August, 1967

164 T h e ] o u r n a l of P E D I A T R I C S

The classification of ne vborn infants

by birth weight and gestational age
The recognition that low-birth-weight infants do not represent a
homogeneous group revived interest in the gestationaI age as an important adjunct
to birth weight in the classification of newborn infants. This paper discusses the
problems generated by the joint classification of births by means of the birth weight
and gestational age. An attempt is made to formulate the objectives and purposes
of such a classification. Certain classification systems currently in use, such as
the percentile curves of Lubchenco and the "'minus two score" of Gruenwald, are
discussed. A scheme for classifying births in five groups is suggested.

j. Yerushalmy, Ph.D. "~

BERIZ~ELlgY~ CALIF.

T H E R F, V t V A L I N r e c e n t y e a r s of gesta- age was estimated by means of the stated

tional age as an additional important cri-
terion for the study of "prematurity" has as
its origin the recognition that "low-birth-
weight" infants do not represent a homo-
geneous group. Not all low-birth-weight in-
fants are the product of pregnancies that
terminate early. A significant number of
them are born at, or near, full term, and
the low birth weight is presumed to be a
reflection of intrauterine maldevelopment
and/or retarded growth. This realization
led to the revival of gestational age as an
important adjunct to birth weight in the
classification of the newborn. 1-7 Gestational
date of the last normal menstrual period,
and it was shown that the reporting of last
menstrual period was adequate f o r the pur-
pose. s, ~ The requirement to include the date
of last menstrual period on the birth and
stillbirth certificates recently adopted in a
number of areas made possible the utilization
of gestational age and birth weight in the
study of very large and unselected groups of
births?0, 11
The introduction of length of gestation as
a second axis of classification creates a num-
See Editor's Column, p. 309.

