Growth velocity of extremely low birth weight preterms at a tertiary neonatal unit in South Africa

Factors associated with small-for-gestational-age births among preterm babies born <2000 g: a multifacility cross-sectional study in Ethiopia

OBJECTIVES

This study aimed to determine the prevalence of small-for-gestational-age (SGA) and appropriate-for-gestational-age (AGA); compare variations in multiple risk factors, and identify factors associated with SGA births among preterm babies born <2000 g.

DESIGN

Cross-sectional study.

SETTING

The study was conducted at five public hospitals in Oromia Regional State and Addis Ababa City Administration, Ethiopia.

PARTICIPANTS

531 singleton preterm babies born <2000 g from March 2017 to February 2019.

OUTCOME MEASURES

Birth size-for-gestational-age was an outcome variable. Birth size-for-gestational-age centiles were produced using Intergrowth-21st data. Newborn birth size-for-gestational-age below the 10th percentile were classified as SGA; those>10th to 90th percentiles were classified as AGA; those >90th percentiles, as large-for-gestational-age, according to sex. SGA and AGA prevalence were determined. Babies were compared for variations in multiple risk factors.

RESULTS

Among 531 babies included, the sex distribution was: 55.44% males and 44.56% females. The prevalences of SGA and AGA were 46.14% and 53.86%, respectively. The percentage of SGA was slightly greater among males (47.62%) than females (44.30%), but not statistically significant The prevalence of SGA was significantly varied between pre-eclamptic mothers (32.42%, 95% CI 22.36% to 43.22%) and non-pre-eclamptic mothers (57.94%, 95% CI 53.21% to 62.54%). Mothers who had a history of stillbirth (adjusted OR (AOR) 2.96 95% CI 1.04 to 8.54), pre-eclamptic mothers (AOR 3.36, 95% CI 1.95 to 5.79) and being born extremely low birth weight (AOR 10.48, 95% CI 2.24 to 49.02) were risk factors significantly associated with SGA in this population.

CONCLUSION

Prevalence of SGA was very high in these population in the study area. Maternal pre-eclampsia substantially increases the risk of SGA. Hence, given the negative consequences of SGA, maternal and newborn health frameworks must look for and use evidence on gestational age and birth weight to assess the newborn's risks and direct care.

Very preterm infants admitted to a tertiary neonatal unit in central Vietnam showed poor postnatal growth

AIM

We aimed to evaluate the postnatal growth of very preterm infants.

METHODS

This was a cross-sectional observational study of neonates born before 32 weeks of gestation and admitted to the neonatal unit at Da Nang Hospital for Women and Children, Vietnam, between 1 February 2020 and 30 September 2020. Morbidities, therapies, nutrition modalities and growth status were recorded from admission to discharge.

RESULTS

The 78 infants (51% female) were born at a median of 29 weeks and mean birth weight of 1247 grams. The mean weight gain velocity from regaining their birth weight until discharge was 12.7 ± 4.9 g/kg/d. At discharge, the Z-scores for weight, length, both weight and length and weight for length were lower than at birth in 94%, 67%, 64% and 95% of infants and the Delta Z-scores were less than -1 in 73%, 44%, 39% and 82%. Late-onset sepsis (LOS) and bronchopulmonary dysplasia (BPD) were significantly associated with growth failure, with adjusted odds ratios of 3.6 and 20.1, respectively.

CONCLUSION

The high rate of poor growth among the very preterm infants in our study indicates the need to reduce LOS and BPD and ensure the availability of human milk fortifier, vitamin and mineral supplements.

Growth of a cohort of very low birth weight and preterm infants born at a single tertiary health care center in South Africa

BACKGROUND

Very low birth weight (VLBW) and extremely low birth weight (ELBW) infants are known to be at high risk of growth failure and developmental delay later in life. The majority of those infants are born in low and middle income countries.

AIM

Growth monitoring in a cohort of infants born with a VLBW up to 18 months corrected age was conducted in a low resource setting tertiary hospital.

METHODS

In this prospective cohort study, 173 infants with a birth weight below 1,501 g admitted within their first 24 h of life were recruited and the 115 surviving until discharged were asked to follow up at 1, 3, 6, 12 and 18 months. Weight, height and head circumferences were recorded and plotted on WHO Z-score growth charts.

RESULTS

Of the 115 discharged infants 89 were followed up at any given follow-up point (1, 3, 6, 12 and/or 18 months). By 12 months of corrected age another 15 infants had demised (13.0%). The infants' trends in weight-for-age z-scores (WAZ) for corrected age was on average below the norm up to 12 months (average estimated z-score at 12 months = -0.44; 95% CI, -0.77 to -0.11), but had reached a normal range on average at 18 months = -0.24; 95% CI, -0.65 to 0.19) with no overall difference in WAZ scores weight between males and female' infants (p > 0.7). Similar results were seen for height at 12 months corrected age with height-for-age z-scores (HAZ) of the study subjects being within normal limits (-0.24; 95% CI, -0.63 to 0.14). The mean head circumference z-scores (HCZ) initially plotted below -1.5 standard deviations (S.D.), but after 6 months the z-scores were within normal limits (mean z-score at 7 months = -0.19; 95% CI, -0.45 to 0.06).

