Monitoring postnatal growth of preterm infants: present and future

Novel growth reference ImaGrow differed from existing charts for preterm children aged 0-2 years

AIM

This study aimed to address the critical need for more accurate growth reference charts for preterm infants, with a particular focus on low- and very low-birth-weight infants.

METHODS

The subjects were recruited at a single tertiary centre. The cohort comprised singleton and twin infants born before 37 weeks of gestation, with data collected from 2000 to 2016. Standardised measurements of body parameters were recorded in this mixed longitudinal survey. LMS method was utilised for data analysis. Statistical analysis was performed using SPSS Statistics Version 21. The validation with another new cohort was executed.

RESULTS

A total of 1781 infants (52.5% boys) met the inclusion criteria. The median gestational age at birth was 30 weeks, with a median birth weight of 1350 grams. The main findings included the construction of ImaGrow charts for low- and very low-birth-weight infants and significant differences in growth trajectories compared to Fenton+WHO charts.

CONCLUSION

Our comprehensive growth references, ImaGrow, are based on a long-term auxological assessment of preterm infants and differ from charts derived from size-at-birth standards or charts for term babies. These charts have significant implications for clinical practice in monitoring and assessing the growth of preterm infants.

Integrated growth assessment in the first 1000 d of life: an interdisciplinary conceptual framework

OBJECTIVES

Prenatal growth affects short- and long-term morbidity, mortality and growth, yet communication between prenatal and postnatal healthcare teams is often minimal. This paper aims to develop an integrated, interdisciplinary framework for foetal/infant growth assessment, contributing to the continuity of care across the first 1000 d of life.

DESIGN

A multidisciplinary think-tank met regularly over many months to share and debate their practice and research experience related to foetal/infant growth assessment. Participants’ personal practice and knowledge were verified against and supplemented by published research.

SETTING

Online and in-person brainstorming sessions of growth assessment practices that are feasible and valuable in resource-limited, low- and middle-income country (LMIC) settings.

PARTICIPANTS

A group of obstetricians, paediatricians, dietitians/nutritionists and a statistician.

RESULTS

Numerous measurements, indices and indicators were identified for growth assessment in the first 1000 d. Relationships between foetal, neonatal and infant measurements were elucidated and integrated into an interdisciplinary framework. Practices relevant to LMIC were then highlighted: antenatal Doppler screening, comprehensive and accurate birth anthropometry (including proportionality of weight, length and head circumference), placenta weighing and incorporation of length-for-age, weight-for-length and mid-upper arm circumference in routine growth monitoring. The need for appropriate, standardised clinical records and corresponding policies to guide clinical practice and facilitate interdisciplinary communication over time became apparent.

CONCLUSIONS

Clearer communication between prenatal, perinatal and postnatal health care providers, within the framework of a common understanding of growth assessment and a supportive policy environment, is a prerequisite to continuity of care and optimal health and development outcomes.

ASSESSMENT OF NEONATAL CARE STANDARD BY THE PREDICTIVE MODEL FOR RETINOPATHY OF PREMATURITY BASED ON WEIGHT GAIN

Care of extremely premature infants is in constant need for evaluation and progress. WINROP, a predictive model based on weight gain, has been developed to reduce the number of stressful examinations for retinopathy for prematurity. Validation studies of WINROP emphasize the difference of applicability in neonatal units of various practice. The aim of the study was to assess the standard of neonatal care by WINROP. Data on extremely premature infants were collected from medical records and entered in WINROP. High- and low-risk WINROP distribution and retinopathy of prematurity outcomes were analyzed. Fifty-four infants, gestational age ≤28 weeks, were included in the study after exclusion of weight related comorbidities. High risk was noted in 74% (n=40) of infants with 24% (n=13) developing retinopathy of prematurity requiring treatment. In low alarm group, there were 3 cases with severe disease. In conclusion, WINROP is not just a provider of predictive information on the severity of retinopathy of prematurity. High-risk alarm indicates the need of adjustment of nutritional strategies. Infants without pathological growth morbidities who develop severe retinopathy of prematurity in low-risk group point to other risk factors for retinopathy of prematurity to be evaluated and changed in future practice.

Delayed Macronutrients' Target Achievement in Parenteral Nutrition Reduces the Risk of Hyperglycemia in Preterm Newborn: A Randomized Controlled Trial

Hyperglycemia (HG) is an independent risk factor of mortality and morbidity in very low birth weight newborns (VLBW). Achievement of high nutritional intakes in the first days of life (DoL) by parenteral nutrition (PN) increases the risk of HG. We aim to assess if a delayed achievement of the PN macronutrient target dose could reduce the occurrence of HG in VLBW. We enrolled 353 VLBW neonates in a randomized controlled clinical trial comparing two PN protocols that differed in the timing of energy and amino acid target dose achievement: (1) early target dose achievement (energy within 4-5 DoL; amino acids within 3-4 DoL) vs. (2) late target dose achievement (energy within 10-12 DoL; amino acids within 5-7 DoL). The primary outcome was the occurrence of HG during the first week of life. An additional endpoint was long-term body growth. We observed a significant difference in the rate of HG between the two groups (30.7% vs. 12.2%, p = 0.003). Significant differences were observed in terms of body growth at 12 months of life between the two groups (weight Z-Score: -0.86 vs. 0.22, p = 0.025; length: -1.29 vs. 0.55, p < 0.001). Delayed achievement of energy and amino acid intake may be useful to reduce the risk of HG along with an increase of growth parameters in VLBW neonates.

After NICU discharge: Feeding and growth of low-income urban preterm infants through the first year

BACKGROUND

Little is known about preterm infant feeding and growth in the outpatient setting, and there are no standardized post-hospital discharge feeding guidelines. This study aims to describe post-neonatal intensive care unit (NICU) discharge growth trajectories of very preterm (<32 weeks gestational age (GA)) and moderately preterm (32-34 0/7 weeks GA) infants managed by community providers and to determine the association between post-discharge feeding type and growth Z-scores and z-score changes through 12 months corrected age (CA).

