A Systematic Review and Meta-Analysis To Revise The Fenton Growth Chart For Preterm Infants

Fenton and Kim BMC Pediatrics 2013, 13:59
http://www.biomedcentral.com/1471-2431/13/59
TECHNICAL ADVANCE
Open Access
A systematic review and meta-analysis to revise

the Fenton growth chart for preterm infants
Tanis R Fenton1,2* and Jae H Kim3
Abstract
Background: The aim of this study was to revise the 2003 Fenton Preterm Growth Chart, specifically to: a)
harmonize the preterm growth chart with the new World Health Organization (WHO) Growth Standard, b) smooth
the data between the preterm and WHO estimates, informed by the Preterm Multicentre Growth (PreM Growth)
study while maintaining data integrity from 22 to 36 and at 50 weeks, and to c) re-scale the chart x-axis to actual
age (rather than completed weeks) to support growth monitoring.
Methods: Systematic review, meta-analysis, and growth chart development. We systematically searched
published and unpublished literature to find population-based preterm size at birth measurement (weight,
length, and/or head circumference) references, from developed countries with: Corrected gestational ages
through infant assessment and/or statistical correction; Data percentiles as low as 24 weeks gestational age or
lower; Sample with greater than 500 infants less than 30 weeks. Growth curves for males and females were
produced using cubic splines to 50 weeks post menstrual age. LMS parameters (skew, median, and standard
deviation) were calculated.
Results: Six large population-based surveys of size at preterm birth representing 3,986,456 births (34,639 births
< 30 weeks) from countries Germany, United States, Italy, Australia, Scotland, and Canada were combined in
meta-analyses. Smooth growth chart curves were developed, while ensuring close agreement with the data between
24 and 36 weeks and at 50 weeks.
Conclusions: The revised sex-specific actual-age growth charts are based on the recommended growth goal for
preterm infants, the fetus, followed by the term infant. These preterm growth charts, with the disjunction between
these datasets smoothing informed by the international PreM Growth study, may support an improved transition of
preterm infant growth monitoring to the WHO growth charts.
Keywords: Infant, Premature, Infant, very low birth weight, Preterm infant, Growth, Weight, Head circumference,
Length, Percentile
Background
The expected growth of the fetus describes the fastest
human growth, increasing weight over six-fold between
22 and 40 weeks. Preterm infants, who are born during
this rapid growth phase, rely on health professionals to
assess their growth and provide appropriate nutrition
and medical care.
* Correspondence: tfenton@ucalgary.ca
1
Alberta Childrens Hospital Research Institute, The University of Calgary,
Calgary, AB, Canada
2
Department of Community Health Sciences, The University of Calgary, 3280
Hospital Drive NW, Calgary, AB, Canada
Full list of author information is available at the end of the article
In 2006, the World Health Organization (WHO)

published their multicentre growth reference study, which
is considered superior [1] to previous growth surveys since
the measured infants were selected from communities in
which economics were not likely to limit growth, among
culturally diverse non-smoking mothers who planned to
breastfeed [2]. Weekly longitudinal measures of the infants
were made by trained data collection teams during the first
2 years of this study [3]. These WHO growth charts,
although recommended for preterm infants after term age
[4], begin at term and so do not inform preterm infant
growth assessments younger than this age.
2013 Fenton and Kim; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.

Optimum growth of preterm infants is considered to be

equivalent to intrauterine rates [5-7] since a superior
growth standard has not been defined. Perhaps the best
estimate of fetal growth may be obtained from large
population-based studies, conducted in developed countries [8], where constraints on fetal growth may be less
frequent.
A recent multicentre study by our group (the Preterm
Multicentre Growth (PreM Growth) Study) revealed that
although the pattern of preterm infant growth was generally consistent with intrauterine growth, the biggest deviation in weight gain velocity between the preterm infants
and the fetus and infant was just before term, between 37
and 40 weeks (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, The Preterm Infant Multicentre Growth
Study. Submitted BMC Ped 2012). Rather than demonstrating the slowing growth velocity of the term infant
during the weeks just before term, the preterm infants had
superior, close to linear, growth at this age. This finding
has been observed by others as well [9-11]. Therefore,
there is evidence to support a smooth transition on
growth charts between late fetal and early infant ages.
Several previous growth charts based on size at birth
presented their data as completed age, which affects the
interpretation and use of a growth chart [12]. The use of
completed weeks when plotting a growth chart requires
all the measurements to be plotted on the whole week
vertical axes. However, the use of completed weeks in a
neonatal unit may not be intuitive, as nursery staff and
parents think of infants as their exact age, and not age
truncated to previous whole weeks. The advent of
computers in health care, for clinical care and health
recording, allow the use of the computer to plot growth
charts, daily and with accuracy. It would make sense to
support plotting daily measurements continuously by
shifting the data collected as completed weeks to the
midpoint of the next week to remove the truncation of
the data collection as completed weeks.
The objectives of this study were to revise the 2003
Fenton Preterm Growth Chart, specifically to: a) use more
recent data on size at birth based on an inclusion criteria,
b) harmonize the preterm growth chart with the new
WHO Growth Standard, c) to smooth the data between
the preterm and WHO estimates while maintaining
integrity with the data from 22 to 36 and at 50 weeks,
d) to derive sex specific growth curves, and to e) re-scale
the chart x-axis to actual age rather than completed
weeks, to support growth monitoring.
Methods
To revise the growth chart, thorough literature searches
were performed to find published and unpublished
Page 2 of 13
population-based preterm size at birth (weight, length,

