Risk factors associated with growth failure in the follow-up of very low birth weight newborns

Association of Neonatal Morbidities and Postnatal Growth Faltering in Preterm Neonates

BACKGROUND/OBJECTIVES

Postnatal growth faltering (PGF) is a risk factor for adverse neurodevelopment in very preterm neonates. The aim of this retrospective study was to determine which infants' baseline characteristics, prenatal risk factors and neonatal morbidities are associated with two definitions of PGF: defined as loss of >2 weight z-scores (severe PGF) or as loss of >1 weight, length, and head circumference z-scores between birth and discharge (complex PGF); Methods: 146 premature newborns (<32 weeks of gestational age, <1500 g) were included in the study. Anonymized data including anthropometric measurements (weight, length, and head circumference), perinatal and neonatal data (demographics, maternal morbidities and previous pregnancies, and neonatal and perinatal morbidities) were extracted from the clinical electronic database. Changes in anthropometric age- and sex-specific z-scores using the Fenton 2013 preterm growth charts were calculated to diagnose severe PGF and complex PGF; Results: The incidence of severe PGF was 11% and complex PGF was 24%. Both PGF definitions were associated with bronchopulmonary dysplasia (BPD), severe retinopathy of prematurity (ROP), longer respiratory support, and longer hospital stay. Severe PGF was associated with surgical necrotizing enterocolitis at 25% vs. 1.5%, p = 0.001. Complex PGF was associated with severe brain injury at 51% versus 27%, p = 0.007. Complex PGF was more common in newborns born most prematurely, while severe PGF was more common in newborns born small for gestational age (SGA); Conclusions: Both severe and complex PGF are associated with several important neonatal morbidities, which might explain why growth faltering is associated with suboptimal neurodevelopment. Appropriate early identification of faltered growth may influence medical and nutrition interventions which in turn could improve the outcome of very preterm newborns.

A Quality Improvement Project to Decrease Fractures Secondary to Metabolic Bone Disease of Prematurity

Introduction

Osteopenia of prematurity is common in the neonatal intensive care unit, with an incidence of up to 54% in extremely low birthweight infants. The baseline fracture rate in our level IV midwestern neonatal intensive care unit was 13%, with poor compliance with recommended intakes of calcium, calcium:phosphorus ratio, and Vitamin D.

Methods

A multidisciplinary team implemented a screening guideline through four Plan-Do-Study-Act cycles, which addressed staff education, vitamin D screening, and incorporation of calcitriol. In total, 150 patients born between October 1, 2019 and April 30, 2023 were screened for mineral intakes, laboratory abnormalities, and the development of fractures or osteopenia.

Results

The incidence of fractures decreased from 13% to 5.3%. Compliance with mineral intakes improved for calcium, calcium: phosphorus ratio, and Vitamin D. Infants born after the guideline were 4.8 times less likely to develop fractures.

Conclusion

Quality improvement methodology successfully decreased the rate of fractures due to osteopenia of prematurity and increased compliance with recommended mineral intakes.

Postnatal growth in small vulnerable newborns: a longitudinal study of 2 million Brazilians using routine register-based linked data

BACKGROUND

Preterm, low-birth weight (LBW) and small-for-gestational age (SGA) newborns have a higher frequency of adverse health outcomes, including linear and ponderal growth impairment.

OBJECTIVE

To describe the growth trajectories and to estimate catch-up growth during the first 5 y of life of small newborns according to 3 vulnerability phenotypes (preterm, LBW, SGA).

METHODS

Longitudinal study using linked data from the 100 Million Brazilian Cohort baseline, the Brazilian National Live Birth System (SINASC), and the Food and Nutrition Surveillance System (SISVAN) from 2011 to 2017. We estimated the length/height-for-age (L/HAZ) and weight-for-age z-score (WAZ) trajectories from children of 6-59 mo using the linear mixed model for each vulnerable newborn phenotype. Growth velocity for both L/HAZ and WAZ was calculated considering the change (Δ) in the mean z-score between 2 time points. Catch-up growth was defined as a change in z-score > 0.67 at any time during follow-up.

RESULTS

We analyzed 2,021,998 live born children and 8,726,599 observations. The prevalence of at least one of the vulnerable phenotypes was 16.7% and 0.6% were simultaneously preterm, LBW, and SGA. For those born at term, all phenotypes had a period of growth recovery from 12 mo. For preterm infants, the onset of L/HAZ growth recovery started later at 24 mo and the growth trajectories appear to be lower than those born at term, a condition aggravated among children with the 3 phenotypes. Preterm and female infants seem to experience slower growth recovery than those born at term and males. The catch-up growth occurs at 24-59 mo for males preterm: preterm + AGA + NBW (Δ = 0.80), preterm + AGA + LBW (Δ = 0.88), and preterm + SGA + LBW (Δ = 1.08); and among females: term + SGA + NBW (Δ = 0.69), term + AGA + LBW (Δ = 0.72), term + SGA + LBW (Δ = 0.77), preterm + AGA + LBW (Δ = 0.68), and preterm + SGA + LBW (Δ = 0.83).