METHODS

This retrospective cohort study included very preterm infants (n = 104) and moderately preterm infants (n = 109) born 2010-2014 and followed in community clinics for low-income, urban families. Infant home feeding and anthropometry were abstracted from medical records. Repeated measures analysis of variance calculated adjusted growth z-scores and z-score differences between 4 and 12 months CA. Linear regression models estimated associations between 4 months CA feeding type and 12 months CA anthropometry.

RESULTS

Moderately preterm infants on nutrient-enriched vs. standard term feeds at 4 months CA had significantly lower length z-scores at NICU discharge that persisted to 12 months CA (-0.04 (0.13) vs. 0.37 (0.21), respectively, P = .03), with comparable length z-score increase for both groups between 4 and 12 months CA. Very preterm infants' 4 months CA feeding type predicted 12 month CA body mass index z-scores (β=-0.66 (-1.28, -0.04)).

CONCLUSION

Community providers may manage preterm infant post-NICU discharge feeding in the context of growth. Further research is needed to explore modifiable drivers of infant feeding and socio-environmental factors that influence preterm infant growth trajectories.

Predictive ability of postnatal growth failure for adverse feeding-related outcomes in preterm infants: an exploratory study comparing Fenton with INTERGROWTH-21st preterm growth charts

BACKGROUND

Postnatal growth failure (PGF) can impact the short- and long-term health outcomes in preterm infants. However, PGF rates vary according to the way it is defined and the growth chart used to monitor the postnatal growth. Fenton-2013 growth charts which suggest following intrauterine fetal growth compared to INTERGROWTH-21st, one specifically constructed for monitoring preterm extrauterine growth.

OBJECTIVE

Exploratory study to determine the PGF definition at first per oral (PO) that is most predictive of adverse oral feeding-related outcomes in preterm infants.

METHODS

Prospectively collected data of preterm infants 24-32 weeks gestation, who were started on cue-based oral feeds at ≤34 weeks gestation were reviewed. Anthropometric data at first PO (weight, length, and head circumference) were compared according to Fenton and INTERGROWTH-21st growth charts. PGF was defined either as <10th percentile, Z-score change (ZSC) of ≥-1.5 from birth, or ZSC of ≥-2.0. Top-quartile (Q4) of feeding-related outcomes (days from first PO to full PO, post-menstrual age at full PO, days from first PO to discharge, and length of hospital stay) was considered as adverse outcome.

RESULTS

Of the 125 infants included, the median birth gestation and weight were 29.4 weeks and 1235 g, respectively. Incidence of appropriate, small, and large for gestational age was similar at birth by both growth charts. ZSC -1.5 for weight by Fenton was significantly higher at first PO vs. INTERGROWTH-21st (p=.02), while percentile <10th and ZSC -2.0 rates were similar. The PGF definition based on individual anthropometrics at first PO that has the best area under the curve (AUC) for adverse feeding-related outcomes was used to create a combined PGF definition for each growth chart. The AUC for the combined PGF for the Fenton and INTERGROWTH-21st was similar (p>.05) and both have moderate sensitivity and negative predictive value, but have low specificity, positive predictive value, and positive likelihood ratio for adverse feeding-related outcomes.

CONCLUSIONS

The tested definitions of PGF at first PO have only small to moderate predictive ability for adverse feeding-related outcomes in preterm infants.

The growth rates and influencing factors of preterm and full-term infants: A birth cohort study

This study aimed to explore the growth rates and influencing factors of the length and weight of preterm and full-term infants in the urban areas of Hubei province to provide a reference for child health and related clinical fields. A birth cohort study was used to analyze the growth rates and influencing factors of the length and weight of preterm and full-term infants using a multivariate regression analysis. The growth rates of the length and weight of preterm infants were significantly lower than those of full-term infants from birth to 3 months of age (P < .05), and gradually caught up to the level of full-term infants after 3 months of age (P > .05). Meanwhile, there were some influencing factors that had significant differences by their contribution to the growth rates of the length and weight of preterm and full-term infants. This study proposed that perinatal factors were attached more importance to the growth rates of preterm infants in the urban areas of Hubei province.

Establishing Postnatal Growth Monitoring Curves of Preterm Infants in China: Allowing for Continuous Use from 24 Weeks of Preterm Birth to 50 Weeks

Background: Early postnatal growth monitoring and nutrition assessment for preterm infants is a public health and clinical concern. We aimed to establish a set of postnatal growth monitoring curves of preterm infants to better help clinicians make in-hospital and post-discharge nutrition plan of these vulnerable infants. Methods: We collected weight, length and head circumference data from a nationwide survey in China between 2015 and 2018. Polynomial regression and the modified LMS methods were employed to construct the smoothed weight, length and head circumference growth curves. Results: We established the P₃, P₁₀, P₂₅, P₅₀, P₇₅, P₉₀, P₉₇ reference curves of weight, length and head circumference that allowed for continuous use from 24 weeks of preterm birth to 50 weeks and developed a set of user-friendly growth monitoring charts. We estimated approximate ranges of weight gain per day and length and head circumference gains per week. Conclusions: Our established growth monitoring curves, which can be used continuously without correcting gestational age from 24 weeks of preterm birth to 50 weeks, may be useful for assessment of postnatal growth trajectories, definition of intrauterine growth retardation at birth, and classification of early nutrition status for preterm infants.

Comparison of intergrowth-21st and Fenton curves for evaluation of premature newborns

Abstract Objectives: to compare the intrauterine and postnatal growth of preterm infants according to the Intergrowth-21st and Fenton curves. Methods: study carried out in a maternity hospital, reference in high-risk pregnancy, with preterm infants born in 2018 who were hospitalized in the neonatal units of the institution. Preterm newborns weighed at least twice after birth were included in the sample and those that were syndromic, malformed or presented fluid retention were excluded. Proportions and means were compared using Pearson’s chi-square and Student’s t tests for paired samples, respectively. The McNemar test was used to compare categorical variables and the Kappa test to verify the degree of agreement between birth weight classifications obtained by the curves. Results: one hundred and fifty three infants with a median gestational age of 34.4 weeks were included. The incidences of the categories of nutritional status at birth did not differ between the curves. There was perfect agreement between the curves, except when newborns born under 33 weeks of gestational age were evaluated, in which case the agreement was substantial. About 21% of the babies classified as small for gestational age (SGA) by Intergrowth-21st were adequate for gestational age (AGA) according to Fenton and, on average, 20% of cases that had postnatal growth restriction (PNGR) according to Fenton standards were categorized as adequate weight by Intergrowth-21st. Postnatal weight classifications obtained by the evaluated curves had perfect agreement. Conclusions: the differences in theclassifications found between the charts reveal the importance of choosing the growth curve for monitoring preterm infants since behaviors based on their diagnoses can impact the life of this population.