and/or head circumference) references. The inclusion
criteria, defined a priori, designed to minimize bias by
restriction [13], were to locate population-based studies
of preterm fetal growth, from developed countries with:
a) Corrected gestational ages through fetal ultrasound
and/or infant assessment and/or statistical
correction;
b) Data percentiles at 24 weeks gestational age or
lower;
c) Sample of at least 25,000 babies, with more than 500
infants aged less than 30 weeks;
d) Separate data on females and males;
e) Data available numerically in published form or
from authors,
f ) Data collected within the past 25 years (1987 to 2012)
to account for any secular trends.
A. Data selection and combination
Major bibliographic databases were searched: MEDLINE

(using PubMed) and CINHAL, by both authors back to
year 1987 (given our 25 year limit), with no language
restrictions, and foreign articles were translated. The
following search terms as medical subject headings and
textwords were used: (Preterm infant OR Premature
Birth[Mesh]) OR (Infant, Premature/classification[Mesh]
OR Infant, Premature/growth and development[Mesh]
OR Infant, Premature/statistics and numerical data[Mesh]
OR Infant, very low birth weight[Mesh]) AND
(percentile OR *centile* OR weeks) AND (weight OR head
circumference OR length). Grey literature sites including
clinical trial websites and Google were searched in February
2012. Reference lists were reviewed for relevant studies.
All of the found data was reported as completed weeks
except for the German Perinatal Statistics, which were
reported as actual daily weights [14]. To combine the
datasets, the German data was temporarily converted to
completed weeks. A final step converted the meta-analyses
to actual age.
B. Combine the data to produce weighted intrauterine
growth curves for each sex
The located data (3rd, 10th, 50th, 90th, and 97th percentiles
for weight, head circumference, and length) that met the
inclusion criteria were extracted by copying and pasting
into spreadsheets. The male and female percentile
curves from each included data set for weight, head
circumference and length were plotted together so they
could be examined visually for heterogeneity (Figures 1, 2,
and 3). The data for each gender were combined by using
the weekly data for the percentiles: 3rd, 10th, 50th, 90th,
and 97th, weighted by the sample sizes. The combined
data was represented by relatively smooth curves.

Figure 1 Boys birthweight centiles (3rd, 50th and 97th) from

the six included studies, along with the boys meta-analysis
curves (bold).
C. Develop growth monitoring curves
To develop the growth monitoring curves that joined

the intrauterine meta-analysis data with the WHO
Growth Standard (WHOGS) smoothly, the following
cubic spline procedure was used to meet two objectives:
Figure 2 Girls head circumference centiles (3rd, 50th and 97th)

centiles from the included studies, along with the girls
meta-analysis curves (dotted), and after 40 weeks, the World
Health Organization centiles (dashed).
Page 3 of 13
Figure 3 Girls length centiles (3rd, 50th and 97th) centiles from
the included studies, along with the meta-analysis curves
(dotted), and after 40 weeks, the World Health Organization
centiles (dashed).
a) To maintain integrity with the meta-analysis curves

from 22 to 36 weeks. Integrity of the fit was
assumed to be agreement within 3% at each week.
b) To ensure fit of the data to the WHO values at 50
weeks, within 0.5%.
Procedure:
1) Cubic splines were used to interpolate smooth
values between selected points (22, 25, 28, 32, 34, 36
and 50 weeks). Extra points were manually selected
at 40, 43 and 46 weeks in order to produce
acceptable fit through the underlying data. The
PreM Growth study (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, The
Preterm Infant Multicentre Growth Study.
Submitted BMC Ped 2012) conducted to inform the
transition between the preterm and WHO data, was
used to inform this step. The Prem Growth Study
found that preterm infants growth in weight
followed approximately a straight line between 37
and 45 weeks, as others have also noted [9-11].
2) LMS values (measures of skew, the median, and the
standard deviation) [15] were computed from the
interpolated cubic splines at weekly intervals. Coles
procedures [15] and an iterative least squares method
were used to derive the LMS parameters (L = Box-Cox
power, M = median, S = coefficient of variation) from
Data source
Voight, 2010
Olsen, 2010
Kramer, 2001
Roberts, 1999
German Perinatal
Survey
Pediatrix Medical Group

