Body size at birth and blood pressure among children in developing countries

CM Lawa, P Eggera,b, O Dadac, H Delgadod, E Kylberge, P Lavinf, G-H Tangg, H von Hertzenh, AW Shiella and DJP Barkera

a MRC Environmental Epidemiology Unit, Southampton General Hospital, Southampton SO16 6YD, UK. E-mail: claw{at}mrc.soton.ac.uk
c Obafemi Awolowo College of Health Sciences, Ogun State University Teaching Hospital, Sagamu, Nigeria.
d Instituto de Nutricion de Centro America y Panama, Guatemala City, Guatemala.
e Section for International Maternal and Child Health, Department for Women's and Children's Health, Uppsala University, Sweden.
f Subterraneo Maternidad, Hospital Barros Luco, Santiago, Chile.
g Family Planning Research Institute of Sichuan, Chengdu, People's Republic of China.
h UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, World Health Organization, Switzerland.

Abstract

Background Studies in developed countries have shown that reduced fetal growth is related to raised blood pressure in childhood and adult life. Little is known about this association in developing countries, where fetal growth retardation is common.

Methods In 1994–1995, we measured blood pressure in 1570 3–6-year-old children living in China, Guatemala, Chile, Nigeria and Sweden. We related their blood pressure to patterns of fetal growth, as measured by body proportions at birth. The children were all born after 37 weeks gestation and weighed more than 2.5 kg at birth.

Results In each country, blood pressure was positively related to the child's current weight. After adjusting for this and gender, systolic pressure was inversely related to size at birth in all countries except Nigeria. In Chile, China and Guatemala, children who were proportionately small at birth had raised systolic pressure. For example, in Chile, systolic pressure adjusted for current weight increased by 4.9 mmHg (95% CI : 2.1, 7.7) for every kilogram decrease in birthweight, by 1 mmHg (95% CI : 0.4, 1.6) for every centimetre decrease in birth length, and by 1.3 mmHg (95% CI : 0.4, 2.2) for every centimetre decrease in head circumference at birth. In Sweden, systolic pressure was higher in children who were disproportionately small, that is thin, at birth. Systolic pressure increased by 0.3 mmHg (95% CI : 0.0, 0.6) for every unit (kg/m3) decrease in ponderal index at birth. These associations were independent of the duration of gestation.

Conclusions Raised blood pressure among children in three samples from China, Central and South America is related to proportionate reduction in body size at birth, which results from reduced growth throughout gestation. The relation between fetal growth and blood pressure may be different in African populations. Proportionately reduced fetal growth is the prevalent pattern of fetal growth retardation in developing countries, and is associated with chronic undernutrition among women. Improvement in the nutrition and health of girls and young women may be important in preventing cardiovascular disease in developing countries.

Keywords Blood pressure, population, pregnancy, epidemiology

Accepted 15 February 2000

Cardiovascular disease is a major cause of mortality and morbidity worldwide,1 and is predicted to remain so.2 Studies of adults in Europe and the United States have shown consistently that those who had lower birthweights have higher blood pressures.36 A similar but smaller relation has been found after adjustment for current size in children in the US, Europe, Japan and New Zealand.3,713 An interpretation of these findings is that levels of blood pressure (and thus essential hypertension), together with other biological risk factors for cardiovascular disease, are ‘programmed’ in utero through influences which alter fetal growth.14 Programming is the process whereby adverse influences acting at critical phases of development permanently alter the body's physiology and structure. Because the main determinant of fetal growth is the supply of nutrients, fetal adaptations to malnutrition (lack of, or imbalance in nutrients) are thought to be a major influence in programming.15

Little is known about the association between birthweight and blood pressure in developing countries, where intra-uterine growth retardation is common.16 An inverse relation between birthweight and blood pressure, after adjustment for current weight, has been shown in studies of children in Zimbabwe,17 South Africa18 and Jamaica.19 No relation was found in Gambian children20 or in a separate study of Jamaican children.21 However, birthweight is a crude summary of fetal growth. The same birthweight may be the outcome of many different paths of growth. In developing countries, fetal growth retardation is usually proportionate, with reduced head size, length and weight at birth. This indicates that the fetus grew slowly throughout gestation, a pattern of growth seen in chronically malnourished populations. By contrast, in developed countries fetal growth retardation is more often disproportionate: the babies are either thin at birth or stunted.15,22,23 This may be a consequence of failure of the fetal nutrient supply in late gestation.

To determine how reduced fetal growth is related to raised blood pressure in countries where chronic malnutrition is common, we studied children whose body proportions at birth had been recorded, in China, Guatemala, Chile and Nigeria, and compared them with children in Sweden.

