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Paternal factors and low birthweight, preterm, and small for gestational age births: a systematic review

  • Prakesh S. Shah
    Correspondence
    Reprints: Prakesh S. Shah, MD, Department of Paediatrics, Mount Sinai Hospital, 775A-600 University Ave., Toronto, Ontario, Canada M5G 1X5
    Affiliations
    Department of Pediatrics, Mount Sinai Hospital, and the Departments of Pediatrics and of Health Policy, Management and Evaluations, University of Toronto, Toronto, Ontario, Canada
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  • Knowledge Synthesis Group on determinants of preterm/low birthweight births
      A systematic review of the risks of a low birthweight (LBW), preterm, and small-for-gestational-age births in relation to paternal factors was performed. Medline, Embase, Cumulative Index of Nursing and Allied Health Literature, and bibliographies of identified articles were searched for English-language studies. Study qualities were assessed according to a predefined checklist. Thirty-six studies of low-to-moderate risk of bias were reviewed for various paternal factors: age, height, weight, birthweight, occupation, education, and alcohol use. Extreme paternal age was associated with higher risk for LBW. Among infants who were born to tall fathers, birthweight was approximately 125-150 g higher compared with infants who were born to short fathers. Paternal LBW was associated with lower birthweight of the offspring. In conclusion, paternal characteristics including age, height, and birthweight are associated with LBW. Paternal occupational exposure and low levels of education may be associated with LBW; however, further studies are needed.

      Key words

      Low birthweight (LBW) birth and preterm births (PTBs) are public health issues with significant individual, familial, and societal impact. Familial influence in the cause of LBW/PTB births is suspected; however, the major research attention has been focused on maternal determinants. Paternal factors (such as advanced paternal age
      • Zhu J.L.
      • Madsen K.M.
      • Vestergaard M.
      • Olesen A.V.
      • Basso O.
      • Olsen J.
      Paternal age and congenital malformations.
      and chemical exposures) have been linked with congenital malformations. De La Rochebrochard et al,
      • De La Rochebrochard E.
      • McElreavey K.
      • Thonneau P.
      Paternal age over 40 years: the “amber light” in the reproductive life of men?.
      in a minireview, concluded that advanced paternal age (>40 years) was associated with miscarriages and fetal deaths. Diseases such as Alpert syndrome, Marfan syndrome, and Waardenberg syndrome are associated with advanced paternal age. Strobino et al
      • Strobino B.R.
      • Kline J.
      • Stein Z.
      Chemical and physical exposures of parents: effects on human reproduction and offspring.
      reviewed the connection between paternal occupational exposure and effect on offspring. They reported that paternal occupation was not associated with spontaneous abortion and that there was a lack of conclusive impact on other birth outcomes.
      For Editors' Commentary, see Table of Contents
      See related editorial,page 99
      Studies have reported paternal factors that influence birthweight or gestational age. However, no comprehensive review of paternal determinants or factors on LBW, PTB, or small for gestational age (SGA) births has been conducted. The objective of this study was to review systematically the risk of an infant with LBW, PTB, and SGA in relation to various reported paternal factors.

      Materials and Methods

      The data were extracted from published articles; therefore, no ethical approval was obtained.

      Criteria for consideration of studies for this review

      Observational studies that explored the association of any of the paternal factors and the outcomes of LBW, PTB, and SGA births of offspring were included in this review. If the study provided adequate information on the method of ascertainment of the paternal factor and its effects on any of the outcomes of interest, the study was eligible for inclusion in the review. We included only information that was available from the publications and did not contact primary authors. Studies that were published as abstracts were excluded.

      Types of studies

      Observational cohort studies, case control studies, and studies of surveys or interviews were included. Reports of data from national or local vital statistics that were not published as peer-reviewed articles were not included.

      Types of participants

      Women who had a live birth were included. Data on reports of maternal influence on birth outcomes were not included in this review.

      Assessment of exposure

      Previous knowledge of the subject indicated that paternal age, anthropometry, paternal birthweight, occupation, and educational background would be probable exposures to be included in the review.
      • Shah P.S.
      • Ohlsson A.
      Intergenerational influences, paternal factors and fetal factors.
      We did not include paternal race as an exposure variable because race has a complex interaction with maternal race. Similarly, we excluded paternal smoking as an exposure because most studies have reported on environmental tobacco exposure, which could have been from partners or other sources, and it was difficult to differentiate. We included studies that reported a collection of ascertainment of exposure data from maternal charts, interview, and direct or indirect assessments.

      Types of outcome measures

      Studies that reported data on any of the following outcomes were included: (1) LBW birth defined as birthweight <2.5 kg; (2) PTB defined as gestational age <37 weeks; (3) birthweight in grams; (4) gestational age in weeks, and (5) SGA birth defined as birthweight <10th percentile for gestational age.

      Search strategy for identification of studies

      Electronic databases (Medline, Embase, and Cumulative Index of Nursing and Allied Health Literature) were searched, with assistance from an experienced librarian, from their inception to March 2009 for all published studies in the English language. The search terms were modified according to database requirements. The reference lists of the identified articles were reviewed to locate additional eligible studies. The articles were scanned initially on the basis of titles and abstracts. The reviewer was not blinded to authors or institution. Selected articles were retrieved in full and were assessed for eligibility. Search terms used were low birthweight; premature birth; preterm birth; small for gestational age; growth, intrauterine; growth restriction, fetal; growth restriction, intrauterine; high risk pregnancy; infant, premature; infant, newborn; pregnancy; familial factors; father, paternal factors, paternal age, paternal birthweight, occupation, education, anthropometry, weight, height, body mass, and body mass index.

      Methods of the review

      Data extraction

      Data from each eligible study were extracted into custom-made data collection forms. Minor modifications (such as combining birthweight means for male and female subjects) and the calculation of raw percentages from available data were done. Confounders that were adjusted for in the analyses in the individual studies were reported. When adjusted data were reported in the primary studies, they were extracted and noted in the results.

      Assessment of quality of included studies

      The methodologic quality of studies was assessed with a predefined checklist that was based on criteria for the sample selection, exposure assessment, outcome assessment, confounder, and analytical and attrition biases (Appendix). The classifications were applied in each category: cannot tell, no bias, low risk, moderate risk, or high risk of bias.

      Data synthesis

      We expected a significant degree of clinical heterogeneity among studies in each of the paternal factors and planned for a systematic review and not metaanalyses from the outset. Qualitative synthesis of the evidence was planned because of the reasons mentioned earlier.

      Heterogeneity and publication bias assessment

      Clinical heterogeneity was assessed and reported in the Tables.