hospitals
Canadian national file
Australian National
Scottish maternity data Italian Neonatal
Perinatal Statistics Unit collection
Study
Bonellie, 2008
Bertino, 2010
WHO, 2006
WHO multicentre growth
reference study
Sample size
2,300,000
130,111
676,605
734,145
100,133
45,462
882
n < 30 weeks
14146
11377
3247
3193
2053
623
N/A
Lowest gestational
age
22
23
22
20
24
23
term
Dates
1995 to 2000
1998 to 2006
1994 to 1996
1991 to 1994
1998 to 2003
2005 to 2007
1997-2003
Data
Weight
Weight, head, length
Weight
Weight
Weight
Exclusion criteria
None stated,
included both
live and stillborn
Multiple births, congenital

anomalies, death before
discharge, outlier measures
(> 2 x interquartile range
below the first and
3rd quartile).
Ontario province was

excluded due to
problems with data
quality.
Omitted multiple and

still births (births < 400
grams did not need to
be recorded)
Multiple births, lethal

anomalies, weights
< 250 grams, and
outlier measures
(> 2 x interquartile
range outside the first
and 3rd quartile).
Multiple births, stillbirths,

major congenital
anomalies, and fetal
hydrops
Maternal smoking, not

breastfeeding, solids before
4 months. Screened for
environmental or
economic constraints.
Method to assess
gestational age
Ultrasound
Neonatologist assessment
assessment 814
weeks and Naegles
rule.
early ultrasound has

increasingly been the
basis for gestational
age assessments in
recent years
Dates, prenatal, or
postnatal assessment
Clinician assessment
based on ultrasound,
maternal dates, and
clinical estimates
Ultrasound assessment
first trimester
Not stated
Assumed a log normal

distribution of birthweight
at each gestational age
and compared the
probabilities of accurate
versus misclassification of
infants gestational age
Omitted outlier
measures (> 2 x
interquartile range
below the first and
3rd quartile).
Cubic spline fitting
Generalized logistic
functions
Omitted outliers > 3 SD,

LMS parameter smoothing,
skew set to one for weight,
cubic spline fitting.
Outliers/smoothing Cubic regression, LMS methods, with the

method
LOESS smoothing, skew set to one and
LMS parameter
further manual smoothing
smoothing

Table 1 Details of the data sources
Page 4 of 13
Identification

Page 5 of 13
2436 records identified through

database searching
153 duplicates identified
Screening
(Medline & Grey literature)
63 records screened
Eligibility
12 additional records identified through other

sources
69 full-text articles excluded:

Date of birth criteria (n=27)
Not developed country (n= 4)
Insufficient n (n=25)
Numerical data not available (n=5)
Not population based (n=3)
Uncorrected gestational ages (n=3)
No direct measurements (n=1)
Duplicate data (n=1)
Included
75 of full-text articles
assessed for eligibility
6 studies included in
meta-analysis
Figure 4 Flow diagram of studies identified, excluded and included in the systematic review.
Table 2 Number of infants each week from each study

Gestational age
Voight, 2010
Olsen, 2010
Bertino, 2010
Kramer, 2001
Roberts, 1999
Bonellie, 2008
Females
Males
Females
Males
Females
Males
Females
Males
Females
Males
Females
Males
22
188
321
80
82
71
74
23
431
560
133
153
106
114
79
95
24
575
704
438
451
20
24
148
156
115
135
120
126
25
713
846
603
722
40
38
184
202
136
180
115
118
26
812
968
773
881
35
58
191
234
188
235
179
172
27
1073
1203
966
1030
52
61
188
254
231
284
174
177
28
1276
1536
1187
1281
79
63
287
330
287
361
246
239
29
1516
1838
1254
1505
70
72
299
392
325
397
245
265
30
1853
2212
1606
1992
107
114
390
467
440
571
317
313
31
2283
2956
2044
2460
126
140
461
584
548
743
136
148
32
3007
3677
165
183
795
997
877
1117
193
205
33
4186
5014
211
240
1055
1368
1200
1471
239
256
34
5936
7291
263
349
2018
2553
2086
2657
374
422
35
5082
6952
366
418
3391
4314
3418
4092
644
653
36
4690
7011
562
665
8203
9648
7320
8788
1048
1265
37
4372
6692
1291
1492
17308
19965
16105
18660
2006
2499
38
5755
8786
3524
3976
47516
51947
47809
51404
4630
6387
39
5978
8324
5295
5452
75068
77623
68846
72871
8699
10706
40
5529
7235
5672
5653
110738
112737
137570
141553
12644
14230
* Not reported.

Page 6 of 13
the multicentre meta-analyses for weight, head

circumference and length. The LMS splines were
smoothed slightly while maintaining data integrity as
noted above.
3) The final percentile curves were produced from the
smoothed LMS values.
4) A grid similar to the 2003 growth chart was used,
but the growth curves were re-scaled along the
x-axis from completed weeks to allow clinicians to
plot infant growth by actual age in weeks, and a
slight modification (scaled to 60 centimeters instead
of 65) was made to the y-axis.
D. Compared the revised charts with the 2003 version
The revised growth charts were compared graphically with

