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  • Compares the weight gain of infants in the early postpartum period (first 12 weeks of delivery) between newborns who were exclusively breastfed and those who were given mixed feeding. It was found that the rate of both weight gain and adiposity was a little bit higher among infants who were exclusively breastfed as compared to those who received mixed feeding.This is consistent with previous studies, although they compared exclusive breastfeeding to formula feeding instead. It is also found that exclusively breastfed infants had 1.3% higher percentage body fat compared to mixed feeding infants at 12 weeks postpartum. Exclusively breastfed infants weighed slightly more at 12 weeks postpartum compared to the mixed feeding infants. We would also like to highlight the need to examine further what happens to the percentage body fat at 6 months and 12 months postpartum as this is when the infants are expected to double and triple their birth weight respectively.
  • This is a publication derived from a cluster-randomised trial in the Republic of Belarus. Its aim was to compare between the breastfeeding promotion intervention (modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative) and the control infant feeding practices. They compared 1378 infants between those who were weaned in the first month and those who were breastfed for the full 12 months with either at least 3 months or at least 6 months of exclusive breastfeeding. The data was analysed according to intention-to-treat and accounted for within-cluster correlation. Mean birth weight was significantly higher in the experimental group by 1 month of age. Difference in weight gain between the 2 groups increased through the 3 months but declined slowly thereafter before disappearing by 12 months. This suggests that prolonged and exclusive breastfeeding has the potential in accelerating weight and length gain in the first few months without any detectable deficit by 12 months of age. They showed that the infants in their experimental group grew faster than those in their control group and backed their findings with statistics. This data was claimed by the team to be the first in humans based on a randomised experiment.

Mbp growth 201112_28092011 Mbp growth 201112_28092011 Presentation Transcript

  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    HKU MBBS Year 3
    Patient Care Project (Mother-Baby) Presentation
    Growth
    Groups 8b – 11
    UGLT 2, QMH
    8, October, 2011
    1
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Part 1Overview of Infant Growth
    Ivan Wong, Philip Lee, Denise So, Jennie Yick, Bernard Shum
  • Part 1. Overview of Infant Growth
    Definition of growth
    Phases of growth
    Factors affecting growth
    Allometric growth
    Measurement of growth
    Abnormal growth
    Failure to thrive
    Overweight
    3
  • Growth
    Growth: increase in the size of the body
    Development: increase in function of processes related to body and mind
    4
  • 5
    Phases of growth
    • Fetal
    • Infantile
    • Childhood
    • Pubertal
  • Factors affecting growth
    Prenatal
    Maternal factors (e.g. size of mother, maternal weight, BMI, toxic exposure, nutritional state, hemodynamic status and stress)
    Placental factors (e.g. size, microstructure, nutrient supply)
    Fetal factors (e.g. genetics, nutrient and hormone production)
    Postnatal
    Genetics (maternal and paternal)
    Nutritional factors
    Hormonal functions (e.g. thyroid, growth hormone)
    Prenatal condition
    Physical health (e.g. chronic illness)
    Mental health (e.g. profound chronic unhappiness  GH secretion↓)
    Socioeconomic factors
    6
  • 7
    Allometric growth
    • Many organs/parts show disproportionate growth
    • at birth the head is about 25% of the body's length
    • but at maturity it is about 12% (or less) of its length
    • The genetic basis of allometric growth involves differential timing of genes; therefore, it is a form of heterochrony
  • 8
    The WHO child growth standards
    (http://www.who.int/childgrowth/standards/)
    • Indicators:
    • Length/height
    • Weight
    • Body mass index
    • Head circumference
    • Arm circumference
    • Subscapular skinfold
    • Triceps skinfold
    • Motor development milestones
  • 9
    Correct technique matters
    Must be performed on a naked infant or a child dressed only in underclothing
    Occipitofrontal circumference is a measure of head and hence brain growth. The maximum of 3 measurements is used
  • 10
    Correct technique matters
  • Growth charts
    11
    Growth parameters should be plotted on charts
    Q. Will the standards be applicable to all children?
    A. The standards describe normal child growth under optimal environmental conditions and can be applied to all children everywhere, regardless of ethnicity, socioeconomic status and type of feeding.