CONCLUSION

Weight gain, length and head circumferences in infants with VLBW discharged showed a catch-up growth within the first 6-18 months of corrected age, with head circumference recovering best. This confirms findings in other studies on a global scale, which may be reassuring for health systems such as those in South Africa with a high burden of children born with low birth weights.

In-hospital Growth of Very Low Birth Weight Preterm Infants: Comparative Effectiveness of 2 Human Milk Fortifiers

OBJECTIVE

Amidst a high prevalence of prematurity, limited research on the growth of very low birth weight (VLBW) preterm infants and the availability of a reformulated fortifier c(RF), the study aimed to compare in-hospital growth of such infants receiving exclusively human milk fortified with either of 2 different formulations in a tertiary South African hospital.

METHODS

In a prospective comparative effectiveness design, intakes and growth of VLBW infants on the Original Fortifier (OF; 2016-2017) were compared with those receiving RF (2017-2018). Daily intake was calculated using published composition of preterm and mature milk with fortifier (OF: 0.2 g protein, 3.5kcal/g powder; RF: 0.4 g protein, 4.4 kcal/g powder). Change in z scores from start to end of fortification for weight (WFAZ), length (LFAZ), and head circumference (HCFAZ) for age was the primary outcome. Additionally, weight gain velocity (g · kg-1 · day-1) and gain in length and head circumference (HC) (cm/week) were calculated.

RESULTS

Fifty-eight infants (52% girls; gestational age: 30 ± 2 weeks; birth weight: 1215 ± 187 g) received OF for 16 days and 59 infants (56% girls; gestational age: 29 ± 2 weeks; birth weight 1202 ± 167 g) received RF for 15 days. Protein intake of RF (3.7 ± 0.4 g · kg-1 · day-1) was significantly higher (P < 0.001) than of OF (3.4 ± 0.2 g · kg-1 · day-1). Protein-to-energy ratio of RF (2.6 ± 0.2 g/100 kcal) was significantly higher (P < 0.001) than of OF (2.3 ± 0.1 g/100 kcal). In both groups, WFAZ and LFAZ decreased; HCFAZ improved slightly. No significant differences (P > 0.05) were noted between the 2 groups for change in z scores, weight gain velocity, length or HC gain.

CONCLUSIONS

Despite a modest increase in protein intake and protein-to-energy ratio, the growth of VLBW infants on RF was not better than on OF during their hospital stay.

Growth of extremely low birth weight infants at a tertiary hospital in a middle-income country

BACKGROUND

Survival of extremely low birth weight (ELBW; birth weight less than 1000 g) infants has improved significantly since the 1990s. Consequently, growth monitoring in ELBW infants has gained more relevance.

METHODS

We conducted this study to describe the growth of ELBW infants at a tertiary hospital, to audit macronutrient intake and explore the association of prematurity complications with growth. This was a retrospective study on 92 ELBW infants born at Charlotte Maxeke Johannesburg Academic Hospital. The association between good growth (regaining birth weight in 21 days or less and subsequent growth velocity > 15 g/kg/day) and complications of prematurity was explored.

RESULTS

Only 11infants (13%) had a discharge weight above the 10th centile when the Fenton growth chart was used compared to 20 infants (22.4%) when the Intergrowth 21st Project growth standard was used. The mean weight velocity was 13.5 g/kg/day and the mean number of days to regain birth weight was 18.2 days. Factors associated with poor growth were late-onset sepsis, persistent patent ductus arteriosus, continuous positive airway pressure for more than 2 days, invasive ventilation, oxygen on day 28 and being kept nil per os. Protein and caloric intake correlate positively with growth velocity. Unlike the Fenton Growth Charts, use of the Intergrowth 21st Project growth standards revealed the association between neonatal factors and poor growth.

CONCLUSION

Growth outcome in infants is poor at 36 weeks postmenstrual age at our institution. Intergrowth 21st Project growth standards were superior to Fenton Growth Charts, however a multicentre study is required before adoption.

Prioritising allocation of donor human breast milk amongst very low birthweight infants in middle-income countries

The use of donor human breast milk instead of formula reduces the risk of necrotising enterocolitis in preterm infants when their mother's own milk is insufficient. Use of donor milk is limited by the cost of establishing a milk bank and a lack of donors, but the optimal rationing of limited donor milk is unclear. This paper uses an economic model to explore how a limited donor milk supply should be allocated across very low birthweight infants in South Africa considering 2 outcomes: maximising lives saved and minimising costs. We developed a probabilistic cohort Markov decision model with 10,000 infants across 4 birthweight groups. We evaluated allocation scenarios in which infants in each group could be exclusively formula-fed or fed donor milk for 14 or 28 days and thereafter formula until death or discharge. Prioritising infants in the lowest birthweight groups would save the most lives, whereas prioritising infants in the highest birthweight groups would result in the highest cost savings. All allocation scenarios would be considered very cost-effective in South Africa compared to the use of formula; the "worst case" was $619 per Disability Adjusted Life Year averted. There is a compelling argument to increase the supply of donor milk in middle-income countries. Our analysis could be extended by taking a longer term perspective, using data from more than one country and exploring the use of donor milk as an adjunct to mother's own milk, rather than a pure substitute for it.