      Results

      Description of studies

      Thirty-eight studies were included in this review.
      • Abel E.L.
      • Kruger M.
      • Burd L.
      Effects of maternal and paternal age on Caucasian and Native American preterm births and birth weights.
      • Astolfi P.
      • De Pasquale A.
      • Zonta L.A.
      Paternal age and preterm birth in Italy, 1990 to 1998.
      • Basso O.
      • Wilcox A.J.
      Paternal age and delivery before 32 weeks.
      • Chen X.K.
      • Wen S.W.
      • Krewski D.
      • Fleming N.
      • Yang Q.
      • Walker M.C.
      Paternal age and adverse birth outcomes: teenager or 40+, who is at risk?.
      • Nahum G.G.
      • Stanislaw H.
      Relationship of paternal factors to birth weight.
      • Olshan A.F.
      • Ananth C.V.
      • Savitz D.A.
      Intrauterine growth retardation as an endpoint in mutation epidemiology: an evaluation based on paternal age.
      • Reichman N.E.
      • Teitler J.O.
      Paternal age as a risk factor for low birthweight.
      • Selvin S.
      • Garfinkel J.
      The relationship between parental age and birth order with the percentage of low birth-weight infants.
      • Tough S.C.
      • Faber A.J.
      • Svenson L.W.
      • Johnston D.W.
      Is paternal age associated with an increased risk of low birthweight, preterm delivery, and multiple birth?.
      • Zhu J.L.
      • Madsen K.M.
      • Vestergaard M.
      • Basso O.
      • Olsen J.
      Paternal age and preterm birth.
      • Cawley R.H.
      • McKeown T.
      • Record R.G.
      Parental stature and birth weight.
      • Klebanoff M.A.
      • Mednick B.R.
      • Schulsinger C.
      • Secher N.J.
      • Shiono P.H.
      Father's effect on infant birth weight.
      • Magnus P.
      • Berg K.
      • Bjerkedal T.
      • Nance W.E.
      Parental determinants of birth weight.
      • Miletic T.
      • Stoini E.
      • Mikulandra F.
      • Tadin I.
      • Roje D.
      • Milic N.
      Effect of parental anthropometric parameters on neonatal birth weight and birth length.
      • Morrison J.
      • Williams G.M.
      • Najman J.M.
      • Andersen M.J.
      The influence of paternal height and weight on birth-weight.
      • Pritchard C.W.
      • Sutherland H.W.
      • Carr-Hill R.A.
      Birthweight and paternal height.
      • To W.W.
      • Cheung W.
      • Kwok J.S.
      Paternal height and weight as determinants of birth weight in a Chinese population.
      • Wilcox M.A.
      • Newton C.S.
      • Johnson I.R.
      Paternal influences on birthweight.
      • Winikoff B.
      • Debrovner C.H.
      Anthropometric determinants of birth weight.
      • Coutinho R.
      • David R.J.
      • Collins Jr, J.W.
      Relation of parental birth weights to infant birth weight among African Americans and whites in Illinois: a transgenerational study.
      • Klebanoff M.A.
      Paternal and maternal birthweights and the risk of infant preterm birth.
      • Little R.E.
      Mother's and father's birthweight as predictors of infant birthweight.
      • Magnus P.
      • Gjessing H.K.
      • Skrondal A.
      • Skjaerven R.
      Paternal contribution to birth weight.
      • Dimich-Ward H.
      • Hertzman C.
      • Teschke K.
      • et al.
      Reproductive effects of paternal exposure to chlorophenate wood preservatives in the sawmill industry.
      • Hooiveld M.
      • Haveman W.
      • Roskes K.
      • Bretveld R.
      • Burstyn I.
      • Roeleveld N.
      Adverse reproductive outcomes among male painters with occupational exposure to organic solvents.
      • Kristensen P.
      • Irgens L.M.
      • Daltveit A.K.
      • Andersen A.
      Perinatal outcome among children of men exposed to lead and organic solvents in the printing industry.
      • Lawson C.C.
      • Schnorr T.M.
      • Whelan E.A.
      • et al.
      Paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin and birth outcomes of offspring: birth weight, preterm delivery, and birth defects.
      • Lin S.
      • Hwang S.A.
      • Marshall E.G.
      • Marion D.
      Does paternal occupational lead exposure increase the risks of low birth weight or prematurity?.
      • Michalek J.E.
      • Rahe A.J.
      • Boyle C.A.
      Paternal dioxin, preterm birth, intrauterine growth retardation, and infant death.
      • Milham S.
      • Ossiander E.M.
      Low proportion of male births and low birth weight of sons of flour mill worker fathers.
      • Min Y.I.
      • Correa-Villasenor A.
      • Stewart P.A.
      Parental occupational lead exposure and low birth weight.
      • Mjoen G.
      • Saetre D.O.
      • Lie R.T.
      • et al.
      Paternal occupational exposure to radiofrequency electromagnetic fields and risk of adverse pregnancy outcome.
      • Sanjose S.
      • Roman E.
      • Beral V.
      Low birthweight and preterm delivery, Scotland, 1981-84: effect of parents' occupation.
      • Savitz D.A.
      • Whelan E.A.
      • Kleckner R.C.
      Effect of parents' occupational exposures on risk of stillbirth, preterm delivery, and small-for-gestational-age infants.
      • Parker J.D.
      • Schoendorf K.C.
      Influence of paternal characteristics on the risk of low birth weight.
      • Passaro K.T.
      • Little R.E.
      • Savitz D.A.
      • Noss J.
      Effect of paternal alcohol consumption before conception on infant birth weight: ALSPAC Study Team: Avon Longitudinal Study of Pregnancy and Childhood.
      • Savitz D.A.
      • Zhang J.
      • Schwingl P.
      • John E.M.
      Association of paternal alcohol use with gestational age and birth weight.
      • Windham G.C.
      • Fenster L.
      • Hopkins B.
      • Swan S.H.
      The association of moderate maternal and paternal alcohol consumption with birthweight and gestational age.
      Some of the included studies reported on >1 paternal factor. Paternal alcohol use was identified as an exposure during the literature review (which was not planned a priori). Eleven studies were excluded after detailed evaluation. Details of included studies and reasons for excluded studies are given in Figure 1.
      • Aschengrau A.
      • Monson R.R.
      Paternal military service in Vietnam and the risk of late adverse pregnancy outcomes.
      • Jaquet D.
      • Swaminathan S.
      • Alexander G.R.
      • et al.
      Significant paternal contribution to the risk of small for gestational age.
      • Joffe J.M.
      • Soyka L.F.
      Paternal drug exposure: effects on reproduction and progeny.
      • Lie R.T.
      • Wilcox A.J.
      • Skjaerven R.
      Maternal and paternal influences on length of pregnancy.
      • Little R.E.
      • Sing C.F.
      Association of father's drinking and infant's birth weight.
      • Little R.E.
      • Sing C.F.
      Father's drinking and infant birth weight: report of an association.
      • Rubin D.H.
      • Leventhal J.M.
      • Krasilnikoff P.A.
      • Weile B.
      • Berget A.
      Father's drinking (and smoking) and infant's birth weight.
      • Schnorr T.M.
      • Lawson C.C.
      • Whelan E.A.
      • et al.
      Spontaneous abortion, sex ratio, and paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin.
      • Schwartz D.A.
      • Newsum L.A.
      • Heifetz R.M.
      Parental occupation and birth outcome in an agricultural community.
      • Townsend J.C.
      • Bodner K.M.
      • Van Peenen P.F.
      • Olson R.D.
      • Cook R.R.
      Survey of reproductive events of wives of employees exposed to chlorinated dioxins.
      • Wolfe W.H.
      • Michalek J.E.
      • Miner J.C.
      • et al.
      Paternal serum dioxin and reproductive outcomes among veterans of Operation Ranch Hand.
      Figure thumbnail gr1
      FIGURE 1Flow diagram of included studies.
      SGA, small for gestational age.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.

