Differential Effect of Growth on Development between AGA and SGA Preterm Infants

Predictive role of NICU-related stress, postpartum depression trajectory and family coping on growth trajectory of moderate-to-late preterm infants: A longitudinal study

AIMS

To describe the changes in moderate-to-late preterm infants' (MLPIs) growth during 12 months of corrected age (CA) and to examine the predictive role of NICU-related stress, postpartum depression trajectory and family coping ability on the physical developmental trajectory of MLPIs.

DESIGN

A prospective longitudinal study.

METHODS

There were 237 mother-infant dyads with at least two follow-up data records included. General characteristics and NICU-related stress were recorded from medical records at baseline. Infants' physical growth was measured at 40 weeks, 1, 3, 6, 9 and 12 months CA during outpatient follow-up. Maternal postpartum depressive symptoms and family coping ability were assessed by questionnaires at 1, 3, 6, 9 and 12 months CA and 1 month CA respectively. We investigated the modifiable factors inside and outside of NICU on the trajectories of physical growth in the first year in MLPIs, mainly by using latent growth curve models with time-varying covariates.

RESULTS

The curved trajectories of weight, length and head circumference in the first year in MLPIs demonstrated gradually slowed growth rates and these infants were above the WHO growth standards for the same age and sex. The latent growth curve models indicated that more NICU-related stress was negatively associated with the weight and length at 40 weeks CA, and family coping ability (parent-child relationship) at 1 month CA was associated with the growth rate of weight. Besides, more NICU-related stress predicted faster length growth rate. The infants of mothers who were in the group of high-level postpartum depression trajectory had a slower growth rate of head circumference.

CONCLUSIONS

Our study identified the modifiable factors along the care continuum influencing the trajectory of MLPIs' physical growth. Nurses should receive more training about infant stress measurement and family-centred care to work in partnership with parents so that MLPIs can reach their full developmental potential. Also, multidisciplinary interventions including stress reduction strategies, close psychological monitoring and education improving parent-infant relationships should be further developed to achieve optimizing growth in the first year of MLPIs.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

It is recommended that nurses pay attention to the long-term physical growth status of MLPIs, and closely support their families. Quantifying NICU-related stress and developing reduction strategies should be the priority for clinical staff during hospitalization. After discharge, persistent screening of depressive symptoms, psychological intervention and education about the parent-child relationship need to be included in the follow-up visits.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution. The study only included patients who were research participants.

Differential effects of growth restriction and immaturity on predicted psychomotor development at 4 years of age in preterm infants

BACKGROUND

Fetal growth restriction and immaturity are associated with poor neurocognitive development and child psychopathology affecting educational success at school and beyond. However, the differential effects of either obstetrical risk factor on predicted psychomotor development have not yet been deciphered.

OBJECTIVE

This study aimed to separately study the impact of growth restriction and that of immaturity on predicted psychomotor development at the preschool age of 4.3 (standard deviation, 0.8) years using birthweight percentiles in a prospective cohort of preterm infants born at ≤37+6/7 weeks of gestation. Differences between small for gestational age newborns with intrauterine growth restriction and those without were described. We examined predicted total psychomotor development score, predicted developmental disability index, calculated morphometric vitality index, and predicted intelligence quotient, Porteus Maze test score, and neurologic examination optimality score in 854 preterm infants from a large prospective screening cohort (cranial ultrasound screening, n=5,301).

STUDY DESIGN

This was a prospective cranial ultrasound screening study with a single-center cohort observational design (data collection done from 1984-1988, analysis done in 2022). The study included 5,301 live-born infants, of whom 854 (16.1%) were preterm infants (≤37+6/7 weeks' gestation), and was conducted on the day of discharge of the mother at 5 to 8 days postpartum from a level 3 perinatal center. Predicted psychomotor development, as assessed by the predicted total psychomotor development score, predicted developmental disability index, calculated morphometric vitality index, predicted intelligence quotient, Porteus Maze test score, and neurologic examination optimality score were calculated. We related psychomotor development indices and measures to gestational age in 3 groups of birthweight percentiles (ie, 10%, 50%, and 90% for small, appropriate, and large for gestational age newborns, respectively) using linear regression analysis, analysis of variance, multivariate analysis of variance, and t test procedures.