Methods

Participants were children who had been born during a study of the duration of lactational amenorrhoea, which was co-ordinated by the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction, based at the World Health Organization (WHO), Geneva. This first study aimed to examine differences in duration of lactational amenorrhoea in relation to breastfeeding practices in seven centres (Chengdu, China; Guatemala City, Guatemala; New Delhi, India; Sagamu, Nigeria; Santiago, Chile; Uppsala, Sweden; and Westmead and Melbourne, Australia). Mother and infant pairs were recruited between 1 and 8 days after birth (2 infants in Uppsala were aged 8–14 days at recruitment). Mothers had to be healthy (of normal nutritional status, [i.e. weight considered normal for that population], and with no intercurrent ill health requiring more than 14 days continuous treatment with a prescribed drug), literate, intending to breastfeed and to have previously breastfed an infant. Babies had to be healthy, born at or after 37 weeks and weighing more than 2.5 kg (2.0 kg in India) or above the 10th centile of the local reference standard. Length of gestation was estimated from the date of the last menstrual period. At admission to the study detailed anthropometry was performed on the mother and the baby. Measurements included the baby's length, weight and head circumference. In both Uppsala and Guatemala City length at admission (and thus ponderal index) was missing in one baby. Head circumference was missing in 8 babies in Uppsala and 4 in Santiago. Measurement of chest circumference was optional. It was not measured in Guatemala City, in 4 babies in Santiago, in 143 babies in Chengdu and in 16 babies in Uppsala. Mother and infant pairs were followed up at 2-weekly intervals and information on infant feeding patterns and mother and infant health collected. Follow-up ceased when the mother had had two normal menstrual periods or became pregnant again. Recruitment of mothers and babies started in 1989 and follow-up for the first study ended in 1993. Full details of the methods have been published.24

Five centres, Chengdu, Guatemala City, Sagamu, Santiago and Uppsala, participated in the study reported in this paper. The Australian centres did not participate for financial reasons, and the New Delhi centre declined to participate. All children who had taken part in the first (WHO) study and who were at least 3 years of age were eligible for inclusion. Those who could be traced and whose parent(s) agreed to their participation were visited during 1994 and 1995 by a fieldworker at home, school or in a health care centre according to local circumstances. After the child had rested for 5 minutes, blood pressure was measured on the left arm at the level of the heart, using an automated blood pressure recorder (Dinamap model 8100). Cuff size was chosen according to the recommendations of the American Heart Association.25 Three measurements were taken at one minute intervals. Weight was measured in light clothing and without shoes to the nearest 0.1 kg. Height was measured three times in the Frankfurt plane to the nearest mm. Arm circumference was measured three times on the flexed left arm at a point halfway between the olecranon and the acromion. Means of measurements made in triplicate were used in analysis. Ambient temperature, time since the last meal and time of measurement were also recorded, as they have been shown to have small effects on blood pressure measurement in some studies.26 All centres used the same protocol for measurement. Anthropometry equipment was calibrated at the beginning and end of the study using fixed weights and measures.

Data were collected on to standard forms which were sent to the co-ordinating centre (Medical Research Council Environmental Epidemiology Unit, Southampton) for computer entry and statistical analysis. The power of the study was calculated from a study of size at birth in relation to blood pressure in 4-year-old children in Salisbury, UK.27 For the sample size (260–380) expected in each centre we had 61–77% power to detect a change of 0.42 mmHg per kg/m3 increase in ponderal index at birth, using a test at the 5% level.

Body proportions at admission to the study were adjusted for the number of days after birth that time of measurements were made by regression techniques. For clarity of presentation, these adjusted measurements are henceforth referred to as birthweight, birth length, etc. The relations between body proportions at birth and blood pressure were analysed using scatter plots and linear regression, which also included adjustments for potential confounders. As recommended by Lucas et al.28 four regression models were described, all with blood pressure as the dependent variable: an early model in which birth size was the independent variable; a combined model including birth size and current size as independent variables; the addition of the interaction of birth size and current size (as their product) to the combined model; and a late model in which current size was the independent variable. Differences between groups were analysed by tabulation of means and using analysis of variance (ANOVA), including adjustments.

The analysis described the relations of body proportions at birth with blood pressure within each centre, and then compared the direction and magnitude of these relations between centres. Such analyses are not affected by between centre variation in observer measurement.

The study received local ethics committee consent in all centres, and parents gave informed consent for their children to participate.

Results

A total of 1570 children (62% of those eligible) had blood pressure measured. Participation ranged from 44% to 73% between the five centres. The commonest reason for non-participation was inability to trace the child (13% to 53% between centres). Refusal to participate ranged from 0.4% to 7%. There were no consistent differences between those who did or did not participate in any body measurement at admission to the original study, gestation, parity, mother's height or weight. Participants were, however, of significantly higher birth order than non-participants in Sagamu and Guatemala City, and participants' weight, length and chest circumference at admission were significantly larger than those of non-participants in Santiago.