      Methodologic quality of included studies

      The results of the quality assessments of the included studies are reported in TABLE 1, TABLE 2, TABLE 3, TABLE 4, TABLE 5, TABLE 6. The studies had low-to-moderate risk of biases. The major criticism of the included studies was that the assessment of exposure in many reports was indirect (such as maternal history, derived or deduced assessment method for occupational exposure). Adjustment of confounders was variable among studies; however, compared with other reports of determinants of LBW/PTB births, most of the studies in this category have accounted for common confounders. Assessment of outcomes was satisfactory in most studies. Many studies reported only incidence or percentage of outcome data and not odds ratio or relative risk and their associated confidence interval. The data in the Tables reflect what is reported in the articles. If the risk estimates are missing from a Table, the implication is that they were not reported.
      TABLE 1Paternal age and relation to low birthweight, preterm, and small-for-gestational-age births
      StudyStudy characteristicsAssessmentRisk of biasResults
      Category, yLBW, OR (95% CI)PTB, OR (95% CI)SGA, OR (95% CI)
      Abel et al
      • Abel E.L.
      • Kruger M.
      • Burd L.
      Effects of maternal and paternal age on Caucasian and Native American preterm births and birth weights.
      ,
      Results mentioned here are adjusted estimates;
      1978-1992; Cohort study performed in North Dakota; used the statewide database; n = 154,391Exposure: maternal historySelection: none21-261.001.00
      Outcome: birth certificatesExposure assessment: low<201.28 (1.02–1.61)1.24 (1.02–1.52)
      Confounders adjusted: socioeconomic status, maternal age, infant sex, raceOutcome assessment: none26-301.07 (0.85–1.33)0.89 (0.80–1.00)
      Confounding factors: low31-351.03 (0.74–1.44)0.88 (0.77–1.02)
      Analytical: none36-401.26 (0.81–1.96)1.01 (0.83–1.21)
      Attrition: cannot tell41-451.35 (0.77–2.35)1.12 (0.77–1.33)
      Overall: low>451.38 (0.71–2.68)1.12 (0.79–1.57)
      Astolfi et al
      • Astolfi P.
      • De Pasquale A.
      • Zonta L.A.
      Paternal age and preterm birth in Italy, 1990 to 1998.
      ,
      Results mentioned here are adjusted estimates;
      1990-1998; Cohort study of nationwide sample from Italy; singleton, first born live births to mothers 20-29 y old and father >20 y old; n = 1,510,823Exposure: vital statistics datasetSelection: none20-241.13 (1.01–1.25)
      Outcome: birth certificatesExposure assessment: low25-291.00
      Confounders adjusted: maternal age, infant sex, couple education, birth periodOutcome assessment: none30-341.03 (0.99–1.07)
      Confounding factors: low35-391.12 (1.08–1.15)
      Analytical: none40-441.23 (1.15–1.31)
      Attrition: low45-491.16 (0.82–1.65)
      Overall: low≥501.15 (0.96–1.38)
      Basso and Wilcox
      • Basso O.
      • Wilcox A.J.
      Paternal age and delivery before 32 weeks.
      ,
      Results mentioned here are adjusted estimates;
      ,
      Data for preterm birth at <32 weeks' gestation.
      1995-2000; Cohort study of national sample from United States; married, non-Hispanic white primiparous women 20-34 y oldExposure: birth certificate; why are the exposure and outcome the same?Selection: low20-241.15 (0.94–1.39)
      Outcome: birth certificatesExposure assessment: low25-291.00
      Confounders adjusted: maternal education, smokingOutcome assessment: none30-340.97 (0.93–1.00)
      Confounding factors: low35-391.02 (0.97–1.08)
      Analytical: none40-441.05 (0.96–1.15)
      Attrition: low45-491.15 (0.98–1.34)
      Overall: low>500.97 (0.73–1.29)
      Chen et al
      • Chen X.K.
      • Wen S.W.
      • Krewski D.
      • Fleming N.
      • Yang Q.
      • Walker M.C.
      Paternal age and adverse birth outcomes: teenager or 40+, who is at risk?.
      ,
      Results mentioned here are adjusted estimates;
      1995-2000; Cohort study performed with nationwide data; 20-29 y-old nulliparous mother who had singleton live birth; n = 2,520,098Exposure: vital statistics datasetSelection: none<201.13 (1.07–1.19)1.15 (1.10–1.20)1.17 (1.13–1.22)
      Outcome: birth certificatesExposure assessment: low20-291.001.001.00
      Confounders adjusted: race, maternal age, education, smoking, alcohol, infant sex, prenatal careOutcome assessment: low30-341.00 (0.99–1.02)0.98 (0.07–0.99)1.03 (1.02–1.04)
      Confounding factors: none35-390.99 (0.97–1.02)0.98 (0.96–1.00)1.02 (1.00–1.04)
      Analytical: none40-440.96 (0.92–1.01)0.99 (0.95–1.03)1.02 (0.98–1.06)
      Attrition: low45-491.01 (0.92–1.10)1.01 (0.94–1.09)1.06 (0.99–1.03)
      Overall: low≥500.91 (0.79–1.05)0.93 (0.83–1.05)1.02 (0.92–1.13)
      Nahum and Stanislaw
      • Nahum G.G.
      • Stanislaw H.
      Relationship of paternal factors to birth weight.
      ,
      Results mentioned here are adjusted estimates;
      1998-2000; Cohort study, private single clinic at Duke University; term, uncomplicated, singletons; n = 241Exposure: maternal historySelection: lowPaternal age was not a significant predictor of birthweight if maternal age was specified (P = .08)
      Outcome: chartsExposure assessment: low
      Confounders adjusted: noneOutcome assessment: none
      Confounding factors: moderate
      Analytical: low
      Attrition: low
      Overall: moderate
      Olshan et al
      • Olshan A.F.
      • Ananth C.V.
      • Savitz D.A.
      Intrauterine growth retardation as an endpoint in mutation epidemiology: an evaluation based on paternal age.
      ,
      Results mentioned here are adjusted estimates;
      1988-1991; Cohort study of statewide data from North Carolina; 20-34 y-old resident mothers who had singleton live birth; n = 254,892Exposure: birth filesSelection: low<191.13 (0.97–1.32)1.23 (1.10–1.39)1.03 (0.88–1.20)
      Outcome: birth filesExposure assessment: low20-241.04 (0.98–1.09)1.09 (1.05–1.14)0.98 (0.93–1.04)
      Confounders adjusted: maternal age, race, gravidity, smoking, marital status, education, infant sexOutcome assessment: low25-291.001.001.00
      Confounding factors: none30-340.96 (0.91–1.01)0.98 (0.95–1.02)1.01 (0.96–1.06)
      Analytical: low35-390.96 (0.89–1.03)1.03 (0.97–1.08)0.95 (0.89–1.03)
      Attrition: low40-441.09 (0.97–1.21)1.05 (0.96–1.14)1.05 (0.93–1.18)
      Overall: low45-491.00 (0.81–1.23)1.09 (0.93–1.28)1.13 (0.92–1.38)
      >500.81 (0.59–1.12)1.08 (0.85–1.36)0.87 (0.63–1.19)
      Reichman and Teitler
      • Reichman N.E.
      • Teitler J.O.
      Paternal age as a risk factor for low birthweight.
      ,
      Results mentioned here are adjusted estimates;
      1998-2000; Cohort study of randomly selected births from 75 hospitals in the United States; >18 y-old mothers who had singleton live birth; n = 4621Exposure: historySelection: moderate<200.7 (0.5–1.0)
      Outcome: chartsExposure assessment: low20-341.00
      Confounders adjusted: maternal age, race, gravidity, marital status, socioeconomic status, infant sexOutcome assessment: none>341.7 (1.3–2.2)
      Confounding factors: none
      Analytical: low
      Attrition: none
      Overall: moderate
      Selvin and Garfinkel
      • Selvin S.
      • Garfinkel J.
      The relationship between parental age and birth order with the percentage of low birth-weight infants.
      1959-1967; Cohort study, singleton live births to white mothers in New York state (excluding New York City); n = 1,515,443Exposure: birth certificatesSelection: low≤198.58%
      Outcome: birth certificatesExposure assessment: low20-246.66%
      Confounder adjusted: maternal ageOutcome assessment: low25-295.77%
      Confounding factors: low30-345.63%
      Analytical: low35-396.08%
      Attrition: low40-446.57%
      Overall: low45-497.38%
      50-547.82%
      ≥557.99%
      Total6.13%
      Tough et al
      • Tough S.C.
      • Faber A.J.
      • Svenson L.W.
      • Johnston D.W.
      Is paternal age associated with an increased risk of low birthweight, preterm delivery, and multiple birth?.
      ,
      Results mentioned here are adjusted estimates;
      1990-1996; Cohort study, provide wide data from Alberta, Canada; mothers between 25-29 y old; n = 259,903Exposure: birth certificatesSelection: none≤191.001.00
      Outcome: birth certificatesExposure assessment: low20-240.84 (0.74–0.95)0.87 (0.77–0.97)
      Confounder adjusted: maternal ageOutcome assessment: none25-290.82 (0.72–0.93)0.82 (0.73–0.93)
      Confounding factors: low30-340.77 (0.67–0.88)0.77 (0.68–0.85)
      Analytical: low35-390.76 (0.66–0.87)0.75 (0.66–0.85)
      Attrition: low40-440.79 (0.68–0.92)0.81 (0.71–0.93)
      Overall: low45-490.93 (0.77–1.13)0.88 (0.74–1.05)
      ≥500.98 (0.75–1.26)0.96 (0.76–1.21)
      Zhu et al
      • Zhu J.L.
      • Madsen K.M.
      • Vestergaard M.
      • Basso O.
      • Olsen J.
      Paternal age and preterm birth.
      ,
      Results mentioned here are adjusted estimates;
      1980-1996; Cohort study; singleton live births in Danish fertility database; first child of couple; father <30 y old and >35 y old; n = 70,347Exposure: national databaseSelection: low20-241.00
      Outcome: national databaseExposure assessment: low25-291.1 (0.9–1.2)
      Confounders adjusted: maternal age, parity, education, income, infant sex, year of birthOutcome assessment: low35-391.1 (1.0–1.3)
      Confounding factors: none40-441.2 (1.0–1.4)
      Analytical: low45-491.2 (0.9–1.5)
      Attrition: none≥501.1 (0.8–1.6)
      Overall: low
      CI, confidence interval; LBW, low birthweight; OR, odds ratio; PTB, preterm; SGA, small-for-gestational-age.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Results mentioned here are adjusted estimates;
      b Data for preterm birth at <32 weeks' gestation.
      TABLE 2Studies of paternal height and offspring birthweight
      StudyStudy characteristicsAssessmentRisk of biasResults
      Category, cmBirthweight, g
      Data are given as mean ± SD;
      Cawley et al
      • Cawley R.H.
      • McKeown T.
      • Record R.G.
      Parental stature and birth weight.
      1949-1950; Cohort study, singleton, live births and no neonatal death in 2 areas (Smethwick and Birmingham, UK); n = 1544Exposure: maternal history and measurementSelection: low<1683239
      Outcome: chartsExposure assessment: low168-1733307
      Confounder adjusted: maternal heightOutcome assessment: none173-1783325
      Confounding factors: moderate178-1833329
      Analytical: low>1833447
      Attrition: moderate
      Overall: moderate
      Klebanoff
      • Klebanoff M.A.
      Paternal and maternal birthweights and the risk of infant preterm birth.
      ,
      Results mentioned here are adjusted estimates.
      1959-1961; Cohort study, singleton, live births from single center in Copenhagen, Denmark; n = 3130Exposure: maternal historySelection: low≤1753325
      Outcome: chartsExposure assessment: low175-1783413
      Confounders adjusted: maternal birthweight, height, weight, smoking, hypertension, education, employment, infant sex, birth orderOutcome assessment: none179-1823413
      Confounding factors: none≥1833421
      Analytical: lowP for trend = .088
      Attrition: moderate
      Overall: moderate
      Magnus et al
      • Magnus P.
      • Berg K.
      • Bjerkedal T.
      • Nance W.E.
      Parental determinants of birth weight.
      1967-1979; Cohort study, singleton, live births who survived neonatal period; data from Norway birth registry; n = 3130Exposure: national databaseSelection: moderateResults reported as mean parental height in each 500-g birthweight category; not mean birthweight in each parental height group
      Outcome: national databaseExposure assessment: low
      Confounders adjusted: noneOutcome assessment: none
      Confounding factors: moderate
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Miletic et al
      • Miletic T.
      • Stoini E.
      • Mikulandra F.
      • Tadin I.
      • Roje D.
      • Milic N.
      Effect of parental anthropometric parameters on neonatal birth weight and birth length.
      2002; Cohort study of all births in the county of Sibenik-Knin, Croatia; n = 550Exposure: survey in prenatal clinicSelection: nonePaternal height correlated significantly with the neonate birthweight (P = .01)
      Outcome: hospital recordExposure assessment: low
      Confounders adjusted: noneOutcome assessment: none
      Confounding factors: moderate
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Morrison et al
      • Morrison J.
      • Williams G.M.
      • Najman J.M.
