was 32.62±2.29 cm, with a non-significant difference (p-value > 0.05). Regarding MAC, it was 11.21±1.08 cm and 11.16±1.11 cm for urban and rural group respectively, with no significant difference(p-value > 0.05). Birth MTC was 13.73±1.25 cm and 13.72±1.30 cm for urban and rural neonates respectively, with a nonsignificant difference (p-value > 0.05). Regarding parity, neonates of primipara mothers were (166), (33.2%) and neonates of multimipara mothers were (334), (66.8%). The OFC for newborns of primipara mothers was 34.18±0.88 cm and it was 34.41±1.08 cm for the newborns of multipara mothers with a highly significant difference between them (p-value < 0.001), It was higher in multipara. The birth Wt for the newborns of primipara mothers was 3.17±0.42 kg, which was significantly less than that of newborns of multipara mothers which was 3.22±0.47 kg. Regarding L, there was no significant difference (p-value > 0.05) between the newborns of primipara mothers which was 49.59±1.91 cm and those of multipara mothers which was it was 49.90±1.65 cm. The results of CC, MAC and MTC for the newborns of primipara mothers were 32.45±2.68 cm, 11.12±1.12 cm and 13.63±1.34 cm, respectively, while for the newborns of multipara mothers the CC was 32.64±1.74 cm, the MAC was 11.23±1.8 cm and the MTC was 13.77±1.22 cm, with no significant difference between the results. Regarding the mode of delivery, VD neonates were (290), (58%) and CS neonates were (210), (42%). The OFC was 34.39±1.00 cm for the vaginal delivery products and it was 34.25±1.06 cm for the caesarean section products. With no significant difference between them. The birth Wt of vaginal delivery products was 3.26±0.46 kg, while that of caesarean section products was 3.13±0.45 kg. With no significant difference between them. Regarding L, it was 49.70±1.87 cm and 49.94±1.54 cm for the vaginal delivery and caesarean section products, respectively. With no significant difference between them.The CC for the vaginal delivery products was 32.56±1.93 cm, while it was 32.60±2.31 cm for the other group. With no significant difference between them. The MAC and MTC for vaginal delivery products were 11.24±1.11 cm and 13.79±1.31 cm respectively, while the MAC for the caesarean section products was 11.14±1.06 cm and the MTC was 13.64±1.20 cm. With no significant difference between them. According to regularity of ANC, neonates of regular ANC were (205), (41%), and those of irregular ANC were (295), (59%). The newborns of mothers who had irregular ANC were heavier and had a larger OFC than those of mothers with regular ANC (p-value < 0.05), while all other measurements (L, CC, MAC and MTC) showed no significant difference. Regarding OFC, it was 34.32±0.94 cm for the regular ANC products, while it was 34.34±1.08 cm for the irregular ANC group. The birth Wt of those with regular ANC group was 3.19±0.41 kg , while it was 3.21±0.49 kg for the newborns of mothers with irregular ANC. The L for those with regular ANC was 49.67±1.93 cm, while for the other group it was 49.89±1.59 cm. The CC for the regular ANC group was 32.49±2.11 cm and it was 32.64±2.09 cm for the other group. The MAC and MTC for the regular ANC group were 11.10±1.08 cm and 13.67±1.29 cm respectively, while for the irregular ANC group the MAC was 11.26±1.10 cm and the MTC was 13.76±1.25 cm.
All of the included measurements were highly correlated with each other, with the best correlation coefficient observed between MAC and MTC (0.766) followed by Wt with MTC (0.671), then Wt with MAC (0.597), then Wt with OFC (0.491).

