THE JOURNAL OF

PEDIATRICS
AUGUST 1967 V o l u m e 71 Number 2

A practical classification of newborn infants

by weight and gestational age
A classification of newborn infants based upon gestational age and birth weight is
proposed,. The advantages o[ establishing such a routine on a nursery service, and the
possibility o[ superimposing neonatal mortality rates upon gestational-age and
birth-weight data are presented.

Frederick C. Battaglia, M.D., and Lula O. Lubchenco, M.D.

DENVER, COLO.

T I ~ E u s e o F some system on a nursery great part upon establishing some convenient

service which facilitates the recognition of
infants born with birth weights dispropor-
tionate for their gestational age, either too
large or too small, is becoming increasingly
important in pediatrics.
Different clinical problems develop in in-
fants of the same birth weight, but different
gestational ages. Furthermore, the identifica-
tion of a high-risk newborn group is facili-
tated by the use of gestational age informa-
tion, as well as birth weight information.
While gestational age information is help-
ful in the identification of newborn infants at
high risk, its widespread use will depend in
From the Departments of Pediatrics and
Obstetrics and Gynecology, University of
Colorado Medical Center.
Supported by Public Health Service Grants
HD00781-03 and HD00373 and the Children's
Bureau in cooperation with the Colorado State
Department of Public Health and the
University of Colorado Medical Center.
Present Address, University o[ Colorado Medical Center,
4200 East 9th Ave. Denver, Colo., 80220.
method of coding and classifying them by
birth weight and gestational age shortly upon
admission to the nursery service (Table I,
See Editor's Column, p. 309
Fig. 2). In essence, this classification divides
newborn infants into 9 groups, 3 by gesta-
tional age, and within each of these groups,
3 subgroups by birth weight.
S U B D I V I S I O N S BY
G E S T A T I O N A L AGE
In accordance with recent recommenda-
tions of the Committee on the Fetus and
Newborn of the American Academy of Pedi-
atrics, the 3 basic divisions by gestational age
have been referred to as Pre-Term, Term,
and Post-Term. Assuming two weeks as a
reasonable error of the estimated gestational
age based upon the first day of the last men-
strual period, Term has been referred to as
Vol. 7I, No. 2, pp. 159-163
160 Battaglia and Lubchenco The Journal o[ Pediatrics
August 1967

T a b l e I, I n s t r u c t i o n s for use of classification study

Part I: Description o[ chart

1. Neonatal mortality risk (NMR):
There are 4 colored zones shown:
White mE infants with < 4% NMR
Yellow infants with 4%-25% NMR
Blue z infants with 25%-50% NMR
Red infants with > 50% NMR
2. GA-BW distribution:
GA to be estimated from 1st day of LMP and classified by completed weeks:
37 weeks + 0 days = 37 weeks
37 weeks + 6 days = 37 weeks
GA: Subdivided along abscissa into 3 categories:
a. Pre-Term (Pr) ~ All infants less than 38 weeks GA, i.e., 37 weeks + 6 days or less.
b. Term (T) ~ All infants between 38th and 42nd weeks GA.
c. Post-Term (Po) ~- All infants of 42 or more weeks GA.
BW: Within each GA group, there are defined 3 subgroups of infants by BW:
a. LGA ~ Infants above 90th percentile.
b. AGA ~--- Infants between 90th and 10th percentile.
c. SGA ~ Infants below 10th percentile.
Thus, 9 groups of newborn infants are defined and coded as follows:
Pr-LGA Born before 38th week, BW above 90th percentile.
Pr-AGA Born before 38th week, BW between 10th and 90th percentile.
Pr-SGA Born before 38th week, BW below 10th percentile.
T-LGA Born between 38th and 42nd weeks, BW above 90th percentile.
T-AGA Born between 38th and 42nd weeks, BW between 10th and 90tb percentile
T-SGA Born between 38th and 42nd weeks, BW below 10th percentile.
Po-LGA Born at or after 42nd week, BW above 90th percentile.
Po-AGA Born at or after 42nd week, BW between 10th and 90th percentiles.
Po-SGA Born at or after 42nd week, BW below 10th percentile.
Part H: Instructions
I. Shortly after delivery, newborn is to be plotted by GA and BW on above chart; check GA estimate
from 1st day of LMP.
2. Colored tape signifying mortality range (white, yellow, blue, or red) of this infant placed on isolette
or bassinet and on chart.
3. Write on colored tape, 1 set of initials applicable to that infant signifying which one of 9 possible cate-
gories he fails into, e.g., T-AGA.
4. Thus: color of tape ~ mortality subgroup
initials on tape ~ GA and BW subgroup.
5. All infants falling on line dividing 2 zones should be coded as in zone with the highest risk,
e.g., infant of 32 completed weeks GA falling on 10th percentile line should be coded as Pr-SGA.

