Postnatal growth failure Causes, consequences and prevention

Transcription

1 Postnatal growth failure Causes, consequences and prevention Bielsko March 9, 2014 Ekhard E. Ziegler, M.D. Fomon Infant Nutrition Unit University of Iowa

2 1995; weeks gestation

3 NICHD Growth Observational Study 2000 Extrauterine Growth Restriction 50th 10th 1500 Weight (grams) Intrauterine growth (50th and 10th percentile) weeks weeks weeks Ehrenkranz RA, et al. Pediatrics 1999;104: Postmenstrual Age (weeks) 3

4 Postnatal growth failure Significance Poor growth = Inadequate nutrition Inadequate nutrition = Impaired neurocognitive development Poor growth is a marker of poor neurocognitive outcome

5 McCance and Widdowson

6 Growth failure and neurodevelopmental outcome Ehrenkranz et al., Pediatrics 2006;117:1253 Setting: NICHD Neonatal Network Subjects: Infants born September 1994 and August 1995 with birth weight g (N=600 discharged) Outcomes: 1. Follow-up at months (MDI, PDI, neurologic assessment (N=495) 2. Weight gain from regained birth weight to discharge

7 Growth failure and neuro-developmental outcome Ehrenkranz et al., Pediatrics 2006;117:1253 Q1 Q2 Q3 Q4 Weight gain (g/kg/d) Head circ. gain (cm/week) Cerebral palsy (%) MDI <70 (%) PDI <70 (%) Neurodev. impairm. (%)

8 Postnatal growth failure and its association with poor neurocognitive outcome Birth year Age at FU Hack yr Lucas yr Weisglas-Kuperus yr Latal-Hajnal yr Georgieff yr Kan et al yr Ehrenkranz yr Franz yr Claas yr Belfort yr Rozé yr

9 Slower vs faster growth Follow-up at years of age Neurocognitive development Feeding Faster Slower p growth growth Average IQ % with IQ < % with CP % with IQ <85 and/or CP Lucas et al., BMJ 317:1481 (1998)

10 VLBW infants (<1250 g), N= 219, z-scores for weight From Latal-Hajnal et al., J Pediat 2003;143:163

11 Extrauterine growth failure B. Latal-Hajnal et al., J Pediat 2003;143: MDI at age 2 yr AGA, no growth failure SGA, catch-up 98.2 AGA, growth failure 94.9 SGA, no catch-up 94.7

12 Growth 1 Week to Term and 18-month Bayley scores Belfort et al., Pediatrics 2011;128:e899-e906 (Data from Australian DINO study [high-dose DHA] conducted by Makrides & Gibson ; infants <33 wks) Points per 1 z-score increment MDI PDI All infants 2.4 ( ) 2.7 ( ) <1250 g 4.7 ( ) 5.9 ( ) >1250 g 1.0 ( ) 0.8 ( ) AGA 1.6 ( ) 1.9 ( ) SGA 11.7 ( ) 11.2 ( )

13 Postnatal growth failure Is associated with poor neurocognitive outcome in dose-dependent fashion

14 Postnatal growth failure Definition 1. Falling off fetal growth trajectory 2. SGA status at 36 weeks PMA among infants born AGA Absence of growth failure: Parallel to fetal growth but 5% less

15 What degree of growth failure is free of adverse late effects? We cannot define any degree of growth failure that is OK

16 Postnatal growth failure Do we still have postnatal growth failure?

17 Henriksen et al. Br J Nutr 2009;102; VLBW infants born

18 Infants born wks Fenton et al. BMC Pediatr 2013;13:92

19 Weight (g) SGA AGA <27 weeks AGA weeks Fenton 90th Fenton 50th Fenton 10th Gestational age (wks)

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21 How does postnatal growth failure cause impaired neurodevelopment? It does not Growth failure and impaired neurodevelopment have the same cause Which is inadequate nutrition

22 Inadequate nutrition Growth failure Inadequate nutrition Impaired neurocognitive development

23 Does slow growth have positive effects? Slow growth may lead to more favorable cardiovascular health outcomes It definitely leads to bad neurocognitive outcomes Therefore, slow growth is unequivocally worse than faster growth Disadvantages clearly outweigh advantages

24 What is the primary cause of growth failure? When energy intakes are adequate, which they often are, inadequate protein intake is the most common cause of poor growth. The most common cause of inadequate protein intake is insufficient fortification of human milk

25 How do we know that extrauterine growth failure is due to inadequate nutrition? Nutrient intakes, especially protein intakes, are lower than required for growth to match growth of the fetus

26 Protein and energy intakes (per kg body weight) Year N BW (GA) Age 4 weeks Age 6 weeks g Energy Protein Energy Protein Simmer Aus < Carlson US < Olsen US < Radmacher US < Regan NZ <32 wk Embleton UK < Carlson US < Cormack NZ < Carlson US <

27 The Factorial Approach 1. Fetal accretion 2. Inevitable losses 3. Efficiency of conversion 4. Efficiency of intestinal absorption

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29 Protein requirement (Factorial method) Body weight g Accretion* (g/d) 2.04 Dermal loss (g/d) 0.14 Urinary loss (g/d) 0.79 Required absorbed (g/d) 2.97 Required enteral intake (g/d) 3.40 (g/kg/d) 4.0 (g/100 kcal) 3.7 * with allowance for efficiency of conversion (90%)

30 Protein and energy requirements of preterm infants (enteral) Body weight Protein Energy Prot/Energy (g) (g/kg/d) (kcal/kg/d) (g/100 kcal)

31 Factorial approach Specific nutrients Weight: g, enteral requirements per kg/d Accretion Requirement Ca (mg) P (mg) Mg (mg) Na (meq) K (meq) Cl (meq)

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33 Recommended Intakes ESPGHAN 2010* Protein g/kg/d g/100 kcal Weight <1000g Weight g Energy *J Pediat Gast Nut 2010;50: kcal/kg/d

34 Postnatal growth failure The main cause is inadequate fortification of human milk

35 The apparent breastfeeding paradox in very preterm infants. Rozé et al., BMJ Open 2012;2:e Breast feeding was associated with an increased risk of losing 1 weight Z-score during hospitalization Adjusted OR EPIPAGE 1.55 ( ) LIFT 2.51 ( ) p

36 At 5 years Rozé J et al. BMJ Open 2012;2:e000834

37 Postnatal growth failure Conclusion We may ever be able to eradicate postnatal growth failure In the meantime we must try Every improvement in nutrition will improve growth and may improve neurocognitive outcome