Table 1Go shows the mean measurements of body proportions at admission to the original study in the 1570 children who had blood pressure measured, and the weight, height and systolic pressure at the time of measurement for this study. There were pronounced differences between centres in size at admission. Babies in Chengdu, Guatemala City and Santiago were proportionately smaller than those in Uppsala, with lower weight, length and head circumference. Babies in Chengdu also had higher ponderal index at admission. The mean age at measurement of systolic pressure was similar. Children in Uppsala were tallest and heaviest, and children in Chengdu lightest and shortest. The highest systolic pressures were in Santiago and the lowest in Guatemala City (Table 1Go).


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Table 1 Mean body measurements of infants at admission to the original study, and mean systolic pressure, weight and height at 3–6 years
 
As expected26,29 systolic pressure was strongly positively related to current weight (Table 2Go). Current height and age at measurement were not related to systolic pressure independently of current weight. Girls tended to have lower systolic pressures than boys but this was only statistically significant in Chengdu (girls lower by 2.1 mmHg 95% CI : –3.7, –0.4). More than one size of cuff was used in Guatemala City, Santiago and Uppsala. Compared to children measured with a child cuff, children measured with a small adult cuff had systolic pressures which were on average 1.1 mmHg higher in Guatemala City and 1.3 and 2.7 mmHg lower in Santiago and Uppsala, respectively. Between 1 and 44 children in each centre were recorded as having cried during part of the examination. The mean systolic pressure of these children was significantly higher than those who were not crying (range of differences 11.5 to 23.3 mmHg). In Sagamu and Santiago two fieldworkers measured blood pressure. In Sagamu there was no statistically significant difference between observers, but in Santiago fieldworkers differed on average by 7.4 mmHg (95% CI : 4.5, 10.4). To ensure analysis was consistent between centres, systolic pressure has been adjusted for gender and status of child (crying or not) in all centres, and for observer in Sagamu and Santiago.


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Table 2 The relation of current weight to systolic pressure aged 3–6 years. Results are expressed as the regression coefficient, b, (95% CI) from the regressions of systolic pressure (mmHg) on current weight (kg)
 
The linear relation of body proportions at birth with systolic pressure is given in Table 3Go. Three regression models are presented.28 The first (the early model) gives the regression coefficient (95% CI) from the individual regressions of systolic pressure (adjusted as described above) on each measurement at birth. The second (the combined model) gives the regression coefficient after adding the effect of current weight and cuff size to the early model. The third (the interaction model) adds the interaction of size at birth and current weight (as their product) to the combined model. The P-value of the interaction term is shown.


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Table 3 The relation of body proportions at birth to systolic pressure at age 3–6 years. Results are expressed as the regression coefficient (95% CI) from the individual regressions of systolic pressure (mmHg) on each measurement at birth after adjusting for gender, observera and child's status at measurement only,b, and after adjusting for gender, observer,a child's status at measurement,b current weight and cuff sizec
 
The early model showed that higher blood pressure (adjusted for gender, observer and child's status at measurement only) tended to be associated with smaller size at birth in Chengdu, Guatemala City and Santiago, although this was only statistically significant for head and chest circumferences in Chengdu and weight, length and head circumference in Santiago. There were no consistent or statistically significant relations for the early model in Sagamu or Uppsala.

The combined model showed that higher blood pressure (adjusted for gender, observer, child's status at measurement, current weight and cuff size) was associated with small size at birth in Chengdu, Guatemala City, Santiago and Uppsala. Significant associations were seen with low head and chest circumferences in Chengdu, with low weight, length and head circumference in Guatemala City and with low weight, length, head and chest circumferences in Santiago. In Uppsala the highest systolic pressures tended to be in those who had a low ponderal index at birth, although this was not statistically significant (P = 0.09). In Sagamu there were no linear relations between any measurement at birth and systolic pressure. No interaction term reached statistical significance in any model in any centre.

Examination of tabulation of means for non-linear trends tended to confirm the associations between body proportions at birth and systolic pressure observed by linear regression analysis, with the association being spread across the range of measurements of body proportions. However, in Chengdu, the inverse relation between systolic pressure and head and chest circumference appeared to be dependent on children in the lowest fifth and lowest two-fifths of the distributions, respectively. In Sagamu, the relations of weight, length and ponderal index at birth with systolic pressure tended to be U-shaped, with the highest pressures in children who were small or large babies at birth. However, quadratic terms fitted to the regression models describing these relations did not reach statistical significance.