    (http://www.who.int/childgrowth/standards/)
  • Interpretation of growth charts
    A single growth parameter should not be assessed in isolation from the other growth parameters
    A single observation is difficult to interpret unless there is marked discrepancy
    The further the parameter lies from the mean, the more likely it is pathological
    Serial measurements are used to show the pattern and determine the rate of growth
    12
  • Examples of abnormal growth (1)
    Failure to thrive
    a description (not a diagnosis) applied to children whose current weight or rate of weight gain is significantly below that of other children of similar age and sex
    Causes:
    Organic (<5%)
    Accompanied by abnormal symptoms or signs
    Non-organic (>95%), e.g.
    Inadequate availability of food
    Psychosocial deprivation
    Neglect or child abuse
    13
  • Examples of abnormal growth (1)
    Failure to thrive
    Investigations
    Most affected infants and toddlers do not require any investigations
    Management
    Multidisciplinary
    Paediatric dietician
    Clinical psychologist
    Social worker
    Nursery
    Carried out in primary care
    Increasing energy intake by dietary and behavioral modification and monitoring growth
    Hospital admission is usually only for severe cases
    14
  • Examples of abnormal growth (2)
    15
    Obesity
    Obesity in children and adolescents is defined as a BMI greater than the 95th percentile
    Increasing major health issue
    Predisposing children to a wide range of medical and psychological problems in childhood and adult life
    Especially type 2 diabetes mellitus and cardiovascular disease
  • Examples of abnormal growth (2)
    16
    Obesity
    Management
    Sustained changes in lifestyle, e.g. healthier eating, increased physical activity, and reduction in physical inactivity  difficult to achieve and even harder to maintain
    Cultural change in our society should be considered, e.g. removal of ‘tuck shops’ and vending machines with unhealthy food and drinks from schools
    Drug treatment and surgical intervention are only appropriate in a small number of children
  • 17
    Part 2 – Statistics from PCP-MB
  • Our Aim:
    Determine whether the growth of infants in HK is influenced by the following factors
    Mode of feeding
    Mode of delivery
    Gestational age at delivery
  • Why we chose these aspects for analysis:
    we chose these topics because:
    1. we believe feeding method and feeding as a whole will have major influence on postnatal growth
    2. Medicalization of pregnancy has led to change in the trend of method of delivery which may impact growth
    3. Assisted delivery method may influence the age of infants at delivery which can later affect postnatal growth
  • Summary of the data sample
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Part 2.1 Does Breast Feeding affect the initial growth rate of newborns?
    Cherlyle Chan, Jason Law, LEUNG Yuen Yee, LUI ShingTsun, Arthur Mak, PUK Kam Yan , Salvio Ng, Amanda Slocum, Jeffrey Tsang
  • 24
    Literature review
  • Literature review
    Fulhan J et al: Update on pediatric nutrition: Breastfeeding, infant nutrition, and growth.Curr Opin Pediatr. 2003 Jun;15(3):323-32.
    • Protein
    • Adequate for growth
    • Vitamins A and B6
    • Highly dependent on maternal stores
    • Sufficient in well-nourished populations
    • Vitamin D
    • Small amount in breast milk
    • Depend on exogenous sources of vitamin D or sunlight for bone health
  • Literature review
    Literature review
    Fulhan J et al: Update on pediatric nutrition: Breastfeeding, infant nutrition, and growth.Curr Opin Pediatr. 2003 Jun;15(3):323-32.
    • Calcium
    • Independent of mother’s diet
    • Fairly constant throughout lactation
    • Iron and Zinc
    • Dependent on:
    • Endogenous stores of infants
    • Amount received through diet
    • Iron must be received from complementary foods or additional supplements after stores diminish (after 6 months)
    • Level of maternal zinc stores is important
  • Literature review
    Anderson AK: Association between Infant Feeding and Early Postpartum Infant Body Composition: A Pilot Prospective Study. Int J Pediatr. 2009;2009:648091. Epub 2009 Mar 12.
    • Aim: To compare the weight gain of infants in the early postpartum period (first 12 weeks of delivery) between newborns who were exclusively breastfed and those who were given mixed feeding
    • Results: Rate of both weight gain and adiposity was a little bit higher among infants who were exclusively breastfed as compared to those who received mixed feeding
    • Consistent with previous studies which compared exclusive breastfeeding with formula feeding
    • Follow-up: further examine the change in percentage body fat at 6 months and 12 months postpartum
  • Literature review
    Kramer MS et al: Breastfeeding and Infant Growth: Biology or Bias?.Pediatrics. 2002 Aug;110(2 Pt 1):343-7.
