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Postnatal growth failure and its prevention
 

Postnatal growth failure and its prevention

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International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

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    Postnatal growth failure and its prevention Postnatal growth failure and its prevention Presentation Transcript

    • Postnatal growth failure and its prevention Ekhard E. Ziegler, M.D. Fomon Infant Nutrition Unit University of Iowa
    • OutlineGrowth failureNutritional support - GeneralEarly enteral nutrition = Gut primingTransition feedingLate enteral nutritionPost-discharge nutrition
    • 1995; 26-29 weeks gestation
    • NICHD Growth Observational Study 2000 Extrauterine 50th 10th Growth Restriction 1500 Weight (grams) 1000 Intrauterine growth (50th and 10th percentile) 24-25 weeks 26-27 weeks 28-29 weeks 500 24 28 32 36Ehrenkranz RA, et al. Pediatrics Postmenstrual Age (weeks) 41999;104:280-9.
    • Postnatal growth failure Consequences
    • McCance and Widdowson
    • Postnatal growth failure Consequences – human studies• Multiple studies show associations of slow growth with poor neurocognitive development and with ROP• All studies are observational with the exception of the trial by Lucas and coworkers
    • Postnatal growth failure and neurocognitive outcome 8-20-12 Birth year Age at FUWeisglas-Kuperus 2009 1983 19 yrHack 1991 1977-79 8 yrLucas 1998 1982-84 8 yrKan et al. 2008 1991-92 8 yrClaas 2011 1996-2005 5.5 yrFranz 2009 1996-99 5 yrLatal-Hajnal 2003 1983-94* 2 yrEhrenkranz 2006 1994-95 2 yrBelfort 2011 2001-06 2yrRozé 2012 2003-08 2 yrGeorgieff 1985 1983 1 yr
    • Postnatal growth failure and neurocognitive outcome 8/20/12 Birth year Age at FUHack 1991 1977-79 8 yrLucas 1998 1982-84 8 yrWeisglas-Kuperus 2009 1983 19 yrLatal-Hajnal 2003 1983-94 2 yrGeorgieff 1985 1983 1 yrKan et al. 2008 1991-92 8 yrEhrenkranz 2006 1994-95 2 yrFranz 2009 1996-99 5 yrClaas 2011 1996-05 5.5 yrBelfort 2011 2001-06 2yrRozé 2012 2003-08 2 yr
    • Slower vs faster growth Follow-up at 7.5-8 years of age Neurocognitive development Feeding Faster Slower p growth growthAverage IQ 99.4 94.8 0.05% with IQ <85 14 31 0.02% with CP 1.5 12 0.03% with IQ <85 and/or CP 15 38 0.003Lucas et al., BMJ 317:1481 (1998)
    • VLBW infants (<1250 g), N= 219, z-scores for weightFrom Latal-Hajnal et al., J Pediat 2003;143:163
    • Extrauterine growth failure B. Latal-Hajnal et al., J Pediat 2003;143:163-70 MDI at age 2 yrAGA, no growth failure 101.7SGA, catch-up 98.2AGA, growth failure 94.9SGA, no catch-up 94.7
    • Growth failure and neuro- developmental outcome Ehrenkranz et al., Pediatrics 2006;117:1253Setting: NICHD Neonatal NetworkSubjects: Infants born September 1994 and August 1995 with birth weight 500–1000 g (N=600 discharged)Outcomes: 1. Follow-up at 18-22 months (MDI, PDI, neurologic assessment (N=495) 2. Weight gain from regained birth weight to discharge
    • Growth failure and neuro-developmentaloutcomeEhrenkranz et al., Pediatrics 2006;117:1253 Q1 Q2 Q3 Q4 Weight gain (g/kg/d) 12.0 15.6 17.8 21.2 Head circ. gain (cm/week) 0.77 0.90 0.96 1.07 Cerebral palsy (%) 21 13 13 6 MDI <70 (%) 39 37 34 21 PDI <70 (%) 35 32 18 14 Neurodev. impairm. (%) 55 49 41 29
    • 25 20 15% CP 10 5 0 Q1 Q2 Q3 Q4 Weight Gain Data of Ehrenkranz et al., Pediatrics 2006; 117:1253