Gestation in these babies, all of whom were born at or after 37 weeks, was not related univariately to systolic pressure in any centre. The relations between body proportions at birth and systolic pressure in each centre showed no consistent or significant changes in magnitude or direction when gestation was included as an additional independent variable. Relations between diastolic pressure and body proportions at birth were also assessed in each centre. In general the associations were in the same direction as those with systolic pressure but smaller in size of effect and of lesser statistical significance.

Time since last meal was not related to systolic pressure in any centre except Guatemala City, where a longer time since the last meal was associated with higher systolic pressure. There was no significant relation between systolic pressure and either ambient temperature or time of measurement in Guatemala City, Sagamu, Santiago and Uppsala. However, in Chengdu, systolic pressures were significantly higher in those who were measured in the afternoon compared to the morning. In addition, systolic pressures were higher at colder ambient temperatures. Further analysis showed that the latter was dependent on seasonal difference, with systolic pressure being higher in the winter months of measurement (November–January), independent of temperature. The analyses in Chengdu were repeated, including time and season of measurement as explanatory variables in the regression models. The direction of the relations between body proportions at birth and systolic pressure were generally unchanged, but they were decreased in size of effect and of borderline statistical significance.

Discussion

The body proportions at birth of the children we studied differed between countries. Compared to those born in Uppsala, those born in Chengdu, Guatemala City and Santiago were smaller in head circumference, length and weight at birth (Table 1Go). Those in Sagamu were thin, with a relatively greater reduction in weight than in length. All babies were born after 37 weeks gestation, and differences in their body proportions therefore reflect fetal growth rather than length of gestation. Our observations suggest that the babies in Chengdu, Guatemala City and Santiago experienced reduced growth throughout gestation, a pattern of growth which is prevalent in chronically malnourished populations. In contrast, babies in Sagamu may have had reduced growth only in the latter half of pregnancy.

The study was a follow-up of children who had already been studied for another purpose. The selection criteria for the original WHO study are likely to have sampled mothers from the more educated or affluent sections of the communities studied, limiting the generalizability of our results. We regard our results as illustrating different population patterns of fetal growth rather than being representative of the five countries studied. Size was measured at admission to the WHO study, within a few days of birth during which some measurements such as head circumference and weight undergo change. We adjusted measurements of size at admission for the number of days after birth that the measurement was made. However, when we repeated the analyses using unadjusted size at admission, no meaningful changes in the results were noted (analyses not shown).

As expected, the relations we have found between birth size and systolic pressure were smaller than those seen in adults, and were most apparent after adjusting for current body weight. We have found that the relations differed between the five countries. In Chengdu, Guatemala City and Santiago, raised systolic pressure was associated with proportionately reduced growth beginning in early gestation. Consistent with the prevalence of chronic malnutrition in these countries, the mothers were short compared with mothers in Uppsala, their mean heights being 154.5, 152.1 and 155.3 cm, respectively, compared to 167.6 cm in Uppsala.

Size at birth was not related to systolic pressure in Sagamu. Whereas studies of children have generally shown an inverse relation between birthweight and blood pressure after adjustment for current weight,3 this inverse relation is less consistent in studies of black populations. A significant inverse relation between birthweight and systolic pressure, after adjustment for current weight, has been found in Jamaican children aged 10–16 years,19 in 5- and 6-year-old children in southern Africa,17,18 and in 7–11-year-old African American boys but not girls.30 However, a study of 10–12-year-olds in Jamaica showed a weak positive relation,21 and there was no relationship in 1–9-year-old Gambian children.20 In a small study of young African American adults, birthweight was weakly positively related to blood pressure.31 These findings suggest that, in black populations, blood pressure may not always be programmed through influences which alter size at birth.

Although smaller size at birth was related to higher systolic pressure after adjustment for current size, in Uppsala, the results did not reach statistical significance. Low ponderal index was the most predictive measurement, which suggests that raised systolic pressure was associated with reduced growth in the latter half of pregnancy. An inverse relation between ponderal index at birth and systolic pressure has been found in other studies of children and adults in Europe.27,32 It has not, however, been found consistently. Published findings show that in developed countries raised blood pressure may be related to either low birthweight, or thinness, or short length at birth.3

In conclusion we have found that raised blood pressure among children in China, Guatemala and Chile is related to proportionate small size at birth, independently of current size. This finding confirms that found in developed countries. It suggests that the long-term effects on the offspring of the promotion of nutrition and health of girls and young women deserve further study in both developed and developing countries.

Acknowledgments

We thank the mothers and children who participated in this study, and the fieldworkers who measured them. We are also grateful to the UNDP/UNFPA/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction for permission to use the data from WHO Project 85917, and to Dr Paul Van Look, Professor Peter Howie, the steering group for WHO Project 85917 and Professor Alan Jackson for help and advice. We thank the Wellcome Trust for financial support.

Notes

b Current address: Worldwide Epidemiology, Glaxo Wellcome Research & Development, London, UK. Back

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