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Growth charts in Neonates- Preterm and term


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Growth charts in Newborn, Preterm and term neonates. All historically used charts in NICU are discussed here.
Presented by Dr Sujit, in Sir Ganga Ram Hospital

Published in: Health & Medicine

Growth charts in Neonates- Preterm and term

  1. 1. Growth Charts Dr Sujit K. Shrestha
  2. 2. Preview History Definition Importance of Growth Monitoring Types of Growth charts Timing of Growth Monitoring On going Studies and Projects Software available.
  3. 3. History - Innovation • The idea of plotting a child’s body measurements on a chart to illustrate their pattern of growth first - Count Philibert de Montbeillard (1720-1785) • George Buffon (1707-1788)  published the chart in his Histoire Naturelle, thus producing the first height growth curve (Tanner 1962). George Buffon, France
  4. 4. 20th Century Effort to Standardize • Until the late 1970s, clinicians used various growth charts to assess child growth. • No uniform measurement methods • Efforts were made to create a standard growth chart that could be used for all population.
  5. 5. Growth a net increase in size or mass of tissues as a result of either multiplication of cells or increase in intracellular substance. - hypertrophy and/or hyperplasia of cells • Fetal growth  by fetal, placental and maternal factors. • Under normal environment fetus grows as per its inherent growth potential to an appropriate size newborn. • Post-natal growth  genetic potential and various internal and external factors. • Therefore growth monitoring important to detect deviation from normal
  6. 6. Definition: Growth Chart • A growth chart is a graphic design of a growth reference presented as a visual display for clinical use. • comprise growth curves which display both the size of the newborn at a series of ages, and at the same time their growth rate or growth velocity over time, based on the slope of the curve. • the charts have become an important tool in child health screening and pediatric clinical workup.
  7. 7. Growth Reference • A statistical summary of anthropometry in a reference group of children • usually presented as the frequency distribution at different ages. • representative of some geographic region at a particular time, e.g. Great Britain in 1990 • involves the mean and SD or alternatively the median and selected centiles, conditioned (usually) on age and sex. • it describe how children grow • To establish whether or not their measurements are typical of the reference group.
  8. 8. Growth Standard • A growth standard is essentially the same as a growth reference except that the underlying reference sample is selected on health grounds. • represents a healthy pattern of growth • the standard shows how children ought to grow rather than how they do grow. • Eg WHO MGRS Growth standards
  9. 9. Difference Reference charts Standard charts Simply describes the growth of a population without taking into the consideration the health of the population. Provides guidance on how a child should grow not just how child is growing. Based on cross sectional data, relatively easy to acquire large sample size Based on prospective and longitudinal monitoring of healthy growth; and diffi cult to acquire large sample size. Increase in incidence of childhood obesity means future descriptive charts will enable more children to be classified as normal even though overweight and obese. Have the potential to diagnose over weight and obesity early which can help in early intervention. Have the potential to over diagnose under nutrition which in turn can lead to overfeeding Have the potential to avoid over diagnosis of under nutrition.
  10. 10. Centile and Z score The centile for an individual indicates his or her size, be it height, weight or body mass index etc. The centile indicates the distance they have travelled along the growth road up to that age. The growth chart quantifies size/distance in terms of the centile. Z scrores-. For population-based assessment—including surveys and nutritional surveillance—the Z-score is widely recognized as the best system for analysis and presentation of anthropometric data because of its advantages compared to the other methods.
  11. 11. Z-score (or SD-score) = (observed value - median value of the reference population) / standard deviation value of reference population Interpreting the results in terms of Z-scores has several advantages: • same statistical relation to the distribution of the reference around the mean at all ages, which makes results comparable across ages groups and indicators. • Z-scores are also sex-independent, thus permitting the evaluation of children's growth status by combining sex and age groups. • These characteristics of Z-scores allow further computation of summary statistics such as means, standard deviations, and standard error to classify a population's growth status.
  12. 12. • Furthermore, individuals whose growth curve tracks along the centiles over time are growing at average velocity, while if the curve crosses centiles up or down the individual is growing faster or slower than average – centile crossing is a measure of relative velocity. • A growth chart visualizes growth velocity, but it does not quantify it – centile crossing is uncalibrated.
  13. 13. Growth velocity • With exponential growth, the logarithm of weight results in a linear function whose slope is equal to the growth velocity. The growth velocity (GV) between two different days, in terms of g/kg/day, can be determined with the following equation: • • where W1 is the weight (in grams) at the first day (D1) and W2 is the weight at the second day (D2). When exponential growth is considered-
  14. 14. Anthropometric measurements Length measurement Instrument- Infantometer
  15. 15. Measurement of Weight Instrument used- • Measurement of weight in this population should be taken on a scale that has been properly calibrated. • The infant should be weighed without clothing or diaper.
