Weight growth velocity of very low birth weight infants: role of gender, gestational age and major morbidities

Weight growth velocity and growth outcomes in very-low-birth-weight infants developing major morbidities

BACKGROUND

Extrauterine growth restriction (EUGR) is common in very-low-birth-weight-infants and may be associated with poor neurodevelopment. The growth velocity of preterm infants is increasing over decades, but the relationship between growth velocity, EUGR, and morbidities of preterm infants remains unknown.

METHODS

A total of 263 infants born between 2012 and 2020, with birthweight <1500 g and gestational age of 24-33 weeks, were included. Birthweight and weight on day of evaluation point (corrected gestational age 36 weeks or discharged, whenever comes first) were converted to age-specific and gender-specific Z-scores and analyzed by multivariable modeling. The average growth velocity was calculated by the exponential model.

RESULTS

Average growth velocity from birth to the evaluation point was 11.8 ± 0.3 g/kg/day. The maximum growth velocity from birth to week 8 postnatal occurred at week 4 postnatal (16.4 ± 0.9 g/kg/day). Infants with smaller birth weight, higher gestational age, and indication of intestinal surgery or those who need more days to achieve full enteral feeding were more favorable to have a weight lower than the 10th centile at the evaluation point. By contrast, most comorbidities of prematurity did not affect either lower age-specific weight Z-scores on the evaluation point or larger change in weight Z-score between birth and evaluation point.

CONCLUSION

EUGR was associated with gestational age and birth weight. Infants with moderate-to-severe bronchopulmonary dysplasia, high-grade intraventricular hemorrhage, or retinopathy of prematurity tend to have slower growth velocity at 3-5 weeks postnatal, but these did not contribute to EUGR.

An Update on Lung Function of Extremely and Very Preterm Infants in Later Life: The Role of Early Nutritional Interventions

Birth occurring at ≤32 weeks' gestation ("very preterm") or at ≤28 weeks' gestation ("extremely preterm") potentially poses considerable health problems for the neonate, including respiratory sequelae, not only during the immediate newborn period, but throughout childhood and into adulthood. With the progressive improvements in neonatal care, the survival of extremely preterm and very preterm neonates has improved substantially. However, a considerable percentage of these infants suffer dysfunctions that may trigger, at some stage later in life, the onset of respiratory morbidities. The interruption of the normal development of the respiratory tract caused by preterm birth, in combination with postnatal lung injury caused by various interventions, e.g., mechanical ventilation and oxygen therapy, increases the risk ofthe development of long-term respiratory deficits in survivors. Those infants that are most affected are those who develop chronic lung disease of prematurity (also called bronchopulmonary dysplasia, BPD), but impaired lung function can develop irrespective of BPD diagnosis. Apart from indicating abnormal lung function in survivors of extreme prematurity, recent long-term follow-up studies also emphasize the crucial role of early nutritional intake as an effective strategy, which promotes lung growth and repair. This article will update the associations between extremely/very preterm birth with long-term respiratory outcomes. It will also discuss the protective effect of nutritional interventions, focusing on recently published follow-up data.

Sex Differences in Patent Ductus Arteriosus Incidence and Response to Pharmacological Treatment in Preterm Infants: A Systematic Review, Meta-Analysis and Meta-Regression

A widely accepted concept in perinatal medicine is that boys are more susceptible than girls to complications of prematurity. However, whether this ‘male disadvantage of prematurity’ also involves persistent patent ductus arteriosus (PDA) has been scarcely investigated. Our aim was to conduct a systematic review and meta-analysis on studies addressing sex differences in the risk of developing PDA among preterm infants. We also investigated whether the response to pharmacological treatment of PDA differs between boys and girls. PubMed/Medline and Embase databases were searched. The random-effects male/female risk ratio (RR) and 95% confidence interval (CI) were calculated. We included 146 studies (357,781 infants). Meta-analysis could not demonstrate sex differences in risk of developing any PDA (37 studies, RR 1.03, 95% CI 0.97 to 1.08), hemodynamically significant PDA (81 studies, RR 1.00, 95% CI 0.97 to 1.02), or in the rate of response to pharmacological treatment (45 studies, RR 1.01, 95% CI 0.98 to 1.04). Subgroup analysis and meta-regression showed that the absence of sex differences was maintained over the years and in different geographic settings. In conclusion, both the incidence of PDA in preterm infants and the response rate to pharmacological treatment of PDA are not different between preterm boys and girls.

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.