the original 2003 Fenton preterm growth chart. To make
the differences in chart values more apparent, the 2003
chart data was also shifted to actual weeks for these comparison figures.
Results
Six large population based surveys [14,16-20] of size at
preterm birth from countries Germany, United States,
Italy, Australia, Scotland, and Canada were located that
met the inclusion criteria (Table 1). The literature search
identified 2436 papers, of which 2373 were discarded as
being not relevant or duplicates based on the titles
(Figure 4). Reviewing reference lists identified another
12 studies. Seventy-five studies were examined in detail,
however 27 of these did not meet the date criteria. Among
the 48 studies that met the date of birth criteria, some did
not meet the other inclusion criteria for the following
reasons: Did not meet the criterion for more than 25,000
babies [21-35], no low gestational age infants less than 25
weeks [31,36-41], insufficient number less than 30 weeks
[34,42-45], no statistical correction for inaccurate
gestational ages [46-48], numerical data not available
[49-51], number of infants each week were not available
Figure 5 Boys meta-analysis weight curves (dotted) with the

final smoothed growth chart curves (dashed).
Figure 6 Boys meta-analysis head circumference curves

(dotted) with the final smoothed growth chart curves (dashed).
[52], number of infants in the subgroups each week were

not available [53], was not population based [54-56], no
direct measurements [27], some of the data [57] was also
in one of the larger included studies [17].
Included in the meta-analyses were almost four million
(3,986,456) infants at birth (34,639 less than 30 weeks)
from six studies for weight (Table 2), and 173,612 infants
for head circumference, and 151,527 for length [16,18].
The World Health Organization data measurements
were made longitudinally on 882 infants.
The individual datasets from the literature showed
good agreement with each other, especially along the
50th and lower centiles (Figures 1, 2, and 3) and the
meta-analysis curves had a close fit with the individual
datasets up to 36 weeks and at 50 weeks (Figures 5, 6, 7).
The final splined weight curves were within 3% of the
meta-analysis curves for 24 through 36 weeks for both genders, except for a 3.8% difference for girls at 32 weeks along
the 90th centile. None of the length measurements differed
by more than 1.8% percent between the meta-analysis and
the splined curves; all weeks of the head circumference
curves were within 1.5%. The meta-analyses for head
Figure 7 Boys meta-analysis length curves (dotted) with the

final smoothed growth chart curves (dashed).

circumference and length for girls and boys were close

enough to normal distributions that normal distributions
were used to summarize the data. The measures at 50
weeks were within 0.5% of the WHOGS values.
Girl and boy charts were prepared (Figure 8 and 9), by
shifting the age by 0.5 weeks to allow plotting by exact
age instead of completed weeks. The LMS Parameters
[15] were used to develop the exact z-score and percentile
calculators for the new growth chart.
In the two graphical comparisons between the revised
growth charts, one for each sex, with the 2003 Fenton
Figure 8 Revised growth chart for girls.
Page 7 of 13
preterm growth chart revealed that the curves were quite

similar (Figures 10 and 11). Generally the new girls curves
were slightly lower (Figure 10) and the new boys slightly
higher (Figure 11) for all 3 parameters (weight, head circumference, and length) than the 2003 curves. The most
dramatic visual and numerical difference between the new
charts and the 2003 chart was the higher shift of the boys
weight curves after 40 weeks compared to the 2003 chart,
reaching a maximum difference at 50 weeks of 650, 580,
and 740 grams at the 3rd, 50th, and 97th percentiles, respectively. The second biggest visual difference was the

Page 8 of 13
Figure 9 Revised growth chart for boys.
lower pattern of the girls length curves below 37 weeks;

the difference in length reached a maximum numerical
value of 1.7 centimeters at 24 weeks along the 97th
percentile.
Discussion
We used a strict set of inclusion criteria to include only
the best data available to convert fetal and infant size data
into fetal-infant growth charts for preterm infants. The revised sex-specific actual-age (versus completed weeks)
growth charts (Figure 9 and 10), are based on birth size information of almost four million births with confirmed or
corrected gestational ages, born in developed countries

(See Features of the new growth chart). The revised charts
are based on the recommended growth goal for preterm
infants, the fetus and the term infant, with smoothing of
the disjunction between these datasets, based on the findings of our international multicentre validation study
(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, The Preterm Infant Multicentre Growth Study.
Submitted BMC Ped 2012). These charts are consistent with the meta-analysis data up to and including

Page 9 of 13
Figure 10 Comparison of the revised growth chart for girls (solid curves) and the 2003 Fenton growth chart (dashed curves) 3rd, 50th,
and 97th percentile curves for length, head circumference, and weight). Both the 2003 and the revised growth curves are shown shifted to
actual weeks.
36 weeks, thus they can be used for the assessment

of size for gestational age for preterm infants under 37
weeks of gestational age. This growth chart is likely applicable to preterm infants in both developed and developing countries since the data was selected from
developed countries to minimize the influence from circumstances that may not have been ideal to support
growth.
Features of the new growth chart
Based on the recommended growth goal for preterm
infants: The fetus and the term infant

Girl and boy specific charts
Equivalent to the WHO growth charts at 50 weeks
gestational age (10 weeks post term age).