      • Andersen M.J.
      The influence of paternal height and weight on birth-weight.
      1980-1996; Cohort study, singleton, live births, term, without anomalies in Queensland University single center study; n = 8556Exposure: maternal historySelection: lowPaternal height was significantly correlated with birthweight (P < .0007)
      Outcome: chartsExposure assessment: low
      Confounder adjusted: maternal body mass indexOutcome assessment: none
      Confounding factors: moderate
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Nahum and Stanislaw
      • Nahum G.G.
      • Stanislaw H.
      Relationship of paternal factors to birth weight.
      ,
      Results mentioned here are adjusted estimates.
      See Table 1 for detailsFathers with height >2 SD above and below the mean had 125-g difference in birthweight of index child
      Pritchard et al
      • Pritchard C.W.
      • Sutherland H.W.
      • Carr-Hill R.A.
      Birthweight and paternal height.
      1967-1971; Cohort study, singleton, live births in Aberdeen, UK, hospital and associated nursing homes of 32-43 weeks' gestational age; n = 5834Exposure: direct measurementSelection: lowSD scores for birthweight were 0.29 higher (approximate correlation of 115-g birthweight) for taller men compared with shorter men
      Outcome: chartsExposure assessment: moderate
      Confounder adjusted: maternal heightOutcome assessment: low
      Confounding factors: moderate
      Analytical: low
      Attrition: low
      Overall: moderate
      To et al
      • To W.W.
      • Cheung W.
      • Kwok J.S.
      Paternal height and weight as determinants of birth weight in a Chinese population.
      1995-1996; Cohort study, singleton, live births of Chinese parents from single center in Hong Kong; >36 weeks' gestational age; n = 355Exposure: direct measurementSelection: lowPaternal height divided in 5 strata (5 cm for 160-180 cm), significantly correlated with birthweight (P < .01)
      Outcome: chartsExposure assessment: none
      Confounders adjusted: maternal prepregnancy weight and heightOutcome assessment: none
      Confounding factors: low
      Analytical: low
      Attrition: moderate
      Overall: moderate
      Wilcox et al
      • Wilcox M.A.
      • Newton C.S.
      • Johnson I.R.
      Paternal influences on birthweight.
      ,
      Results mentioned here are adjusted estimates.
      1992-1993; Cohort study, singleton, term, live births without congenital anomaly from single center in Nottingham, UK; n = 571Exposure: direct measurementSelection: low<1703322 ± 396
      Outcome: chartsExposure assessment: none170-1743406 ± 473
      Confounders adjusted: smoking, maternal height, paternal weightOutcome assessment: none175-1793465 ± 432
      Confounding factors: low180-1843474 ± 470
      Analytical: low185-1893503 ± 351
      Attrition: low>1903585 ± 378
      Overall: low
      Winikoff and Debrovner
      • Winikoff B.
      • Debrovner C.H.
      Anthropometric determinants of birth weight.
      1992-1993; Cohort study, singleton primiparous, term live births; uncomplicated pregnancies from a single clinic in New York; n = 259Exposure: maternal historySelection: moderatePaternal height was significantly associated with variations in birthweight (P < .05)
      Outcome: chartsExposure assessment: low
      Confounders adjusted: maternal height, paternal weight, maternal prepregnancy weight, weight gain during pregnancyOutcome assessment: none
      Confounding factors: low
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Data are given as mean ± SD;
      b Results mentioned here are adjusted estimates.
      TABLE 3Studies of paternal weight and body mass index and their relation to birthweight and low birthweight
      StudyStudy characteristics, assessment and risk of biasesResults
      CategoryBirthweight, g
      Data are given as mean ± SD;
      Klebanoff
      • Klebanoff M.A.
      Paternal and maternal birthweights and the risk of infant preterm birth.
      ,
      Results mentioned here are adjusted estimates.
      See Table 2 for details<20.08 kg/m23188
      20.08-21.56 kg/m23276
      21.57-23.05 kg/m23261
      >23.05 kg/m23293 (P for trend = .049)
      Magnus et al
      • Magnus P.
      • Berg K.
      • Bjerkedal T.
      • Nance W.E.
      Parental determinants of birth weight.
      See Table 2 for detailsResults reported as mean parental weight in each 500-g birthweight category; not mean birthweight in each parental weight group
      Miletic et al
      • Miletic T.
      • Stoini E.
      • Mikulandra F.
      • Tadin I.
      • Roje D.
      • Milic N.
      Effect of parental anthropometric parameters on neonatal birth weight and birth length.
      See Table 2 for detailsPaternal bodyweight correlated significantly with the neonate birthweight (P = .01)
      Morrison et al
      • Morrison J.
      • Williams G.M.
      • Najman J.M.
      • Andersen M.J.
      The influence of paternal height and weight on birth-weight.
      See Table 2 for detailsPaternal weight was not significantly correlated with birthweight (P > .05)
      Nahum and Stanislaw
      • Nahum G.G.
      • Stanislaw H.
      Relationship of paternal factors to birth weight.
      ,
      Results mentioned here are adjusted estimates.
      See Table 1 for detailsPaternal weight and BMI were not significant predictor of birthweight once maternal weight (P = .16) and BMI (P = .42) were taken in account, respectively
      To et al
      • To W.W.
      • Cheung W.
      • Kwok J.S.
      Paternal height and weight as determinants of birth weight in a Chinese population.
      See Table 2 for detailsPaternal weight divided in 9 strata (5 kg strata for <50 to >90 kg) was not correlated with birthweight (P = .052); paternal BMI divided in 4 strata (5 kg/m2 strata for <20 to >35 kg/m2) was not correlated with birthweight (P = .33)
      Wilcox et al
      • Wilcox M.A.
      • Newton C.S.
      • Johnson I.R.
      Paternal influences on birthweight.
      ,
      Results mentioned here are adjusted estimates.
      See Table 2 for details<59 kg3522 ± 268
      60-69 kg3320 ± 512
      70-79 kg3486 ± 522
      80-89 kg3511 ± 520
      90-99 kg3550 ± 437
      100-109 kg3657 ± 419
      >110 kg3608 ± 373
      Winikoff and Debrovner
      • Winikoff B.
      • Debrovner C.H.
      Anthropometric determinants of birth weight.
      See Table 2 for detailsPaternal weight was not associated with variations in birthweight (P > .05)
      BMI, body mass index.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Data are given as mean ± SD;
      b Results mentioned here are adjusted estimates.
      TABLE 4Paternal birthweight and relation to birthweight, low birthweight, and preterm births
      AuthorStudy characteristicsAssessmentRisk of biasResults
      CategoryBirthweightPreterm birth
      Coutinho et al
      • Coutinho R.
      • David R.J.
      • Collins Jr, J.W.
      Relation of parental birth weights to infant birth weight among African Americans and whites in Illinois: a transgenerational study.
      1989-91; Cohort study of fathers born from 1956-1975 derived from Illinois vital records; n = 128,152Exposure: birth recordSelection: lowBlack father LBWInfant LBW, 14.3%; RR 1.3 (95% CI, 1.1–1.5)
      Outcome: birth certificateExposure assessment: lowBlack father normal birthweightInfant LBW, 11.5%
      Confounders adjusted: noneOutcome assessment: lowWhite father LBWInfant LBW, 5.7%; RR 1.2 (95% CI, 1.0–1.2)
      Confounding factors: moderateWhite father normal birthweightInfant LBW, 5.0%
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Klebanoff et al
      • Klebanoff M.A.
      • Mednick B.R.
      • Schulsinger C.
      • Secher N.J.
      • Shiono P.H.
      Father's effect on infant birth weight.
      1959-1961; Cohort study, fathers born in this period derived from Danish population register and their singleton, liveborn, children born from 1974-1989; n = 1258Exposure: birth recordSelection: low<3 kg5.1%
      Outcome: birth certificateExposure assessment: moderate3-3.9 kg7.1%
      Confounders adjusted: maternal birthweightOutcome assessment: low>4 kg6.9%
      Confounding factors: moderate
      Analytical: low
      Attrition: moderate
      Overall: moderate
      Klebanoff
      • Klebanoff M.A.
      Paternal and maternal birthweights and the risk of infant preterm birth.
      ,
      Results mentioned here are adjusted estimates.
      See Table 2 for details<3 kg3317 g
      3-3.9 kg3384 g
      >4 kg3493 g
      P for trend = .002
      Little
      • Little R.E.
      Mother's and father's birthweight as predictors of infant birthweight.
      12-mo period; matched cohort study based on alcohol drinking status, singleton, live births from single center in Copenhagen, Denmark; n = 377Exposure: maternal historySelection: low<3 kg3487 g
      Outcome: maternal historyExposure assessment: low3-3.999 kg3555 g
      Confounders adjusted: maternal birthweightOutcome assessment: none>4 kg3707 g
      Confounding factors: moderate
      Analytical: low
      Attrition: moderate
      Overall: moderate
      Magnus et al
      • Magnus P.
      • Gjessing H.K.
      • Skrondal A.
      • Skjaerven R.
      Paternal contribution to birth weight.
      1967-1998; Cohort study, singleton, live births from medical birth registry of Norway; n = 3130Exposure: birth registerSelection: lowFather normal birthweightInfant LBW, 2.9%
      Outcome: birth registerExposure assessment: lowFather LBWInfant LBW, 6.8%
      Confounders adjusted: noneOutcome assessment: low
      Confounding factors: moderate
      Analytical: none
      Attrition: cannot tell
      Overall: moderate
      CI, confidence interval; LBW, low birthweight, RR, relative risk.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Results mentioned here are adjusted estimates.
      TABLE 5Studies of paternal occupation and low birthweight, preterm, and small-for-gestational-age births
      AuthorStudy characteristicsExposure and its assessmentAssessmentRisk of biasResults
      CategoryLBW, OR (95% CI)PTB, OR (95% CI)SGA, OR (95% CI)
      Dimich-Ward et al
      • Dimich-Ward H.
      • Hertzman C.
      • Teschke K.
      • et al.
      Reproductive effects of paternal exposure to chlorophenate wood preservatives in the sawmill industry.
      ,
      Results mentioned here are adjusted estimates;
      1952-1988; Cohort study; fathers who worked in saw mills for at least 1 y in British Columbia, Canada; n = 2128Chlorophenate wood preservative assessed by calculating exposure time from type of jobOutcome: birth certificateSelection: lowUp to 3 mo before conception0.99 (0.99–1.00)1.00 (0.99–1.00)1.00 (0.99–1.00)
      Confounders adjusted: maternal and paternal age, infant sex, birth yearExposure assessment: moderate3 mo before conception1.01 (0.92–1.08)0.99 (0.93–1.05)1.00 (0.96–1.04)
      Outcome assessment: lowThrough entire pregnancy0.99 (0.97–1.01)0.96 (0.94–0.98)
      Only data which were significant are reported here;
      1.01 (0.99–1.02)
      Confounding factors: low
      Analytical: low
      Attrition: cannot tell
      Overall: moderate
      Hooiveld et al
      • Hooiveld M.
      • Haveman W.
      • Roskes K.
      • Bretveld R.
      • Burstyn I.
      • Roeleveld N.
      Adverse reproductive outcomes among male painters with occupational exposure to organic solvents.
      ,
      Results mentioned here are adjusted estimates;
      2001; Comparative cohort study; fathers who worked as painters (472 cases) were compared with carpenters (462 control subjects) in The Netherlands; n = 934Organic solvents for painters assessed by questionnaireOutcome: questionnaireSelection: lowLow level (0.17–0.38)1.5 (0.5–4.3)1.6 (0.7–3.9)
      Confounders adjusted: maternal age, smoking, alcohol use, chemical exposure; paternal smoking, alcohol useExposure assessment: moderateIntermediate level (0.38–1.02)1.6 (0.7–3.8)1.5 (0.7–3.2)
      Outcome assessment: lowHigh level (1.03–4.66)1.9 (0.9–4.7)0.8 (0.3–2.0)
      Confounding factors: none
      Analytical: none
      Attrition: moderate
      Overall: moderate
      Kristensen et al
      • Kristensen P.
      • Irgens L.M.
      • Daltveit A.K.
      • Andersen A.
      Perinatal outcome among children of men exposed to lead and organic solvents in the printing industry.
      ,
      Results mentioned here are adjusted estimates;
      Male printing workers between 1930-1974 alive at 1960 census; exposure to lead, solvent, and both combined; n = 6251Lead and solvent exposure classified based on job codesOutcome: national birth registerSelection: lowLead only0.9 (0.61–1.02)1.2 (0.93–1.5)