CONCLUSIONS

Children born preterm seem to reach L/HAZ and WAZ growth trajectories lower than those attained by children born at term, a condition aggravated among the most vulnerable.

Orofacial characteristics of the very low-birth-weight preterm infants

OBJECTIVE

To evaluate the orofacial characteristics of very low-birth-weight preterm infants through anthropometric facial measures, orofacial anteroposterior analysis and the relationship between the gum pads.

METHOD

Orofacial examinations was performed in 154 infants, classified into two groups: Group A comprised 54 very low-birth-weight infants who were examined after clinical stabilization and before hospital discharge, and Group B comprised 100 full-term infants.

RESULTS

The average anthropometricmeasurements in millimetres for Group A and Group B were as follows: upper third:30.2 and 31.1; middle third: 24.2 and 25.9; lower third: 27.6 and 29.9; facial width: 64.8and 81.4. Regarding the orofacial anteroposterior analysis, the results showed that in99% of these infants, the mandible was in a retrognathic position relative to the maxilla.Group A and Group B had the following distributions of the relationship between thegum pads: overbite-overjet: 43% and 77%; overjet: 39% and 17%; open bite: 15% and3%; end-to-end: 2% and 1%; overbite: both 2%.

CONCLUSION

The very low-birth-weight preterm infants showed the upper third with the highest values in the facialharmony analysis, followed by the lower third and the middle third; and exhibited themandible in a retrognathic position relative to the maxilla, and with overbite-overjet themost prevalent type of gum pad relationship. The study emphasizes the importance of orofacial examination during neonatal hospitalization and the investigation of birth weight and gestational age in a multidisciplinary therapeutic approach that includes orofacial neonatal evaluation and actions that promote oral health, besides foster follow-up studies.

Applying Methods for Postnatal Growth Assessment in the Clinical Setting: Evaluation in a Longitudinal Cohort of Very Preterm Infants

AIM

To analyze different methods to assess postnatal growth in a cohort of very premature infants (VPI) in a clinical setting and identify potential early markers of growth failure.

METHODS

Study of growth determinants in VPI (≤32 weeks) during hospital stay. Nutritional intakes and clinical evolution were recorded. Growth velocity (GV: g/kg/day), extrauterine growth restriction (%) (EUGR: weight < 10th centile, z-score < -1.28) and postnatal growth failure (PGF: fall in z-score > 1.34) at 36 weeks postmenstrual age (PMA) were calculated. Associations between growth and clinical or nutritional variables were explored (linear and logistic regression).

RESULTS

Sample: 197 VPI. GV in IUGR patients was higher than in non-IUGRs (28 days of life and discharge). At 36 weeks PMA 66.0% of VPIs, including all but one of the IUGR patients, were EUGR. Prevalence of PGF at the same time was 67.4% (IUGR patients: 48.1%; non-IUGRs: 70.5% (p = 0.022)). Variables related to PGF at 36 weeks PMA were initial weight loss (%), need for oxygen and lower parenteral lipids in the first week.

CONCLUSIONS

The analysis of z-scores was better suited to identify postnatal growth faltering. PGF could be reduced by minimising initial weight loss and assuring adequate nutrition in patients at risk.

Motor trajectories of preterm and full-term infants in the first year of life

BACKGROUND

Motor development occurs throughout periods of motor skill acquisition, adjustment and variability. The objectives of this study were to analyze and compare biological and health characteristics and motor skill acquisition trajectories in preterm and full-term infants during the first year of life.

METHODS

Two thousand, five hundred and seventy-nine infants (1,361 preterm) from 22 states were assessed using the Alberta Infant Motor Scale. Multivariate General Linear Model, t-tests, ANOVA, and Tukey tests were used.

RESULTS

An age × group significant interaction was found for motor scores. On follow-up tests full-term infants had higher scores in prone, supine, sitting and standing postures that require trunk control from 9 to 10 months of age; although this advantage was observed for sitting from the second month of life.

CONCLUSION

During the first trimester of life, preterm infants have higher scores in the supine and standing postures. Regarding motor trajectories, from newborn to 12 months, the period of higher motor acquisition was similar between full-term and preterm infants for prone (3-10 months), supine (1-6 months), and standing (6-12 months). For the sitting posture, however, full-term infants had a period of intensive motor learning of acquisition from the first to 7 months of life, whereas for preterm infants a shorter period was observed (3-7 months).

CONCLUSION

Although the periods of higher motor acquisition were similar, full-term infants had higher scores in more control-demanding postures. Intervention for preterm infants needs to extend beyond the first months of life, and include guidance to parents to promote motor development strategies to achieve control in the higher postures.

Chest circumference in full-term newborns: how can it be predicted?

BACKGROUND

Although over the years a number of studies have used chest circumference (CC) as a sensitive tool to identify the health status of infants, a particularly important aspect for this population is the lack of data on normal values and prediction equations. In order to facilitate and validate the interpretation of CC data in newborn (NB), the aim was to study the relation between CC and other anthropometric variables and develop a predictive equation for CC in a population of full-term newborns.

