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Original ArticleBreastfeeding Motivation and exclusive BreastfeedingOriginal Article

DOI: 103126/JNPS.V4113

Ashish Jain1, Sudharshan Raj Chitgupikar2, Madhavi Bhardwaraj1, Preethi Subramanian2

1Department of of Neonatology, Maulana Azad Medical College and Associated Lok Nayak Hospital, Bahadur Shah Zafar Marg, New 
Delhi, India 
2Department of of Paediatrics, Mediciti Institute of Medical Sciences, Medchal Mandal, Ghanpur, Hyderabad, India

Nasal Anthropometry among Term and Preterm Indian 
Neonates- Does Size Matter?

Introduction: The binasal prongs are used in neonatal intensive care unit 
(NICU) to provide nasal Continuous Positive Airway Pressure (n-CPAP) in preterm 
neonates. A variable degree of nasal trauma is the most common complication 
of n-CPAP therapy. This can be reduced by use of appropriately sized binasal 
prongs that are customized to the anatomical measurements of noses. The aim 
was to estimate the nasal two-dimensional anthropometrical parameters among 
Indian neonates across different gestations; to compare between both sexes 
and between neonates with different intra uterine growth status and gestational 
ages. 

Methods: Hundred and one neonates across different gestational ages (24 – 
42 weeks) and intrauterine growth status who were admitted to the NICU of a 
tertiary teaching hospital were enrolled and grouped into five categories based 
on their gestational ages viz. 37 – 42 weeks, 34 – 36 weeks, 31 – 33 weeks, 
28 – 30 weeks, and 24 – 27 weeks. Seven nasal and para-nasal measurements 
were taken (nostril width, nostril length, columella width, columella length, nose 
width, nose length and philtrum length) for each neonate using a vernier caliper. 

Results: All anthropometrical measurements differed significantly across 
gestations especially between 37 - 42 and 24 - 27 wks (p = 0.00). Males 
differed from females only with respect to nostril width (p = 0.032). The 
measurements  varied significantly when compared among small for gestational 
age, appropriate for gestational age and large for gestational age neonates. 

Conclusions: The nasal parameters differed significantly among various GA 
and intra-uterine growth statuses, which should help design appropriate sizes 
of bi-nasal prongs.

Abstract

*Corresponding Author
Ashish Jain
Associate Professor,
Department of of Neonatology, 
Maulana Azad Medical College and 
Associated Lok Nayak Hospital, 
Bahadur Shah Zafar Marg, New Delhi, 
India
Email: neoashish2008@gmail.com

Article History 
Received On : 05 Apr, 2022
Accepted On : 11 Dec, 2022

Funding sources: None

Conflict of Interest: None

Keywords: Inappropriately sized nasal 
prongs; Nasal parameters; Nasal trauma

Online Access

DOI:
https://doi.org/10.3126/jnps.v42i2.44302

Introduction
It is a well-known fact that respiratory distress syndrome (RDS) affects a significant 
proportion of preterm neonates1 and is one of the major causes of neonatal mortality. 
Hence, the recent Neonatal Resuscitation Program (NRP) guidelines recommend a 
delivery room respiratory support in the form of Nasal Continuous Positive Airway 
Pressure (n-CPAP) which can provide a positive end-expiratory pressure of around 5 
cm H2O, for these vulnerable preterm babies.

2,3 The use of n-CPAP in these babies has 
been reported to lead to earlier transition in the delivery room area, lower mortality, 
lower rates of intraventricular hemorrhage and bronchopulmonary dysplasia as 

Copyrights & Licensing © 2022 by author(s). This is an Open Access article distribut-
ed under Creative Commons Attribution License (CC BY NC )