      Confounders adjusted: gestational age, birth order, infant sex, multiple gestation, previous still birth, consanguinity, maternal chronic diseasesExposure assessment: moderateSolvents only1.1 (0.89–1.4)1.4 (1.1–1.8)
      Outcome assessment: noneLead plus solvent1.2 (0.92–1.5)1.2 (0.89–1.5)
      Confounding factors: noneOther1.01.0
      Analytical: low
      Attrition: Cannot tell
      Overall: moderate
      Lawson et al
      • Lawson C.C.
      • Schnorr T.M.
      • Whelan E.A.
      • et al.
      Paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin and birth outcomes of offspring: birth weight, preterm delivery, and birth defects.
      ,
      Results mentioned here are adjusted estimates;
      1987-1988; Matched cohort study; workers from plants in New York and Missouri; matched population selected from neighbors; n = 11532,3,7,8-Tetrachloro-dibenzo-p-dioxin assessed from blood sample and modeled calculationOutcome: birth certificate or maternal reportSelection: lowReferenceMean birthweight, 3402 g0.8 (0.6–1.1)
      Confounders adjusted: maternal age, accidents, smoking, alcohol and medication useExposure assessment: moderate<20 pg/gMean birthweight, 3396 g
      Outcome assessment: low20-254 pg/gMean birthweight, 3360 g
      Confounding factors: moderate>255 pg/gMean birthweight, 3485 g
      Analytical: low
      Attrition: moderate
      Overall: moderate
      Lin et al
      • Lin S.
      • Hwang S.A.
      • Marshall E.G.
      • Marion D.
      Does paternal occupational lead exposure increase the risks of low birth weight or prematurity?.
      ,
      Results mentioned here are adjusted estimates;
      1981-1992; Matched cohort study; fathers exposed to high lead levels (>40 μg/dL before 1986 and >25 μg/dL after 1986 (n = 747) compared with male bus drivers (n = 2259) in New York, 1974-1989 (n = 1258)Lead exposure assessed from laboratory reports of workersOutcome: birth certificateSelection: lowGeneral exposure (risk ratio)1.00 (0.67–1.50)0.89 (0.64–1.26)0.86 (0.64–1.15)
      Confounders adjusted: paternal age, maternal education, maternal complications, prenatal care, race, parity, infant sexExposure assessment: lowLead exposure for >5 years (risk ratio)3.40 (1.39–8.35)
      Only data which were significant are reported here;
      3.03 (1.35–6.77)
      Only data which were significant are reported here;
      0.82 (0.28–2.37)
      Outcome assessment: none
      Confounding factors: none
      Analytical: low
      Attrition: cannot tell
      Overall: low
      Michalek et al
      • Michalek J.E.
      • Rahe A.J.
      • Boyle C.A.
      Paternal dioxin, preterm birth, intrauterine growth retardation, and infant death.
      1961-1971; Matched cohort study; children of fathers exposed to herbicide spray during Vietnam conflict (n = 859) compared with children of unexposed Air Force veterans (n = 1223); n = 20822,3,7,8-Tetrachloro-dibenzo-p-dioxin assessed from blood sample and modeled calculationOutcome: chartsSelection: lowControl (≤10 ppt)1.01.0
      Confounders adjusted: noneExposure assessment: moderateCases (≤10 ppt)1.4 (0.9–2.3)0.9 (0.6–1.4)
      Outcome assessment: noneLow (<79 ppt)0.5 (0.2–1.2)0.9 (0.6–1.3)
      Confounding factors: moderateHigh (≥79 ppt)1.3 (0.8–2.3)0.9 (0.6–1.3)
      Analytical: low
      Attrition: moderate
      Overall: moderate
      Milham and Ossiander
      • Milham S.
      • Ossiander E.M.
      Low proportion of male births and low birth weight of sons of flour mill worker fathers.
      1980-2002; Cohort study; fathers who were flour mill workers in Washington state; n = 59Fumigants used to kill insects, mainly methyl bromide and phosphine; assessed by history of work-related exposureOutcome: birth certificateSelection: lowUnexposed (male children)Mean birthweight, 3511 g
      Confounders adjusted: noneExposure assessment: moderateUnexposed (female children)Mean birthweight, 3389 g
      Outcome assessment: noneExposed (male children)Mean birthweight, 3180 g
      Confounding factors: moderateExposed (female children)Mean birthweight, 3602 g
      Analytical: moderate
      Attrition: cannot tell
      Overall: moderate
      Min et al
      • Min Y.I.
      • Correa-Villasenor A.
      • Stewart P.A.
      Parental occupational lead exposure and low birth weight.
      1981-1989; Case control study; control subjects enrolled in another study in Baltimore-Washington DC; cases (n = 220) were LBW; controls were not LBW (n = 522); n = 742Lead exposure assessed by history regarding type of job and hours exposedOutcome: birth certificateSelection: lowNo exposure1.0
      Confounders adjusted: noneExposure assessment: lowThreshold, ≤0.010.70 (0.37–1.27)
      Outcome assessment: noneThreshold, >0.1 to <0.51.67 (0.65–4.30)
      Confounding factors: moderateThreshold, ≥0.54.7 (1.1–20.2)
      Only data which were significant are reported here;
      Analytical: moderate
      Attrition: low
      Overall: moderate
      Mjoen et al
      • Mjoen G.
      • Saetre D.O.
      • Lie R.T.
      • et al.
      Paternal occupational exposure to radiofrequency electromagnetic fields and risk of adverse pregnancy outcome.
      ,
      Results mentioned here are adjusted estimates;
      1976-1995; Cohort study; all births in national registry of Norway where exposure risk can be determined; n = 28,435Radiofrequency fields exposure assessed based on type of occupationOutcome: birth certificateSelection: lowProbably unexposed1.001.00
      Confounders adjusted: calendar year, place of birth, educationExposure assessment: moderatePossibly exposed0.99 (0.96–1.02)1.03 (0.98–1.07)
      Outcome assessment: noneProbably exposed1.08 (1.03–1.15)
      Only data which were significant are reported here;
      1.03 (0.94–1.13)
      Confounding factors: low
      Analytical: none
      Attrition: cannot tell
      Overall: moderate
      Sanjose et al
      • Sanjose S.
      • Roman E.
      • Beral V.
      Low birthweight and preterm delivery, Scotland, 1981-84: effect of parents' occupation.
      1981-1984; Cohort study in Scotland, regarding parental occupation and liveborn infants; n = 177,746Classified as manual and nonmanual jobs; no direct assessment of any exposureOutcome: birth certificateSelection: noneNonmanual3.8%3.9%3.4%
      Confounders adjusted: noneExposure assessment: moderateManual; potential hazard5.1%4.5%4.7%
      Outcome assessment: noneManual; other6.0%5.2%5.6%
      Confounding factors: moderate
      Analytical: none
      Attrition: cannot tell
      Overall: moderate
      Savitz et al
      • Savitz D.A.
      • Whelan E.A.
      • Kleckner R.C.
      Effect of parents' occupational exposures on risk of stillbirth, preterm delivery, and small-for-gestational-age infants.
      ,
      Results mentioned here are adjusted estimates;
      ,
      Only significant results are reported; all other occupations had nonsignificant relationships.
      1980; Cohort study; “National Natality Study” in United States; n = 177,746Paternal occupations held within 12 mo of birthOutcome: birth certificateSelection: lowX-ray1.5 (1.0–2.3)
      Only data which were significant are reported here;
      Confounders adjusted: maternal smoking, race, infant sexExposure assessment: moderateBenzene1.5 (1.1–2.3)
      Only data which were significant are reported here;
      Outcome assessment: noneChromium1.4 (1.0–1.9)
      Only data which were significant are reported here;
      Confounding factors: lowMinerals and compounds1.3 (1.0–1.8)
      Only data which were significant are reported here;
      Analytical: none
      Attrition: cannot tell
      Overall: moderate
      CI, confidence interval; LBW, low birthweight; OR, odds ratio; ppt, parts per trillion; PTB, preterm; SGA, small-for-gestational-age.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Results mentioned here are adjusted estimates;
      b Only data which were significant are reported here;
      c Only significant results are reported; all other occupations had nonsignificant relationships.
      TABLE 6Miscellaneous paternal factors and low birthweight, preterm, and small-for-gestational-age births
      StudyStudy characteristicsAssessmentRisk of biasResults
      CategoryLBW, OR (95% CI)PTB, OR (95% CI)SGA, OR (95% CI)
      PATERNAL EDUCATION
      Abel et al
      • Abel E.L.
      • Kruger M.
      • Burd L.
      Effects of maternal and paternal age on Caucasian and Native American preterm births and birth weights.
      ,
      Results mentioned here are adjusted estimates.
      See Table 1 for detailsLess than high school9.3% male; 8.4% female
      High school5.5% male; 7.8% female
      College6.3% male; 5.5% female
      Parker and Schoendorf
      • Parker J.D.
      • Schoendorf K.C.
      Influence of paternal characteristics on the risk of low birth weight.
      1984-1988; Cohort study; natality data from 47 states; singleton live births to married white or black women >17 y old; n = 9,740,852Exposure: national databaseSelection: lowLess than high school1.53 (1.51–1.55)
      Outcome: national databaseExposure assessment: moderateHigh school graduate1.28 (1.27–1.30)
      Confounders adjusted: maternal race, age, parity, educationOutcome assessment: noneSome college1.14 (1.12–1.15)
      Confounding factors: lowCollege graduate1.00
      Analytical: none
      Attrition: low
      Overall: moderate
      PATERNAL ALCOHOL USE
      Little
      • Little R.E.
      Mother's and father's birthweight as predictors of infant birthweight.
      See Table 4 for detailsOccasionalMean birthweight, 3646 gMean gestational age, 41.2 wk
      RegularMean birthweight, 3465 gMean gestational age, 40.5 wk
      Passaro et al
      • Passaro K.T.
      • Little R.E.
      • Savitz D.A.
      • Noss J.
      Effect of paternal alcohol consumption before conception on infant birth weight: ALSPAC Study Team: Avon Longitudinal Study of Pregnancy and Childhood.
      1991-1992; Cohort study; Avon County, England; singleton live births; n = 7756Exposure: questionnaireSelection: none
      Outcome: hospital recordsExposure assessment: noneNone5.6%6.4%NA
      Confounders adjusted: gestational age, infant sex, primiparity, maternal smoking, maternal body mass index, maternal race, maternal education, maternal age, marital status, marijuana use, caffeine use, alcohol intakeOutcome assessment: noneLess than weekly4.1%5.7%
      Confounding factors: noneWeekly3.5%5.4%
      Analytical: none1-2 drinks/d4.4%5.9%
      Attrition: moderate3+ drinks/d4.3%6.5%
      Overall: moderate
      Savitz et al
      • Savitz D.A.
      • Zhang J.
      • Schwingl P.
      • John E.M.
      Association of paternal alcohol use with gestational age and birth weight.
      1959-1966; Cohort study, San Francisco, CA; singleton live births to married women; n = 10,232Exposure: historySelection: lowNo alcohol1.01.0
      Outcome: chartsExposure assessment: low0-0.5 drinks/d0.9 (0.7–1.1)1.0 (0.8–1.3)
      Confounders adjusted: parental smoking, maternal alcohol use, race, education, prenatal care, infant sexOutcome assessment: none0.5-1 drinks/d1.1 (0.8–1.4)1.0 (0.7–1.4)
      Confounding factors: low1-1.5 drinks/d0.8 (0.6–1.1)1.2 (0.9–1.6)
      Analytical: low1.5-2 drinks/d1.0 (0.7–1.5)0.9 (0.5–1.4)
      Attrition: moderate>2 drinks/d0.8 (0.5–1.3)1.1 (0.7–1.7)
      Overall: moderate
      Windham et al
      • Windham G.C.
      • Fenster L.
      • Hopkins B.
      • Swan S.H.
      The association of moderate maternal and paternal alcohol consumption with birthweight and gestational age.
      1986-1987; Control arm of a case-control study, California; singleton live births; n = 1252Exposure: interviewSelection: noneNo alcohol7.3%14.8%8.0%; AOR, 1.0 (Reference)
      Outcome: birth certificateExposure assessment: none1-13 drinks/wk7.1%14.0%9.3%; AOR, 1.2 (0.7–1.9)
      Confounders adjusted: maternal age, race, parity, marital status, education, employment status, insurance status, caffeine consumption, cigarette smoking, hypertension, infant sexOutcome assessment: none14-20 drinks/wk2.7%10.8%13.5%; AOR, 1.3 (0.5–2.9)
      Confounding factors: none≥21 drinks/wk9.6%17.8%16.4%; AOR, 1.4 (0.7–1.9)
      Analytical: low
      Attrition: none
      Overall: moderate
      AOR, adjusted odds ratio; CI, confidence interval; LBW, low birthweight; NA, not available; OR, odds ratio; PTB, preterm; SGA, small-for-gestational-age.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.
      a Results mentioned here are adjusted estimates.