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.

Differences in Postnatal Growth of Preterm Infants in Northern China Compared to the INTERGROWTH-21st Preterm Postnatal Growth Standards: A Retrospective Cohort Study

BACKGROUND

The INTERGROWTH-21st preterm postnatal growth standards (IPPGS) have increasingly been used to evaluate the growth of preterm infants worldwide. However, the validity of IPPGS's application to specific preterm populations remains controversial. This retrospective cohort study aimed to formulate reference growth charts for a preterm cohort in northern China and compare them to the IPPGS.

METHODS

A total of 1,827 healthy preterm infants with follow-up visits before 70 weeks of postmenstrual age (PMA) were retrospectively sampled from a preterm cohort (N = 2,011) born between 1 January 2011 and 28 February 2021, at the First Affiliated Hospital of Shandong First Medical University. Using the Generalized Additive Models for Location, Scale, and Shape method, 5,539 sets of longitudinal data were used to construct percentile and Z-score charts of length, weight, and head circumference (HC) at 40-64 weeks of PMA. Z-scores of length, weight, and HC (LAZ, WAZ, and HCZ) before 64 weeks were calculated using the IPPGS. Differences in the 50th percentile values between preterm infants and IPPGS (dLength, dWeight, and dHC) were calculated. Z-scores were assigned to six PMA clusters: 40-44, 44-48, 48-52, 52-56, 56-60, and 60-64 weeks for comparison between sexes.

RESULTS

For eligible infants, the mean PMA and weight at birth were 33.93 weeks and 2.3 kg, respectively. Boys, late preterm infants, twins, and infants with exclusively breastfeeding accounted for 55.8, 70.6, 27.8, and 45.9%, respectively. Compared to IPPGS, preterm infants were longer and heavier, especially for dLength in girls (range, 2.19-2.97 cm), which almost spanned the 50th and 90th percentiles of IPPGS. The dHC tended to narrow with PMA for both sexes. The mean LAZ, WAZ, and HCZ of both sexes at all PMA clusters were >0, especially for LAZ and WAZ (about 1.0 relative to IPPGS), indicating higher levels than the IPPGS at 40-64 weeks. Girls had larger LAZ at each PMA cluster, larger WAZ at 40-44 weeks, and lower HCZ after 56 weeks than boys. HCZ declined with PMA for both sexes.

CONCLUSION

Postnatal growth of this preterm cohort was considerably higher than that of the IPPGS at 40-64 weeks of PMA with sex differences.

Neuropsychological Development and New Criteria for Extrauterine Growth Restriction in Very Low-Birth-Weight Children

Background: Controversy between short-term neonatal growth of very low birth-weight preterm (VLBW) and neurodevelopment may be affected by criteria changes of extrauterine growth restriction (EUGR). Objective: to determine if new EUGR criteria imply modifications in the relationship between old criteria and results of neuropsychological tests in preterm children. Patients and methods: 87 VLBW at 5–7 years of age were studied. Neuropsychological assessment included RIST test (Reynolds Intellectual Sctreening Test) and NEPSY-II (NE neuro, PSY psycolgy assessment) tests. The relationships between these tests and the different growth parameters were analyzed. Results: RIST index was correlated with z-score Fenton’s weight (p = 0.004) and length (p = 0.003) and with z-score IGW-21’s (INTERGRWTH-21 Project) weight (p = 0.004) and length (p = 0.003) at neonatal discharge, but not with z-score difference between birth and neonatal discharge in weight, length, and HC for both. We did not find a statistically significant correlation between Fenton or IGW-21 z-scores and scalar data of NEPSY-II subtasks. Conclusion: In our series, neonatal growth influence on neuropsychological tests at the beginning of primary school does not seem robust, except for RIST test. New EUGR criteria do not improve the predictive ability of the old ones.

Variation in Neonatal Nutrition Practice and Implications: A Survey of Australia and New Zealand Neonatal Units

Background: Significant global variation exists in neonatal nutrition practice, including in assigned milk composition values, donor milk usage, fortification regimens, probiotic choice and in methods used to calculate and report nutrition and growth outcomes, making it difficult to synthesize data to inform evidence-based, standardized nutritional care that has potential to improve neonatal outcomes. The Australasian Neonatal Dietitians' Network (ANDiN) conducted a survey to determine the degree to which neonatal nutritional care varies across Australia and New Zealand (A&NZ) and to highlight potential implications.

Materials and Methods: A two-part electronic neonatal nutritional survey was emailed to each ANDiN member (n = 50). Part-One was designed to examine individual dietetic practice; Part-Two examined site-specific nutrition policies and practices. Descriptive statistics were used to examine the distribution of responses.

Results: Survey response rate: 88%. Across 24 NICU sites, maximum fluid targets varied (150–180 mL.kg.d⁻¹); macronutrient composition estimates for mothers' own(MOM) and donor (DM) milk varied (Energy (kcal.dL⁻¹) MOM: 65–72; DM 69–72: Protein (g.dL⁻¹): MOM: 1.0–1.5; DM: 0.8–1.3); pasteurized DM or unpasteurized peer-to-peer DM was not available in all units; milk fortification commenced at different rates and volumes; a range of energy values (kcal.g⁻¹) for protein (3.8–4.0), fat (9.0–10.0), and carbohydrate (3.8–4.0) were used to calculate parenteral and enteral intakes; probiotic choice differed; and at least seven different preterm growth charts were employed to monitor growth.

Discussion: Our survey identifies variation in preterm nutrition practice across A&NZ of sufficient magnitude to impact nutrition interventions and neonatal outcomes. This presents an opportunity to use the unique skillset of neonatal dietitians to standardize practice, reduce uncertainty of neonatal care and improve the quality of neonatal research.

