Tanis R Fenton

Validating the weight gain of preterm infants between the reference growth curve of the fetus and the term infant

BackgroundCurrent fetal-infant growth references have an obvious growth disjuncture around 40xa0week gestation overlapping where the fetal and infant growth references are combined. Graphical smoothening of the disjuncture to connect the matching percentile curves has never been validated. This study was designed to compare weight gain patterns of contemporary preterm infants with a fetal-infant growth reference (derived from a meta-analysis) to validate the previous smoothening assumptions and inform the revision of the Fenton chart.MethodsGrowth and descriptive data of preterm infants (23 to 31xa0weeks) from birth through 10xa0weeks post term age were collected in three cities in Canada and the USA between 2001 and 2010 (nu2009=u2009977). Preterm infants were grouped by gestational age into 23–25, 26–28, and 29–31xa0weeks. Comparisons were made between the weight data of the preterm cohort and the fetal-infant growth reference.ResultsMedian weight gain curves of the three preterm gestational age groups were almost identical and remained between the 3rd and the 50th percentiles of the fetal-infant-growth-reference from birth through 10xa0weeks post term. The growth velocity of the preterm infants decreased in a pattern similar to the decreased velocity of the fetus and term infant estimates, from a high of 17–18xa0g/kg/day between 31–34xa0weeks to rates of 4–5xa0g/kg/day by 50xa0weeks in each gestational age group. The greatest discrepancy in weight gain velocity between the preterm infants and the fetal estimate was between 37 and 40xa0weeks; preterm infants grew more rapidly than the fetus. The infants in this study regained their birthweight earlier compared to those in the 1999 National Institute of Child Health and Human Development report.ConclusionThe weight gain velocity of preterm infants through the period of growth data disjuncture between 37 and 50xa0weeks gestation is consistent with and thus validates the smoothening assumptions made between preterm and post-term growth references.

A systematic review and meta-analysis of the nutrient content of preterm and term breast milk

BackgroundBreast milk nutrient content varies with prematurity and postnatal age. Our aims were to conduct a meta-analysis of preterm and term breast milk nutrient content (energy, protein, lactose, oligosaccharides, fat, calcium, and phosphorus); and to assess the influence of gestational and postnatal age. Additionally we assessed for differences by laboratory methods for: energy (measured vs. calculated estimates) and protein (true protein measurement vs. the total nitrogen estimates).MethodsSystematic review results were summarized graphically to illustrate the changes in composition over time for term and preterm milk. Since breast milk fat content varies within feeds and diurnally, to obtain accurate estimates we limited the meta-analyses for fat and energy to 24-hour breast milk collections.ResultsForty-one studies met the inclusion criteria: 26 (843 mothers) preterm studies and 30 (2299 mothers) term studies of breast milk composition. Preterm milk was higher in true protein than term milk, with differences up to 35% (0.7xa0g/dL) in colostrum, however, after postnatal day 3, most of the differences in true protein between preterm and term milk were within 0.2xa0g/dL, and the week 10–12 estimates suggested that term milk may be the same as preterm milk by that age. Colostrum was higher than mature milk for protein, and lower than mature milk for energy, fat and lactose for both preterm and term milk. Breast milk composition was relatively stable between 2 and 12xa0weeks. With milk maturation, there was a narrowing of the protein variance. Energy estimates differed whether measured or calculated, from −9 to 13%; true protein measurement vs. the total nitrogen estimates differed by 1 to 37%.ConclusionsAlthough breast milk is highly variable between individuals, postnatal age and gestational stage (preterm versus term) were found to be important predictors of breast milk content. Energy content of breast milk calculated from the macronutrients provides poor estimates of measured energy, and protein estimated from the nitrogen over-estimates the protein milk content. When breast milk energy, macronutrient and mineral content cannot be directly measured the average values from these meta-analyses may provide useful estimates of mother’s milk energy and nutrient content.

