What really constitutes Extrauterine growth restriction(EUGR)

[Akash Sharma]

It is not uncommon to have extreme preterm babies being under weight and stunted at 36 or 40 weeks PMA. 

Our standard of care for postnatal nutrition has traditionally been to provide nutrients which matches fetal accretion rate. But is it really wise to give the same quantity of nutrients. Preterm birth and exposure to postnatal life in itself would cause epigenetic changes in how a neonate shoudl. Metabolize and assimilate the nutrients administered. 

So what really constitutes as EUGR. Is it only the 10 th centile at 36 weeks and 40 weeks PMA or is it standard deviation scores below expected (like 1SD below the 10 th centile - considering that some amount of postnatal growth restriction is acceptable and expected due to the loss in the first 2 weeks )

For us its a complex issue of allowing the neonates to grow at their own centile (even below the 3 rd centile) as providing excess nutrition for catchup might result in more fat mass instead of fat free mass. (ultimate goal being adequate and appropriate body composition, linear and mass growth) 

On a bigger picture the question that needs to be answered is - Should EUGR be determined by a statistical definition alone based on anthropometric parameters OR should it be based on the adverse body composition analysis and neurodevelopmental outcomes at a prespecified  time (which is obviously more difficult) 

[Kedar Sawleshwarkar]

That’s really tough to answer it velocity of growth and lean body mass should be the priority probably. 

[Stefan Johansson]

Dear @Akash Sharma, thanks for posting about this!

We spend much time on nutrition, but personally, I tend to feel confused on this higher level. Some infants grow well, while some infants grow poorly whatever we do...

We use a computerized program (https://www.nutrium.se/) and make individual fortification to every preterm infant. Weights are plotted on a growth curve (starting at 24 wks) and we aim to achieve a "normal growth velocity". For SGA infants we tend to think about the patophysiology, if it is IUGR due to placental reasons (like pre-eclampsia), we think there is a potential for this baby to be AGA. So we expect catch-up growth and (if needed) try to promote that with fortifications.

We don't use the term EUGR in our unit, but we strive to get all infant withn the "normal" weight range, for us that means that we want infants within +/- 2 SD on the growth chart.

Coming to your question... we tend to use the growth-chart-definition of poor growth rather than body-composition analyses or clinical endpoints (which are also more like outcomes of growth)

[Akash Sharma]

Thanks for sharing your views @Stefan Johanssonsir.

What growth charts does your unit follow for extreme preterm and very preterms as norms. I would like to cite the article by Villar etal for the purpose of discussion about what postnatal growth standards to follow for preteen babies. 

"Villar J, Giuliani F, Barros F, et al. Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change. Pediatrics. 2018;141(2):e20172467. doi:10.1542/peds.2017-2467". 

Even after the Intergrowth 21 data the growth of less than 32 weeks babies still remain unanswered. 

By selection of an appropriate comparator only one can conclude whether increment in calorie and protein intake should be done or not. Currently we use Fenton's charts for the same. (which I feel isn't the right way to  about it) 

 

 

[bimalc]

On 6/1/2019 at 4:18 AM, Akash Sharma said:

"Villar J, Giuliani F, Barros F, et al. Monitoring the Postnatal Growth of Preterm Infants: A Paradigm Change. Pediatrics. 2018;141(2):e20172467. doi:10.1542/peds.2017-2467".

The approach these authors suggest is really only implementable for moderate to late preterm infants.  The overall approach is tempting to extend to more extreme premature infants, but I'm not aware of anyone pulling together the data to do this (Presumably the NRN in the US has the underlying data and VON may as well, though both are limited datasets in terms of post-discharge data.  CHNC has a much higher risk and outworn population but does have a validated PHIS linkage as well as (theoretically) neonatal follow-up data).

On 6/1/2019 at 3:52 AM, Stefan Johansson said:

make individual fortification to every preterm infant.