      Paternal age

      There was variability in age cut-offs that were used in the studies as well as the reference age for comparison of groups. Exploratory analysis of a relationship between paternal age and LBW births was conducted. Figure 2 demonstrates the relationship of paternal age (mid values from all reported age groups and conversion of the 25- to 28-year age group as the reference group for each study) and LBW births in 6 studies that reported the odds of LBW births in various age groups. A “saucer-shaped” association can be inferred with higher odds at both extremes. No association between paternal age and PTB or SGA births was identified in any of the studies. Characteristics of the included studies, assessment of biases, and reported results are outlined in Table 1.
      Figure thumbnail gr2
      FIGURE 2Scatter plot of paternal age and odds ratio for low birthweight (LBW) births that were reported in various age groups.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.

      Paternal height

      Paternal height showed significant correlation with birthweight of the offspring in most of the studies. On average, there was 125-150 g reduction in birthweight of the offspring of short vs tall fathers. Characteristics of the included studies, assessment of biases, and reported results are given in Table 2.

      Paternal weight and body mass

      Most of the studies reported a nonsignificant relationship with paternal body weight or mass and birthweight and LBW births. In 1 study, a significant relationship became nonsignificant when maternal body mass was considered. Characteristics of the included studies, assessment of biases, and reported results are given in Table 3.

      Paternal birthweight

      Three studies reported that an infant's birthweight increased as paternal birthweight increased. The odds of a LBW birth were higher if the father had a LBW birth. Interestingly, 1 study reported higher rates of PTBs as the father's birthweight increased; however, this might be attributed to maternal characteristic. Characteristics of the included studies, assessment of biases, and reported results are given in Table 4.