    • Aim: To compare between the breastfeeding promotion intervention (modeled on the WHO/UNICEF Baby-Friendly Hospital Initiative) and the control infant feeding practices
    • Compared infants who were weaned in the first month with those who were breastfed for the full 12 months with either at least 3 months or at least 6 months of exclusive breastfeeding
    • Results:Mean birth weight was significantly higher in the experimental group by 1 month of age. Difference in weight gain increased through the 3 months but declined slowly thereafter before disappearing by 12 months
    • This suggests that prolonged and exclusive breastfeeding has the potential in accelerating weight and length gain in the first few months without any detectable deficit by 12 months of age.
  • Data Analysis
    Data Analysis
  • Data Analysis
    The weight of FEMALE babies against age
    Breast-fed female babies (blue) VSFormula-fed female babies (red)
    Implications:
    Growth rate of breast-fed female babies is higher than that of formula-fed.
    Thereis significant evidence in the beneficial effects of breast feeding over formula feeding on growth in female babies.
  • Data Analysis
    The weight of MALE babies against age
    Breast-fed male babies (blue) VSFormula-fed male babies (red)
    Implications:
    The growth rate of breast-fed male babies is similar to that of formula-fed.There is no significant evidence of the beneficial effects of breast feeding on growth in male babies.
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Part 2.2 Does the mode of delivery affect the initial growth rate of newborns?
    Keedon Wong, Becky Ma, Jonathan Chow, Ponie Lee, Kathy Lam, Ling Kong, Staccato Lau, Andrew Mak, Lee Kit Ming
  • 33
    Literature review
  • Literature Review
    Planned cesarean versus planned vaginal delivery at term: Comparison of newborn infant outcomes1
    Kolas et. al (2005) American Journal of Obstetrics and Gynecology
    There were no significant differences in the risks for low Apgar score and neurologic symptoms.
    Planned vaginal delivery versus elective caesarean section in singleton term breech presentation: a study of 1116 cases2.
    Golfier et. al (2001).European Journal of Obstetrics & Gynecology and Reproductive Biology
    C-section is better for infant health but worse for maternal health in breech presentation.
     
    Mode of Delivery and Asthma - Is There a Connection? 3
    Kero et. al (2002) Pediatric Research
    The register study showed the cumulative incidence of asthma at the age of seven to be significantly higher in children born by caesarean section (4.2%) than in those vaginally delivered (3.3%),
  • Data Analysis
    Data Analysis
  • Methodology
    Pool of Data
    Assisted Vaginal Delivery
    Natural Vaginal Delivery
    Caesarean
    Delivery
    Assisted Vaginal Delivery
    Natural Vaginal Delivery
    Caesarean
    Delivery
    Growth rate of:
    • Head circumference
    • Body Length
    • Body Weight
    Growth rate of:
    • Head circumference
    • Body Length
    • Body Weight
    Growth rate of:
    • Head circumference
    • Body Length
    • Body Weight
    Any Statistical Differences?
    Any Statistical Differences?
  • Methodology
    Growth Rate (GR)
    Variable DAY 0 – Variable NEXT EARLIEST DAY WITH DATA
    Duration in between (Gestational Weeks)
    Head Circumference DAY 0 – Head Circumference DAY 10
    Example
    Gestational Weeks in between (2)
  • Results
    GR of Body Weight
    t-test for equality of Means between ‘Assisted’ & ‘Natural Vaginal Delivery’
    t-test for equality of Means between ‘Caesarean’ & ‘Natural Vaginal Delivery’
    Difference in GR of Body Weight; p=0.585
    Difference in GR of Body Length; p=0.248
    Difference in GR of Head Circumference; p=0.558
    Difference in GR of Body Weight; p=0.877
    Difference in GR of Body Length; p=0.155
    Difference in GR of Head Circumference; p=0.730
    GR of Body Length
    Statistically Insignificant
    GR of Head Circumference
  • Discussion
    New Questions
    Literature
    Are there any confounding factors?
    Perhaps the parameters (head circumference/body weight/body length) might not be sensitive enough to document growth rate in this study?
    Equation for growth rate might not capture the real growth rate accurately?
    This is a pilot study with no other research data on the same set of parameters.
    7 studies further reviewed: compared the outcomes of vaginal delivery and cesarean section by:
    infant health, e.g. mortality rate, risk of respiratory morbidity 1-4,
    birth weight5-6,
    and growth-related hormone measurements7.