Stefan - when you say individual fortification, are you looking solely at patient characteristics or are you assessing (for milk fed babies) the caloric density and relative macronutrient composition of the milk (mother's own or donor) in order to guide degree of fortification?  At the Pediatric Academic Society Meeting in the US this year there was a Swedish vendor (https://www.mirissolutions.com) selling an FDA-approved solution for human milk analysis: Do you have experience with this device?

[Stefan Johansson]

@bimalc Yes, we use the Miris milk analyzer. Our hospital runs the Milk Bank for the Stockholm region , so we have all this inhouse (and do milk analyses for all other hospitals as well).

Mothers start pumping usually day.1 so after a week or so, most preterm infants get their own mother's milk. Until then, from the milk bank.

All milk bank batches are analysed, and mother's own milk is analysed after ~10 days and then weekly or bi-weekly. A small amount of each pumping (1-2 ml I think) is collected during 24h and this selection is analysed.

With the software Nutrium (https://www.nutrium.se/, also a small Swe company BTW, started by a neonatologist in Umeå) we input the milk spec's and then "add" the fortifications in the software, to tailor it per baby. We are directed by the growth curve and also the recommendations (ESPGHAN etc). The software gives a very detailed feedback, all macro and micro-nutrients are marked red, yellow and green depending if ("too little/much", "close", and "within recommendations"). If milk is not analysed, we use a "sham" specification, one for "immature/early" and one for "mature/late" breast milk until we have data on the actual batch of breast milk.

So, we spend a some time and resources on nutrition   although it sometimes feel we over-engineer, we really aim to optimize nutrition on an individual basis. And the whole setup has become integrated in our daily routines, so it works smoothly.

There are some publications where this detailed nutrition data (extracted from this software) has been used, the second ref also showing that many extrem preterm infants get malnourished during the first weeks of life.

https://www.ncbi.nlm.nih.gov/pubmed/26690864

https://www.ncbi.nlm.nih.gov/pubmed/23855971

[Stefan Johansson]

A new Cochrane review related to EUGR

 

https://www.evidencealerts.com/Articles/AlertedArticle/87436

[Dr.Smah]

On 6/3/2019 at 10:34 AM, Stefan Johansson said:

@bimalc Yes, we use the Miris milk analyzer. Our hospital runs the Milk Bank for the Stockholm region , so we have all this inhouse (and do milk analyses for all other hospitals as well).

Mothers start pumping usually day.1 so after a week or so, most preterm infants get their own mother's milk. Until then, from the milk bank.

All milk bank batches are analysed, and mother's own milk is analysed after ~10 days and then weekly or bi-weekly. A small amount of each pumping (1-2 ml I think) is collected during 24h and this selection is analysed.

With the software Nutrium (https://www.nutrium.se/, also a small Swe company BTW, started by a neonatologist in Umeå) we input the milk spec's and then "add" the fortifications in the software, to tailor it per baby. We are directed by the growth curve and also the recommendations (ESPGHAN etc). The software gives a very detailed feedback, all macro and micro-nutrients are marked red, yellow and green depending if ("too little/much", "close", and "within recommendations"). If milk is not analysed, we use a "sham" specification, one for "immature/early" and one for "mature/late" breast milk until we have data on the actual batch of breast milk.

So, we spend a some time and resources on nutrition   although it sometimes feel we over-engineer, we really aim to optimize nutrition on an individual basis. And the whole setup has become integrated in our daily routines, so it works smoothly.

There are some publications where this detailed nutrition data (extracted from this software) has been used, the second ref also showing that many extrem preterm infants get malnourished during the first weeks of life.

https://www.ncbi.nlm.nih.gov/pubmed/26690864

https://www.ncbi.nlm.nih.gov/pubmed/23855971

Strongly recommending the concept of breastmilk analysis although it is not activated or gets attention in my region 

[talatahmed@sbcglobal.net]

https://www.nutrium.se/

Is this available in English?

 

[bimalc]

17 hours ago, talatahmed@sbcglobal.net said:

Is this available in English?

In the top right corner of the site is a link to an English language version of the software, but I did not see extensive English language documentation