      Paternal occupation

      Higher and prolonged lead exposures were associated with higher risk of LBW birth and PTB; however, details of timing of exposure in relation to pregnancy were not available in detail to assess direct effect. One large study reported a higher adjusted risk of SGA births among workers who were exposed to benzene, chromium, and other minerals and a higher risk of PTBs among workers who were exposed to x-rays. Other occupations that were assessed were not associated with higher risk of adverse outcomes. Characteristics of the included studies, assessment of biases, and reported results are given in Table 5.

      Paternal education

      One study reported a higher risk of LBW births and another reported a higher risk of PTBs among fathers who had a high school education only, compared with fathers who had a college education. Characteristics of the included studies, assessment of biases, and reported results are given in Table 6.

      Paternal alcohol use

      One small study reported a 200-g reduction in birthweight with regular alcohol use; other studies reported no difference in the risk of LBW birth or PTBs with different levels of paternal alcohol use.
      • Little R.E.
      Mother's and father's birthweight as predictors of infant birthweight.
      • Passaro K.T.
      • Little R.E.
      • Savitz D.A.
      • Noss J.
      Effect of paternal alcohol consumption before conception on infant birth weight: ALSPAC Study Team: Avon Longitudinal Study of Pregnancy and Childhood.
      • Savitz D.A.
      • Zhang J.
      • Schwingl P.
      • John E.M.
      Association of paternal alcohol use with gestational age and birth weight.
      • Windham G.C.
      • Fenster L.
      • Hopkins B.
      • Swan S.H.
      The association of moderate maternal and paternal alcohol consumption with birthweight and gestational age.
      Characteristics of the included studies, assessment of biases, and reported results are given in Table 6.

      Comment

      In this systematic review of 36 studies on paternal factors and birth outcomes, certain positive and negative associations were observed. Extreme paternal ages (<20 and >40 years) may be associated with LBW; however, no consistent associations with PTBs and SGA births were identified. Paternal height and paternal occupational exposure to lead were associated with LBW and birthweight of the offspring. The infant's birthweight increased with a higher paternal birthweight. Paternal weight, body mass, and occupational exposures to herbicides, plant work, woodwork and paternal alcohol use were not associated with birth outcomes. A lower level of paternal education was associated with LBW/PTB and SGA births; however, confirmation of data from larger studies is warranted.

      Paternal age

      Advanced paternal age has been linked with fetal loss,
      • Selvin S.
      • Garfinkel J.
      Paternal age, maternal age and birth order and the risk of a fetal loss.
      congenital malformations,
      • Olshan A.F.
      • Schnitzer P.G.
      • Baird P.A.
      Paternal age and the risk of congenital heart defects.
      single gene disorders,
      • Stene J.
      • Fischer G.
      • Stene E.
      • Mikkelsen M.
      • Petersen E.
      Paternal age effect in Down's syndrome.
      lower intelligence, dyslexia,
      • Jayasekara R.
      • Street J.
      Parental age and parity in dyslexic boys.
      and mental disorders
      • Krishnaswamy S.
      • Subramaniam K.
      • Indran H.
      • et al.
      Paternal age and common mental disorders.
      in children. Studies of the impact of paternal age on LBW, PTB, or SGA outcomes have concluded varied results.
      • Abel E.L.
      • Kruger M.
      • Burd L.
      Effects of maternal and paternal age on Caucasian and Native American preterm births and birth weights.
      • Astolfi P.
      • De Pasquale A.
      • Zonta L.A.
      Paternal age and preterm birth in Italy, 1990 to 1998.
      • Olshan A.F.
      • Ananth C.V.
      • Savitz D.A.
      Intrauterine growth retardation as an endpoint in mutation epidemiology: an evaluation based on paternal age.
      • Zhu J.L.
      • Madsen K.M.
      • Vestergaard M.
      • Basso O.
      • Olsen J.
      Paternal age and preterm birth.
      Biologic rationale behind the influence of paternal age on birth outcomes stems from the identification of greater expression of paternal genes on the placenta
      • Miozzo M.
      • Simoni G.
      The role of imprinted genes in fetal growth.
      and higher chances of mutation that involves those genes in immature men compared with mature men
      • Schwartz D.
      • Mayaux M.J.
      • Spira A.
      • et al.
      Semen characteristics as a function of age in 833 fertile men.
      and in men of advanced age.
      • Crow J.F.
      The origins, patterns and implications of human spontaneous mutation.
      A paternal “weathering” phenomenon (ie, biologic effects of male aging that is hastened by harsh living conditions over years) has been suspected.
      • Reichman N.E.
      • Teitler J.O.
      Paternal age as a risk factor for low birthweight.
      The overall impression from our systematic review of included studies and the plot of paternal age–LBW birth incidence curve suggest that, if there was an effect of paternal age on LBW birth, it would appear to be modest for advanced paternal age.

      Paternal anthropometry

      All 10 reviewed studies reported an increase in birthweight as father's height increased. The magnitude of increase between the lowest group and the highest group was approximately 125-150 g. No studies reported incidences of LBW, PTB, or SGA births. The effect is presumed to be of genetic origin.
      • To W.W.
      • Cheung W.
      • Kwok J.S.
      Paternal height and weight as determinants of birth weight in a Chinese population.
      Studies of paternal weight and its influence on birthweight revealed contradictory results. Two studies reported an approximate 75- to 100-g increase in birthweight among the highest weight/body mass index group,
      • Wilcox M.A.
      • Newton C.S.
      • Johnson I.R.
      Paternal influences on birthweight.
      • Klebanoff M.A.
      Paternal and maternal birthweights and the risk of infant preterm birth.
      compared with the lowest weight/body mass index group. Three studies reported no significant influence.
      • Nahum G.G.
      • Stanislaw H.
      Relationship of paternal factors to birth weight.
      • Morrison J.
      • Williams G.M.
      • Najman J.M.
      • Andersen M.J.
      The influence of paternal height and weight on birth-weight.
      • To W.W.
      • Cheung W.
      • Kwok J.S.
      Paternal height and weight as determinants of birth weight in a Chinese population.
      All of these studies had very small sample sizes, and a large population-based study is warranted.

      Paternal birthweight

      Lower paternal birthweight was associated with lower infant birthweight. Paternal LBW was associated with higher risk of an infant with LBW, which is an effect that is similar to maternal LBW. PTB rate was lower for fathers in the LBW birth category. However, this information comes from very few and small studies. Ascertainment issues regarding birthweight of the father should not be ignored in the interpretation of these results. Also, studies from different countries were included in this review; therefore, it may have affected the results because there are different norms for birthweight in different ethnic backgrounds.

      Paternal occupational exposure

      There are 2 pathways by which paternal exposure contribute to an effect on birth outcomes: either paternal exposure leads to maternal exposure and the effect is exerted or paternal exposure leads to alteration in the germ cell line that leads to either increased infertility or abnormality in conception.
      • Strobino B.R.
      • Kline J.
      • Stein Z.
      Chemical and physical exposures of parents: effects on human reproduction and offspring.
      Lead, dioxin, and organic solvents are the more commonly studied exposures. Animal experiments reported lower birthweight after male animal exposure to lead.
      • Stowe H.D.
      • Goyer R.A.
      Reproductive ability and progeny of F 1 lead-toxic rats.
      Lead exposure has been shown to be associated with infertility, still births, and spontaneous abortions.
      • Savitz D.A.
      • Whelan E.A.
      • Kleckner R.C.
      Effect of parents' occupational exposures on risk of stillbirth, preterm delivery, and small-for-gestational-age infants.
      The effect is suspected to be due to effects on the metabolic activity of the sperm.
      • Jager S.
      Sperm nuclear stability and male infertility.
      Higher and prolonged exposure to lead may be associated with increased risk of LBW births and PTBs; however, ascertainment bias played a major role in included studies. Agent Orange was a widely used herbicide in Vietnam, and contamination of this by dioxin prompted a series of studies that explored the association of paternal exposure with birth outcomes.
      • Lawson C.C.
      • Schnorr T.M.
      • Whelan E.A.
      • et al.
      Paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin and birth outcomes of offspring: birth weight, preterm delivery, and birth defects.
      Two studies reported no significant association between exposure to dioxin and LBW birth or PTB.
      • Lawson C.C.
      • Schnorr T.M.
      • Whelan E.A.
      • et al.
      Paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin and birth outcomes of offspring: birth weight, preterm delivery, and birth defects.
      • Michalek J.E.
      • Rahe A.J.
      • Boyle C.A.
      Paternal dioxin, preterm birth, intrauterine growth retardation, and infant death.
      Organic solvents can pass the blood-testis barrier and the placenta. Two studies of this association revealed no significant association.
      • Hooiveld M.
      • Haveman W.
      • Roskes K.
      • Bretveld R.
      • Burstyn I.
      • Roeleveld N.
      Adverse reproductive outcomes among male painters with occupational exposure to organic solvents.
      • Kristensen P.
      • Irgens L.M.
      • Daltveit A.K.
      • Andersen A.
      Perinatal outcome among children of men exposed to lead and organic solvents in the printing industry.
      Several studies of occupational exposure assessment have classified exposure based on interviews, databases, and expected hours of exposure.
      • Dimich-Ward H.
      • Hertzman C.
      • Teschke K.
      • et al.
      Reproductive effects of paternal exposure to chlorophenate wood preservatives in the sawmill industry.
      • Hooiveld M.
      • Haveman W.
      • Roskes K.
      • Bretveld R.
      • Burstyn I.
      • Roeleveld N.
      Adverse reproductive outcomes among male painters with occupational exposure to organic solvents.
      • Kristensen P.
      • Irgens L.M.
      • Daltveit A.K.
      • Andersen A.
      Perinatal outcome among children of men exposed to lead and organic solvents in the printing industry.
      • Lawson C.C.
      • Schnorr T.M.
      • Whelan E.A.
      • et al.
      Paternal occupational exposure to 2,3,7,8-tetrachlorodibenzo-p-dioxin and birth outcomes of offspring: birth weight, preterm delivery, and birth defects.
      • Milham S.
      • Ossiander E.M.
      Low proportion of male births and low birth weight of sons of flour mill worker fathers.
      The possibility of misclassification and recall bias cannot be ruled out.