  16. 16. Head circumference • flexible tape • measure at the maximum diameter through the supraorbital ridge to the occiput. • The value should be reported to the nearest 0.01 cm
  17. 17. Growth Charts: Intrauterine Growth Charts Post-natal growth charts Battaglia and Lubchenco 1967 Usher and Maclean 1969 Babson and Benda 1976 Fenton 2003 Fenton 2013 Berry et al 1997 Ehrenkranz 1999 CDC 2000 WHO 2006 Intergrowth 21st 2014
  18. 18. Intrauterine Growth Charts • Over dozen published world wide • Only few includes weight, length, and HC • USA (Lubchenco 1966) • Canada (Usher & McLean 1969) • South Wales (Beeby 1996) • Sweden (Niklasson 1991) • South Wales/Sweden/Canada (Fenton 2003) • USA (Olsen 2010)
  19. 19. Handbook of Growth and Growth Monitoring in Health and Disease edited by Victor R. Preedy
  20. 20. Limitations of Growth charts
  21. 21. Limitation of available Intra Uterine growth charts • Small sample size • Not being gender specific • Used LMP as mean of Gestation age- 40% error caused by maternal factors • Do not describe longitudinal fetal growth. • Preterm infant is inherently different from fetus, so concerns about using IU charts as standards.
  22. 22. Importance of Growth monitoring specially in Preterm infants • During Hospital stay • Rapid gain- Fluid overload, catch-up • Low gain- inadequate nutrition, illnesses • Neurodevelopmental effects • Standard formula vs Preterm enriched formula observation • Erenkranz’s observation • Metabolic effect • Overweight , obesity • Metabolic syndrome
  23. 23. Lubchenco 1967 Study Multicenter, Retrospective study. Population Full-Term and Premature Infant Nurseries from July, 1948, to January, 1961 Size- 5635 Low socio-economic status White and Hispanic Centre Colorado General Hospital ,USA High Altitude Duration Between August 31, 1994 and August 9, 1995 26-42 weeks POG Measurements Body weight, length, head circumference, and weight-length ratio- Ponderal Index. Data type Cross Sectional
  24. 24. Lubchenco Benefits • Used Ponderal Index, a new parameter in charts • A better accepted chart than previous models • In conjunction with intrauterine weight charts, permit the identification of infants with unusual intrauterine growth patterns. • aid in the design of future research. Drawbacks Charts of intrauterine growth in length, HC , weight, and weight-length ratio are only approximate definitions of the group pattern of fetal growth with gestational age. Population based on only one country and of high altitude. Advice
  25. 25. Pediatrics. 1999 Aug;104(2 Pt 1):280-9. Longitudinal growth of hospitalized very low birth weight infants. Ehrenkranz RA1, Younes N, Lemons JA, Fanaroff AA,
  26. 26. Ehrenkranz 1999 Study Large, multicenter, prospective cohort study. Population 1660 infants with birth weights between 501 to 1500 g admitted by 24 hours of age, included if they survived >7 days (168 hours) and were free of major congenital anomalies. Centre 12 NICHHD Neonatal Research Network centers, USA Duration Between August 31, 1994 and August 9, 1995 Measurements Body weight, length, head circumference, and MAC Endpoint discharge, transfer, death, 120 days, or body weight of 2000 g Data type Longitudinal data
  27. 27. Erenkranz Benefits • These growth curves  better understand postnatal growth • help identify infants developing illnesses affecting growth, • aid in the design of future research. Drawbacks Cannot be taken as optimal. Small Sample Size Single Population- so cannot be used for world population. It is limited by the lack of data describing daily caloric and nutritional intake, therefore, growth could not be correlated with nutritional intake Advice Further RCTs on factors affecting postnatal growth- Calorie Pediatrics. 1999 Aug;104(2 Pt 1):280-9. Longitudinal growth of hospitalized very low birth weight infants. Ehrenkranz RA1, Younes N, Lemons JA, Fanaroff AA,
  28. 28. Babson and Benda chart • The growth chart by Babson and Benda (1976) shows means and standard deviations for birth weight, head circumference, and length from a gestational age of 26 weeks to 1 year of age. • For the newborns, Babson obtained data from mostly Caucasian infants born in Portland, Oregon, for the years from 1959 through 1966. • 39,743 infants with gestational ages from 27 to 44 weeks, including 3381 infants with gestational ages from 27 to 37 weeks were included in the study. • The gestational age was based on the LMP. • Mean and standard deviation for 3 parameters were measured from the chart and were converted into percentiles.