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202262

Original Article Nasal aNthropometry of INdIaN NeoNates

compared to use of mechanical ventilation directly.4 

Various CPAP generators as well as nasal interfaces, have been 
innovated and improvised in the past. Diverse interface devices 
like nasopharyngeal tube, single nasal prongs, bi-nasal prongs, 
nasal cannula have been used to deliver n-CPAP in neonates 
however, each of these have their own merits and limitations. 
Short bi-nasal prongs are commonly used in recent times and have 
shown to have better respiratory outcomes in neonates with RDS 
as compared to use of nasopharyngeal or single nasal prongs.5 
The major and the most common complication of n-CPAP therapy 
in preterm neonates is the variable degree of nasal trauma.6,7 
Even though there is no recognized classification specifically 
addressing to the nasal trauma secondary to n-CPAP in neonates, 
the US National Pressure Ulcer Advisory Panel8,9 guidelines for 
staging have been often used in most of the neonatal studies. This 
classification has attempted to grade nasal injury from early stage 
of non-blanchable erythema with intact skin to an advanced stage 
of necrosis, with full thickness skin loss. In a study using the above 
classification of nasal trauma in neonates on n-CPAP, 42.5% 
of neonates developed nasal trauma. 88.3% had stage I nasal 
trauma, 11% stage II trauma and 0.7% had stage III trauma.9 
A similar incidence (20 - 60%) with nasal septum being the 
commonest site for injury was reported by another study.10 Fischer 
et al, in a large cohort of preterm with different gestational ages 
and weights, reported an increase in the relative risk of nasal 
injury when the gestational age was < 32 weeks, birth weight < 
1500 grams, n-CPAP duration < 5 days and Neonatal Intensive 
Care Unit (NICU) stay was < 14 days.9 The higher incidence of 
nasal trauma in smaller babies is most of the times attributed to 
the soft, fragile skin, ischemia prone underlying tissue and more 
importantly the ill-fitting, inappropriately sized binasal prongs.6 
The number of the injuries and their severity can be reduced if an 
appropriate size binasal prongs are used, that are customized to 
the anatomical measurements of the noses.

Even though it is undoubtedly an important prerequisite to have 
the nasal sizes for development of the safe nasal interface sizes, 
there are few studies that look at the nasal anatomical parameters 
in Indian neonates of different gestations. Most of the prongs that 
are used in the Indian setup are based on the studies and sizes 
of the western babies. Our study aims to assess nasal parameters 
in neonates of different gestations for development of appropriate 
size binasal prongs.

Methods
This observational study was performed in the Neonatology 
Department of a tertiary care and teaching hospital of North India 
between January 2016 and April 2016. The study was approved 
by the ethical committee of the institution. All the procedures 
followed were in accordance with the ethical standards of the 
responsible committee on human experimentation (institutional or 
regional) and with the Helsinki Declaration of 1964, as revised 
in 2000. All neonates born (live or stillbirth) were enrolled in 
the study within 72 hours of birth. The neonates who had any 
congenital malformation or facial dysmorphism of the nasal or 
para-nasal area were excluded from the study. It was pre-decided 
to measure at least five babies (male or female) in each gestational 
category for appropriate representation in each group. The 

gestational categories in which the measurements were taken 
were 24+1 - 27 completed weeks; 28+1 - 30 completed weeks; 
31+1 - 33 completed weeks; 34+1 - 36 completed weeks and 37+1 
- 42 completed weeks. A gestational assessment was done within 
72 hours of birth using the New Expanded Ballard Score.11 Based 
on Ghosh et al,12 who reported the mean width of columella of 
term neonates as 2.5 mm with SD of 0.1, we calculated the 
sample size with a precision of 0.2 mm and confidence interval 
of 95% which came to 100 neonates. Candidates were enrolled 
after taking due informed consent from the parents or the primary 
caregiver. Baseline information including age in completed days, 
sex, and birth weight, appropriateness of growth for the estimated 
gestational age and date of birth were recorded. A Vernier 
caliper with a least count of 0.1 mm was used for measuring 
the various parameters. For this study, all the measurements were 
made by a Vernier caliper. The measurements were done using 
aseptic technique by an experienced paediatrician (Figures 
1 & 2). Special care was taken to perform the same with all 
asepsis when the baby was quiet and sleeping. The mother was 
always with the baby when the measurements were taken. Each 
measurement was done at least thrice successively, and the mean 
of the measurements was finally recorded. Seven nasal and para-
nasal parameters were measured (in mm), which were: (1) Nasal 
length ; measurement from the base of the nose to the tip of the 
nose (2) Nasal width (outer ala to ala distance) (3) Nostril length 
(Base of the nostril to the highest point) (4) Nostril width (The 
horizontal measurement from one side to other) (5) Columella 
length (The length from the base to the highest point on columella 
in the center) (6) Columella width (This was taken at the base of 
the columella) (7) Philtrum length (The length from the point of 
attachment of columella to the upper margin of the upper lip).