Male Disadvantage in Oxidative Stress-Associated Complications of Prematurity: A Systematic Review, Meta-Analysis and Meta-Regression

A widely accepted concept is that boys are more susceptible than girls to oxidative stress-related complications of prematurity, including bronchopulmonary dysplasia (BPD), retinopathy of prematurity (ROP), necrotizing enterocolitis (NEC), intraventricular hemorrhage (IVH), and periventricular leukomalacia (PVL). We aimed to quantify the effect size of this male disadvantage by performing a systematic review and meta-analysis of cohort studies exploring the association between sex and complications of prematurity. Risk ratios (RRs) and 95% CIs were calculated by a random-effects model. Of 1365 potentially relevant studies, 41 met the inclusion criteria (625,680 infants). Male sex was associated with decreased risk of hypertensive disorders of pregnancy, fetal distress, and C-section, but increased risk of low Apgar score, intubation at birth, respiratory distress, surfactant use, pneumothorax, postnatal steroids, late onset sepsis, any NEC, NEC > stage 1 (RR 1.12, CI 1.06–1.18), any IVH, severe IVH (RR 1.28, CI 1.22–1.34), severe IVH or PVL, any BPD, moderate/severe BPD (RR 1.23, CI 1.18–1.27), severe ROP (RR 1.14, CI 1.07–1.22), and mortality (RR 1.23, CI 1.16–1.30). In conclusion, preterm boys have higher clinical instability and greater need for invasive interventions than preterm girls. This leads to a male disadvantage in mortality and short-term complications of prematurity.

IL-6 Predicts Poor Early Post-Natal Growth in Very Low-Birth-Weight Infants in a Low-Middle Income Setting

BACKGROUND

Extra-uterine growth restriction (EUGR) is common in preterms and may be associated with elevated pro-inflammatory cytokines.

OBJECTIVE

Describe postnatal growth in a cohort of very low-birth-weight (VLBW) infants and determine the association of interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α) in umbilical cord blood with growth at 40 weeks and 12 months postmenstrual age (PMA).

METHODS

Single-centre, prospective cohort study conducted from 1 June 2017 to 31 January 2019 with follow-up to 31 March 2020. Infants <1500 g at birth were enrolled, cord blood collected for IL-6 and TNF-α assays and postnatal care, including anthropometry, provided to 12 months PMA. Informed consent and ethics approval were obtained.

RESULTS

In total, 279 patients were enrolled; 84 (30.1%) died before 12 months and 91 (32.6%) lost to follow-up. Anthropometry was available for 151 infants at 40 weeks and 105 at 12 months. Z-Scores at 40 weeks for males and females combined were -2.5, -2.1 and -1.2 for weight, length and head circumference. EUGR occurred in 103/113 (91.2%), 98/107 (91.6%) and 70/109 (64.2%) participants for weight, length and head circumference. Elevated IL-6 was associated with restricted weight (56.0 vs. 14.5 pg/ml, p = 0.02) and length (60.4 vs. 7.3 pg/ml, p = 0.01) at 40 weeks. There was no difference in IL-6 at 12 months and no difference in TNF-α at 40 weeks or 12 months.

CONCLUSION

The study reports significant EUGR. Elevated IL-6 was associated with growth restriction at 40 weeks but not 12 months PMA.

The "Fortilat" Randomized Clinical Trial Follow-Up: Auxological Outcome at 18 Months of Age

Human milk fortification is a routine clinical practice for feeding preterm infants. We hypothesized that donkey milk can be a suitable basis for developing an innovative human milk fortifier. Our randomized controlled single-blind clinical trial, named “Fortilat”, evaluated the feeding tolerance, growth and clinical short-term outcomes in a population of preterm infants fed with a novel multi-component fortifier and a protein concentrate derived from donkey milk. The aim of the current study is to extend the previous findings and to evaluate the auxological outcomes of the infants enrolled in the “Fortilat” trial at 18 months of age. In the previous trial “Fortilat”, the fortification protocol followed was the same for the two groups, and the two diets were designed to be isoproteic and isocaloric. All infants enrolled in the trial were included in a premature infant developmental evaluation program consisting of hospital visits at 40 ± 1 weeks of postmenstrual age, and at 6, 12 and 18 months of corrected age. Weight, head circumference and length were expressed in z-score using neonatal Intergrowth21st and INeS charts at birth, and WHO 0–5 years growth charts at 18 months. 122 children (Bovine-arm = 62, Donkey-arm = 60) were included in this study. All the observations were recorded in the interval of 18 ± 3 months of the correct age. The two groups did not differ for head circumference, length or weight at 18 months of age. Our data show that fortifiers derived from donkey milk had not different long term auxological outcomes of standard bovine-derived fortifier, but the new donkey milk fortifier was well tolerated in our population.

Time to regain birth weight predicts neonatal growth velocity: A single-center experience

BACKGROUND

Failure to Thrive (FTT) describes the development of an inappropriate pattern of growth, generally secondary to inadequate nutritional intake, and is associated with several negative outcomes. We describe key features among neonates with FTT as well as the variables that predicted their growth after birth at a Neonatal Intensive Care Unit.