    • Growth 1 Week to Term and 18-month Bayley scoresBelfort et al., Pediatrics 2011;128:e899-e906(Data from Australian DINO study [high-dose DHA] conducted by Makrides & Gibson 2001-2005; infants <33 wks) Points per 1 z-score increment MDI PDIAll infants 2.4 (0.8 - 3.9) 2.7 ( 1.2 - 4.2)<1250 g 4.7 (2.1 - 7.4) 5.9 ( 3.2 - 8.6)>1250 g 1.0 (-0.8 - 2.8) 0.8 (-0.9 - 2.5)AGA 1.6 (0.0 - 3.3) 1.9 (0.3 - 3.5)SGA 11.7 (4.5 - 18.8) 11.2 (1.8 - 20.7)
    • Does slow growth have positive effects?Slow growth may lead to more favorable cardiovascular health outcomesIt definitely leads to bad neurocognitive outcomesTherefore, slow growth is unequivocally worse than faster growthDisadvantages clearly outweigh advantages
    • Slow weight gain and ROPThe relative risk of Severe ROP for each10 g/day lowering of weight gain was 1.15 (CI 1.06-1.24)Binenbaum et al., Pediatrics 2011;127:e607-14ELBW Infants enrolled in Need of Transfusion study2000-2003
    • Early growth and risk of ROP1. Wallace et al., J AAPOS 2000;4:343-7 Threshold ROP was associated with GA at birth, weight gain, volume of transfused RBC, sepsis2. Allegaert et al., J AAPOS 2003;7:34-37 IUGR and postnatal weight gain are risk factors for threshold ROP
    • Postnatal growth failureQ: How does growth failure cause poor neurocognitive development, ROP?A: It does notQ: Then how is the association explained?A: Both have the same cause – inadequate nutrition
    • Inadequate nutrition Growth failureInadequate nutrition Impaired neurocognitive development
    • Postnatal growth failure Cause(s)
    • Nutrient requirements
    • Protein and energy requirements of preterm infants (parenteral)Body weight (g) Protein Energy Prot/Energy (g/kg/d) (kcal/kg/d) (g/100 kcal) 500- 700 3.5 89 3.9 700- 900 3.5 92 3.8 900-1200 3.5 101 3.51200-1500 3.4 108 3.11500-1800 3.2 109 2.91800-2200 3.0 111 2.7
    • Protein and energy requirements of preterm infants (enteral)Body weight Protein Energy Prot/Energy (g) (g/kg/d) (kcal/kg/d) (g/100 kcal) 500-700 4.0 105 3.8 700-900 4.0 108 3.7 900-1200 4.0 119 3.41200-1500 3.9 125 3.11500-1800 3.6 128 2.81800-2200 3.4 131 2.6
    • Recommended Intakes ESPGHAN 2010* Protein g/kg/d g/100 kcalWeight <1000g 4.0-4.5 3.6-4.1Weight 1000-1800 g 3.5-4.0 3.2-3.6 Energy 110-135 kcal/kg/d*J Pediat Gast Nut 2010;50:85-91
    • Protein and energy intakes (per kg body weight) Year N BW Age Age (GA) 4 weeks 6 weeks g Energy Protein Energy ProteinSimmer Aus 92-94 90 <2078 109 2.5 114 2.7Carlson US 95 39 <1300 97 2.6 103 2.7Olsen US 94-96 564 <1500 102 2.5 - -Radmacher US 97-00 220 <1000 98 2.8 108 2.9Regan NZ 98 37 <32 wk 108 2.3 149 3.0Embleton UK 99 38 <1750 121 3.1 - -Carlson US 01 46 <1000 107 3.1 116 3.2Cormack NZ 03-04 34 <1790 140 2.8 - -Carlson US 06 68 <1000 110 3.3 118 3.4
    • Postnatal growth failure CauseQ: How do we know that inadequate protein intakes is causing growth failure?A: 1. Protein is limiting for growth 2. Calories are not limiting if >100 kcal/kg 3. Protein intakes are generally less than required for growth similar to the fetus
    • Postnatal growth failure Cause• All studies reporting nutrient intakes show inadequate intakes• Inadequate intakes are linked to poor neurocognitive outcome
    • Postnatal growth failure Definition• Falling off of fetal growth trajectory• AGA at birth, SGA at 36 weeks PMA (for comparative purposes)
    • Can we define a degree of growthfailure that is free of adverse effects? No
    • Postnatal growth failure Do we still have it?