METHODS

Cross-sectional study, carried out with full-term infants. The anthropometric (CC, head circumference - HC, length, age and weight) and hemodynamic variables were evaluated during the first 24 h of life. Bivariate analysis was performed between CC and HC, weight, length and type of delivery, followed by multiple linear regression analysis, including variables that were significant in the bivariate analysis. For data analysis, we used the SPSS program, considering p < 0.05 and 95% CI.

RESULTS

The birth weight of the 120 NB varied between 2580 and 4225 g (mean 3360 g) and the gestational age between 37 and 42 weeks (mean 39 weeks). Approximately 61% of the sample were delivered vaginally and 67 (56%) were boys. The variables that remained statistically associated with CC after multivariate analysis were weight (β 0.003, CI: 0.002: 0.003, p = 0.001) and HC (β 0.287, CI: 0.156: 0.417, p = 0.001). For the linear regression model, the predictive equation of CC was 14.87+ (0.003 x weight) + (0.287 x HC), with a prediction of 76%.

CONCLUSION

The results show a positive correlation between CC and weight, length and HC, and based on the linear regression model, the predictive equation for CC is based only on weight and HC.

Influence of Parenteral Nutrition Delivery Techniques on Growth and Neurodevelopment of Very Low Birth Weight Newborns: A Randomized Trial

Background and Objectives: In very low birth weight (VLBW) newborns, parenteral nutrition (PN) is delivered via a peripheral venous catheter (PVC), a central venous catheter (CVC), or a peripherally inserted central venous catheter (PICC). Up to 45% of PICCs are accompanied by complications, the most common being sepsis. A PVC is an unstable PN delivery technique requiring frequent change. The growth and neurodevelopment of VLBW newborns may be disturbed because of catheters used for early PN delivery and complications thereof. The aim of the conducted study was to evaluate the effect of two PN delivery techniques (PICC and PVC) on anthropometric parameters and neurodevelopment of VLBW newborns. Materials and Methods: A prospective randomized clinical trial was conducted in VLBW (≥750–<1500 g) newborns that met the inclusion criteria and were randomized into two groups: PICC and PVC. We assessed short-term outcomes (i.e., anthropometric parameters from birth until corrected age (CA) 36 weeks) and long-term outcomes (i.e., anthropometric parameters from CA 3 months to 12 months as well as neurodevelopment at CA 12 months according to the Bayley II scale). Results: In total, 108 newborns (57 in the PICC group and 51 in the PVC group) were randomized. Short-term outcomes were assessed in 47 and 38 subjects, and long-term outcomes and neurodevelopment were assessed in 38 and 33 subjects of PICC and PVC groups, respectively. There were no differences observed in anthropometric parameters between the subjects of the two groups in the short- and long-term. Mental development index (MDI) < 85 was observed in 26.3% and 21.2% (p = 0.781), and psychomotor development index (PDI) < 85 was observed in 39.5% and 54.5% (p = 0.239) of PICC and PVC subjects, respectively. Conclusions: In the short- and long-term, no differences were observed in the anthropometric parameters of newborns in both groups. At CA 12 months, there was no difference in neurodevelopment in both groups.

Mineral Homeostasis and Effects on Bone Mineralization in the Preterm Neonate

Most bone formation and mineralization occurs late in gestation. Accretion of adequate minerals is a key element of this process and is often interrupted through preterm birth. In utero, mineral transport is accomplished via active transport across the placenta and does not require fetal hormone input. Postnatal mineral homeostasis requires a balance of actions of parathyroid hormone, calcitonin, and vitamin D on target organs. Preterm birth, asphyxia, acidosis, and prolonged parenteral nutrition increase the risk of mineral imbalance and metabolic bone disease (MBD). Aggressive postnatal nutrition is key to preventing and treating MBD in preterm infants.

Prediction of Postnatal Growth Failure among Very Low Birth Weight Infants

Postnatal growth failure (PGF) in preterm infants remains an important clinical issue. In this study, we analysed the incidence of PGF among very low birth weight (VLBW) infants and evaluated the risk factors for PGF based on the data of 2799 VLBW infants obtained from the Korean Neonatal Network database from 2013 to 2014. PGF was defined as a decrease in weight Z score between birth and discharge of more than −1.28 using the Fenton growth charts. Risk factors were evaluated in relation to birth weight for gestational age, namely small (SGA) or appropriate (AGA) for gestational age, using propensity score matching used for between-group differences. The overall incidence of PGF was 45.5%, with a rate of 68.9% in the SGA group and 36.2% in the AGA group. PGF was negatively correlated with gestation and birth weight; additionally, PGF was associated with a higher incidence of co-morbidities. Predictors of PGF in the SGA group were respiratory distress syndrome and days to attain 100 mL/kg of enteral feeding. The only predictor of PGF in the AGA group was days to attain 100 mL/kg of enteral feeding. Early initiation and aggressive progression of enteral nutrition may decrease the incidence of PGF.