encompassing all infants born with gesta- ages. 1-6 T h e s e studies h a v e b e e n c a r r i e d o u t

t i o n a l ages f r o m t h e t h i r t y - e i g h t h c o m p l e t e d
w e e k u p to b u t n o t i n c l u d i n g t h e f o r t y - s e c o n d
c o m p l e t e d week. T h u s , all infants b o r n be-
fore 38 c o m p l e t e d weeks are r e f e r r e d to as
P r e - T e r m , a n d all b o r n a f t e r the forty-first
c o m p l e t e d w e e k as P o s t - T e r m .
SUBDIVISIONS BY
BIRTH WEIGHT
S e v e r a l reports h a v e b e e n p u b l i s h e d re-
cently establishing a f r e q u e n c y distribution
of i n f a n t b i r t h weights at v a r i o u s gestational
on w i d e l y d i f f e r e n t p o p u l a t i o n groups. I t is
not surprising, therefore, t h a t s o m e striking
differences in t h e f r e q u e n c y distribution of
i n f a n t b i r t h w e i g h t ' s at various gestational
ages h a v e b e e n f o u n d . H o w e v e r , this v a r i a -
tion is n o t p r e s e n t in the l o w e r p e r c e n t i l e
curves a n d a g r e e m e n t a m o n g the v a r i o u s
studies on t h e t e n t h p e r c e n t i l e d i s t r i b u t i o n is
g o o d ? T h i s is t r u e in p a r t because t h e r e is
a l o w e r absolute limit to t h e birth weight, so
t h a t the d a t a t e n d to cluster into a t i g h t e r
group. M o r e i m p o r t a n t l y , in those studies
 UNIVERSITY OF COLORADO MEDICAL CENTER
CLASSIFICATION OF N E W B O R N S
BY B I R T H W E I G H T AND GESTATIONAL AGE

GRAMS AND BY N E O N A T A L MORTALITY RISK

lllllllllllllll In HIS
uunnnuunounnnn u n m u m
mmmnu~nmmmmnmnmmmmn
mmmmmmmnummmmmmmmwn~m,~,~
mnnnunnm mnunuununuumn~,~
im-- ===I
mmnummmnmmnnunm~imsummmnunnunm
mmulimmiiuw~auim,oH,=uBa
nmmmmmmmmununnpmnmum mnnmu
u n ~ m mnuunnumwn~ammmmmmma Fig.
i~ltlli INN~IHi i~-a Jill
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W E E K S OF G E S T A T I O N