A randomised controlled trial of high vs low volume initiation and rapid vs slow advancement of milk feeds in infants with birthweights ≤ 1000 g in a resource-limited setting

BACKGROUND

Optimal feeding regimens for infants ≤ 1000 g have not been established and are a global healthcare concern.

AIMS AND OBJECTIVES

A controlled trial to establish the safety and efficacy of high vs low volume initiation and rapid vs slow advancement of milk feeds in a resource-limited setting was undertaken.

METHODS

Infants ≤ 1000 g birthweight were randomised to one of four arms, either low (4 ml/kg/day) or high (24 ml/kg/day) initiation and either slow (24 ml/kg/day) or rapid (36 ml/kg/day) advancement of exclusive feeds of human milk (mother's or donor) until a weight of 1200 g was reached. After this point, formula was used to supplement insufficient mother's milk. The primary outcome was time to reach 1500 g.

RESULTS

infants were recruited (51: low/slow; 47: low/rapid; 52: high/slow; 50: high/rapid). Infants on rapid advancement regimens reached 1500 g most rapidly (hazard ratio 1.48, 95% CI 1.05-2.09, P=0.03). The rapid advancement groups also regained birthweight more rapidly (hazard ratio 1.77, 95% CI 1.26-2.50, P=0.001). There was no apparent effect of high vs low initiation volumes but there was some evidence of interaction between interventions. There were no significant differences in other secondary outcomes, including necrotising enterocolitis, feed intolerance and late-onset sepsis.

CONCLUSIONS

In this small pilot study, higher initiation feed volumes and larger daily increments appeared to be well tolerated and resulted in more rapid early weight gain. These data provide justification for a larger study in resource-limited settings to address mortality, necrotising enterocolitis and other important outcomes.

Low birth weight, very low birth weight and extremely low birth weight in African children aged between 0 and 5 years old: a systematic review

Low birth weight (LBW<2500), very low birth weight (VLBW<1500), extremely low birth weight (ELBW<1500) infants are at high risk for growth failure that result in delayed development. Africa is a continent that presents high rates of children born with LBW, VLBW and ELBW particularly sub-Saharan Africa. To review the existing literature that explores the repercussions of LBW, VLBW and ELBW on growth, neurodevelopmental outcome and mortality in African children aged 0–5 years old. A systematic review of peer-reviewed articles using Academic Search Complete in the following databases: PubMed, Scopus and Scholar Google. Quantitatives studies that investigated the association between LBW, VLBW, ELBW with growth, neurodevelopmental outcome and mortality, published between 2008 and 2015 were included. African studies with humans were eligible for inclusion. From the total of 2205 articles, 12 articles were identified as relevant and were subsequently reviewed in full version. Significant associations were found between LBW, VLBW and ELBW with growth, neurodevelopmental outcome and mortality. Surviving VLBW and ELBW showed increased risk of death, growth retardation and delayed neurodevelopment. Post-neonatal interventions need to be carried out in order to minimize the short-term effects of VLBW and ELBW.

Probiotics, feeding tolerance, and growth: a comparison between HIV-exposed and unexposed very low birth weight infants

OBJECTIVE

The aim of this study was to compare the effect of administration of probiotics on feeding tolerance and growth outcomes of HIV-exposed (but uninfected) versus HIV non-exposed preterm infants. The null hypothesis of this study states that there will be no difference in the feeding tolerance and growth outcomes for both probiotic-exposed and unexposed premature very low birth weight infants.

METHODS

A randomized, double-blind, placebo-controlled trial was conducted during the period from July 2011 to August 2012. HIV-exposed and non-exposed premature (<34 wk gestation) infants with a birth weight of ≥500 g and ≤1250 g were randomized to receive either a probiotic mixture or placebo. The multispecies probiotic mixture consisted of 1 × 10(9) CFU, Lactobacillus rhamnosus GG and Bifidobacterium infantis per day and was administered for 28 d. Anthropometrical parameters, daily intakes, and feeding tolerance were monitored.

RESULTS

Seventy-four HIV-exposed and 110 unexposed infants were enrolled and randomized (mean birth weight 987 g ± 160 g, range, 560-1244 g; mean gestational age 28.7 wk). In all 4227 probiotic doses were administered (mean 22.9/infant). There was no difference in the average daily weight gain for treatment groups or HIV exposure. The HIV-exposed group achieved significantly higher z scores for length and head circumference at day 28 than the unexposed group (P < 0.01 and P = 0.03, respectively). There were no differences in the incidence of any signs of feeding intolerance and abdominal distension between the groups.

CONCLUSION

Probiotic supplementation did not affect growth outcomes or the incidence of any signs of feeding intolerance in HIV exposure.