Large preterm birth sample size of 4 million infants;
Recent population based surveys collected between
1991 to 2007
Data from developed countries including
Germany, Italy, United States, Australia, Scotland,

and Canada
Curves are consistent with the data to 36 weeks,
thus can be used to assign size for gestational age up
to and including 36 weeks.
Chart is designed to enable plotting as infants are
measured, not as completed weeks. The x axis was
adjusted for this chart so that infant size data can be
plotted without age adjustment, i.e. Babies should be
plotted as exact ages, that is a baby at 25 3/7 weeks
should be plotted along the x axis between 25 and
26 weeks.
Exact z-score and percentile calculator available for
download from http://ucalgary.ca/fenton. Data is
available for research upon request.
It may be more intuitive to plot on growth charts
using exact ages rather than on the basis of complete

Page 10 of 13
Figure 11 Comparison of the revised growth chart for boys (solid curves) and the 2003 Fenton growth chart (dashed curves) 3rd, 50th,
and 97th percentile curves for length, head circumference, and weight). Both the 2003 and the revised growth curves are shown shifted to
actual weeks.
weeks. Several years ago, the WHO used completed age

for growth chart development [12]. This recommendation was likely due to the way data had been collected in
the past, that is all 26 0/7 through 26 6/7 week infants
were included in the 26 week completed week category.
However, with the use of computers to plot on growth
charts comes the potential to more accurately plot measurements to the exact day of data collection. Thus the
time scale of the horizontal axes of these new growth
charts were re-scaled to actual age, for ease of use and understanding. For example, a baby at 25 3/7 can be intuitively plotted between 25 and 26 weeks.
Exact z-score and centile calculators for the revised
charts are available for download: http://ucalgary.ca/
fenton. Data is available for research upon request.
The data revealed that between 22 weeks to 50 weeks
post menstrual age, the fetus/infant multiplies its weight
tenfold, for example, the girls median weight increased
from a median of 520 to 5360 grams. Using a fetal-infant
growth chart allows clinicians to compare preterm infants

growth to an estimated reference of the fetus and the
term infant.
There was a remarkably close fit of the included preterm
surveys for weight, head circumference and length from
the 6 countries, especially at the 50th percentile, even
though the data came from different countries.
The splining procedures we used have produced a
chart that has integrity and good agreement with the
original data. Smoothing of the LMS parameters is
recommended since minor fluctuations are more likely
due to sampling errors rather than physiological events
[15]. Experts recommend that growth charts be developed
based on smoothed L, M and S, to constrain the adjacent
curves so that they relate to each other smoothly [15]. The
World Health Organization set their L parameter to 1 for
head circumference and length, while they maintained the
exact L values for infants weights [58]. The data under
study here revealed the same effect as the WHO data; we