Discussion:-
In the current study we tried to establish normal values for anthropometric measurements (Wt, L, OFC, CC, MAC and MTC) for 500 full term newborn in Najaf city.The mean birth (Wt, L and OFC ) were (3.208 kg, 49.803 cm and 34.33 cm) respectively , the Wt was significantly lower (p-value < 0.05) than NCHS mean (3.274 kg) [34] . Table  (1) -page 10-shows the results regarding gender, the current study shows a significant difference (p-value < 0.05)in the measurement of CC only, where the males has higher CC than females, with a non-significant difference in other measurements. The OFC result (34.429 cm for males and 34.228 cm for females) were in agreement with Telater et al. study in Istanbul 2009 [56] , Nickavar et al. study in Tehran 2007 [57] and with Abdul-Hameed et al. study in AL-Yarmouk hospital-Baghdad 2002 [80]. The mean CC for males and females were 32.777 and 32.358 cm, respectively. These results agree with previous studies [56,57] , where males CC was higher than that of females. The MAC was higher in males(11.21 cm) than in females (11.18 cm) and this result disagrees with Copper study in 1993 [58] and with Calcutta study in 1991 [59] . The MTC results(13.79 cm for males and 13.64 cm for females)with no significant difference (p-value > 0.05) and this result agrees with Huque study in 2007 [54] . As shown in Table(2) -page11-, when we compared the mean values of the studied measurements according to residency of mothers, there was a highly significant difference in birth Wt (P-value < 0.001) which was higher among the newborns of urban mothers than those of rural and this is in agreement with other studies [60,61,62,63] . While, there was a significant difference in OFC (p-value < 0.05) which was higher in newborns of rural mothers than those of urban. The Wt result may be related to maternal exhaustion as a cause for growth restriction in utero [64] , this agree with Phung et al. 2003 study in Europe [65] but disagree with Nada et al. study in Mousl city 2008,and with other studies [66,67] . Regarding parity, as shown in table(3) -page 12-the products of a multipara had higher values of OFC with a highly significant difference (p-value < 0.001), and significantly higher birth Wt (p-value < 0.05), in general the other measurements were higher in newborns of multipara women than those of primipara women but with no significant statistical difference (p-value > 0.05). By comparing the results according to the mode of delivery (Table 4)-page 13-it was found that a slightly higher OFC, Wt, MAC and MTC in the newborns of mothers who delivered vaginally than those who delivered by caesarean section, this means that mothers may have an unexpected complication during their pregnancies and thus need delivery by caesarean section and this is in agreement with other study [60] .  [64,68] . Interpretation of growth parameters requires plotting the measurements on a percentile charts constructed from a similar race and environmental population. Table ( Female OFC measurements were equal to Al-Marzoki and Hussain 2010 In Hilla in the 5th, 10th and 50th percentiles, and equal to NCHS in the 10th percentile and to Abdul-Hameed et al. 2002 in Baghdad in the 25th And 50th, and to Telatar 2009 in Istanbul in the 50th, 75th and 90th percentiles. Regarding the Wt, male Wt measurements were equal to th percentile NCHS in the 5th percentile and to Hilla study in the 25th, 90th, and 95th percentiles. Female Wt was equal to Hilla study in the 50th, 75th and 90th percentiles and to Baghdad study in the 75th and 95th percentiles. The male length measurements were similar to Hilla study in the 10th, 25th, 50th, 75th and 95th percentiles and to NCHS in the 50th percentile only. Female length measurements were similar to Hilla study in all percentiles and equal to NCHS in 75th percentile only. By comparing the current study results (Table  8) with other national and international studies, we found that:-

List of abbreviations
The means of OFC were 34.429 cm and 34.228 cm for males and females respectively, with highly significant lower male and female values than Tehran study ( p-value < 0.001), while significantly lower male values than Istanbul study results ( p-value < 0.05), with a non significant difference from other studies. The mean Wt of boys in the current study was 3.256 kg and it was of a highly significant difference from Baghdad and Istanbul studies (pvalue < 0.001), where the current study result was higher than Baghdad result but lower than Istanbul study result, with a non significant difference from other studies. The mean Wt of girls in the current study was 3.154 kg and it was of a highly significant difference from Baghdad and Istanbul studies (p-value < 0.001), where the current study result was higher than Baghdad result but lower than Istanbul study result, and significantly lower than NCHS study result ( p-value < 0.05), and a non significant difference from other studies.The mean L of males was 49.948 cm in the current study and it was higher than Istanbul and lower than Tehran study with a highly significant difference ( pvalue < 0.001), but higher than Baghdad study with a significant difference ( p-value < 0.05), and a non significant difference from other studies. The mean L for females, it was 49.636 cm and it was higher than Baghdad and Istanbul study results with study with a highly significant difference ( p-value < 0.001), with a non significant difference from other studies. The mean CC of males was 32.777 cm, which was lower than Tehran study with a highly significant difference ( p-value < 0.001), with a non significant difference from Istanbul study, while that of females was 32.358 cm which was lower than Tehran study with a highly significant difference ( p-value < 0.001), and lower than Istanbul study with a significant difference (p-value < 0.05). These results agree with multiple national and international studies including: AL-Mefraji. S.H study in AL-Kadhimya teaching hospital in Baghdad (2002Baghdad ( -2004 which shows that most of measurements were less than standard references [70] . Many researchers have attempted to identify a suitable anthropometric surrogate to identify birth Wt which is reliable , simple and logistically feasible in field conditions .Some studies have recommended that CC, MAC and OFC may be used as anthropometric surrogate to identify birth Wt [72,73,74,75] ,other studies recommended MTC [76,77,78] ,therefore we considered all the studied anthropometric measurements in a correlation coefficient matrix (