Figure 1. Measuring nasal width using vernier caliper



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 63

Original ArticleNasal aNthropometry of INdIaN NeoNates

Figure 2. Measuring columellar width using vernier caliper

Measurements were statistically analyzed and tabulated. 
Arithmetic mean for each parameter in each group with standard  
deviations were calculated. One way analysis of variance 
(ANOVA) was used for comparing mean values of different 
groups; post hoc Tukey’s HSD (Honestly significant difference) 
test was used to identify the significance of differences of mean 
among these groups and student t-test was used for comparing 
two groups with continuous variables. All the calculations / tests 
were performed with the help of SPSS 2.0. A p-value of < 0.05 
was considered statistically significant.

Results
101 neonates were enrolled in the study from GA of 24 weeks 
till 42 weeks. Among the study group, 50.5% (51 / 101) were 
males. 23.76% (24 / 101) neonates were extremely low birth 
weight (ELBW), 24.75% (25 / 101) were very low birth weight 
(VLBW) and 28.71% (29 / 101) were low birth weight (LBW).  
Among all, 72.28% (73/101) were preterms. 

The comparison of nasal measurements among different 
gestational age groups using one way ANOVA is shown in Table 
1. On comparison of the five gestational groups, the estimated 
p values were highly significant for all the parameters. Post hoc 
analysis for nostril width revealed significant difference between 
37 - 42 weeks group and 28 - 30 weeks group (p = 0.0052) 
and between 37 - 42 weeks and 24 - 27 weeks group (p = 
0.008). For nostril length post hoc analysis revealed significance 
only for difference in measurements between 37 - 42 weeks and 
24 - 27 weeks (p = 0.0273). With respect to columella width, 
the difference was significant when compared among the groups: 
37 - 42 weeks vs 28 - 30 weeks (p = 0.0000); 37 - 42 weeks vs 
24 - 27 weeks (p = 0.0000); 34 - 36 weeks vs 28 - 30 weeks (p 
= 0.0272); 34 - 36 weeks vs 24 - 27 weeks (p = 0.0001) and 
31 - 33 weeks vs 24 - 27 weeks (p = 0.0101). For columella 
length post hoc analysis revealed significant difference for 37 
- 42 weeks vs 34 - 36 weeks (p = 0.0057); 37 - 42 weeks vs 
31 - 33 weeks (p = 0.0062); 37 - 42 weeks vs 28 - 30 weeks (p 
= 0.0005); 37 - 42 weeks vs 24 - 27 weeks (p = 0.0000) and 
31 - 33 weeks vs 24 - 27 weeks (p = 0.0442). For nose width 
the difference among groups were significant except for 34 - 36 
weeks vs 31 - 33 weeks and 28 - 30 weeks vs 24 - 27 weeks. 
For nose length, post hoc analysis revealed significant difference 
among all groups except 34 - 36 weeks vs 31 - 33 weeks and 28 
– 30 weeks vs 24 - 27 weeks. Philtrum length showed significant 
difference only between 37 - 42 weeks vs 28 - 30 weeks (p = 
0.0343) and 37 - 42 weeks vs 24 – 27 weeks (p = 0.0239).

Table 1.  Comparison of parameters among different gestational groups [mean (mm) ± S.D.]