      Other paternal factors

      Paternal alcohol intake was not associated significantly with PTB/SGA births in 1 study,
      • Savitz D.A.
      • Zhang J.
      • Schwingl P.
      • John E.M.
      Association of paternal alcohol use with gestational age and birth weight.
      but another study reported a 180-g increase in mean birthweight among offspring of the occasional drinker, compared with regular drinkers.
      • Little R.E.
      • Sing C.F.
      Father's drinking and infant birth weight: report of an association.
      The biologic rationale for such an effect remains to be understood. Less than a high school education was associated with a higher rate of PTB, and education less than college level was associated with higher odds of LBW births. Paternal low education level may be a marker for other underlying health determinants such as poverty, adverse home environment, and associated stress.
      There was significant heterogeneity in the reported studies that assessed paternal factors and its association to offspring outcomes. Keeping this in mind, we planned for a systematic review from the onset and not metaanalyses. Major clinical heterogeneities among studies were identified for inclusion of the studies (single institution-based study vs national sample) and for adjustment of confounders (different studies controlled for different confounders). A number of studies identified associations in univariate analyses; however, when confounders such as maternal factors were considered, the association became nonsignificant. The major issues with parental occupational exposure were ascertainment of a bias for exposure and recall bias.
      Strengths of this systematic review lie in the focused question, comprehensive and extensive literature search, and inclusion of studies from various countries. However, there are limitations of this review. First, there was heterogeneity in studies even within various exposure categories. Second, data on paternal factors are not collected regularly because fathers may not be present at prenatal visits and data are collected from mothers. The information that is collected could be subject to inaccuracies. Additionally, occupational exposure data were obtained from administrative databases or calculated in terms of duration or intensity of exposure. This is subject to ascertainment bias. Additionally, no detailed information regarding the timing of exposure and the protection used by fathers were reported. Third, various studies adjusted for different confounders in their analyses, and some studies did not adjust for confounders. It is important to adjust for various maternal confounders to assess the independent effect of paternal exposure. This limited our ability to conclude anything definitively about any of the factors. Fourth, publication bias should be considered. There is a possibility that, if the studies reported no association for any of the paternal exposures, there may have been less likelihood of publication. Fifth, we restricted our search to English language publications primarily because of the scope of information that may or may not be available in other languages. Literature searchers have found minimal difference with the inclusion of non-English language articles.
      • Moher D.
      • Pham B.
      • Lawson M.L.
      • Klassen T.P.
      The inclusion of reports of randomised trials published in languages other than English in systematic reviews.
      We have not included gray literature, abstracts, and proceedings because the quality of such studies cannot be assessed adequately. Finally, none of the studies used any objective measure to confirm paternity; the data on paternity were obtained from maternal history in all studies.

      Implications

      There are clinically significant and important implications of these results. Pregnancies that were conceived from younger and advanced age fathers, short-statured fathers, fathers who were LBW at birth, and fathers with less than a college education could be considered to be at a greater risk. This information can be used during counseling and education sessions.

      Conclusion

      In this comprehensive systematic review of paternal factors, associations were identified for paternal age, height, and LBW. Higher paternal birthweight resulted in heavier offspring. Heavy and prolonged lead exposure may be associated with LBW. Paternal weight, body mass, and workers with occupational exposures to herbicides, plant work, and wood were not associated with birth outcomes. Low paternal education may be associated with LBW/PTB births; however, further studies are warranted.

      Acknowledgments

      We sincerely thank Elizabeth Uleryk, Chief Librarian at the Hospital for Sick Children, Toronto, for her contribution in developing search strategy and running searches on a periodic basis, for which she did not receive any compensation. Contributors: guarantor: Shah PS; grant concept and design: all members of the group; study concept and design: Shah PS; acquisition of data, analysis, and interpretation of data, drafting of the manuscript: Shah PS; critical revision of the manuscript for intellectual content: Shah PS and all members of group. Members of the Knowledge Synthesis Group on determinants of LBW/preterm births: Prakesh S Shah, University of Toronto, Toronto, Ontario, Canada; Arne Ohlsson, University of Toronto, Ontario, Canada; Sarah D McDonald, McMaster University, Hamilton, Ontario, Canada; Eileen Hutton, McMaster University, Hamilton, Ontario, Canada; Vibhuti Shah, University of Toronto, Toronto, Ontario, Canada; Joseph Beyene, University of Toronto, Toronto, Ontario, Canada; Corine Frick, University of Calgary, Calgary, Alberta, Canada; Fran Scott, University of Toronto, Toronto, Ontario, Canada; Kellie E Murphy, University of Toronto, Ontario, Canada; Christine Newburn-Cook, University of Alberta, Edmonton, Alberta, Canada; Victoria Allen, Dalhousie University, Halifax, Nova Scotia, Canada.

      Appendix

      Tabled 1Quality assessment tool
      BiasNoneLowModerateHighCannot tell
      SelectionConsecutive unselected populationSample selected from large population; selection criteria not definedSample selection ambiguous; sample may be representativeSample selection ambiguous; sample likely not representativeNA
      Sample selected from general population rather than a select groupA select group of population (eg, based on race, ethnicity, residence)Eligibility criteria not explainedA very select population was studied, which made it difficult to generalize findingsNA
      Rationale for case and control selection explainedRationale for case and control subjects not explainedNA
      Follow-up or assessment time explainedFollow-up or assessment time not explainedNA
      Exposure assessmentDirect questioning (interview) or completion of survey by mother at the time of exposure or close to the time of exposureAssessment of exposure from global datasetExtrapolating data from population exposure sample (with some assumptions) and not direct assessment at any timeIndirect method of assessment (obtaining data from others and not from mother or father)NA
      Direct measurement of exposure (laboratory)Indirect assessment (postal survey, mailed questionnaire)NA
      Outcome assessmentAssessment from hospital record, birth certificate, or direct question to mother regarding birthweightAssessment from administrative databaseAssessment from “open-ended” questions (was your baby early? or premature? or small? or before due date)Assessment from nonvalidated sources or generic estimate from overall populationNA
      Direct question to mother regarding gestational ageNA
      Confounding factorControlled for common confoundersOnly certain confounders adjustedNot controlled for confoundersNA
      AnalyticalAnalyses appropriate for the type of sampleAnalyses not accounting for common statistical adjustment (eg, multiple analyses) when appropriateSample size estimation unclear, or only subsample of eligible patients was studiedAnalyses inappropriate for the type of sample/studyNA
      Analytical method accounted for sampling strategy in cross-sectional studySample size calculation not performed; all available eligible patients studiedNA
      Sample size calculation performed and adequate sample studiedSample size calculated; reasons for not meeting sample size givenNA
      Attrition0-10% attrition and reasons for loss of follow-up data explained0-10% attrition and reasons for loss of follow-up data not explained11-20% attrition; reasons for loss of follow-up data not explained>20% attrition; reasons for loss of follow-up data not explainedNA
      All subjects from initiation of study to the final outcome assessment were accounted for11-20% attrition; reasons for loss of follow-up data explained>20% attrition but reasons for loss of follow up explainedNA
      All subjects from initiation of study to final outcome assessment not accounted forNA
      NA, information was not available from published report.
      Shah. Paternal factors and LBW/PTB. Am J Obstet Gynecol 2010.

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      Linked Article

      • Do fathers matter? Paternal contributions to birth outcomes and racial disparities
        American Journal of Obstetrics & GynecologyVol. 202Issue 2
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          Studies have rarely considered the impact of paternal factors on perinatal outcomes generally or on racial differences therein. Shah et al1 have produced a literature review that begins to delve into the contribution of fathers to the risk of adverse birth outcomes. Paternal exposures that were selected for inclusion in their database search were father's age, anthropometry (eg, height, weight), self birthweight, occupational exposures, and education. After a systematic search of the literature, the authors identified the father's age, current weight, and his own birthweight as risk factors for low birthweight and suggest that paternal occupation and education may be important but have not consistently been reported to increase the risk of adverse birth outcomes.
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