found that both head circumference and length were close

enough to normal distributions that normal distributions
could summarize the data, while the exact Ls were needed
to retain the nuances of the weight curves.
The differences between the revised growth charts and
the 2003 Fenton preterm growth chart may reflect
improvements since the selected preterm growth references
for the new versions are more likely globally representative
of fetal and infant growth. Some of the differences between
the current charts and the 2003 version are likely due to
the separation into girl and boy charts, since the shifts
of the girls curves tend to be downward and the boys
curves upward. The weight shifts after 40 weeks were
upward for both sexes, due to the higher values for the
WHOGS compared to the CDC growth reference [59] at
10 weeks post term.
The ideal growth pattern of preterm infants remains
undefined. These revised growth charts were developed
based on the growth patterns of the fetus (as has been
determined by size at birth in the large population studies) and the term infant (based on the WHO Growth
Standard) [2]. Ultrasound studies and comparison of
subgroups of prematurely born infants suggest that the
fetal studies, such as those used in this development, may
be biased by the premature birth since fetuses who remain
in utero likely differ in important ways from babies who
are born early [60,61]. However, fetal size from these
imperfect studies may be the best data available at this
point in time for comparing the growth of preterm infants
since the alternative, to compare to in utero infants
requires extrapolation from ultrasound measurements. To
use other premature infants as the growth reference for
preterm infants may not be ideal since the ideal growth of
preterm infants has not been defined, has been changing
over time [62], and is influenced by the nutrition and
medical care received after birth [63,64].
Although the WHOGS is considered to be a growth
standard, the infants in the population-based surveys of
size at birth are more likely representative of the reference
populations and were not selected to be healthy. Thus
these growth charts are growth references and are not a
growth standard. The INTERGROWTH study, currently
underway, will rectify this problem, since their purpose is
to develop prescriptive standards for fetal and preterm
growth [65].
Conclusion
The inclusion of data from a number of developed countries
increases the generalizability of the growth chart. The
revised preterm growth chart, harmonized with the World
Health Organization Growth Standard at 50 weeks, may
support an improved transition of preterm infant growth
monitoring to the WHO charts.
Page 11 of 13
Competing interests
The authors declare that they have no competing interests.
Authors contributions
The authors responsibilities were as follows: JHK suggested the study, TRF &
JHK designed the study and conducted independent literature searches, TRF
extracted the data, performed the statistical analysis, and wrote the
manuscript. Both of the authors contributed to interpret the findings and
writing the manuscript, and both authors read and approved the final
manuscript.
Acknowledgements
Many thanks to Patrick Fenton and Misha Eliasziw for statistical assistance,
Roseann Nasser, Reg Sauve, Debbie OConnor, and Sharon Unger for
encouragement and advice, and Jayne Thirsk for editing advice.
Author details
1
Alberta Childrens Hospital Research Institute, The University of Calgary,
Calgary, AB, Canada. 2Department of Community Health Sciences, The
University of Calgary, 3280 Hospital Drive NW, Calgary, AB, Canada. 3Division
of Neonatology, UC San Diego Medical Center, 200 West Arbor Drive MPF
1140, San Diego, CA, USA.
Received: 12 October 2012 Accepted: 10 April 2013
Published: 20 April 2013
References
1. Secker D: Promoting optimal monitoring of child growth in Canada:
using the new WHO growth charts. Can J Diet Pract Res 2010, 71:e1e3.
2. De Onis M, Garza C, Victora CG, Onyango AW, Frongillo EA, Martines J: The
WHO Multicentre Growth Reference Study: planning, study design, and
methodology. Food Nutr Bull 2004, 25:S15S26.
3. Borghi E, De Onis M, Garza C, den BJ V, Frongillo EA, Grummer-Strawn L,
Van Buuren S, Pan H, Molinari L, Martorell R, Onyango AW, Martines JC:
Construction of the World Health Organization child growth standards:
selection of methods for attained growth curves. Stat Med 2006,
25:247265.
4. Dietitians of Canada, Canadian Pediatric Society, College of Family
Physicians of Canada, Community Health Nurses of Canada: Promoting
Optimal Monitoring of Child Growth in Canada: Using the New WHO
Growth Charts. Can J Diet Pract Res 2010, 71:122.
5. Committee on Nutrition American Academy Pediatrics: Nutritional Needs of
Preterm Infants, Pediatric Nutrition Handbook. 6th edition. Elk Grove Village
Il: American Academy Pediatrics; 2009.
6. Agostoni C, Buonocore G, Carnielli VP, De CM, Darmaun D, Decsi T, et al:
Enteral nutrient supply for preterm infants. A comment of the ESPGHAN
Committee on Nutrition. J Pediatr Gastroenterol Nutr 2010, 50:8591.
7. Nutrition Committee, Canadian Paediatric Society: Nutrient needs and
feeding of premature infants. CMAJ 1995, 152:17651785.
8. United Nations Statistics Division: Composition of macro geographical
(continental) regions, geographical sub-regions, and selected economic and
other groupings. http://unstats.un.org/unsd/methods/m49/m49regin.
htm#developed.
9. Niklasson A, Engstrom E, Hard AL, Wikland KA, Hellstrom A: Growth in very
preterm children: a longitudinal study. Pediatr Res 2003, 54:899905.
10. Bertino E, Coscia A, Mombro M, Boni L, Rossetti G, Fabris C, Spada E, Milani
S: Postnatal weight increase and growth velocity of very low birthweight
infants. Arch Dis Child Fetal Neonatal Ed 2006, 91:F349F356.
11. Krauel VX, Figueras AJ, Natal PA, Iglesias PI, Moro SM, Fernandez PC, MartinAncel A: Reduced postnatal growth in very low birth weight newborns
with GE < or = 32 weeks in Spain. An Pediatr (Barc) 2008, 68:206212.
12. World Health Organization: Physical status: the use and interpretation of
anthropometry. Report of a WHO Expert Committee. World Health Organ
Tech Rep Ser 1995, 854:1452.
13. Hennekens CH, Buring JE: Analysis of epidemiologic studies: Evaluating
the role of confounding. In Epidemiology in Medicine. Edited by Mayrent SL,
Little B. Boston; 1987:287323.
14. Voigt M, Zels K, Guthmann F, Hesse V, Gorlich Y, Straube S: Somatic
classification of neonates based on birth weight, length, and head
circumference: quantification of the effects of maternal BMI and
smoking. J Perinat Med 2011, 39:291297.