Gestational age 
(wks) n (%)

Nostril width Nostril length Columella width  Columella
length

Nose width Nose length Philtrum length

42 – 37
N = 28 (27.72)

1.77 ± 5.68 0 ± 3.77 0.35 ± 4.11 1.77 ± 8.02 1.06 ± 20.71 1.77 ± 17.36 2.12 ± 7.89

36 – 34
N = 21 (20.79)

0 ± 4.74 1.06 ± 3.29 0.707 ± 3.67 0.707 ± 7 2.12 ± 18.14 1.41 ± 15.45 0 ± 7.52

31 – 33
N = 22 (21.78)

2.47 ± 4.77 1.06 ± 3.68 0.70 ± 3.36 0 ± 7.02 1.41 ± 16.84 1.06 ± 14.45 1.06 ± 7.52

30 – 28
N = 23 (22.78)

0.35 ± 4.17 0.71 ± 3.6 0 ± 3.22 0 ± 6.83 2.12 ± 15.07 0.71 ± 13.22 0.35 ± 6.87

27 – 24
N = 7 (6.93)

0.71 ± 3.5 0 ± 2.79 0 ± 2.64 0 ± 5.79 0 ± 14.28 0.35 ± 12.07 0 ± 6.29

p-value
(ANOVA)

0.000 0.005 0.000 0.000 0.000 0.000 0.001

S.D. – Standard deviation; ANOVA: - Analysis of Variance.

The comparison of the parameters between both sexes using 
independent student t-test (Table 2), did not show any significant 

difference except nostril width (p = 0.032). 



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  202264

Original Article Nasal aNthropometry of INdIaN NeoNates

Table 2. Comparison of parameters between both sexes [mean (mm) ± SDs

Sex Nostril width Nostril length Columella width Columella length Nose width Nose length Philtrum length

Male (n = 51) 0.941 ± 4.99 0.636 ± 3.66 0.668 ± 3.56 0.997 ± 7.23 2.690 ± 17.62 1.992 ± 15.13 1.202 ± 7.53

Female (n = 50) 0.913 ± 4.59 0.776 ± 3.43 0.523 ± 3.54 0.821 ± 7.10 2.637 ± 17.59 2.274 ± 14.91 1.051 ± 7.25

p-value
(Independent t test)

0.032 0.111 0.875 0.492 0.959 0.610 0.217

Table 3 depicts the comparison of nasal parameters among 
neonates with different growth status using one way ANOVA. 
On comparison of the three groups, the p values for nose width 
(0.000), columella width (0.01) and philtrum length (0.004) were 
found to be significant. Post hoc analysis revealed significant 

difference between AGA and SGA (p=0.0193) for columella 
width; between AGA vs LGA (p = 0.0004) and SGA vs LGA (p = 
0.0000) for nose width and between AGA vs LGA (p = 0.0030) 
and SGA vs LGA (p = 0.0051) for philtrum length.

Table 3. Comparison of parameters among neonates with different growth status [mean (mm) ± S.D.]

Growth Status n(%) Nostril width Nostril length Columella width Columella length Nose width Nose length Philtrum length

(AGA) N = 71 (70.29) 0.996 ± 4.76 0.751 ± 3.58 0.609 ± 3.63 0.981 ± 7.22 2.617 ± 17.66 2.235 ± 15.06 0.904 ± 7.31

(SGA) N = 25 (24.75) 0.777 ± 4.70 0.612 ± 3.40 0.523 ±  3.26 0.645  ± 6.90 1.947 ± 16.54 1.719 ± 14.54 1.061 ± 7.30

(LGA) N = 5 (4.96) 0.447 ± 5.70 0.671 ± 3.70 0.274 ± 3.80 0.758 ±  7.70 0.822 ± 22.10 1.475 ± 16.90 2.761 ± 9.00

p-value (ANOVA) 0.083 0.481 0.01 0.080 0.000 0.073 0.004

S.D. – Standard deviation; ANOVA: - Analysis of Variance.