From the Child Health and Development
Studies of the Division of Biostatisties, School
of Public Health, University of California,
Berkeley; the Permanente Medical Group and
the Kaiser Foundation Research Institute.
Supported by grants Nos. IID 00718 and
RG5332 of the National Institutes of Health.
~Address: Child Health and Development Studies,
3867 Howe St., Oakland, Cali]. 94511.
Vol. 71, No. 2, pp. t64-172
ber of problems. Thus, Gruenwald 12 recently
pointed out the confusion in terminology
which currently exists in the literature. More
important, however, is the need to formulate
clearly the purposes and objectives which the
classification system is to serve.
Volume 71 Birth-weight and gestationaI-age classification
Number 2
It is the purpose of this presentation to
attempt to formulate such objectives, to re-
view certain of the systems currently in use,
and to suggest a classification scheme which
more nearly meets the objectives.
OBJECTIVES
It has been demonstrated that low-birth-
weight infants do not represent a homogene-
ous group. It was shown that mortality rates
of low--birth-weight neonatal infants of differ-
ent gestational ages differ? -4, 9-~a In addition,
it has been observed clinically that some
children with certain severe congenital anom-
alies were born at low birth weights after
relatively long gestations. 13-16
A more detailed investigation has shown
that infants who reached the same low-birth-
weight at different gestational ages differed
markedly in several respects? 7 Underweight
infants with the shortest gestation for their
birth weight were found to have a more
difficult time in adapting to the extrauterine
environment than did infants with the same
birth weights but with longer gestational
periods. Thus, the former infants experienced
higher neonatM mortality rates, longer stays
in the hospital immediately after birth, and
longer occupancy of incubators. However,
when the low birth weight infants of short
gestation survived the first few months of
life, their prognosis in terms of health and
growth was better than that of the low birth
weight infants of long gestation. The latter
infants also had a higher incidence of severe
congenital anomalies.
These findings are helpful in formulating
objectives for classification systems of new-
born infants based on birth weight and gesta-
tional age. It may be stated that an adequate
classification system must facilitate the sub-
division of low-birth-weight infants according
to gestational age in meaningful subgroups--
meaningful in the sense that the experience
of the infants in these subgroups relative to
mortality, morbidity, and congenital anom-
alies is in accord with the above findings.
It is obvious that no simple classification
scheme can be expected to provide as much
information as may be obtained by a corn-
1 65
prehensive investigation. A certain amount
of detail must be sacrificed for the sake of
simplicity. The usefulness of a classification
system may be judged by the balance which
it achieves in attaining maximum simplicity
with the sacrifice of a minimum of essential
detail.
The achievement of the desired balance
depends, among other things, upon an evalu-
ation of the relative importance of the birth-
weight and gestational-age factors. For ex-
ample, if birth weight has a significantly
greater effect on outcome than does gesta-
tional age (or vice versa), the classification
system must be constructed to bring into
sharp focus the interaction between the two,
rather than the effect of the predominant
one. In other words, the subgroups of the
classification system should differentiate low-
birth-weight infants of different rates of
intrauterine growth.
In this connection it is instructive to com-
pare the variation of the neonatal mortality
rate by birth weight and gestational age:
Table I was constructed from data covering
a three-year period of live-born infants in
New York City. ~
The rates in the vertical columns vary
according togestational age only, since they
relate to very limited birth-weight groups
(250 grams). The rates along the horizontal
rows vary by birth weight alone, since they
relate to a single week of gestation. The
mortality rate varies with birth weight to a
much greater extent than it does with gesta-
tional age. For example, for infants in the
birth-weight group of 1,501 to 1,750 grams,
the range of the neonatal mortality rate was
from 517 to about 128, whereas for all in-
fants born at 32 weeks of gestation the varia-
tion of the rate was much greater; it ranged
from around 800 to 24. These observations
are in accord with those of Abernathy and
associates, is who reported similar findings
for a large number of characteristics related
to outcome of pregnancy.
In light of the above, the adequacy of a
~I am greatly indebted to Dr. Erhardt and the late Dr.
Jacobziner of the New York City Health Department for
making copies of the birth and death certificates available
to me.
1 66 Yerushalmy
classification system may be judged (a) by
the extent to which it satisfies the major
objective--namely that it reflects differences
in rate o[ intrauterine growth, and (b) by
the balance which it achieves in attaining
maximum simplicity with the sacrifice of a
mininmm of essential detail. We will use
these guidelines in reviewing certain classi-
fication systems.
R E V I E W OF S O M E
CLASSIFICATION SYSTEMS
CURRENTLY IN USE
A number of different classification sys-
tems based on birth weight and gestational
age have been proposed and used in the last
few years. Among the most frequently en-
countered are the percentile curves con-
structed by Lubchenco, a9 sometimes referred
to as the "Denver curves," and the "minus-
two score" proposed by Gruenwald. 20
The percentile curves. These are con-
structed by arraying the infants in each week
of gestation in ascending birth-weight order
and assembling the lowest 10 per cent in each
gestation week to form the tenth percentile
curve, and similarly for the twenty-fifth, fif-
tieth, seventy-fifth, and ninetieth percentiles.
These curves and others constructed on the
same principle by other workers TM 2~ have
been used by a number o{ investigators as
standards. In particular, the tenth percentile
curve is being accepted as representing the
infants who have experienced retarded intra-
uterine growth. Groups of infants with a
special condition, for example, those with a
given congenital malformation, are plotted
on these curves. If it is found that a relatively
large number of them fall within the area
bounded by the tenth percentile curve, it is
assumed that intrauterine growth retardation
is implicated in that condition. 23-2~
This conclusion, however, may not be
justified. Since the birth-weight distribution
differs greatly for the different percentiles,
the low-birth-weight factor often predom-
inates and obscures the comparison. Infants
falling below the tenth percentile curve ob-
viously are of much lower birth weight than
those falling above it. Since, as was shown
The ]ournaI o[ Pediatrics
August 1967
above, the birth weight is a much more im-
portant factor as regards outcome than is
gestational age, it is not possible to conclude
that the special condition is related to re-
tarded growth, because it may be due in
whole or in part to the low birth weight.
A more serious defect may be seen from
the following consideration. Percentile curves
can be constructed under two procedures:
(1) infants are arrayed by birth weight in
each week of gestation and the 10 per cent
of lowest weight for each week are assem-
bled to form the tenth percentile curve
(Lubchenco procedure), and (2) infants are
arrayed by gestational age in each narrow
birth-weight group and the 10 per cent of
longest gestation for each birth-weight group
are assembled to form a tenth percentile
curve. These two curves represent basically
the same phenomenon as regards interaction
between birth weight and gestational age.
The tenth percentile curve under Procedure
No. 1 represents the smallest infants for
gestational age and therefore is composed of
infants of relatively slow intrauterine growth.
The tenth percentile curve under Procedure
No. 2 represents infants with the longest ges-
tation for their birth weight and therefore
is also composed of infants of relatively slow
intrauterine growth.
A priori there is no reason to prefer one
procedure over the other. It is, however, to
be expected that, if the percentile method
is valid, the curves provided by the two pro-
cedures should not convey contradictory in-
formation. A review of Figs. 1 and 2 shows
that such is not the case.
Figs. 1 and 2 were constructed from the
same data of Table I--with the use of Pro-
cedure No. 1 and Procedure No. 2, respec-
tively. The two figures classify the births
differently with respect to rate of intrauterine
growth.
For example, if a pediatrician is presented
with an infant of 34 weeks' gestation with a
birth weight of 2,000 grams and he plots
these values on the Lubchenco type curve
(Fig. 1, point A), the point is under the
tenth percentile curve. He would therefore
be inclined to infer that the infant has been
Volume 71 Birth-weight and gestational-age classification 16 7
Number 2