    None of these studies show direct
    relationship between modes of
    delivery and growth.
    Limitations
    Variability in the duration between data points used to measure GR
    Low sample size
    Assumed linear growth of infant
    Reporting & selection bias
    Future Study
    How does the mode of delivery affect growth hormones levels in newborns?
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Part 2.3 Does the gestational age at delivery affect the initial growth rate of newborns?
    Simon Chan, Tom Chow, Bernice Yu, Denise Cheng, Derek Ng, Eric Ng, Simon Yan, Cyrus Lai, Herriet Tsang
  • 41
    Literature review
  • Literature Review
    Growth of preterm infants
    Catch-up growth
    Gairdner, D., and Pearson, J. (1971)
    4 phases of growth usually observed:
    • Phase 1: immediate postnatal weight loss.
    • Phase 2: (half to 1week) Rate of growth is similar to that of the foetus of comparable gestational age.
    • Phase 3: growth rate accelerates, much exceeds that of the foetus.
    • Phase 4: continue in the same percentile.
  • 30 preterm white infants of AGA weight born <32 complete weeks of gestation were studied
    No significant correlations to suggest that insufficient early weight gain affected later patterns of weight.
    Literature: Phase 3 – Catch-up phase?
    Is term newborn body composition being achieved postnatally in preterm infants?
    Roggero et al (2009)
    Insufficient early weight gain in preterm babies andinfluence on weight at 12 months
    Davies D P and Kennedy J D, (1981)
    Preterm infants <30weeks gestation studied
    Weight, length and head circumference were smaller in the preterm group (no catch-up evident)
  • Assessment of Gestational Age
    Estimation from last menstrual period(LMP)
    Naegele’s rule : Add seven days and subtract three months from the LMP
  • Assessment of Gestational Age (2)
    Prenatal Ultrasonography
    Before visualization of the embryo
    30 + Gestational sac diameter (mm) = Gestational day
    After visualization
    - Crown – rump length
    - Biparietal diameter, Head circumference,
    Femur length, Abdominal circumference
  • Assessment of Gestational Age (3)
    New Ballard Score
    Determine GA through Neuromuscular and Physical assessment of a newborn
    Physical parameters: Skin, Lanugo, Plantar surface, Breast, Eye/Ear, Genitals (M/F)
    Neuromuscular parameters: Posture, Square window, Arm recoil, Popliteal angle, Scarf sign, Heel to ear
  • ……… In 530 infants, gestational age by last menstrual period was confirmed by agreement within 2 weeks with gestational age by prenatal ultrasonography (C-GLMP). For these infants, correlation between gestational age by NBS and C-GLMP was 0.97. Mean differences between gestational age by NBS and C-GLMP were 0.32 +/- 1.58 weeks and 0.15 +/- 1.46 weeks among the extremely premature infants (less than 26 weeks) and among the total population, respectively. ………
  • Data Analysis
    Data Analysis
  • Data processing
  • Definition of Preterm Birth
    From WHO:
    Defined as childbirth occurring at less than 37 completed weeksor 259 days of gestation
    Major determinant of neonatal mortality and morbidity
    Has long-term adverse consequences for health
  • Assumptions in data analysis
  • Is growth rate associated with gestational age at birth?
    Conclusion: The lines of best fit shows that in general, there is a positive linear correlation between gestational age at delivery and rate of postnatal growth. However, R2 shows that the strength of association is (very) weak.
  • Closer look at such correlation
    This part of the table shows that the three parameters have significant and strong correlation with each other. Reflecting that there are agreement in these measurements.
    The table shows that the correlation between the three growth rate parameters with gestational age at birth are all statistically non-significant. Thus the small positive correlation may be spurious.
  • Even if there is no association, do preemies grow quicker?
    (catch up growth)
    Conclusion
    This shows that the rate of gain in weight, length, and head circumference are similar between preterm and full term infants.
  • Conclusion
    The difference in rate of gain in weight, length, head circumference are not significant
  • Looking deeper into catch up growth
    For males, the rate of growth for full term and preterm infants are similar.
    For female however , there appears to be significant difference.
    Significant since the 95% CI do not overlap
    This is strange !?
  • Explanation
    Since there is only 1 preterm female in the sample group
    Variance cannot be estimated (therefore not drawn on the graph) and has to be assumed equal in T test.