PRE.TERM I TERM I POST.TERM J

UNIVERSITY OF COLORADO MEDICAL CENTER

CLASSIFICATION OF NEWBORNS

GRAMS SY B t R T H W E ( G H T AND GESTATIONAL AGE

Fig. 2

24 25 26 27 2B 29 3 0 31 32 33 34 3 5 3 6 37 3 8 39 4 0 41 42 43 44 45 46

WEEKS OF GESTATION

'E-TERM I,ERM I,O..,.M I

16 2 Battaglia and Lubchenco
that have reported neonatal and perinatal
mortality rates, there has been good agree-
ment among the studies for mortality rates
in a given birth weight and gestationaI age
group5 ~'4 All of these studies have confirmed
the clinical impression that infants born with
birth weights small for their gestational ages
have lower neonatal mortality rates than do
infants of the same weight born earlier in
gestation but greater mortality rates than in-
fants of the same gestational age who have
appropriate birth weights.
The tenth and ninetieth percentile group-
ings based upon both male and female in-
fants from the study of Lubchenco and as-
sociates ~ have been used for the subdivisions
by weight.
All infants above the ninetieth percentile
are referred to as Large for their Gestational
Age, those below the tenth percentile as
Small for their Gestational Age, and those
between the tenth and ninetieth percentile
as Appropriate for their Gestational Age. As
pointed out by Battaglia and asso.ciates, 3 the
choice of which population distribution is
used in the subdivisions by weight would
make little difference in the position of the
tenth percentile, but does make a big dif-
ference in the position of the ninetieth per-
centile.
The Colorado study was chosen for two
reasons: first, it was one of the earliest stud-
ies giving a frequency distribution by birth
weight and gestational age and thus is the one
most familiar to pediatricians. Secondly, this
study has the tightest distribution of appro-
priate for their gestational age infants at
early gestational ages. It seemed worthwhile to
incorporate "this tight distribution" in a clas-
sification proposed for detection of high-
risk infants, since previous studies have
shown that the neonatal mortality rate of
large infants born early is higher by weight
alone than is expected.
NEONATAL MORTALITY RATES
The Neonatal Mortality Rate data of
Erhardt, ~ have been adapted to the birth
weight-gestational age chart. This is the
largest study of mortality rates at given birth
weights and gestational ages. Though it is not
The Journal o/ Pediatrics
August 1967
ideal for such purposes, it is the best available
at this time. Ideally, one would like more nu-
merous Neonatal Mortality Rate zones with
each zone encompassing a narrower mortality
rate group. In addition, such mortality rates
should be based upon local data and revised
frequently (Figs. 1 and 2 contain the same
birth weight-gestational age classification; one
with and one without the superimposed
mortality zones). Thus, the basic classifica-
tion of nine newborn groups can be used
as is, or with Erhardt's data, or with local
Neonatal Mortality Rates substituted when
indicated.
NURSERY PROCEDURE
At the time of admission to the nursery,
the head nurse plots the infant's birth weight
and gestationai age on the chart shown in Fig.
2, using the estimated age calculated by the
house staff from the last day of menstrual
period on the obstetrical chart. The color
of the tape denotes the appropriate Neo-
natal Mortality Rate zone and the letter-
ing, which of the nine gestational age-
birth weight groups the infant falls into
( Table 1).
All infants falling in a blue or red mortal-
ity zone, i.e., 25 per cent or greater risk of
dying, should be admitted to a high-risk
nursery. In addition, all infants who have
any significant clinical problem, regardless of
classification, are admitted to a high-risk
nursery.
The method described above provides a
convenient means of defining Pre-Term,
Term, and Post-Term infants, and the mor-
tality risk makes possible a decision as to type
of nursery care needed for an individual in-
fant. The advantages of setting up such a
routine on a nursery service are considerable.
First, it ensures that all infants in a high
Neonatal Mortality Rate group will be ob-
served closely. Secondly, it makes it a great
deal more convenient on house staff or at-
tending staff rounds to identify small for their
gestational age and large for their gestational
age infants, particularly in separating small
for their gestationaI age Term infants from
appropriate for their gestational age Pre-
Term infants.
Volume 71 Birth-weight and gestationaI-age classification 1 6 3
Number 2
REFERENCES
1. Lubchenco, L. O., Hansman, C., Dressler, M.,
and Boyd, E.: Intrauterine growth as estimated
from liveborn birth-weight data at 24 to 42
weeks of gestation, Pediatrics 32: 793, 1963.
2. Butler, N. R., and Bonham, D. G., editors:
Perinatal mortality: The first report of the
British perinatal mortality survey, London,
1963, E. & S. Livingstone, Ltd.
3. Battaglla, F. C., Frazier, T. M., and I-Iellegers,
A. E.: Birth weight, gestational age, and preg-
nancy outcome, with special reference to high-
birth-weight-low-gestational-age infant, Pedi-
atrics 37: 717, 1966.
4. Ehrhardt, C. L., Joshi, G. B., Nelson, F. G.,
Kroll, B. H., and Weiner, L.: Influence of
weight and gestation on perinatal and neonatal
mortality by ethnic group, Am. J. Pub. Health
54: 1841, 1964.
5. Gruenwald, P.: Growth of the human fetus:
I. Normal growth and its variation, Am. J.
Obst. & Gynec. 94" 1112, 1966.
6. van den Berg, B. J., and Yerushalmy, J.: The
relationship of the rate of intrauterine growth
of infants of low birth weight to mortality,
morbidity, and congenital anomalies, J. PEDIAT.
69: 531, 1966.