INTERGROWTH-21st very preterm size at birth reference charts

844 www.thelancet.com Vol 387 February 27, 2016 malformations, or ultrasound evidence of FGR, and 37 because of implausible anthropometric measurements or gestational age estimates. As expected, perinatal events (eg, higher pre-eclampsia, caesarean section, and neonatal mortality rates) for these very preterm babies diff ered from the Newborn Size Standards (appendix). The third, 10th, 50th, 90th, and 97th smoothed centile curves for weight, length, and head circumference at birth according to gestational age and sex, superimposed on the individual data, are shown in the appendix (actual centile values and corresponding equations are provided in the appendix and at the INTERGROWTH-21st website). Values for birthweight and head circumference at 33 weeks’ gestation overlapped perfectly with the original Newborn Size Standards; values for length were complementary at the median level, but less so at the extreme centiles because of the diff erently shaped curves in early and late pregnancy (fi gure). We present very preterm reference charts for newborn baby size at birth using the same underlying population, methods, instruments, standardisation protocols, and statistical analyses as for the Newborn Size Standards, which they complement well. They provide neonatologists with a single way to assess and screen newborn babies from 24 to 42 weeks’ gestation. The head circumference charts are particularly important in view of the urgent need, in the midst of the Zika virus outbreak, to assess the head size of newborn babies with a set of standardised, gestational-age specifi c charts, to avoid over-reporting of cases of microcephaly across all aff ected regions.

Physiological adjustment to postnatal growth trajectories in healthy preterm infants

Background:International guidelines suggest that growth of preterm infants should match intrauterine rates. However, the trajectory for extrauterine growth may deviate from the birth percentile due to an irreversible, physiological loss of extracellular fluid during postnatal adaptation to extrauterine conditions. To which “new” physiological growth trajectory preterm infants should adjust to after completed postnatal adaptation is unknown. This study analyzes the postnatal growth trajectories of healthy preterm infants using prospective criteria defining minimal support, as a model for physiological adaptation.Methods:International, multi-center, longitudinal, observational study at five neonatal intensive care units (NICUs). Daily weights until day of life (DoL) 21 of infants with undisturbed postnatal adaptation were analyzed (gestational ages: (i) 25–29u2009wk, (ii) 30–34u2009wk).Results:981 out of 3,703 admitted infants included. Maximum weight loss was 11% (i) and 7% (ii) by DoL 5, birth weight regained by DoL 15 (i) and 13 (ii). Infants transitioned to growth trajectories parallel to Fenton chart percentiles, 0.8 z-scores below their birth percentiles. The new trajectory after completed postnatal adaptation could be predicted for DoL 21 with R2 = 0.96.Conclusion:This study provides a robust estimate for physiological growth trajectories of infants after undisturbed postnatal adaptation. In the future, the concept of a target postnatal trajectory during NICU care may be useful.

Age of introduction of first complementary feeding for infants: a systematic review

BackgroundDespite a World Health Organization recommendation for exclusive breastfeeding of all full-term infants to 6 months of age, it is not clear what the health implications may be. Breast milk alone may not meet the nutrition needs for all growing infants, leaving them at risk for deficiencies. The objective of this study was to investigate the relationship between moderate (4 months) versus late (6 months) introduction of complementary foods to the full-term breastfed infant on iron status and growth.MethodsAn electronic search of peer-reviewed and gray-literature was conducted for randomized control trials (RCTs) and observational studies related to the timing of introduction of complementary foods. Iron status and growth data from the relevant RCTs were analyzed using RevMan 5.2.11.ResultsThree RCTs and one observational study met the inclusion criteria. Meta-analysis showed significantly higher hemoglobin levels in infants fed solids at 4 months versus those fed solids at 6 months in developing countries [mean difference [MD]: 5.0 g/L; 95xa0% CI: 1.5, 8.5 g/L; Pu2009=u20090.005]. Meta-anaysis also showed higher serum ferritin levels in the 4-month group in both developed and developing countries [MD: 26.0 μg/L; 95xa0% CI: -0.1, 52.1 μg/L, Pu2009=u20090.050], [MD: 18.9 μg/L; 95xa0% CI: 0.7, 37.1 μg/L, Pu2009=u20090.040]. Short follow-up periods and small sample sizes of the included studies were the major limitations.ConclusionsRCT evidence suggests the rate of iron deficiency anemia in breastfed infants could be positively altered by introduction of solids at 4 months.

Colorectal surgery patients prefer simple solid foods to clear fluids as the first postoperative meal.