METHODS

A retrospective single center study of 340 patients grouped into FTT (n = 100) and non-FTT (n = 240) was conducted. FTT was defined as having a weight <10th percentile on the Fenton 2013 curve at the time of discharge. For analyzing growth velocity, 204 patients were grouped into 4 quartiles based on their calculated growth velocity (grams/kilograms/day [g/kg/day]; 4th quartile had the highest velocity). Multivariate regression models were used to identify predictors of growth velocity.

RESULTS

When comparing FTT vs. non-FTT patients, lower birth weights (1897.9 ± 561.4 vs. 2445.9 ± 783.0 g, t_(255.1) = -7.2, p < 0.001) and higher growth velocities (9.2 ± 3.9 vs. 8.0 ± 4.1 g/kg/day, t_(153.6) = 2.2, p = 0.03) were noted. Among patients with higher growth velocities, birth weights were lower (1st to 4th quartiles: 2474.0 ± 677.0, 2000.0 ± 297.0, 1715.0 ± 285.0, 1533.0 ± 332.0 g, F_{(3, 200)} = 46.5, p < 0.001, adjusted R² = 0.4). Days to regain birth weight was the most consistent predictor of growth velocity in our overall patient sample (β [SE] = -0.3 [0.03], p < 0.001) and in the lowest growth velocity quartile subgroup (β [SE] = -0.3 [0.04], p < 0.001).

CONCLUSIONS

Days to regain birth weight was consistently the strongest predictor of neonatal growth velocity along with difference in gender positive predicting growth velocity in the total sample. This highlights the importance of the first week of life in growth pattern establishment.

Extrauterine Growth Restriction: Definitions and Predictability of Outcomes in a Cohort of Very Low Birth Weight Infants or Preterm Neonates

Extrauterine Growth Restriction (EUGR) refers to inadequate growth during hospitalization. Current definitions for EUGR are varied and can be classified as cross-sectional (weight at a given t-time <10th centile) or longitudinal (weight loss between birth and a given t-time >1SD). Different t-times are also considered in literature, such as 36 weeks of gestational age (GA) or age at discharge. The aim of this study is to investigate whether EUGR could predict the auxological outcome at 24–30 months, and to evaluate the agreement between cross-sectional and longitudinal definitions. In total, 1589 infants with GA <30 weeks or birthweight ≤ 1500 g and without major congenital anomalies were included in this study. Cross-sectional and longitudinal EUGR were calculated at 36 and 40 weeks of GA, at discharge, and at 28 days. The concordance between the two definitions was estimated by Kappa coefficient. At 24–30 months, 803 infants were measured again. The agreement between the two definitions of EUGR was low. Both EUGR and not-EUGR groups were at lower centiles for weight, but at higher centiles for head circumference at 24–30 months than at birth. Longitudinal EUGR was associated with a poorer growth outcome for weight and height circumference than cross-sectional EUGR. No differences were observed for length. An agreed definition of EUGR is highly desirable in clinical practice to assess medical and nutritional interventions in preterm neonates. Based on the results of this study, we recommend the use of the longitudinal evaluation, that proved to better predict the auxological long-term outcome with respect to the cross-sectional one.

Delayed initiation of enteral feeds is associated with postnatal growth failure among preterm infants managed at a rural hospital in Uganda

BACKGROUND

Prematurity is the leading cause of mortality in children under 5 years of age globally and is also frequently associated with postnatal growth failure (PGF). Although most preterm births occur in low resource settings, little is known about their postnatal growth outcomes especially in rural areas. We evaluated the incidence and factors associated with PGF among preterm infants managed at a rural hospital in Uganda.

METHODS

Retrospective cohort study of preterm infants discharged from Kiwoko Hospital neonatal intensive care unit (NICU) from July 2017 to June 2018. Inclusion criteria included gestational age 26 up to but not including 37 weeks, admission within 24 h of birth and at least 7 days hospital stay. Exclusion criteria included major congenital anomalies and missing gestational age or birth weight. Birth and discharge weights from clinical notes were plotted on Fenton 2013 growth charts. Gestation age was determined by last normal menstruation period (LNMP), extracted from the mother's antenatal card or early obstetric ultrasound scan reports. Postnatal growth failure was diagnosed if discharge weight was less than the 10th percentile for estimated gestational age. Other data from the clinical notes included demographic characteristics, neonatal morbidities as assigned by the attending physician and infant feeding practices. Multivariable logistic regression was used to explore factors associated with PGF.

RESULTS

A total of 349 preterm infants with a mean gestational age of 31 (range 26 to 36) weeks were included. The incidence proportion of PGF was 254/349 (73%). Factors significantly associated with postnatal growth failure included: delayed initiation of enteral feeds [AOR = 3.70, 95% (CI 1.64 to 8.33)], sepsis [AOR = 6.76, 95% (CI 2.15 to 21.2)], multiple gestation [AOR = 1.81, 95% (CI 1.01 to 3.24)] and male gender [AOR = 1.71 95% (CI 1.01 to 2.91)].