Fenton vs. Intergrowth-21st: Postnatal Growth Assessment and Prediction of Neurodevelopment in Preterm Infants

Although the survival rate of preterm infants has improved over the years, growth failure and associated impaired neurodevelopmental outcome remains a significant morbidity. Optimal nutrition plays an important role in achieving adequate postnatal growth. Accurate growth monitoring of preterm infants is critical in guiding nutritional protocols. Currently, there is no consensus regarding which growth assessment tool is suitable for monitoring postnatal growth of preterm infants to foster optimal neurodevelopmental outcomes while avoiding future consequences of aggressive nutritional approaches including increased risk for cardiovascular disease and metabolic syndrome. A retrospective single center cohort study was conducted to compare the performance of two growth-assessment tools, Fenton and Intergrowth-21st (IG-21st) in the classification of size at birth, identification of impaired growth and predicting neurodevelopment. A total of 340 infants with mean gestational age of 30 weeks were included. Proportion of agreement between the two tools for identification of small for gestational age (SGA) was high 0.94 (0.87, 0.1) however, agreement for classification of postnatal growth failure at discharge was moderate 0.6 (0.52, 0.69). Growth failure at discharge was less prevalent using IG-21st. There was significant association between weight-based growth failure and poor neurodevelopmental outcomes at 12 and 24 months of age.

Are small-for-gestational-age preterm infants at increased risk of overweight? Statistical pitfalls in overadjusting for body size measures

OBJECTIVE

The objective of this study is to analyze the effect of adjusting for body measures on the association between small for gestational age (SGA) and overweight at 3 years.

STUDY DESIGN

Data were obtained from the Preterm Infant Multicenter Growth Study (n = 1089). Logistic regression was used, to adjust for confounders with additional adjustments separately for weight and height at 21 months. Marginal structural models (MSMs) estimated the direct effect of SGA on overweight.

RESULTS

The crude and adjusted for confounders models yielded null associations between SGA and overweight. Adjusting for height yielded a positive association (odds ratio (OR): 2.31, 95% CI: 0.52-10.26) and adjusting for weight provided a significantly positive association (OR: 6.60, 95% CI: 1.10-37.14). The MSMs, with height and weight held constant, provided no evidence for a direct effect of SGA on overweight (OR: 0.83, 95% CI: 0.14-5.01, OR: 0.71, 95% CI: 0.18-2.81, respectively).

CONCLUSION

Adjusting for body measures can change the association between SGA and overweight, providing spurious estimates.

Variation in very preterm extrauterine growth in a European multicountry cohort

OBJECTIVE

Extrauterine growth restriction (EUGR) among very preterm infants is related to poor neurodevelopment, but lack of consensus on EUGR measurement constrains international research. Our aim was to compare EUGR prevalence in a European very preterm cohort using commonly used measures.

DESIGN

Population-based observational study.

SETTING

19 regions in 11 European countries.

PATIENTS

6792 very preterm infants born before 32 weeks' gestational age (GA) surviving to discharge.

MAIN OUTCOME MEASURES

We investigated two measures based on discharge-weight percentiles with (1) Fenton and (2) Intergrowth (IG) charts and two based on growth velocity (1) birth weight and discharge-weight Z-score differences using Fenton charts and (2) weight-gain velocity using Patel's model. We estimated country-level relative risks of EUGR adjusting for maternal and neonatal characteristics and associations with population differences in healthy newborn size, measured by mean national birth weight at 40 weeks' GA.

RESULTS

About twofold differences in EUGR prevalence were observed between countries for all indicators and these persisted after case-mix adjustment. Discharge weight <10th percentile using Fenton charts varied from 24% (Sweden) to 60% (Portugal) and using IG from 13% (Sweden) to 43% (Portugal), while low weight-gain velocity ranged from 35% (Germany) to 62% (UK). Mean term birth weight strongly correlated with both percentile-based measures (Spearman's rho=-0.90 Fenton, -0.84 IG, p<0.01), but not Patel's weight-gain velocity (rho: -0.38, p=0.25).

CONCLUSIONS

Very preterm infants have a high prevalence of EUGR, with wide variations between countries in Europe. Variability associated with mean term birth weight when using common postnatal growth charts complicates international benchmarking.

Extrauterine growth restriction in extremely preterm infants based on the Intergrowth-21st Project Preterm Postnatal Follow-up Study growth charts and the Fenton growth charts

Growth charts are essential for monitoring the postnatal growth of preterm infants. The preterm postnatal follow-up study (PPFS) of the Intergrowth-21st Project provides new growth standards based on a longitudinal study. This study was conducted to investigate the prevalence of extrautrine growth restriction (EUGR) and the associated factors of EUGR in preterm infants, using the PPFS charts and the Fenton charts. Data of 1,356 infants with gestational age (GA) less than 28 weeks from the Korean Neonatal Network were analysed. The prevalence of small for gestational age (SGA) of weight and length was higher with the Intergrowth charts than with the Fenton charts. EUGR in weight and length was more prevalent when using the Fenton charts. Multivariate analysis showed that low GA, high birthweight z score, male, treated patent ductus arteriosus (PDA), necrotizing enterocolitis, intraventricular haemorrhage and duration of parenteral nutrition (PN) were associated with EUGR in weight by the Intergrowth charts. High birthweight z score, treated PDA and PN duration were associated with EUGR defined by the Fenton charts.Conclusion: Compared to the Fenton charts, SGA was more defined and EUGR was less prevalent in extremely low gestational infants, while EUGR defined by the Intergrowth charts categorized infants with adverse clinical courses more elaborately. What is Known: • Preterm infants are at risk of postnatal growth restriction (PGR), although optimal postnatal growth is important for the long-term outcomes. • Growth charts are essential tools to monitor the postnatal growth of preterm infants. What is New: • PGR of weight and length were less defined with the Intergrowth charts than the Fenton charts. • PGR defined by the Intergrowth preterm postnatal follow-up study (PPFS) chart categorized preterm infants with morbidities more elaborately than the Fenton charts.