PURPOSE: Randomized controlled trials have established that there is no benefit to withholding oral food and fluids from colorectal surgery patients postoperatively. The aim of this survey was to determine food preferences for the first postoperative meal and compare these with a traditional clear-fluid diet. METHODS: One hundred forty-five elective colorectal surgery patients were surveyed about their preferences for 35 common foods within 72 hours of surgery and their levels of nausea, hunger, and pain. Preferences were examined by postoperative day (one vs. two) and levels of nausea, hunger, and pain. RESULTS: The survey showed that patients significantly preferred solid foods as early as the first postoperative day and their preferences had little congruency with the traditional clear-fluid diet. Foods highest in preference, such as eggs, regular broth soup (e.g., chicken noodle soup), toast, and potatoes, were significantly more preferred than common clear-fluid diet items such as gelatin, clear broth, and carbonated beverages (P < 0.01). Oral supplements were preferred by only 44%. Patients reported low levels of nausea, hunger, and pain. CONCLUSION: Postoperative colorectal surgery patients prefer to receive simple solid foods rather than a clear-fluid diet as their first postoperative meal.

Body composition at birth and its relationship with neonatal anthropometric ratios: the newborn body composition study of the INTERGROWTH-21st project

BackgroundWe aimed to describe newborn body composition and identify which anthropometric ratio (weight/length; BMI; or ponderal index, PI) best predicts fat mass (FM) and fat-free mass (FFM).MethodsAir-displacement plethysmography (PEA POD) was used to estimate FM, FFM, and body fat percentage (BF%). Associations between FFM, FM, and BF% and weight/length, BMI, and PI were evaluated in 1,019 newborns using multivariate regression analysis. Charts for FM, FFM, and BF% were generated using a prescriptive subsample (n=247). Standards for the best-predicting anthropometric ratio were calculated utilizing the same population used for the INTERGROWTH-21st Newborn Size Standards (n=20,479).ResultsFFM and FM increased consistently during late pregnancy. Differential FM, BF%, and FFM patterns were observed for those born preterm (34+0−36+6 weeks’ gestation) and with impaired intrauterine growth. Weight/length by gestational age (GA) was a better predictor of FFM and FM (adjusted R2=0.92 and 0.71, respectively) than BMI or PI, independent of sex, GA, and timing of measurement. Results were almost identical when only preterm newborns were studied. We present sex-specific centiles for weight/length ratio for GA.ConclusionsWeight/length best predicts newborn FFM and FM. There are differential FM, FFM, and BF% patterns by sex, GA, and size at birth.

Protein intakes are associated with reduced length of stay: a comparison between Enhanced Recovery After Surgery (ERAS) and conventional care after elective colorectal surgery

Background: Protein can modulate the surgical stress response and postoperative catabolism. Enhanced Recovery After Surgery (ERAS) protocols are evidence-based care bundles that reduce morbidity.Objective: In this study, we compared protein adequacy as well as energy intakes, gut function, clinical outcomes, and how well nutritional variables predict length of hospital stay (LOS) in patients receiving ERAS protocols and conventional care.Design: We conducted a prospective cohort study in adult elective colorectal resection patients after conventional (n = 46) and ERAS (n = 69) care. Data collected included preoperative Malnutrition Screening Tool (MST) score, 3-d food records, postoperative nausea, LOS, and complications. Multivariable regression analysis assessed whether low protein intakes and the MST score were predictive of LOS.Results: Total protein intakes were significantly higher in the ERAS group due to the inclusion of oral nutrition supplements (conventional group: 0.33 g · kg-1 · d-1; ERAS group: 0.54 g · kg-1 · d-1; P < 0.02). This group difference in protein intake was maintained in a multivariable model that controlled for differences between baseline and surgical variables (P = 0.001). Oral food intake did not differ between the 2 groups. The ERAS group had shorter LOS (P = 0.049) and fewer total infectious complications (P = 0.01). Nausea was a predictor of protein intake. Nutrition variables were independent predictors of earlier discharge after potential confounders were controlled for. Each unit increase in preoperative MST score predicted longer LOSs of 2.5 d (95% CI: 1.5, 3.5 d; P < 0.001), and the consumption of ≥60% of protein requirements during the first 3 d of hospitalization was associated with a shorter LOS of 4.4 d (95% CI: -6.8, -2.0 d; P < 0.001).Conclusions: ERAS patients consumed more protein due to the inclusion of oral nutrition supplements. However, total protein intake remained inadequate to meet recommendations. Consumption of ≥60% protein needs after surgery and MST scores were independent predictors of LOS. This trial was registered at clinicaltrials.gov as NCT02940665.