    • Postnatal growth failure Is alive and well
    • Henriksen et al. Br J Nutr 2009;102;1179-86 VLBW infants born 2003-2005
    • ELGAN study, infants born 2002-2004Martin C R et al. Pediatrics 2009;124:649-657
    • FIGURE 3 Senterre & Rigo, JPGN 2011;53:536-542 Group D: GA=27.0±1.1 wks 2
    • Prevention of postnatal growth failure
    • Postnatal growth failurePrevention begins at birth andcomes through good nutrition
    • Objective of nutritional support To protect the brain
    • Phases of nutritional supportPhase 1: - Parenteral nutrition - Gut primingPhase 2: Transition feeding: Enteral phased in, parenteral phasedoutPhase 3: Enteral (late)Phase 4: Post-discharge
    • Early nutrition period
    • Phases of nutritional supportPhase 1: Parenteral
    • Parenteral nutrition of premature infantsQ: Why parenteral nutrition?A: Because immaturity of the gut precludes enteral nutition in adequate amountsQ: Who needs parenteral nutrition?A: All infants weighing <1800 g (optional for infants >1800 g)
    • Parenteral nutrition Recent historyBefore 1999: - Glucose only from birth - Amino acids started on Day 3-4, low dose, gradually increased - Lipids Day 4-5, low dose, slowly increasedAbout 1999: Amino acids Day 1-2, still low doseAbout 2002: Amino acids at time zero, 1.5 g/kg/d2005: te Baake et al., time zero at 2.6 g/kg/d2010: Transition to time zero nearly complete, dose 3.0 to 3.5 g/kg/d
    • Data of B E Stephens et al., Pediatrics 2009;123:1337 124 ELBW infants born in 2000 and 2001
    • Data from BE Stephens et al., Pediatrics 2009;123:1337
    • Data of B E Stephens et al., Pediatrics 2009;123:1337 124 ELBW infants born in 2000 and 2001
    • Data from BE Stephens et al., Pediatrics 2009;123:1337
    • Parenteral nutrition of premature infants Principles• Start AA at birth, lipids within 24 hrs• Push GIR• Keep as short as possible but as long as necessary
    • Parenteral nutrition of the premature infant Starter NVN at Iowa• First intravenous fluid• (30 -) 60 ml/kg/d• 10% glucose, 5% amino acids,• Na 10 mEq/L (as phosphate)• Ca 20 mEq/L (as gluconate)• Mg 4 mEq/L• No potassium, trace elements, vitamins3/12/10
    • Parenteral nutrition Full NVN as soon as possible• 10% Glucose, increase GIR q 12 hrs• 3.5 g/kg/d of amino acids (no need to go to 4 g/kg/d)• Full electrolytes, minerals, trace minerals, vitamins• Dont look at BUN
    • From: Ridout et al., J Perinatol. 2005;25:130
    • Parenteral nutrition of premature infants Amino acids• No need to go higher than 3.5 g/kg/day• No need (excuse) for going below 3.5 g/ kg/day Glucose• Push GIR
    • Parenteral nutrition Lipids• Start within 24 hrs of birth• Primary reason is DHA• Dose 1 g/kg/d• Give slowly• No need to monitor triglycerides
    • IntralipidSoybean oil 20 g/dlEgg yolk phospholipids 1.2 g/dlFatty acids Linoleic acid 50 % bad Linolenic acid 7% Arachidonic 0.3 % DHA 0.34 % goodAlpha-tocopherol 1.45 mg/dl
    • Parenteral nutrition of VLBW infants Good practice 2011• Start amino acids within 2 hrs of birth• Start with 3 g/kg/d (minimum of 1.5 g/kg/dkg/d) and increase to maximum 3.5 g/kg/d• Start lipids within 24 hrs of birth at 1.0 g/kg/d and increase to 2.0 g/kg/d• Start glucose at 4 mg/kg/min and increase daily by 1-2 mg/kg/min if maintaining euglycemia• Don’t stop TPN until enteral feeds are >90% of full
    • The importance of parenteral nutrition It protects the brain
    • Good nutrition does not save lives It saves brains
    • Fenton chart