[
4.000 r- 90%
I
~'~5oo
~ pI 50%

~3000I

~2500
10%

1500 I

1 0 0 0~-- I I I I I I I
26 28 30 32 54 36 38 40 4.2
Gestation ('weeks)
Fig. 1. Percentile curves constructed under procedure (1) : Infants arrayed by birth weight in
ascending order in each week of gestation and assembled to form tenth, fiftieth, and ninetieth
percentiles (based on data for a 3 year period in New York City).

90~176 50% 10%

4000

3500

3000

~O~ 25oo

~ 2000 Be

1500

I000
[ I I I I [ I I i
26 28 30 32 34 36 38 40 42
Gestation (weeks)
Fig. 2. Percentile curves c o n s t r u c t e d u n d e r p r o c e d u r e ( 2 ) : I n f a n t s a r r a y e d by gestational age
in d e s c e n d i n g order in each n a r r o w b i r t h - w e i g h t g r o u p a n d assembled to f o r m tenth, fiftieth,
a n d n i n e t i e t h percentiles (based on d a t a for a 3 year period in N e w York City).
1 68 Yerushalmy The ]ournaI o[ Pediatrics
August 1967

Table I. Neonatal mortality rates by birth weight and gestational age, New York
City, 1957-1959 (single white live born infants)

Birth weight
(grams)
Gestation 1,001- ] 1,251- 1,501- 1,751- 2,001- 2,251- 2,501- 3,001-
(weeks) < 1,000 1,250 1,500 1,750 2,000 2,250 2,500 3,000 3,500 3,501+ Total
0-27 944.8 800.0 615.9 305.6 1 4 7 . 1 219.5 111.1 73.2 41.7 83.3 674.2
28 887.3 645.6 594.3 517.2 218.8 74.1 58.8 34.5 20.0 -- 400.0
29 833.3 476~9 471.7 442.3 160.7 161.3 68.2 12.0 22.2 27.8 291.0
30 862.1 526.3 474.5 407.4 383.7 137.3 39.0 25.4 -- 15.2 207.1
31 772.7 518.5 362.6 274.0 375.0 179.5 73.7 16.7 4.1 20.6 166.9
32 866.7 590.9 400.0 252.3 1 9 0 . 3 109.9 98.7 25.2 23.7 6.1 112.6
33 800.0 2 9 4 . 1 509.4 287.7 142.9 102.6 92.5 16.4 5.0 4.3 70.6
34 750.0 400.0 342.1 205.9 128.3 63.8 46.7 24.5 11.4 13.6 41.6
35 777.8 333.3 285.7 250.0 107.0 57.3 28.1 20.6 10.8 13.0 28.4
36 777.8 125.0 416.7 127.7 84.1 47.3 23.8 13.8 5.0 7.7 17.1
37 714.3 333.3 360.0 156.9 91.8 56.6 18.9 9.3 5.4 9.2 12.0
38 666.7 666.7 71.4 2 3 9 . 1 111.1 39.0 12.2 6.0 4.1 5.0 6.7
39 500.0 400.0 277.8 303.0 68.8 37.0 19.0 4.3 3.3 3.6 4.8
40 428.6 500.0 222.2 178.6 76.3 49.0 16.0 5.8 4.0 3.1 4.7
41-42 714.3 333.3 476.2 350.0 149.1 47.9 21.1 9.6 3.6 4.0 5.7
43+ t000.0 666.7 500.0 230.8 139.5 77.8 41.3 12.3 7.6 8.0 10.4
Total 917.0 613.9 464.8 283.4 151.9 61.6 24.8 8.1 4.3 4.5 14.1

retarded in intrauterine growth. O n the gestation. T h e y are being referred to as "-2