Comparison of Postnatal Growth Charts of Singleton Preterm and Term Infants Using World Health Organization Standards at 40-160 Weeks Postmenstrual Age: A Chinese Single-Center Retrospective Cohort Study

There remains controversy regarding whether the growth charts constructed from data of term infants, such as those produced by the World Health Organization (WHO) standards, can appropriately evaluate the postnatal growth of preterm infants. This retrospective cohort study, conducted in the First Affiliated Hospital of Shandong First Medical University in Jinan China, aimed to compare the postnatal growth charts of singleton preterm and term infants using WHO standards at 40-160 weeks postmenstrual age (PMA). A total of 5,459 and 15,185 sets of longitudinal measurements [length/height, weight, head circumference (HC), and body mass index (BMI)] from birth to 160 weeks PMA were used to construct growth charts for 559 singleton preterm (mean PMA at birth, 33.84 weeks) and 1,596 singleton term infants (born at 40 weeks PMA), respectively, using the Generalized Additive Models for Location, Scale, and Shape (GAMLSS) method. Z-scores (prematurity corrected) were calculated using WHO Anthro software. Compared to WHO standards, all parameters of preterm infants were increased, especially in terms of length/height and weight; the gap between the two almost spanned two adjacent centile curves. Compared to term controls, the length/height, weight, and BMI of preterm infants were higher at 40 weeks PMA, surpassed by term infants at 52-64 weeks PMA, and quite consistent thereafter. The HC of preterm infants at 40-160 weeks PMA was quite consistent with both term controls and the WHO standards. The Z-scores for length/height, weight, and BMI of preterm infants relative to the WHO standards gradually decreased from 1.20, 1.13, and 0.74 at 40-44 weeks PMA to 0.67, 0.42, and 0.03 at 132-160 weeks PMA, respectively; Z-scores for HC of preterm infants rapidly decreased from 0.73 to 0.29 at 40-50 weeks PMA, and then fluctuated in the range of 0.08-0.23 at 50-160 weeks PMA. Preterm infants had higher growth trajectories than the WHO standards and similar but not identical trajectories to term infants during the first 2 years of life. These findings reemphasize the necessity of constructing local growth charts for Chinese singleton preterm infants.

Growth patterns over 2 years after birth according to birth weight and length percentiles in children born preterm

PURPOSE

To analyze growth patterns over 2 years after birth according to preterm infant birth weight and length percentiles.

METHODS

Anthropometric measurements of 82 preterm infants were retrospectively reviewed. Preterm infants with birth weight or length below the 10th percentile were classified as small for gestational age (SGA) (n=19) and those between the 10th and 89th percentile as appropriate for gestational age (AGA) (n=63). The association between the length standard deviation score (SDS) at 2 years of corrected age and clinical factors were analyzed.

RESULTS

The length SDS of the SGA group was significantly increased at 6 months (-1.30±1.71) and 24 months (-0.97±1.06) of corrected age. The length SDS was lower in the SGA group than those in the AGA group at 6 months (-1.30±1.71 vs. -0.25±1.15, P=0.004), 18 months (-0.97±1.39 vs. -0.03±1.29, P=0.015), and 24 months (-0.97±1.06 vs. -0.29±1.12, P=0.022,). The percentage of children with a length SDS of <-2 (growth failure) at 24 months was 15.8% in the SGA group and 4.8% in the AGA group (P=0.108). Multiple linear regression analysis demonstrated that length at 24 months of corrected age was negatively correlated with birth length below the 10th percentile (coefficient β=-0.91, P=0.001) and duration of stay in the neonatal intensive care unit (NICU) (coefficient β=-0.01, P=0.001).

CONCLUSION

Despite the fact that catch-up growth occurs during the early period of infancy in a large portion of preterm SGA infants, a significant portion of these infants show growth failure at 24 months of age. Growth over 2 years after birth is affected by birth length and duration of stay in the NICU in preterm children.

Long-term effects on growth of an energy-enhanced parenteral nutrition in preterm newborn: A quasi-experimental study

Aim

To assess the best energy intake in Parenteral Nutrition (PN) for preterm newborns, considering both possible benefits for growth and risk of complications.

Methods

Quasi-experimental study comparing two cohorts of newborns, receiving Energy-Enhanced vs. Standard PN (Cohort A, from 1st January 2015 to 31 January 2016 and Cohort B from 1st February 2016 to 31 March 2017; respectively) after implementation of a change in the PN protocol. The primary outcome measure was growth at 24 months of life. The PN associated complications were also measured.

Results

We enrolled 132 newborns in two Cohorts, similar for prenatal and postnatal clinical characteristics. Although, body weight and length at 24 months of life were significantly higher (p<0.05) in the Cohort A (11.1, 95% CI 10.6 to 11.6 Kg; 85.0 95% CI 83.8 to 86.2 cm) compared with Cohort B (10.4, 95% CI 9.9 to 10.9 Kg; 81.3 95% CI 79.7 to 82.8 cm), body weight and length Z-Score in the first 24 months of life were similar between the two Cohorts. The rate of PN associated complications was very high in both study Cohorts (up to 98% of enrolments). Multivariate analysis showed that length at 24 months was significantly associated with receiving standard PN (cohort A) in the first week of life and on the energy intake in the first week of life. We also found a marginally insignificant association between Cohort A assignment and body weight at 24 months of life (p = 0.060).

Conclusions

Energy-enhanced PN in early life has not significant effects on long-term growth in preterm newborns. The high prevalence of PN associated complications, poses concerns about the utility of high energy intake recommended by current guidelines for PN.

Modelling predictive gender- and gestation-specific weight reference centiles for preterm infants using a population-based cohort study

We aimed to model longitudinal data to create predictive growth charts for weight in preterm infants from birth till discharge, that took into account the differing growth rates post-birth when compared to in-utero growth and therefore was more representative of the data than the UK1990 reference charts. Data from birth until discharge (or death), was collected and rigorously cleaned for all infants born at <32 weeks of gestation over a 4-year period. Means and standard deviations from the UK1990 reference charts were used to compute standard deviation scores (SDS) for our cohort. 2/3rd of the data was randomly selected and used to create gestation and gender-specific predictive weight centile lines through novel application of mixed modelling methods. The remaining 1/3rd of the data was used to test model fit by comparing expected vs actual weights for the new model with those predicted by the UK1990 model. Data from 1,510 preterm infants was analysed. 1067 of these were used to produce the predictive model. Weekly SDS were significantly lower than predicted throughout hospital stay for all gestation groups when compared with UK1990 data. The test data (n = 539) fitted the new centile lines substantially better than those modelled by the UK1990 centile lines. Mixed modelling of longitudinal data produced new predictive references for weight centiles of preterm infants. A large population-based prospective study is needed to produce representative longitudinal reference growth charts using these methods.