RESULTS

The key result of our study is the observation that in preterm infants born at ≤37+6/7 weeks of gestation, growth restriction as compared with immaturity is the prime risk factor for impairment of overall predicted psychomotor development, intelligence quotient, Porteus Maze test results, and neurologic examination optimality score at the preschool age of 4.3 (standard deviation, 0.8) years (P<.001). This is particularly true for intrauterine growth restriction. These detrimental effects of growth restriction become more prominent with decreasing gestational age (P<.001). As expected, growth restriction in preterm infants born at ≤37+6/7 weeks of gestation was associated with a number of obstetrical risk factors, including hypertension in pregnancy (P<.001), multiple pregnancy (P<.001), pathologic cardiotocography (P=.001), and low pH (P=.007), increased pCO2 (P=.009), and poor pO2 (P<.001) in umbilical arterial blood. Of note, there were no differences in cerebral hemorrhage or white matter damage among small, appropriate, and large for gestational age birthweight percentile groups, suggesting an independent mechanism of brain injury caused by preterm growth restriction resulting in poor psychomotor development.

CONCLUSION

Compared with immaturity, growth restriction in preterm infants has more intense detrimental effects on psychomotor development, necessitating improved risk stratification. This finding has implications for clinical management, parental consultation, and early intervention strategies to improve school performance, educational success, and mental health in children. The mechanisms of brain injury specific to growth restriction in preterm infants require further elucidation.

Growth variables and obstetrical risk factors in newborns are associated with psychomotor development at preschool age

BACKGROUND

Low birthweight resulting from preterm birth or fetal growth restriction is associated with poor neurocognitive development and child psychopathology affecting school performance and educational success. Prediction of developmental performance may therefore serve as a basis for early intervention strategies to improve educational success and mental health of our children in a timely manner.

OBJECTIVE

This study aimed to explore the predictive capacity of morphometric variables taken at birth and that of obstetrical risk factors to predict developmental performance at 4.3 (standard deviation, 0.8) years preschool age. We examined predicted Total psychomotor development score, predicted Developmental disability index, calculated Morphometric vitality index, and predicted Intelligence quotient, Maze test, and Neurologic examination optimality score in a large prospective screening (cranial ultrasound screening, n=5,301) and validation cohort (n=508,926).

STUDY DESIGN

In a single-center cohort observational study design (data collection done from 1984-1988, analysis done in 2022), a prospective cranial ultrasound screening study (1984-1988) was carried out on 5,301 live-born infants, including 571 (10.8%) preterm infants (≤36 weeks gestation), on the day of discharge of the mother at 5 to 8 days postpartum from a level 3 perinatal center. Predicted psychomotor development as assessed by predicted Total psychomotor development score, predicted Developmental disability index, calculated Morphometric vitality index, and predicted Intelligence quotient, Maze test, and Neurologic examination optimality score, was calculated. We related growth variables and obstetrical risk factors to Psychomotor development indices, and calculated Morphometric vitality index using odds ratios, receiver operating characteristics, analysis of variance, and multivariate analysis of variance.

RESULTS

The key result of our study is the observation that simple morphometric measures from newborns at birth like weight/head circumference ratio predict overall psychomotor development at 4.3 years (standard deviation, 0.8) of preschool age. Psychomotor development was assessed by predicted Total psychomotor development score, predicted Intelligence quotient, Maze test, and Neurologic examination optimality score, and related to weight/head circumference ratio in linear regression (P<.001) and ROC curve analyses (P<.001). Further, white matter damage strongly predicted adverse outcome in predicted Developmental disability index (P<.001). There was also a close correlation between calculated Morphometric vitality index and predicted Developmental disability index (P<.001). Finally, brain body weight ratio, weight/head circumference ratio, preterm birth, reduced Apgar at 10 minutes, weight/length ratio, and white matter damage yielded highest odds ratios for adverse outcome in predicted Total psychomotor development score and in predicted Developmental disability index (P<.001) and high effect sizes in reduced predicted Intelligence quotient, Maze test, and Neurologic examination optimality scores.

CONCLUSION

Simple morphometric data, birth variables, and obstetrical risk factors bear predictive capacity for neurocognitive performance in children at 4.3 years (standard deviation, 0.8) of age and hence provide a basis for parental consultation and early intervention to improve school performance, educational success, and mental health in developed and developing countries.

A novel shape-based approach to identify gestational age-adjusted growth patterns from birth to 11 years of age

Child growth patterns assessment is critical to design public health interventions. However, current analytical approaches may overlook population heterogeneity. To overcome this limitation, we developed a growth trajectories clustering pipeline that incorporates a shape-respecting distance, baseline centering (i.e., birth-size normalized trajectories) and Gestational Age (GA)-correction to characterize shape-based child growth patterns. We used data from 3945 children (461 preterm) in the 2004 Pelotas Birth Cohort with at least 3 measurements between birth (included) and 11 years of age. Sex-adjusted weight-, length/height- and body mass index-for-age z-scores were derived at birth, 3 months, and at 1, 2, 4, 6 and 11 years of age (INTERGROWTH-21st and WHO growth standards). Growth trajectories clustering was conducted for each anthropometric index using k-means and a shape-respecting distance, accounting or not for birth size and/or GA-correction. We identified 3 trajectory patterns for each anthropometric index: increasing (High), stable (Middle) and decreasing (Low). Baseline centering resulted in pattern classification that considered early life growth traits. GA-correction increased the intercepts of preterm-born children trajectories, impacting their pattern classification. Incorporating shape-based clustering, baseline centering and GA-correction in growth patterns analysis improves the identification of subgroups meaningful for public health interventions.