CONCLUSION

Nearly three quarters of preterm infants managed at a rural hospital in Uganda had postnatal growth failure. Delayed initiation of enteral feeds and sepsis were highly associated with postnatal growth failure. Enteral feeds should be initiated as soon as possible in these infants to reduce early protein deficits and hence postnatal growth failure.

Optimizing the growth of very-low-birth-weight infants requires targeting both nutritional and nonnutritional modifiable factors specific to stage of hospitalization

BACKGROUND

Data on how baseline characteristics, acuity, morbidity, and nutrition work in combination to affect the growth of very-low-birth-weight (VLBW, <1500 g) infants are limited.

OBJECTIVE

We aimed to determine factors associated with in-hospital weight, length, and head circumference (HC) trajectories of VLBW infants.

METHODS

VLBW infants (n = 316) from the GTA-DoMINO trial were included. Linear mixed-effects models assessed relations of baseline characteristics, acuity (at birth, across hospitalization), major morbidities, and nutrition (enteral feeding type, macronutrient/energy intakes) with changes in anthropometrics over hospitalization (days 1-8, 9-29, 30-75).

RESULTS

Specific factors and the strength of their associations with growth depended on in-hospital time interval. Small-for-gestational-age infants experienced weight gain (4.3   g · kg-1 · d-1; 95% CI: 2.0, 6.5   g · kg-1 · d-1) during days 1-8, versus weight loss (-4.6     g · kg-1 · d-1; 95% CI: -5.6, -3.7     g · kg-1 · d-1) among appropriate-for-gestational-age infants (P < 0.001). Positive-pressure ventilation (versus oxygen/room air) was associated with slower weight (-1.8    g · kg-1 · d-1) and HC (-0.25 cm/wk) gain during days 9-29 (P < 0.001). Morbidities were negatively associated with growth after days 1-8, with patent ductus arteriosus (PDA) showing negative associations with weight (-2.7     g · kg-1 · d-1), length (-0.11 cm/wk), and HC (-0.21 cm/wk) gain during days 9-29 (P < 0.001). Macronutrient/energy intakes were associated with weight across hospitalization (P ≤ 0.01), with greater weight gain (1.3-3.0 g  ·  kg-1  ·  d-1) among infants achieving macronutrient/energy recommendations during days 9-29 and 30-75. Macronutrient/energy intakes were associated with HC during the first month (P = 0.013-0.003), with greater HC gain (0.07-0.12 cm/wk) among infants achieving protein, lipid, and energy recommendations during days 9-29.

CONCLUSIONS

Baseline characteristics, acuity, morbidity, and nutrition factors were independently associated with VLBW infant growth. A focus on achieving macronutrient/energy recommendations and improving nutrient delivery to PDA-diagnosed infants may yield improvements to their growth. This trial was registered at www.isrctn.com as ISRCTN35317141.

Intrapartum prediction of emergency delivery due to non-reassuring fetal status at 40 weeks' gestation in low-risk pregnancies: contribution of Doppler parameters, maternal history, and intrapartum clinical characteristics

OBJECTIVE

To assess the added value of Doppler parameters, maternal history, and intrapartum clinical characteristics for the prediction of emergency delivery due to non-reassuring fetal status in low-risk pregnancies.

METHODS

This was a prospective cohort of low-risk pregnancies undergoing ultrasound assessment at 40 weeks' gestation within 7 days of delivery. The main outcome was emergency cesarean section due to non-reassuring fetal status. The association between Doppler parameters, intrapartum clinical characteristics, and maternal history was performed by logistic regression. The predictive performance of the constructed models was assessed by receiver operating characteristic (ROC) curve analysis and the area under the curve (AUC).

RESULTS

From 403 included pregnancies, 18.6% (n = 75) underwent an emergency delivery due to non-reassuring fetal status. The mean gestational age at birth was 40.5 (SD 5) days. Middle cerebral artery pulsatility index (MCA) and cerebroplacental ratio (CPR) were lower in the emergency cesarean section group (1.16 versus 1.30; p < .001, and 1.61 versus 1.78; p = .001, respectively). There was a higher incidence of small-for-gestational-age neonates (20 versus 10.1%; p = .017), lower Apgar scores at the 5th minute (9.7 versus 9.9; p = .006), and NICU admissions (9 versus 3%; p = .016) in the emergency cesarean section group. The base model comprised nulliparity, and the finding of meconium-stained amniotic fluid during labor, achieving an AUC of 66%, while the addition of the MCA Z-score significantly improved the previous model (AUC: 73%; DeLong: p = .008).

CONCLUSIONS

In low-risk pregnant woman at term, the addition of MCA Z-score to a previous model comprising maternal history and intrapartum clinical findings, significantly improves the prediction of emergency delivery due to non-reassuring fetal status.