    T test shows that there is no significant difference between female premies and full-tern infants rate of growth
  • Summary of results
    Data analysis shows that there is no significant association between gestational age of delivery and postnatal rate of growth.
    Data shows that there is no significant difference in rate of growth between preterm and full term infants. -- No catchup growth observed.
  • Discussion & Limitations
    Disccusion
    It is contra-intuitive
    growth rate is higher in infants born at higher gestational age.
    Despite the correlation being very weak and statistically insignificant.
    Phase 3 - Catch up growth was not demonstrated.
    due to our growth rate estimates only reflecting the initial rate of growth during the earliest post-natal period.
    These estimates may be reflecting phase 2 growth so the significant acceleration has not been captured by the data.
    Limitations
    • Although significant difference in rate of growth was not apparent between full and pre-term, this may be due to:
    • Insufficient sample size, not enough preterm infants (particularly female), no extreme of preterm.
    • Growth recording was not implemented stringently.
    • Our assumptions that genetic factors, calories intake, living environment or health issues are the same for all infants may not be true.
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Part 3Conclusion & improvement
    Overall
  • Conclusion
    1.) Breast Feeding
    2.) Gestational age
    3.) Mode of delivery
    No Significant Correlation between growth rate
    Why?!
  • 64
    Conclusion
    Due to
    1.) Small Sample size (<70 participants)
    2.) Reporting Bias (too many missing data)
    ~Further Improvement of the research
    1.) Using Data along with previous year PCP-MB to compare to increase sample size or to compare
    2.) Trying hard to ask every pair of PCP-MB to gather as many relevant information as much as possible
  • Reference (1)
    1. Golfier F, Vaudoyer F, Ecochard R, et al: Planned vaginal delivery versus elective caesarean section in singleton term breech presentation: a study of 1116 cases.Eur J ObstetGynecolReprod Biol. 2001;98:186-92.
    2. Kero J, Gissler M, Gronlund MM, et al: Mode of delivery and asthma -- is there a connection? Pediatr Res. 2002;52:6-11.
    3. Kolas T, Saugstad OD, Daltveit AK, et al: Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. Am J Obstet Gynecol. 2006;195:1538-43.
    4. Morrison JJ, RennieJM,Milton PJ: Neonatal respiratory morbidity and mode of delivery at term: influence of timing of elective caesarean section. Br J ObstetGynaecol. 1995;102:101-6.
    5. Lee KS, Khoshnood B, Sriram S, et al: Relationship of cesarean delivery to lower birth weight-specific neonatal mortality in singleton breech infants in the United States.Obstet Gynecol. 1998;92:769-74.
    6. Naylor CD, Sermer M, Chen E, et al: Cesarean delivery in relation to birth weight and gestational glucose tolerance: pathophysiology or practice style? Toronto Trihospital Gestational Diabetes Investigators.Jama. 1996;275:1165-70.
    .
  • 66
    Reference (2)
    7.Bird JA, Spencer JA, Mould T, et al: Endocrine and metabolic adaptation following caesarean section or vaginal delivery. Arch DisChild Fetal Neonatal Ed. 1996;74:F132-4.
    8. J Cockerill, S Uthaya, C J Doré, and N Modi: Accelerated postnatal head growth follows preterm birth.ArchDis Child Fetal Neonatal Ed. 2006 May;91(3):F184-7. Epub 2006 Jan 12.
    9. Luciana Friedrich, Paulo M. C. Pitrez, Renato T. Stein, Marcelo Goldani, Robert Tepper, and Marcus H. Jones: Growth Rate of Lung Function in Healthy Preterm Infants. Am J RespirCrit Care Med. 2007 Dec 15;176(12):1269-73. Epub 2007 Sep 20.
    10. Paola Roggero , Maria LorellaGiannì, Orsola Amato et al: Is term newborn body composition being achieved postnatally in preterm infants? Early Hum Dev. 2009 Jun;85(6):349-52. Epub 2009 Jan 21.
    11. Gairdner, D., and Pearson, J.: A Growth Chart for Premature and other Infants. Arch Dis Child. 1971 Dec;46(250):783-7.
    12. Davies D P and Kennedy J D: Insufficient early weight gain in preterm babies and influence on weight at 12 months. Arch Dis Child. 1986 Jan;61(1):96
  • UNIVERSITY OF HONG KONG
    LI KA SHING FACULTY OF MEDICINE
    Q&A
    THANK YOU