other hand, if he enters the same values on
Fig. 2, the point plots beyond the fiftieth
percentile (Fig. 2, point A ) . H e would there-
fore conclude that the infant is of normal
intrauterine growth. A similar discrepancy
m a y be noted for point B in the two figures
(37 weeks' gestation and 2,250 grams), and
in m a n y other combinations of birth weight
and gestation.
It is idle to speculate whether or not one
of the procedures is superior to the other. It
is certainly not our intention to argue that
one of them is a better representation of the
true situation than is the other. The impor-
tant point is that completely different impres-
sions are conveyed by the two procedures--a
very basic weakness of the percentile method
of classification.
I t should also be pointed out that either
of these procedures of constructing percentile
curves is not simple, since it involves con-
siderable arithmetic manipulation, and each
group must construct its own set of curves.
Minus-two score. This classification, pro-
posed by Gruenwald, 20 relates to infants
whose birth weight is below two standard
deviations from the m e a n in each week of
score neonates," "small for dates, . . . . chronic
fetal distress," "growth-retarded neonates,"
and so on. T h e method is not different in
concept from that of Lubchenco; indeed, it
represents the "21/~ to 3" percentile curve on
the Lubchenco scheme. Consequently, all the
limitations indicated above for the Denver
curves apply with equal force to the "-2
score" method, An added disadvantage is
that the " - 2 score neonates," or, as they are
usually referred to, the "small for dates,"
are often compared to the remaining low-
birth-weight infants, that is, infants weighing
2,500 grams or less, minus the small for dates
infants. Findings concerning any handicaps
found for the " - 2 score" babies are often
presented with the implication that the han-
dicap is related to the fact that the infants
are small for dates. 26-2s This conclusion, how-
ever, is not justified, because the differences
found between the small for dates infants
and the remaining low-birth-weight infants
may merely reflect the fact that the " - 2
score" infants are small but not necessarily
that they are small for dates. Indeed, the
difference in birth weight between the small
for dates group and the remainder of the
Volume 71 Birth-weight and gestational-age classification
Number 2
low-birth-weight group is so great that any
comparison between them is not meaningful.
For births of 37 weeks or more gestation,
the "-2 score" and the low-birth-weight in-
fants represent, on the whole, the same
group; consequently, no comparison is pos-
sible. For births of less than 37 weeks' gesta-
tion, the mean birth weight of the small for
dates infants is considerably below that of
the remainder of the low-birth-weight infants
(1,378 versus 1,857 grams).
Therefore, it is obvious that the classifica-
tion scheme in which infants of the lowest
birth weight for each gestational week are
selected to form either the tenth percentile
or the small for dates group cannot be used
to evaluate adequately the relationship to
intrauterine growth retardation.
Cross-tabulation by birth weight and gesta-
tion. The other main method of classification
utilizes the accepted dividing points of 2,500
grams and of 37 weeks as points of separa-
tion.29, s0 The newborn infants are thus di-
vided into four groups: (1) mature by both
criteria; (2) mature by birth weight, pre-
mature by gestation; (3) mature by gesta-
tion, premature by birth weight; and (4)
premature according to both. This classifica-
tion possesses a number of desired properties.
It is relatively simple, it provides unique
subgroups, it uses distinct and definite points
of separation, and thus can be universally
applied. However, the method retains the
major deficiency that the subgroups differ
grossly in birth weights. The separation of
infants with birth weights of 2,500 grams or
less into those of less than 37 weeks and
those of 37 weeks or more gestation does not
provide an adequate comparison by which
the length of gestation effect can be evalu-
ated. For here again, there is too great a
discrepancy in the mean birth weight. For
example, the perinatal mortality rate of in-
fants of low birth weight and also of low
gestation is nearly five times as high as that
of low-birth-weight infants of long gestation
(374.2 versus 74.5 per 1,000). However, the
mean birth weights of the two groups also
differ greatly (i,735 versus 2,288 grams).
It is therefore not possible to conclude that
1 69
the high rate in the < 37 "~eeks' group is
due to the short gestation, because it may be
due to low birth weight.
A SUGGESTED CLASSIFICATION
It is obvious that detailed tabulations by
birth weight and gestation such as are shown
in Table I provide much of the data neces-
sap/ for the investigation and understanding
of the role of the rate of intrauterine growth
in pregnancy outcome. Such tables, however,
are much too complex for use in the day-by-
day operations of pediatricians and obstetri-
cians.
The problem turns, therefore, to finding a
satisfactory compromise--to provide a classi-
fication scheme which is not too complex and
at the same time identifies groups which, for
broad gestational age groupings, do not differ
too much in their mean birth weight so that