Growth patterns of preterm infants in Korea

With advancements in neonatal care and nutrition, the postnatal growth of preterm infants has improved; however, it remains an issue. Accurate assessments of growth using a standardized reference are needed to interpret the intrauterine and postnatal growth patterns of preterm infants. Growth in the earlier periods of life can contribute to later outcomes, and the refinement of postnatal growth failure is needed to optimize outcomes. Catchup growth occurs mainly before discharge and until 24 months of age, and very low birth weight infants in Korea achieve retarded growth later in life. Knowing an infant's perinatal history, reducing morbidity rates during admission, and performing regular monitoring after discharge are required. Preterm infants with a lower birth weight or who were small for gestational age are at increased risk of poor neurodevelopmental outcomes. Furthermore, poor postnatal growth is predictive of adverse neurodevelopmental outcomes. Careful monitoring and early intervention will contribute to better development outcomes and national public health improvements.

Applying the recommended indicators for the diagnosis of preterm and neonatal malnutrition: Answers to frequently asked questions

In 2018, a committee of expert preterm/neonatal registered dietitian nutritionists published recommended indicators for the diagnosis of malnutrition in preterm infants and neonates. This was in response to a need for indicators appropriate to the preterm/neonatal population, given the emphasis on diagnosing malnutrition in the pediatric and adult population. Since the publication, the authors have received numerous questions regarding the application and use of the indicators. This paper answers questions regarding the three categories of indicators and billing and reimbursement. The goal is to develop uniformity in the application of the malnutrition indicators for quality improvement and research efforts.

Head growth during neonatal intensive care unit stay is related to the neurodevelopmental outcomes of preterm small for gestational age infants

BACKGROUND

To investigate postnatal growth patterns and their relationship with the neurodevelopment of preterm infants born small for gestational age (SGA).

METHODS

This retrospective cohort study analyzed 90 infants born SGA with a birthweight <1500 g or gestational age <32 weeks. Length, weight, and head circumference (HC) were recorded at birth, 35 weeks postmenstrual age (PMA), 40 weeks PMA, and 4, 9, and 18 months corrected age (CA). Neurodevelopmental outcomes were assessed using the Bayley-III scales at 18 months CA.

RESULTS

The Z-score of HC in SGA infants increased from birth to 40 weeks PMA. Failure of head growth catch-up to the 10th percentile by four months CA and all three parameters by nine months CA were associated with worse neurodevelopmental outcomes. Z-score changes in head growth between birth and 35 weeks PMA were significantly associated with neurodevelopmental outcomes (p = 0.006; adjusted odds ratio, 6.964; 95% confidence interval: 1.763-27.506).

CONCLUSION

Head growth trajectory during neonatal intensive care unit stay is associated with neurodevelopmental outcomes in preterm SGA infants. If head growth catch-up is achieved by four months CA and length and weight catch-up by nine months CA, preterm SGA infants are predicted to have optimal neurodevelopment at 18 months CA.

Head Growth and Neurodevelopment of Preterm Infants with Surgical Necrotizing Enterocolitis and Spontaneous Intestinal Perforation

Spontaneous intestinal perforation (SIP) and surgical necrotizing enterocolitis (NEC) are intestinal conditions requiring surgical intervention in preterm infants. We aimed to compare the head growth and neurodevelopment of preterm infants with SIP and surgical NEC. A retrospective single-center study was performed in preterm infants born at less than 32 weeks of gestation and who had undergone surgery for NEC or SIP. Data from the Bayley Scales of Infant and Toddler Development 3rd Edition (Bayley-III) at 24 months of corrected age (CA) and the Korean Ages and Stages Questionnaire (K-ASQ) or Korean Developmental Screening Test (K-DST) at 36 months were collected. Among 82 eligible infants, 60 infants had surgical NEC, and 22 infants were diagnosed with SIP. Head growth was faster until CA 4 months in preterm infants with SIP than in those with surgical NEC. At 36 months, abnormal findings in the K-ASQ or K-DST were more prevalent in the NEC group than in the SIP group in the gross motor (48.2% vs. 0%, p = 0.015), fine motor (40.7% vs. 0%, p = 0.037), cognitive (55.6% vs. 12.5%, p = 0.047), and social domains (44.4% vs. 0%, p = 0.032). More studies evaluating the neurodevelopmental outcomes of preterm infants with surgical NEC and SIP are required.