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.

Postnatal length and weight growth velocities according to Fenton reference and their associated perinatal factors in healthy late preterm infants during birth to term-corrected age: an observational study

Background

Optimum early postnatal growth is critical for early and later health of preterm infants. Postnatal length and weight growth velocities and their associated perinatal factors in healthy late preterm infants without restriction of neonatal complications and nutritional problems have not been widely studied.

Methods

As part of ongoing longitudinal follow-up study of growth and development of preterm infants in Shandong Qianfoshan Hospital in China, 599 healthy late preterm infants without neonatal complications and nutritional problems were sampled from 795 preterm infants born in January 2014 to April 2017. Perinatal factors, growth parameters, growth velocities(ΔLengthZ and ΔWeightZ: Z-score changes of length and weight) during birth and term-corrected age were documented. Associated variables of growth velocities were analyzed by bivariate and multivariate regression analyses. Adjusted ΔLengthZ and ΔWeightZ were compared between/among subgroups of associated variables using analysis of covariance. Catch-up growth were defined as ΔLengthZ or ΔWeightZ > 0.67.

Results

The mean ΔLengthZ and ΔWeightZ were 0.28, 0.65, respectively. Catch-up growth of length and weight was ubiquitous(30.7, 46.2%, respectively). Faster length growth velocity was associated with male, larger postmenstrual age(PMA) at birth, younger mother and larger PMA at visit; Faster weight growth velocity was associated with male, unfavorable intrauterine growth status defined by birth weight percentile(Small-for-Gestational-Age(<P10), Appropriate-for-Gestational-Age(P10–90), Large-for-Gestational-Age(>P90)), twin and larger PMA at visit. When adjusted for associated co-variables, weight catch-up growth existed in subgroups of 36 weeks PMA at birth, male, twin and SGA, while AGA almost reached this standard with mean adjusted ΔWeightZ as 0.66. Although none of these subgroups got length catch-up growth standard, infants of 36 weeks PMA at birth had statistically rapider length growth velocity than 34 and 35 weeks PMA at birth subgroups(mean adjusted ΔLengthZs of 34, 35 and 36 weeks subgroups: 0.10, 0.22, 0.38, respectively).

Conclusions

Postnatal length and weight growth velocities of healthy late preterm infants from birth to term-corrected age were much superior than that of Fenton reference, especially for weight, with ubiquitous catch-up growth. Different associated factors for length and weight growth signified the necessity of constructing more detailed growth standards by specific stratification for associated factors.

[Follow-up observation of catch-up growth of preterm infants after discharge and risk factors for extrauterine growth retardation]

OBJECTIVE

To investigate the catch-up growth of preterm infants within a corrected age of 6 months and the risk factors for extrauterine growth retardation (EUGR).

METHODS

A total of 321 preterm infants who were discharged after treatment in the neonatal intensive care unit and had regular follow-up documents with complete follow-up records were enrolled. According to the Prenatal Health Care Norms in 2015, these infants were divided into low-risk group with 69 infants and high-risk group with 252 infants. The Z-score method was used to evaluate body weight, body length, and head circumference, and the catch-up growth of the preterm infants within a corrected age of 6 months was analyzed. A multivariate logistic regression analysis was performed to identify the risk factors for EUGR at the corrected age of 6 months.

RESULTS

The percentage of preterm infants with Z scores of body weight, body length, and head circumference of < -2 (not reach the standard for catch-up growth) in both groups decreased gradually with increasing corrected age. At the corrected age of 6 months, the percentages of preterm infants whose body weight, body length, and head circumference did not reach the standard for catch-up growth in the low-risk group were reduced to 1.4% (1/69), 2.9% (2/69), and 1.4% (1/69) respectively, while in the high-risk group, these percentages were reduced to 1.2% (3/252), 1.6% (4/252), and 3.6% (9/252) respectively. The high-risk group had a significantly higher incidence rate of EUGR at the corrected age of 6 months than the low-risk group (28.2% vs 15.9%, P=0.039). The multivariate logistic regression analysis showed that multiple birth (OR=2.68, P=0.010), low birth weight (<1 000 g: OR=14.84, P<0.001; 1 000-1 499 g: OR=2.85, P=0.005), and intrauterine growth retardation (IUGR) (OR=11.41, P<0.001) were risk factors for EUGR at the corrected age of 6 months, while nutritional enhancement after birth (OR=0.25, P<0.001) reduced the risk of EUGR.

CONCLUSIONS

Most preterm infants can achieve catch-up growth at the corrected age of 6 months. High-risk preterm infants have a high incidence rate of EUGR at the corrected age of 6 months. Multiple birth, low birth weight, and IUGR are risk factors for EUGR, while rational nutritional enhancement after birth can reduce the incidence rate of EUGR in preterm infants.

[Follow-up observation of catch-up growth of preterm infants after discharge and risk factors for extrauterine growth retardation]

OBJECTIVE

To investigate the catch-up growth of preterm infants within a corrected age of 6 months and the risk factors for extrauterine growth retardation (EUGR).

METHODS

A total of 321 preterm infants who were discharged after treatment in the neonatal intensive care unit and had regular follow-up documents with complete follow-up records were enrolled. According to the Prenatal Health Care Norms in 2015, these infants were divided into low-risk group with 69 infants and high-risk group with 252 infants. The Z-score method was used to evaluate body weight, body length, and head circumference, and the catch-up growth of the preterm infants within a corrected age of 6 months was analyzed. A multivariate logistic regression analysis was performed to identify the risk factors for EUGR at the corrected age of 6 months.