SMFM Special Statement: State of the science on multifetal gestations: unique considerations and importance

We sought to review the state of the science for research on multiple gestations. A literature search was performed with the use of PubMed for studies to quantify the representation of multiple gestations for a sample period (2012-2016) that were limited to phase III and IV randomized controlled trials, that were written in English, and that addressed at least 1 of 4 major pregnancy complications: fetal growth restriction or small-for-gestational-age fetus, gestational diabetes mellitus, preeclampsia, and preterm delivery. Of the 226 studies that are included in the analysis, multiple pregnancies were most represented in studies of preterm delivery: 17% of trials recruited both singleton and multiple pregnancies; another 18% of trials recruited only multiple pregnancies. For trials that studied preeclampsia, fetal growth restriction, and gestational diabetes mellitus, 17%, 8%, and 2%, respectively, recruited both singleton and multiple gestations. None of the trials on these 3 topics were limited to women with a multiple pregnancy. Women with a multiple pregnancy are at risk for complications similar to those of women with singleton pregnancies, but their risk is usually higher. Also, the pathophysiologic condition for some complications differs in multiple gestations from those that occur in singleton gestations. Conditions that are unique to multiple pregnancies include excess placenta, placental crowding or inability of the uteroplacental unit to support the normal growth of multiple fetuses, or suboptimal placental implantation sites with an increased risk of abnormal placental location. Other adverse outcomes in multiple gestations are also influenced by twin-specific risk factors, most notably chorionicity. Although twins have been well represented in many studies of preterm birth, these studies have failed to identify adequate predictive tests (short cervical length established over 2 decades ago remains the single best predictor), to establish effective interventions, and to differentiate the underlying pathophysiologic condition of twin preterm birth. Questions about fetal growth also remain. Twin growth deviates from that of singleton gestations starting at approximately 32 weeks of gestation; however, research with long-term follow-up is needed to better distinguish pathologic and physiologic growth deviations, which include growth discordance among pairs (or more). There are virtually no clinical trials that are specific to twins for gestational diabetes mellitus or preeclampsia, and subgroups for multiple pregnancies in existing trials are not large enough to allow definite conclusions. Another important area is the determination of appropriate maternal nutrition or micronutrient supplementation to optimize pregnancy and child health. There are also unique aspects to consider for research design in multiple gestations, such as designation and tracking of the correct fetus prenatally and through delivery. The correct statistical methods must be used to account for correlated data because multiple fetuses share the same mother and intrauterine environment. In summary, multiple gestations often are excluded from research studies, despite a disproportionate contribution to national rates of perinatal morbidity, mortality, and health-care costs. It is important to consider the enrollment of multifetal pregnancies in studies that target mainly women with singleton gestations, even when sample size is inadequate, so that insights that are specific to multiple gestations can be obtained when results of smaller studies are pooled together. The care of pregnant women with multiple gestations presents unique challenges; unfortunately, evidence-based clinical management that includes the diagnosis and treatment of common obstetrics problems are not well-defined for this population.

Somatic growth from birth to 6 months in low birth weight, in Bukavu, South Kivu, Democratic Republic of the Congo

BACKGROUND

Low birth weight (LBW) is one of the leading causes of perinatal and infant morbidity and mortality, as well as of impaired growth and neurocognitive development. This study aimed to evaluate the evolution of anthropometric parameters and the nutritional status of LBW infants and to analyze factors influencing the growth failure during their first 6 months of life (or adjusted age).

METHODS

This was a prospective cohort study for 6 months, including 100 infants born with LBW and 100 infants born at full-term and with normal weight. The z-scores weight for age, height for age, head circumference for age and weight for height were computed with the software Epinut and WHO Anthro 2005. Descriptive statistics, bivariate analysis and multivariable logistic regression analyses were employed to identify factors associated with growth failure. Growth failure was defined as a decrease in weight z-score (standard deviation score) of over 0.67 during one of the study's periods. The statistical significance threshold was fixed at 0.05.

FINDINGS

At 6 months of life (or adjusted age), 15.3% of LBW were underweight, 51.4% were stunted, 4.2% had an emaciation and 25% had a head circumference for age<-2 z-scores. Risk factor for growth failure was male sex (OR=1.56 [95% CI: 1.03-2.23]). The symmetrical intra-uterine growth retardation was a protector factor for growth failure (OR=0.49 [95% CI: 0.25-0.98]).

CONCLUSION

In the short term, LBW infants may have growth disorders. It is necessary to emphasize the importance of growth assessment of LBW children and proper education of their mothers about nutrition of their children for early and timely diagnosis and management of growth retardation and prevention of subsequent problems.

Adipokines played a limited role in predicting temporary growth differences between very low birthweight infants with and without bronchopulmonary dysplasia

AIMS

This study explored whether growth was poorer among very low birthweight (VLBW) infants with bronchopulmonary dysplasia (BPD) and assessed adipokine levels as predictors of early growth.