Discussion
The present study is an attempt to determine the basal values 
for various nasal parameters in different gestational age groups 
of the local population of neonates belonging to the north-
western part of India. The study suggests that, as the gestation 
progresses, all the seven parameters assessed increase and 
values differ significantly between the gestation groups more so 
in the first and the last categories (37 - 42 weeks and below 28 
weeks). JS et al13published a cross sectional study in 2019 on 
discrepancy in physical dimensions of nose and CPAP interface 
in 32 preterm neonates from 26+0 - 34+6 weeks gestation. The 
various anthropometric measurements were done using 3D 
photogrammetry. The measurements were observed to increase as 
weight of neonates’ weight increased. 

On comparison of male and female participants of the study, it 
was found that nostril width differs significantly between the two 
groups, being larger in males. This finding was comparable to 
the study done by Khandekar et al,14 who reported mean nasal 
widths as 15.5 mm and 14.5 mm in male and female neonates 
respectively. They also found that mean columellar height in term 
neonates was 4.2 mm in male babies and 4.1 mm in females. 
Mean columellar width was 4.5 mm in male neonates and 4.4 mm 
in females. No comparison of means was done to assess whether 
the two groups differ with respect to the parameters assessed. 
Also, preterm babies were not a part of this study. Our study 
found lesser mean columellar width but larger columellar length 
and nasal width values compared to their study. Our study also 
noted no significant difference in measured parameters (except 
nostril width) between male and female babies.

Ghosh A et al12 studied craniofacial anthropometric measurements 
of 1860 term neonates (1060 normal birth weight and 800 low 
birth weight) of Northeastern India and reported that there was 
significant difference In measurements of nose length, Columella 
width, and length and width of philtrum between males and 
females with male neonates having higher measurements. But 
preterm neonates were not included in this study. Our study did 
not find such statistically significant difference between the two 
sexes except for nostril width. This could probably be attributed to 
lesser sample size. In another study done by Agnihotri et al15 for 
assessment of craniofacial anthropometry in infants and newborns, 
it was found that philtrum length differs in male and female 
neonates with p-value less than 0.05 while no such difference 
was found in the present study. Preterm neonates were again not 
a part of this study. Wong et al16 assessed comparability of 3D 
digital photogrammetric images and direct methods and found 
them to be comparable on validity and reliability for craniofacial 
assessment. 

A comparison among AGA, SGA and LGA groups, showed that 
columella width, nose width and philtrum length differ significantly 
between the three groups being the largest in LGA babies and the 
smallest in SGA babies. These would be an important data looking 
at the proportion of the SGA babies in the Indian population, 
as the current interfaces available are mainly derived from AGA 
preterm population. When we analyzed our data and applied post 
hoc (Tukey’s HSD) after ANOVA, we found significant difference 
in nostril width and length; columellar width and length in the 
categories of GA < 28 weeks; 31 - 33 and ≥ 37 weeks.

The nomograms of the nasal and the paranasal parameters of the 
Indian babies of different gestation would be vital data to develop 
the indigenous (Indian), novel and customized nasal prongs for 
the Indian babies, translating into lesser nasal injury and better 



J Nepal Paediatr Soc | VOL 42 | ISSUE 02 |MAY-AUG,  2022 65

Original ArticleNasal aNthropometry of INdIaN NeoNates

outcomes. The variation in the measurements between different 
gestation categories would be important to develop the minimum 
range of the nasal prongs that can fit most of the Indian neonates, 
this minimum range would add to reduction in the running cost 
in the widely existent constraint settings. Although our study is 
an important study for the nasal anthropometry among Indian 
neonates, one major limitation is lesser number (n = 7) of 
extremely preterm infants available for enrollment.

Conclusions
Post-hoc HSD suggests the use of at-least three different sizes of 
nasal prongs in Indian neonates (< 28 weeks;  31 - 33 and ≥ 37 
weeks). Larger and multicentric studies are required before this 
can be put into use for manufacturing customized nasal prongs 
for Indian neonates. 

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https://doi.org/10.1055/s-0039-1699120