meaningful comparisons can be achieved.
Such a classification system is presented in
Table II.
The scheme retains the advantages of the
distinct points of separation (2,500 grams
and 37 weeks) but separates out from the
low birth weight groups the smallest infants
(1,500 grams or less). The rationale behind
this scheme is first that the mortality rate of
this group of very small infants is extremely
high--two thirds of them die in the first
month of life. They therefore represent spe-
cial problems which should not be diluted
by their inclusion with the other low-birth-
weight infants. Second, they could not be
separated by gestation in a similar way to
the other low-birth-weight infants since only
around 7 per cent of them occur at 37 or
Table II. A suggested classification of
newborn infants by birth weight and
gestational age
Birth weight (weeks)
Group (grams) Gestation
I 1,500 or less All
II 1,501-2,500 Less than 37
III 1,501-2,500 37 or more
IV 2,501 or more Less than 37
V 2,501 or more 37 or more
1 70 Yerushalmy
more weeks of gestation. In fact, more than
half of them occur at 28 weeks of gestation
or less. Consequently', if they are to be stud-
ied for retarded growth, they must be han-
dled differently than the remaining low-
birth-weight infants. Third, and most impor-
tant from the point of view of the objectives
of the suggested classification, their inclusion
dilutes the remainder of the low-birth-weight
infants and makes impossible meaningful
comparisons to detect the effects of retarded
growth. Consequently, it is proposed that
newborn infants be classified in five groups
(Table II).
These groups are distinguishable in their
ability to survive the neonatal period (Fig.
3). Thus, even the infants in Group IV, con-
sisting of those who weigh more than 2,500
grams but were of less than 37 weeks gesta-
tion, experienced a threefold increase in neo-
natal mortality compared to those in Group
V. There was a further doubling of the mor-
tality rate for Group III infants, a further
on
Do
2500
1500
Gestation
Fig. 3. Graphic presentation of the division of newborn infants in 5 groups by birth weight
and gestational age, and the neonatal mortality rate in each group (based on data for a 3
year period in New York City).
The Journal o[ Pediatrics
August 1967
threefold increase for those of Group II, and
a large sevenfold additional increase for the
tiny infants of Group I.
It is true that this scheme does not succeed
in equalizing Groups II and III entirely for
birth weight, but the difference in the mean
birth weight is not very large (2,136 versus
2,284 grams).
One test of the adequacy of the use of
Groups II and III for the purpose of in-
vestigating the differences in infants of dif-
ferent rates of intrauterine growth is to
determine whether the findings agree with
those obtained by the more comprehensive
investigation 17 in which the groups were
made identical for birth weight. In that
study of low-birth-weight infant% the neo-
natal mortality rate was higher for the
infants with a short gestation period than for
those with a longer gestation, whereas the
latter infants had a higher incidence of se-
vere congenital anomalies. Table III demon-
strates that, by the use of the proposed classi-
37
37
(weeks)
Volume 71
Number 2
Table I I I . Neonatal mortality rates and per
cent of infants with severe congenital
anomalies for infants weighing 1,501-2,500
grams divided into those of less than 37
weeks and of 37+ weeks' gestational age
Neonatal Per cent
mortality o[ in[ants
rate per with se-
In[ants o[ birth weight 1,000 live vere a n o ? r ~ -
1,501-2,500 grams births ~ alies t
Group II
Of ~ 37 weeks' gestation 104.3 5.9
Group I I I
Of 37+ weeks' gestation 32.0 11.0
~New York City, from 1957 to 1959.
~'Child Health and Development Studies, from 1959 to
1964.
fication, similar results are obtained. Thus
the neonatal mortality rate is m u c h higher
for Group I I (short gestation) than for
Group I I I (long gestation) (104.3 versus
32.0). T h e incidence of severe anomalies, on
the other hand, was m u c h higher for Group
I I I than for G r o u p I I (11.0 versus 5.9).
T h e concepts and objectives on which the
suggested classification is based appear to
be valid. T h e classification succeeds in ful-
filling the main objective of separating, in a
gross way, infants of low birth weight ac-
cording to rates of intrauterine growth.
It may, however, be questioned whether
the suggested exact points of separation,
namely 2,500 grams, 37 weeks, and espe-
cially 1,500 grams are optimal. A prelim-
inary analysis indicates that no m a j o r ad-
vantages would be gained from changing
either of the two accepted limits of 2,500
grams and 37 weeks nor the 1,500 grams
limit for identifying the very small infants.
However, in view of the known differences
in the distribution according to birth weight
and gestational age of the different races, the
sexes, and other groups, more intensive study
of the desired dividing points is indicated.
The author wishes to thank Dr. B6a J. van
den Berg for many suggestions and critical com-
ments, and Mrs. Margaret McCann for assistance
in statistical activities.
Birth-weight and gestational-age classification 17 1
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172 Yerushalmy
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