15. Cole TJ, Green PJ: Smoothing reference centile curves: the LMS method
and penalized likelihood. Stat Med 1992, 11:13051319.
16. Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel BS: New intrauterine
growth curves based on United States data. Pediatrics 2010, 125:e214e224.
17. Roberts CL, Lancaster PA: Australian national birthweight percentiles by
gestational age. Med J Aust 1999, 170:114118.
18. Bertino E, Spada E, Occhi L, Coscia A, Giuliani F, Gagliardi L, Gilli G, Bona G,
Fabris C, De CM, Milani S: Neonatal anthropometric charts: the Italian
neonatal study compared with other European studies. J Pediatr
Gastroenterol Nutr 2010, 51:353361.
19. Bonellie S, Chalmers J, Gray R, Greer I, Jarvis S, Williams C: Centile charts for
birthweight for gestational age for Scottish singleton births. BMC
Pregnancy Childbirth 2008, 8:5.
20. Kramer MS, Platt RW, Wen SW, Joseph KS, Allen A, Abrahamowicz M,
Blondel B, Breart G: A new and improved population-based Canadian
reference for birth weight for gestational age. Pediatrics 2001, 108:E35.
21. Karna P, Brooks K, Muttineni J, Karmaus W: Anthropometric measurements
for neonates, 23 to 29 weeks gestation, in the 1990s. Paediatr Perinat
Epidemiol 2005, 19:215226.
22. Kwan AL, Verloove-Vanhorick SP, Verwey RA, Brand R: Ruys JH: [Birth
weight percentiles of premature infants needs to be updated].
Ned Tijdschr Geneeskd 1994, 138:519522.
23. Riddle WR, DonLevy SC, Lafleur BJ, Rosenbloom ST, Shenai JP: Equations
describing percentiles for birth weight, head circumference, and length
of preterm infants. J Perinatol 2006, 26:556561.
24. Figueras F, Figueras J, Meler E, Eixarch E, Coll O, Gratacos E, Gardosi J,
Carbonell X: Customised birthweight standards accurately predict
perinatal morbidity. Arch Dis Child Fetal Neonatal Ed 2007, 92:F277F280.
25. Fok TF, So HK, Wong E, Ng PC, Chang A, Lau J, Chow CB, Lee WH: Updated
gestational age specific birth weight, crown-heel length, and head
circumference of Chinese newborns. Arch Dis Child Fetal Neonatal Ed 2003,
88:F229F236.
26. Cole TJ, Williams AF, Wright CM: Revised birth centiles for weight, length
and head circumference in the UK-WHO growth charts. Ann Hum Biol
2011, 38:711.
27. Salomon LJ, Bernard JP, Ville Y: Estimation of fetal weight: reference range
at 2036 weeks gestation and comparison with actual birth-weight
reference range. Ultrasound Obstet Gynecol 2007, 29:550555.
28. Cole TJ, Freeman JV, Preece MA: British 1990 growth reference centiles for
weight, height, body mass index and head circumference fitted by
maximum penalized likelihood. Stat Med 1998, 17:407429.
29. Gibbons K, Chang A, Flenady V, Mahomed K, Gardener G, Gray PH:
Validation and refinement of an Australian customised birthweight
model using routinely collected data. Aust N Z J Obstet Gynaecol 2010,
50:506511.
30. Ogawa Y, Iwamura T, Kuriya N, Nishida H, Takeuchi H, Takada M: Birth size
standards by gestational age for Japanese neonates. Acta Neonat Jpn
1998, 34:624632.
31. Storms MR, Van Howe RS: Birthweight by gestational age and sex at a
rural referral center. J Perinatol 2004, 24:236240.
32. Romano-Zelekha O, Freedman L, Olmer L, Green MS, Shohat T: Should fetal
weight growth curves be population specific? Prenat Diagn 2005, 25:709714.
33. Ooki S, Yokoyama Y: Reference birth weight, length, chest circumference,
and head circumference by gestational age in Japanese twins.
J Epidemiol 2003, 13:333341.
34. Vergara G, Carpentieri M, Colavita C: Birthweight centiles in preterm
infants. A new approach. Minerva Pediatr 2002, 54:221225.
35. Bernstein IM, Mohs G, Rucquoi M, Badger GJ: Case for hybrid fetal growth
curves: a population-based estimation of normal fetal size across
gestational age. J Matern Fetal Med 1996, 5:124127.
36. Ramos F, Perez G, Jane M, Prats R: Construction of the birth weight by
gestational age population reference curves of Catalonia (Spain):
Methods and development. Gac Sanit 2009, 23:7681.
37. Visser GH, Eilers PH, Elferink-Stinkens PM, Merkus HM, Wit JM: New Dutch
reference curves for birthweight by gestational age. Early Hum Dev 2009,
85:737744.
38. Roberts C, Mueller L, Hadler J: Birth-weight percentiles by gestational age,
Connecticut 19881993. Conn Med 1996, 60:131140.
39. Zhang X, Platt RW, Cnattingius S, Joseph KS, Kramer MS: The use of
customised versus population-based birthweight standards in predicting
perinatal mortality. BJOG 2007, 114:474477.
Page 12 of 13
40. Gielen M, Lindsey PJ, Derom C, Loos RJ, Souren NY, Paulussen AD, Zeegers
MP, Derom R, Vlietinck R, Nijhuis JG: Twin-specific intrauterine growth
charts based on cross-sectional birthweight data. Twin Res Hum Genet
2008, 11:224235.