METHODS

We studied 53 VLBW infants born in Tampere University Hospital up to 12 months of corrected age (CA). The median gestational age of the 21 infants with BPD and 32 infants without BPD was 29 weeks, and the median birthweights were 930 (635-1470) and 1185 (650-1470) grams. Growth parameters, macronutrients intake and plasma levels of adipokines were measured.

RESULTS

Bronchopulmonary dysplasia infants were lighter than controls until 36 weeks of CA, with catch-up growth achieved by three months of CA. Adipsin levels were lower in BPD infants at 28 days of postnatal age. High leptin levels seemed protective for low weight for height at nine months of CA. The duration of ventilator therapy predicted low weight for height, length for age and body mass index and BPD predicted low length for age at 12 months of CA.

CONCLUSIONS

Catch-up growth in VLBW infants with BPD was achieved by three months of CA, but adipokines played a limited role in predicting growth. Shortening ventilator therapy could help growth in VLBW infants.

Monitoring postnatal growth of preterm infants: present and future

BACKGROUND

There is no consensus with regard to which charts are most suitable for monitoring the postnatal growth of preterm infants.

OBJECTIVE

We aimed to assess the strategies used to develop existing postnatal growth charts for preterm infants and their methodologic quality.

DESIGN

A systematic review of observational longitudinal studies, having as their primary objective the creation of postnatal growth charts for preterm infants, was conducted. Thirty-eight items distributed in 3 methodologic domains ("study design," "statistical methods," and "reporting methods") were assessed in each study. Each item was scored as a "low" or "high" risk of bias. Two reviewers independently selected the studies, assessed the risk of bias, and extracted data. A total quality score [(number of "low risk" of bias marks/total number of items assessed) × 100%] was calculated for each study. Median (range, IQR) quality scores for each methodologic domain and for all included studies were computed.

RESULTS

Sixty-one studies met the inclusion criteria. Twenty-seven (44.3%) of the 61 studies scored ≥50%, of which 10 scored >60% and only 1 scored >66%. The median (range, IQR) quality score for the 61 included studies was 47% (26-75%, 34-56%). The scores for the domains study design, statistical methods, and reporting methods were 44% (19-67%, 33-52%), 25% (0-88%, 13-38%), and 33% (0-100%, 0-33%), respectively. The most common shortcomings were observed in items related to anthropometric measures (the main variable of interest), gestational age estimation, follow-up duration, reporting of postnatal care and morbidities, assessment of outliers, covariates, and chart presentation.

CONCLUSIONS

The overall methodologic quality of existing longitudinal studies was fair to low. To overcome these problems, the Preterm Postnatal Follow-up Study, 1 of the 3 main components of The International Fetal and Newborn Growth Consortium for the 21st Century Project, was designed to construct preterm postnatal growth standards from a prospective cohort of "healthy" pregnancies and preterm newborns without evidence of fetal growth restriction.

Weight Growth Velocity and Postnatal Growth Failure in Infants 501 to 1500 Grams: 2000-2013

BACKGROUND

Very low birth weight infants often gain weight poorly and demonstrate growth failure during the initial hospitalization. Although many of the major morbidities experienced by these infants during their initial NICU stays have decreased in recent years, it is unclear whether growth has improved.

METHODS

We studied 362 833 infants weighing 501 to 1500 g without major birth defects born from 2000 to 2013 and who were hospitalized for 15 to 175 days at 736 North American hospitals in the Vermont Oxford Network. Average growth velocity (GV; g/kg per day) was computed by using a 2-point exponential model on the basis of birth weight and discharge weight. Postnatal growth failure and severe postnatal growth failure were defined as a discharge weight less than the 10th and third percentiles for postmenstrual age, respectively.

RESULTS

From 2000 to 2013, average GV increased from 11.8 to 12.9 g/kg per day. Postnatal growth failure decreased from 64.5% to 50.3% and severe postnatal growth failure from 39.8% to 27.5%. The interquartile ranges for the hospitals participating in 2013 were as follows: GV, 12.3 to 13.4 g/kg per day; postnatal growth failure, 41.1% to 61.7%; and severe postnatal growth failure, 19.4% to 36.0%. Adjusted and unadjusted estimates were nearly identical.

CONCLUSIONS

For infants weighing 501 to 1500 g at birth, average GV increased and the percentage with postnatal growth failure decreased. However, in 2013, half of these infants still demonstrated postnatal growth failure and one-quarter demonstrated severe postnatal growth failure.

Birth status, child growth, and adult outcomes in low- and middle-income countries

OBJECTIVE

To assess the impact of being born preterm or small for gestational age (SGA) on several adult outcomes.

STUDY DESIGN

We analyzed data for 4518 adult participants in 5 birth cohorts from Brazil, Guatemala, India, the Philippines, and South Africa.