Predictors of knowledge and practice of exclusive breastfeeding among health workers in Mwanza city, northwest Tanzania

BackgroundUniversal exclusive breastfeeding (EBF) for the first 6xa0months is estimated to reduce infant mortality by 13–15% (9 million) in resource poor countries. Although 97% of women initiate breastfeeding in Tanzania, exclusive breastfeeding for 6xa0months remains below 50%. Accurate knowledge and practical skills pertaining to exclusive breastfeeding among health workers is likely to improve breastfeeding rates. Our study reports the health workers’ knowledge and practice on EBF in Mwanza City, northwest of Tanzania.MethodsOne principal researcher and two research assistants conducted data collection from 11 June–6 July 2012. In total, 220 health care workers including: 64 clinicians (medical specialists, residents, registrars, assistant medical officers and clinical officers) and 156 nurses were interviewed using a structured knowledge questionnaire. Amongst 220 health workers, 106 were observed supporting Breastfeeding using a checklist. Logistic regression was used to determine factors associated with exclusive breastfeeding knowledge and desirable skills.ResultsAlmost half of the 220 health workers interviewed correctly described EBF as defined by the World Health Organization. Only 52 of 220 respondents had good knowledge. In the adjusted analysis, working at hospital facility level compared to dispensary (OR 2.1; 95% CI 1.1–4.0, p-valueu2009=u20090.032) and attending on job training (OR 2.7; 95% CI 1.2–6.1, p-valueu2009=u20090.015) were associated with better knowledge. In total, 38% of respondents had a desirable level of practical skills. Clinicians were more likely to have good practice (OR 3.6; 95% CI 1.2–10.8; p-valueu2009=u20090.020) than nurses. Most of the health workers had no training on EBF, and were not familiar with breastfeeding policy.ConclusionLess than 25% of healthcare workers surveyed had good knowledge of EBF. These findings identify the need for comprehensive training and mentoring of health workers on exclusive breastfeeding, making breastfeeding policies available and understood, along with supportive supervision and monitoring.

Individualized Postnatal Growth Trajectories for Preterm Infants

BACKGROUNDnGrowth of preterm infants is monitored using fetal charts despite individual trajectories being downshifted postnatally by adaptational processes. The study aims to compare different approaches to create individualized postnatal trajectories.nnnMETHODSnThree approaches to achieve growth similar to healthy term infants at 42+0/7 weeks postmenstrual age (PMA) on World Health Organization growth standards (WHOGS) (target weight) were tested by comparing trajectories obtained by: 1) following birth percentiles (Birth-Weight-Percentile Approach); 2) following percentiles achieved at day of life 21 (Postnatal-Percentile Approach); 3) using day-specific fetal median growth velocities starting at day of life 21 (Fetal-Median-Growth Approach [FMGA]). The primary outcome was delta weight (ΔW), defined as difference between target weight (WHOGS) at 42+0/7 weeks and weight predicted by trajectories. The secondary outcome was ΔW vs %fat mass in a cohort of 20 disease-free surviving very low-birth-weight infants.nnnRESULTSnBirth-Weight-Percentile and Postnatal-Percentile Approach showed high ΔW; FMGA alone reduced ΔW. Introducing a factor to FMGA to reflect the transition to extrauterine conditions (Growth-Velocity Approach [GVA]) minimized ΔW. GVA merged with target and best normalized for body composition related to ΔW.nnnCONCLUSIONSnGVA provides an evidence-based approach for individualized growth trajectories. GVA is based on physiologic data and that healthy preterm infants adjust their postnatal trajectory below their birth percentile. GVA may reflect a biologic principle because it matches consistently with WHOGS at 42+0/7 weeks for all preterm infants from 24 to 34 weeks. This concept could become a bedside tool to aid clinicians in monitoring growth, guiding nutrition, and minimizing chronic adult disease risks as a consequence of unguided, inappropriate growth.