41. Monroy-Torres R, Ramirez-Hernandez SF, Guzman-Barcenas J, Naves-Sanchez
J: [Comparison between five growth curves used in a public hospital].
Rev Invest Clin 2010, 62:121127.
42. Blair EM, Liu Y, de Klerk NH, Lawrence DM: Optimal fetal growth for the
Caucasian singleton and assessment of appropriateness of fetal growth: an
analysis of a total population perinatal database. BMC Pediatr 2005, 5:13.
43. Carrascosa A, Yeste D, Copil A, Almar J, Salcedo S, Gussinye M:
[Anthropometric growth patterns of preterm and full-term newborns
(2442 weeks gestational age) at the Hospital Materno-Infantil Vall
dHebron (Barcelona)(19972002]. An Pediatr (Barc) 2004, 60:406416.
44. Rousseau T, Ferdynus C, Quantin C, Gouyon JB, Sagot P: [Liveborn birthweight of single and uncomplicated pregnancies between 28 and 42
weeks of gestation from Burgundy perinatal network]. J Gynecol Obstet
Biol Reprod (Paris) 2008, 37:589596.
45. Polo A, Pezzotti P, Spinelli A, Di LD: Comparison of two methods for
constructing birth weight charts in an Italian region. Years 20002003.
Epidemiol Prev 2007, 31:261269.
46. Oken E, Kleinman KP, Rich-Edwards J, Gillman MW: A nearly continuous
measure of birth weight for gestational age using a United States
national reference. BMC Pediatr 2003, 3:6.
47. Montoya-Restrepo NE, Correa-Morales JC: [Birth-weight curves]. Rev Salud
Publica (Bogota) 2007, 9:110.
48. Dollberg S, Haklai Z, Mimouni FB, Gorfein I, Gordon ES: Birth weight
standards in the live-born population in Israel. Isr Med Assoc J 2005,
7:311314.
49. Kierans WJ, Kendall PRW, Foster LT, Liston RM, Tuk T: New birth weight and
gestational age charts for the British Columbia population. BC Medical J
2006, 48:2832.
50. Uehara R, Miura F, Itabashi K, Fujimura M, Nakamura Y: Distribution of birth
weight for gestational age in Japanese infants delivered by cesarean
section. J Epidemiol 2011, 21:217222.
51. Lipsky S, Easterling TR, Holt VL, Critchlow CW: Detecting small for
gestational age infants: the development of a population-based
reference for Washington state. Am J Perinatol 2005, 22:405412.
52. Niklasson A, Albertsson-Wikland K: Continuous growth reference from
24th week of gestation to 24 months by gender. BMC Pediatr 2008, 8:8.
53. Alexander GR, Kogan MD, Himes JH: 19941996 U.S. singleton birth
weight percentiles for gestational age by race, Hispanic origin, and
gender. Matern Child Health J 1999, 3:225231.
54. Davidson S, Sokolover N, Erlich A, Litwin A, Linder N, Sirota L: New and
improved Israeli reference of birth weight, birth length, and head
circumference by gestational age: a hospital-based study. Isr Med Assoc J
2008, 10:130134.
55. Kato N, A: [Reference birthweight for multiple births in Japan]. Nihon
Koshu Eisei Zasshi 2002, 49:361370.
56. Braun L, Flynn D, Ko CW, Yoder B, Greenwald JR, Curley BB, Williams R,
Thompson MW: Gestational age-specific growth parameters for infants
born at US military hospitals. Ambul Pediatr 2004, 4:461467.
57. Thomas P, Peabody J, Turnier V, Clark RH: A new look at intrauterine
growth and the impact of race, altitude, and gender. Pediatrics 2000,
106:E21.
58. World Health Organization: The WHO Child Growth Standards. http://www.
who.int/childgrowth/standards/en/.
59. Kuczmarski RJ, Ogden CL, Guo SS, Grummer-Strawn LM, Flegal KM, Mei Z,
Wei R, Curtin LR, Roche AF, Johnson CL: 2000 CDC Growth Charts for the
United States: methods and development. Vital Health Stat 2002,
11:1190.
60. Hutcheon JA, Platt RW: The missing data problem in birth weight
percentiles and thresholds for small-for-gestational-age. Am J Epidemiol
2008, 167:786792.
61. Sauer PJ: Can extrauterine growth approximate intrauterine growth?
Should it? Am J Clin Nutr 2007, 85:608S613S.
62. Christensen RD, Henry E, Kiehn TI, Street JL: Pattern of daily weights
among low birth weight neonates in the neonatal intensive care unit:
data from a multihospital health-care system. J Perinatol 2006, 26:3743.
63. Valentine CJ, Fernandez S, Rogers LK, Gulati P, Hayes J, Lore P, Puthoff T,
Dumm M, Jones A, Collins K, Curtiss J, Hutson K, Clark K, Welty SE: Early

Page 13 of 13
amino-acid administration improves preterm infant weight. J Perinatol

2009, 29:428432.
64. Senterre T, Rigo J: Reduction in postnatal cumulative nutritional deficit
and improvement of growth in extremely preterm infants. Acta Paediatr
2012, 101:e64e70.
65. Study Coordinating Unit: INTERGROWTH-21st. http://intergrowth21.org.uk/.
doi:10.1186/1471-2431-13-59
Cite this article as: Fenton and Kim: A systematic review and metaanalysis to revise the Fenton growth chart for preterm infants. BMC
Pediatrics 2013 13:59.
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Fenton and Kim BMC Pediatrics 2013, 13:59