RESULTS

In the study population, 12.8% of males and 11.9% of females were born preterm, and 26.8% of males and 22.4% of females were born term but SGA. Adults born preterm were 1.11 cm shorter (95% CI, 0.57-1.65 cm), and those born term but SGA were 2.35 cm shorter (95% CI, 1.93-2.77 cm) compared with those born at term and appropriate size for gestational age. Blood pressure and blood glucose level did not differ by birth category. Compared with those born term and at appropriate size for gestational age, schooling attainment was 0.44 years lower (95% CI, 0.17-0.71 years) in those born preterm and 0.41 years lower (95% CI, 0.20-0.62 years) in those born term but SGA.

CONCLUSION

Being born preterm or term but SGA is associated with persistent deficits in adult height and schooling, but is not related to blood pressure or blood glucose level in low- and middle-income settings. Increased postnatal growth is associated with gains in height and schooling regardless of birth status, but not with increases in blood pressure or blood glucose level.

Imprinted and X-linked non-coding RNAs as potential regulators of human placental function

Pregnancy outcome is inextricably linked to placental development, which is strictly controlled temporally and spatially through mechanisms that are only partially understood. However, increasing evidence suggests non-coding RNAs (ncRNAs) direct and regulate a considerable number of biological processes and therefore may constitute a previously hidden layer of regulatory information in the placenta. Many ncRNAs, including both microRNAs and long non-coding transcripts, show almost exclusive or predominant expression in the placenta compared with other somatic tissues and display altered expression patterns in placentas from complicated pregnancies. In this review, we explore the results of recent genome-scale and single gene expression studies using human placental tissue, but include studies in the mouse where human data are lacking. Our review focuses on the ncRNAs epigenetically regulated through genomic imprinting or X-chromosome inactivation and includes recent evidence surrounding the H19 lincRNA, the imprinted C19MC cluster microRNAs, and X-linked miRNAs associated with pregnancy complications.

Implementation of the INTERGROWTH-21st Project in Italy

Turin, Italy, was one of the two European sites for the INTERGROWTH-21(st) Project. The sample for the Newborn Cross-Sectional Study (NCSS) was drawn from two obstetric hospitals that together account for 79% of the city's approximately 12,000 births per year. Women were recruited for the Fetal Growth Longitudinal Study (FGLS) from ten antenatal clinics serving the city's largest obstetric hospital, Azienda Ospedaliera OIRM-S. Anna. Special activities to encourage participation and raise awareness of the project in this population included obtaining an endorsement from the coordinator of the city's antenatal care service, and disseminating information about the project to women through posters and leaflets in antenatal clinics. One of the major challenges at this site was the low recruitment rate in the early phase of FGLS because of the high prevalence of smoking and of women >35 years old in the population. The addition of six extra recruiting clinics served to increase the pool of potentially eligible women who could be screened and led to a marked improvement in the recruitment rate.

Nutritional recommendations for the late-preterm infant and the preterm infant after hospital discharge

Early nutritional support of preterm infants is critical to life-long health and well being. Numerous studies have demonstrated that preterm infants are at increased risk of mortality and morbidity, including disturbances in brain development. To date, much attention has focused on enhancing the nutritional support of very low and extremely low birth weight infants to improve survival and quality of life. In most countries, preterm infants are sent home before their expected date of term birth for economic or other reasons. It is debatable whether these newborns require special nutritional regimens or discharge formulas. Furthermore, guidelines that specify how to feed very preterm infants after hospital discharge are scarce and conflicting. On the other hand, the late-preterm infant presents a challenge to health care providers immediately after birth when decisions must be made about how and where to care for these newborns. Considering these infants as well babies may place them at a disadvantage. Late-preterm infants have unique and often-unrecognized medical vulnerabilities and nutritional needs that predispose them to greater rates of morbidity and hospital readmissions. Poor or inadequate feeding during hospitalization may be one of the main reasons why late-preterm infants have difficulty gaining weight right after birth. Providing optimal nutritional support to late premature infants may improve survival and quality of life as it does for very preterm infants. In this work, we present a review of the literature and provide separate recommendations for the care and feeding of late-preterm infants and very preterm infants after discharge. We identify gaps in current knowledge as well as priorities for future research.

Postnatal growth restriction and predictors of nutritional outcome in very low birth weight infants fed human milk and assisted by the Kangaroo Mother Care method

OBJECTIVE

[corrected] The study sought to determine the prevalence of postnatal growth restriction (PNGR) and the predictors of nutritional outcome in very low birth weight (VLBW) infants.