  29. 29. Babson and Benda • Limitations- • X axis begins at 26 weeks gestation- limits plotting younger preterms • Y axis has 500gm interval increments-Precise plotting difficult • Small sample size with only 45 babies of 30 weeks or lesser gestation. • 15 years old at time of creating charts and now >50 years old
  30. 30. Fenton 2003 Study Meta-analysis of Studies Population The Newborn parameters were based on a. Birth weight- Kramer et al 2001 . USG was used in estimating Gestation age, CDC b. Length and head circumference- Niklasson and Beeby. Gestation- LMP and obstetric assessment. Gestation age between 22 and 50 weeks. Centre Calgary,Canada. Duration 1980 to 2002 Measurements Weight, length and head circumference Data type Cross sectional data predominantly
  31. 31. FENTO N Benefits 1. This new fetal-infant chart- updated Babson type 2. This chart will allow a comparison for preterm infants as young as 22 weeks of gestation first with intrauterine and then with post term references and it can replace the one developed by Babson which has been used in neonatal intensive care for over 25 years. 3. The larger sample sizes and more accurate gestational age assignments used here may provide better confidence in the extreme percentiles. 4. It could be used for the assessment of size for gestational age for infants smaller than 2 kilograms. 5. Shows 3, 10, 25, 50, 90 and 97 th Percentiles
  32. 32. Disadvantages: 1. Initial parts of the curves are based on the size of fetuses at birth, which do not show the change in weight that occurs after birth. 2. This is followed by curves based on the growth of term infants who have not had the growth depressing effect of prematurity. 3. Predominantly data were cross sectional.- Longitudinal postnatal growth chart- show the pattern of initial weight loss after birth followed by subsequent growth of a sample of preterm infants.
  33. 33. Disadvantages: 4. Not based on the growth standard for preterm infants, that is, on fetal growth. Therefore they do not show an infant’s growth velocity or catch-up in growth relative to the fetus or the term infant. 5. Further, the curves on a longitudinal growth chart are highly influenced by the medical and nutritional care of the sample infants; growth patterns may change with innovations in medical and nutritional care 6. Like with all metanalysis , heterogenesity of data sources is a set back.
  34. 34. WHO MCGS 2006 Study Recent population based surveys Population The 2006 WHO growth curves for children are based on data from the WHO MGRS, a study conducted in six sites: Pelotas, Brazil; Accra, Ghana; Delhi, India; Oslo, Norway; Muscat, Oman; and Davis, California. Centre Multi-centric Duration 1997-2003 Measurements weight, length and head circumference Data type Longitudinal data
  35. 35. Continued Benefits 1. Children from socioeconomic status that does not constrain growth of the child* 2. Six Countries from different continents including both developed and developing countries. 3. Based on population of breast fed babies. The international infant feeding recommendations in effect at the time of the study included exclusive breastfeeding for at least 4 months (although predominantly breastfed infants were also included in the study)# 4. The WHO growth curves for children aged <24 months were based on the longitudinal component of MGRS, in which cohorts of newborns were measured from birth through age 23 months. Longitudinal data were collected at birth, 1 week, and every 2 weeks for the fi rst 2 months after birth, monthly through age 12 months, and bimonthly from age 14 to 24 months
  36. 36. Continued Benefits 15. The WHO growth curves for children aged 24-59 months were based on the cross-sectional component MGRS, in which groups of children at specifi c ages were measured at a specifi c point in time. The crosssectional data represented 6,669 children. 6. Data were collected in the same communities as those used to create the curves for children aged <24 months, typically just after completion of the longitudinal study. 7. Other than the infant feeding criteria, the inclusion criteria used for the cross-sectional data collection for ages <24 months and 24-59 months were the same. 8. To eliminate the effect of overweight children on the weight distributions in the WHO curves for children aged 24-59 months, weight measurements of >2 standard deviations above the study median were excluded; a total of 226 (2.7%) weight measurements were excluded.
  37. 37. Disadvantages: - Does not address Growth of Preterm infants.