RESULTS

The percentage of preterm infants with Z scores of body weight, body length, and head circumference of < -2 (not reach the standard for catch-up growth) in both groups decreased gradually with increasing corrected age. At the corrected age of 6 months, the percentages of preterm infants whose body weight, body length, and head circumference did not reach the standard for catch-up growth in the low-risk group were reduced to 1.4% (1/69), 2.9% (2/69), and 1.4% (1/69) respectively, while in the high-risk group, these percentages were reduced to 1.2% (3/252), 1.6% (4/252), and 3.6% (9/252) respectively. The high-risk group had a significantly higher incidence rate of EUGR at the corrected age of 6 months than the low-risk group (28.2% vs 15.9%, P=0.039). The multivariate logistic regression analysis showed that multiple birth (OR=2.68, P=0.010), low birth weight (<1 000 g: OR=14.84, P<0.001; 1 000-1 499 g: OR=2.85, P=0.005), and intrauterine growth retardation (IUGR) (OR=11.41, P<0.001) were risk factors for EUGR at the corrected age of 6 months, while nutritional enhancement after birth (OR=0.25, P<0.001) reduced the risk of EUGR.

CONCLUSIONS

Most preterm infants can achieve catch-up growth at the corrected age of 6 months. High-risk preterm infants have a high incidence rate of EUGR at the corrected age of 6 months. Multiple birth, low birth weight, and IUGR are risk factors for EUGR, while rational nutritional enhancement after birth can reduce the incidence rate of EUGR in preterm infants.

The INTERGROWTH-21st fetal growth standards: toward the global integration of pregnancy and pediatric care

The purpose of the INTERGROWTH-21^st project was to develop international, prescriptive standards for fetal growth assessed by ultrasound and fundal height, preterm postnatal growth, newborn size and body composition, maternal weight gain, and infant development at the age of 2 years. Hence, we have produced, based on World Health Organization recommendations, the first comprehensive set of international standards of optimal fetal and newborn growth that perfectly match the existing World Health Organization child growth standards. Uniquely, the same population was followed up longitudinally from 9 weeks of fetal life to 2 years of age, with growth, health, and nutritional status assessment at 2 years supporting the appropriateness of the population for construction of growth standards. The resulting package of clinical tools allows, for the first time, growth and development to be monitored from early pregnancy to infancy. The INTERGROWTH-21^st fetal growth standards, which are based on observing >4500 healthy pregnancies, nested in a study of >59,000 pregnancies from populations with low rates of adverse perinatal outcomes, show how fetuses should grow-rather than the more limited objective of past references, which describe how they have grown at specific times and locations. Our work has confirmed the fundamental biological principle that variation in human growth across different populations is mostly dependent on environmental, nutritional, and socioeconomic factors. We found that when mothers' nutritional and health needs are met and there are few environmental constraints on growth, <3.5% of the total variability of skeletal growth was due to differences between populations. We propose that not recognizing the concept of optimal growth could deprive the most vulnerable mothers and their babies of optimal care, because local growth charts normalize those at highest risk for growth restriction and overweight, and can be valuable for policymakers to ensure rigorous evaluation and effective resource allocation. We strongly encourage colleagues to join efforts to provide integrated, evidence-based growth monitoring to pregnant women and their infants worldwide. Presently, there are 23.3 million infants born small for gestational age in low- to middle-income countries according to the INTERGROWTH-21^st newborn size standards. We suggest that misclassification of these infants by using local charts could affect the delivery of optimal health care.

The satisfactory growth and development at 2 years of age of the INTERGROWTH-21st Fetal Growth Standards cohort support its appropriateness for constructing international standards

Background

The World Health Organization recommends that human growth should be monitored with the use of international standards. However, in obstetric practice, we continue to monitor fetal growth using numerous local charts or equations that are based on different populations for each body structure. Consistent with World Health Organization recommendations, the INTERGROWTH-21^st Project has produced the first set of international standards to date pregnancies; to monitor fetal growth, estimated fetal weight, Doppler measures, and brain structures; to measure uterine growth, maternal nutrition, newborn infant size, and body composition; and to assess the postnatal growth of preterm babies. All these standards are based on the same healthy pregnancy cohort. Recognizing the importance of demonstrating that, postnatally, this cohort still adhered to the World Health Organization prescriptive approach, we followed their growth and development to the key milestone of 2 years of age.

Objective

The purpose of this study was to determine whether the babies in the INTERGROWTH-21^st Project maintained optimal growth and development in childhood.

Study Design

In the Infant Follow-up Study of the INTERGROWTH-21^st Project, we evaluated postnatal growth, nutrition, morbidity, and motor development up to 2 years of age in the children who contributed data to the construction of the international fetal growth, newborn infant size and body composition at birth, and preterm postnatal growth standards. Clinical care, feeding practices, anthropometric measures, and assessment of morbidity were standardized across study sites and documented at 1 and 2 years of age. Weight, length, and head circumference age- and sex-specific z-scores and percentiles and motor development milestones were estimated with the use of the World Health Organization Child Growth Standards and World Health Organization milestone distributions, respectively. For the preterm infants, corrected age was used. Variance components analysis was used to estimate the percentage variability among individuals within a study site compared with that among study sites.

Results

There were 3711 eligible singleton live births; 3042 children (82%) were evaluated at 2 years of age. There were no substantive differences between the included group and the lost-to-follow up group. Infant mortality rate was 3 per 1000; neonatal mortality rate was 1.6 per 1000. At the 2-year visit, the children included in the INTERGROWTH-21^st Fetal Growth Standards were at the 49th percentile for length, 50th percentile for head circumference, and 58th percentile for weight of the World Health Organization Child Growth Standards. Similar results were seen for the preterm subgroup that was included in the INTERGROWTH-21^st Preterm Postnatal Growth Standards. The cohort overlapped between the 3rd and 97th percentiles of the World Health Organization motor development milestones. We estimated that the variance among study sites explains only 5.5% of the total variability in the length of the children between birth and 2 years of age, although the variance among individuals within a study site explains 42.9% (ie, 8 times the amount explained by the variation among sites). An increase of 8.9 cm in adult height over mean parental height is estimated to occur in the cohort from low-middle income countries, provided that children continue to have adequate health, environmental, and nutritional conditions.