METHODS

Cross-sectional study conducted in a maternity school between July 2005 and August 2006. One-hundred and twelve VLBW infants were assessed during hospitalization, fed unfortified human milk and assisted by Kangaroo Mother Care. The dependent variables included the number of days required to reach minimum weight and regain birth weight, the percentage of weight loss, and the deterioration of nutritional status. These parameters were converted into a factor termed "nutritional outcome" using factor analysis. Multiple linear regressions were used to identify predictors of nutritional outcome.

RESULTS

PNGR was observed in 89.3% of the infants at hospital discharge. The predictors of nutritional outcome were: appropriate-for-gestational-age infants, children of mothers aged ≤ 20 years old, need for mechanical ventilation, longer stays in the neonatal intensive care unit, and a greater number of days to achieve full enteral nutrition.

CONCLUSION

It is important to know the factors that negatively influence the nutritional outcome of VLBW infants, as these can be modified through the improvement of perinatal care and can reduce PNGR.

Body composition in newborn infants: 5-year experience in an Italian neonatal intensive care unit

The aim of nutrition in neonatology is to achieve a healthy growth that mimics, both in terms of growth rates and quality of growth, that of a normal fetus of the same gestational age. In addition, providing an optimal amount and quality of nutrients significantly contributes to the attainment of a neurodevelopment similar to that of an infant born at term. Yet, a high risk of developing metabolic syndrome in relation to aggressive nutrition and accelerated postnatal growth velocity has been reported in former preterm infants. Considering the strict interrelationship that exists between early nutrition, growth, and subsequent health, the development of body composition in early infancy, in terms of fat mass, may contribute to the long-term "programming" process. Hence, accurate and non-invasive measurement of infant body composition, which evaluates the quality in addition to the amount of weight gain, represents a useful tool for gaining further insight into the relationship between birth weight or time in utero and future development. Preterm infants, including those born small for gestational age, have been reported to develop an increased and/or aberrant adiposity, in addition to postnatal growth retardation, when assessed at term-corrected age. However, within the first 5 months, preterm infants, either born adequate or small for gestational age, show a recovery of fat mass, and attain fat mass values comparable to those of full-term infants assessed at birth. The metabolic consequences of these findings on the long-term health need to be further clarified.

Growth of a cohort of very low birth weight infants in Johannesburg, South Africa

Background

Little is known about the growth of VLBW infants in South Africa. The aim of this study was to assess the growth of a cohort of VLBW infants in Johannesburg.

Methods

A secondary analysis of a prospective cohort was conducted on 139 VLBW infants (birth weight ≤1500 g) admitted to Charlotte Maxeke Johannesburg Academic Hospital. Growth measurements were obtained from patient files and compared with the World Health Organization Child Growth Standards (WHO-CGS) and with a previous cohort of South African VLBW infants. The sample size per analysis ranged from 11 to 81 infants.

Results

Comparison with the WHO-CGS showed initial poor growth followed by gradual catch up growth with mean Z scores of 0.0 at 20 months postmenstrual age for weight, -0.8 at 20 months postmenstrual age for length and 0.0 at 3 months postmenstrual age for head circumference. Growth was comparable with that of a previous cohort of South African VLBW infants in all parameters.

Conclusions

Initial poor growth in the study sample was followed by gradual catch up growth but with persistent deficits in length for age at 20 months postmenstrual age relative to healthy term infants.

Rapid recovery of fat mass in small for gestational age preterm infants after term

Background

Preterm small for gestational age (SGA) infants may be at risk for increased adiposity, especially when experiencing rapid postnatal weight gain. Data on the dynamic features of body weight and fat mass (FM) gain that occurs early in life is scarce. We investigated the postnatal weight and FM gain during the first five months after term in a cohort of preterm infants.

Methodology/Principal Findings

Changes in growth parameters and FM were prospectively monitored in 195 infants with birth weight ≤1500 g. The infants were categorized as born adequate for gestational age (AGA) without growth retardation at term (GR−), born AGA with growth retardation at term (GR+), born SGA. Weight and FM were assessed by an air displacement plethysmography system. At five months, weight z-score was comparable between the AGA (GR+) and the AGA (GR−), whereas the SGA showed a significantly lower weight.The mean weight (g) differences (95% CI) between SGA and AGA (GR−) and between SGA and AGA (GR+) infants at 5 months were −613 (−1215; −12) and −573 (−1227; −79), respectively. At term, the AGA (GR+) and the SGA groups showed a significantly lower FM than the AGA (GR−) group. In the first three months, change in FM was comparable between the AGA (GR+) and the SGA groups and significantly higher than that of the AGA (GR−) group.The mean difference (95% CI) in FM change between SGA and AGA (GR−) and between AGA (GR+) and AGA (GR−) from term to 3 months were 38.6 (12; 65); and 37.7 (10; 65). At three months, the FM was similar in all groups.

Conclusions

Our data suggests that fetal growth pattern influences the potential to rapidly correct anthropometry whereas the restoration of fat stores takes place irrespective of birth weight. The metabolic consequences of these findings need to be elucidated.