  38. 38. Fenton 2013 Study Metanalysis of studies Population Large preterm birth sample size of 4 million infants Data from developed countries including Germany, Italy, United States, Australia, Scotland and Canada Centre Alberta, Canada. Duration 1991 to 2007 Measurements of weight, length and head circumference Data type Cross sectional data for Preterm infants
  39. 39. Continued Benefits 1. Based on the recommended growth goal for preterm infants: The fetus and the term infant 2. Girl and boy specific charts 3. Equivalent to the WHO growth charts at 50 weeks gestational age (10 weeks post term age). 4. Large Sample size of 4 million, with large preterm population. 5. More recent Data ( 1991-2007)
  40. 40. FENTON Benefits 1. Data from several Developed nations- can be used for both developing and developed. 2. Curves are consistent with the data to 36 weeks, thus can be used to assign size for gestational age up to and including 36 weeks. 3. Chart is designed to enable plotting as infants are measured, not as completed weeks. The x axis adjusted for this chart so that infant size data can be plotted without age adjustment
  41. 41. Disadvantages: 1. These growth charts are growth references and are not a growth standard 2. Ideal growth pattern of preterm remains undefined as charts were based on fetal growth and term babies.
  42. 42. Intergrowth 21st Chart: For the first time (panel), international standards for newborn size for each gestational age based on data from its NCSS subpopulation, which conformed at population and individual levels to the prescriptive approach used in the WHO MGRS. 1. These new standards - conceptual and practical link to WHO Child Growth Standards, which have been adopted by more than 125 countries worldwide. 2. Gestation age based on USG 3. Included 20,486 eligible women between May 14, 2009, and Aug 2, 2013. 4. Bridges gaps in clinical and population assessments for fetuses, neonatal babies, and infants through provision of similar instruments to monitor child growth seamlessly from early pregnancy to age 5 years and to screen for stunting and wasting.
  43. 43. 5 Studies are included in the Project • Fetal Longitudinal Growth Study - a multicentric, population- based assessment of fetal growth in eight countries. • USG was taken for fetal anthropometric measurements prospectively from 14+0 weeks gestation until birth in a cohort of women. women had a reliable estimate of gestational age confirmed by USG measurement of fetal crown–rump length in the first trimester. • The five primary ultrasound measures were obtained every 5 weeks (within 1 week either side) from 14 weeks to 42 weeks of gestation. • The best fitting curves for the five measures were selected using second-degree fractional polynomials and further modelled in a multilevel framework to account for the longitudinal design of the study.
  44. 44. • A total 4607 eligible women were included. • A cohort of women with adequate nutrition and health status with less risk of intrauterine growth restriction were selected. • All women had reliable estimate of gestational age confirmed by USG. A 3rd, 5th 10th, 50th, 90th, 95th and 97th centile curves according to gestational age for these ultrasound measures were obtained, representing the international standards for fetal growth . • These international fetal growth standards for the clinical interpretation of routinely taken ultrasound measurements and for comparisons across populations.
  45. 45. PPFS and NCSS • For Preterm Postnatal Follow-up Study, all preterm newborns of more than 26 weeks and less than 37 weeks were followed post-delivery for evaluation of postnatal growth. All preterms from FLGS who met criteria of healthy or stable preterm were included. • The Newborn Cross-Sectional Study, a component of intergrowth-21st project, weight, length, and head circumference in all newborn infants were measured, in addition to the data collected prospectively for pregnancy and the perinatal period. Newborn anthropometric measures were obtained within 12 h of birth. A total of 20,486 eligible women were enrolled between May 14, 2009, and Aug 2, 2013. A 3rd, 10th, 50th, 90th, and 97th centile curves were obtained according to gestational age and sex.
  46. 46. 5. Software for clinical and epidemiological use free of charge, including an app to calculate Z scores and centiles. 6. The standards are prescriptive—ie, they describe optimum size in newborn infants without congenital abnormalities. 7. These standards are population-based, multiethnic, multicountry, and sex-specific, and they arise from a prospective study.
  47. 47. 8.Several processes were applied across all eight study sites— All were uniform and followed a standarized protocol. 9. Present centiles for birthweight, length, and head circumference by sex and gestational age based on a prescriptive approach that are integrated with the corresponding fetal growth standards. 10. The observed and smoothed centiles were almost identical and presented the 3rd, 10th, 50th, 90th, and 97th centile curves according to gestational age and sex.
  48. 48. Disadvantages • A shortcoming of studying such a low-risk group is that there were relatively few early preterm births despite the large sample size; hence, we had to limit the range of the standards by setting the lower limit of the curves to those born at 33 weeks of gestation. • It might not be feasible to construct standards for very preterm newborn infants using such a strictly defined subpopulation of preterm babies who are at higher risk of intrauterine growth restriction and other major pregnancy and neonatal complications
  49. 49. Time Schedule for Monitoring
  50. 50. • Sri Lanka becomes the first country to adopt the INTERGROWTH-21st Preterm Standards • 125 nations have adopted so far
  51. 51. THANK YOU
  52. 52. • THE END