Conclusion

The cohort enrolled in the INTERGROWTH-21^st standards remained healthy with adequate growth and motor development up to 2 years of age, which supports its appropriateness for the construction of international fetal and preterm postnatal growth standards.

Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change

There is no consensus regarding how the growth of preterm infants should be monitored or what constitutes their ideal pattern of growth, especially after term-corrected age. The concept that the growth of preterm infants should match that of healthy fetuses is not substantiated by data and, in practice, is seldom attained, particularly for very preterm infants. Hence, by hospital discharge, many preterm infants are classified as postnatal growth-restricted. In a recent systematic review, 61 longitudinal reference charts were identified, most with considerable limitations in the quality of gestational age estimation, anthropometric measures, feeding regimens, and how morbidities were described. We suggest that the correct comparator for assessing the growth of preterm infants, especially those who are moderately or late preterm, is a cohort of preterm newborns (not fetuses or term infants) with an uncomplicated intrauterine life and low neonatal and infant morbidity. Such growth monitoring should be comprehensive, as recommended for term infants, and should include assessments of postnatal length, head circumference, weight/length ratio, and, if possible, fat and fat-free mass. Preterm postnatal growth standards meeting these criteria are now available and may be used to assess preterm infants until 64 weeks' postmenstrual age (6 months' corrected age), the time at which they overlap, without the need for any adjustment, with the World Health Organization Child Growth Standards for term newborns. Despite remaining nutritional gaps, 90% of preterm newborns (ie, moderate to late preterm infants) can be monitored by using the International Fetal and Newborn Growth Consortium for the 21st Century Preterm Postnatal Growth Standards from birth until life at home.

Concept Analysis of Growth Failure in Preterm Infants in the NICU

Growth failure has not been consistently defined for preterm infants, which contributes to unclear clinical guidelines for optimal growth and development. Therefore, the purpose of this concept analysis was to identify all uses and attributes of the concept, present model and contrary cases, identify antecedents and consequences, define empirical referents, and provide an operational definition of growth failure among preterm infants in the NICU.

Nutrition for the Extremely Preterm Infant

With advancements in the care of preterm infants, the goals in nutritional care have expanded from survival and mimicking fetal growth to optimizing neurodevelopmental outcomes. Inadequate nutritional support may be a risk factor for major complications of prematurity; conversely, higher disease burden is a risk for growth restriction. Early complete parenteral nutrition support, including intravenous lipid emulsion, should be adopted, and the next challenge that should be addressed is parenteral nutrition customized to fit the specific needs and metabolism of the extremely preterm infant. Standardized feeding protocols should be adopted.

Postnatal growth standards for preterm infants: the Preterm Postnatal Follow-up Study of the INTERGROWTH-21(st) Project

BACKGROUND

Charts of size at birth are used to assess the postnatal growth of preterm babies on the assumption that extrauterine growth should mimic that in the uterus.

METHODS

The INTERGROWTH-21(st) Project assessed fetal, newborn, and postnatal growth in eight geographically defined populations, in which maternal health care and nutritional needs were met. From these populations, the Fetal Growth Longitudinal Study selected low-risk women starting antenatal care before 14 weeks' gestation and monitored fetal growth by ultrasonography. All preterm births from this cohort were eligible for the Preterm Postnatal Follow-up Study, which included standardised anthropometric measurements, feeding practices based on breastfeeding, and data on morbidity, treatments, and development. To construct the preterm postnatal growth standards, we selected all live singletons born between 26 and before 37 weeks' gestation without congenital malformations, fetal growth restriction, or severe postnatal morbidity. We did analyses with second-degree fractional polynomial regression models in a multilevel framework accounting for repeated measures. Fetal and neonatal data were pooled from study sites and stratified by postmenstrual age. For neonates, boys and girls were assessed separately.

FINDINGS

From 4607 women enrolled in the study, there were 224 preterm singleton births, of which 201 (90%) were enrolled in the Preterm Postnatal Follow-up Study. Variance component analysis showed that only 0·2% and 4·0% of the total variability in postnatal length and head circumference, respectively, could be attributed to between-site differences, justifying pooling the data from all study sites. Preterm growth patterns differed from those for babies in the INTERGROWTH-21(st) Newborn Size Standards. They overlapped with the WHO Child Growth Standards for term babies by 64 weeks' postmenstrual age.

INTERPRETATION

Our data have yielded standards for postnatal growth in preterm infants. These standards should be used for the assessment of preterm infants until 64 weeks' postmenstrual age, after which the WHO Child Growth Standards are appropriate. Size-at-birth charts should not be used to measure postnatal growth of preterm infants.

FUNDING

Bill & Melinda Gates Foundation.

Executive summary: evaluation of the evidence to support practice guidelines for nutritional care of preterm infants-the Pre-B Project

Preterm birth (infants born at <37 wk of gestational age) is a significant clinical and public health challenge in the United States and globally. No universally accepted practice guidelines exist for the nutritional care of preterm infants. To address the current state of knowledge and to support systematic reviews that will be used to develop evidence-informed guidance, a consortium consisting of the American Academy of Pediatrics, the ASN, the American Society for Parenteral and Enteral Nutrition, the Academy of Nutrition and Dietetics, the Food and Drug Administration, the CDC, the USDA/Agricultural Research Service (USDA/ARS), and the Eunice Kennedy Shriver National Institute of Child Health and Human Development/NIH initiated the Pre-B Project. The project included the constitution of 4 thematic working groups charged with the following tasks: 1) develop a series of topics/questions for which there is sufficient evidence to support a systematic review process to be conducted by the Academy of Nutrition and Dietetics' Evidence Analysis Library (EAL), leading to the development of new guidelines for nutritional care of preterm infants, and 2) develop a targeted research agenda to address priority gaps in our understanding of the role of nutrition in the health and development of preterm/neonatal intensive care unit infants. This review consists of a project overview including a summary of a workshop hosted by the USDA/ARS Children's Nutrition Research Center and summary reports of the 4 working groups established to address the following themes: 1) nutrient specifications, 2) clinical/practical issues in enteral feeding, 3) gastrointestinal and surgical issues, and 4) current standards for assessing infant feeding outcomes. These reports will serve as the basis for the ultimate guideline development process to be conducted by the Academy of Nutrition and Dietetics' EAL.