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2023 Aap Nce Presentation

The document describes postnatal growth reference charts for very preterm infants. It discusses how modern nutrition practices have allowed postnatal growth rates in the NICU to approximate intrauterine growth rates. The document presents a large dataset of postnatal growth measurements for preterm infants. It finds that while early postnatal growth is slower than fetal growth, growth accelerates to match fetal rates by 34 weeks. It then describes a web application called NICUgrowth that provides tools to visualize and track infant growth against these new references.

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Juan M Aguilar
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24 views26 pages

2023 Aap Nce Presentation

The document describes postnatal growth reference charts for very preterm infants. It discusses how modern nutrition practices have allowed postnatal growth rates in the NICU to approximate intrauterine growth rates. The document presents a large dataset of postnatal growth measurements for preterm infants. It finds that while early postnatal growth is slower than fetal growth, growth accelerates to match fetal rates by 34 weeks. It then describes a web application called NICUgrowth that provides tools to visualize and track infant growth against these new references.

Uploaded by

Juan M Aguilar
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Postnatal Growth Reference Charts

for Very Preterm Infants


Fu-Sheng Chou, MD PhD
---
Kaiser Permanente Riverside Medical Center, Riverside, CA
Southern California Permanente Medical Group, Pasadena, CA
---
X: @nicugrowth_app | https://nicugrowth.app
---
Fu-Sheng.X.Chou@kp.org | admin@nicugrowth.app
Conflict of Interest Disclosure

I have NO relevant financial relationships with the manufacturer(s) of


any commercial product(s) and/or provider(s) of commercial services
discussed in this CME activity.

I DO NOT intend to discuss an unapproved/investigative use of a


commercial product/device in my presentation.

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Acknowledgements
• Dr. Reese Clark for project approval & mentorship
• Dr. Hung-Wen (Henry) Yeh for introducing model technique,
mentorship, and friendship
• Dr. Mitchell Goldstein for introducing me to Dr. Clark
• Dr. Tanis Fenton for the LMS table for 2013 Fenton growth charts and
the discussion around intrauterine vs. postnatal growth references
• Dr. Irene Olsen & Dr. Veeral Tolia for insightful comments on the
early versions of the manuscript

admin@nicugrowth.app X/Twitter: @nicugrowth_app


The Clinical Question

“The goal of feeding regimens for low-birth-weight infants is to obtain a prompt


postnatal resumption of growth to a rate approximating intrauterine growth because
this is believed to provide the best possible conditions for subsequent normal
development.”
~ AAP 1977

How does the rate of postnatal growth under modern nutrition


practice approximate the rate of intrauterine growth?

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Racially Diverse Large Data Set
Method

Pediatrix Clinical Data Warehouse Total Female Male


Number of infants (22 4/7-30 3/7wk) n = 89,218 n = 41,798 n = 47,420
Number of Data points
Weight 5,478,055 2,602,008 2,876,047
Length 755,687 358,968 396,719
Head Circumference 1,316,087 620,079 696,008
Race/ethnicity
White 36,628 (41%) 16,930 (40%) 19,698 (43%)
Black 25,577 (29%) 12,537 (30%) 13,040 (27%)
Hispanic 17,008 (19%) 7,772 (19%) 9,236 (19%)
Asian 2,643 (3%) 1,179 (3%) 1,464 (3%)
Other 7,362 (8%) 3,380 (8%) 3,982 (8%)

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Difference in intrauterine vs. Postnatal Growth
Figure 1

Black: 2013 Fenton weight curves Pink: 25-week female group

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Intrauterine vs. Postnatal Growth Rate
Figure 2

Weight Length Head Circumference

cm/week

cm/week
g/day

0
0
0

PMA PMA PMA

Solid: 97th percentile | Dashed: 3rd percentile


Intrauterine vs. Postnatal Growth
Figure 3

g/day
Three Phases of Postnatal Growth
Expected daily weight
Initial Weight Loss gain (g/day)
Birth to BW regained 0

Weight Acceleration (g/kg/day)


BW regained to 34 weeks PMA

g/kg/day
Stable Weight Gain (g/day)
34 weeks PMA and beyond
0 Expected % daily weight
gain (g/kg/day)
BW regained

34 weeks
PMA
admin@nicugrowth.app X/Twitter: @nicugrowth_app
Details available in the manuscript

https://doi.org/10.1038/s41467-023-41069-0

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Altered Growth Trajectory Following Preterm Birth

Conception Term Fully


Birth grown

Early Fenton/Olsen/INTERGROWTH 21st


fetal
growth Preterm
Birth NICU Postnatal Growth
Charts

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Postnatal Growth Charts WebApp

nicugrowth.app

USER ID: test


PASSWORD: Password is
test Encrypted!
All lower-case

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Accessing the Data Entry Table
Step 3.
Double-click on a corresponding cell to enter value

Step 1. Baby X

Select or create an ID
Enter GA/Sex if new
ID

nicugrowth.app
Full-Version WebApp

Step 4.
Step 2. Click to (re)calculate percentile/z-
Click READY-SET-GO to load datatable score
Step 5.
& calculate percentile/z-score Save the entered data

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Hover Over Measurement Data Points to Reveal
Details DOL starts from 0

Scroll
down

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Actual Weight Gain vs. Trajectory

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Trajectory Percentile Calculation

( )
𝑛
1
𝑇𝑟𝑎𝑗𝑒𝑐𝑡𝑜𝑟𝑦 𝑝𝑒𝑟𝑐𝑒𝑛𝑡𝑖𝑙𝑒= min ∑(
0 <𝑝<100 𝑛 𝑖=1
𝑚𝑒𝑎𝑠𝑢𝑟𝑒𝑚𝑒𝑛𝑡 𝑖 − 𝔼𝑝 𝑖)
2

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Clinical Use of Trajectory Percentile

1. Predict growth rate

2. Guide timing of transitioning to the WHO charts

3. Guide post-illness growth goal and nutrition needs

4. Assess postnatal growth failure

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#1. Predict Growth Rates & Nutrition Needs

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#1. Predict Growth Rates & Nutrition Needs

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#2. Guide timing of transitioning to WHO Charts

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#2. Guide timing of transitioning to WHO
Charts

23.6%ile = 2913g

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#2. Guide timing of transitioning to WHO
Charts

Trajectory percentile
as birth weight
percentile

2913g

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#3. Identify Pre-Illness Trajectory Percentile

Surgical
NEC on
DOL14

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#3. Identify Pre-Illness Trajectory Percentile

Surgical
NEC on
DOL14

admin@nicugrowth.app X/Twitter: @nicugrowth_app


#4. Assess Postnatal Growth Failure
• Snapshot of growth at 36 weeks PMA vs. growth falling off the percentile

• Longitudinal intra-personal comparison


• Correlate better with long-term neurodevelopmental and cardiometabolic
outcomes?
admin@nicugrowth.app X/Twitter: @nicugrowth_app
Reflecting on This Project
• Growth rate is dynamic
• The three-phase growth is likely valid, what we can work on is
setting growth rate goals for each phase
• The existence of measurement errors, including birth measurements
Trajectory percentile (longitudinal) vs. individual z-scores
(snapshots)

admin@nicugrowth.app X/Twitter: @nicugrowth_app


Summary & Limitations
• Racially diverse, large-scale real-world dataset
• Allow peer-to-peer comparisons
• Provides realistic expectation of growth
• One additional way to involve parents in infant care nicugrowth.app

• Now available from 22 4/7 to 34 3/7 weeks


• Do not represent optimal growth
• A valuable clinical and research tool

Thank You! Any Questions?


admin@nicugrowth.app X/Twitter: @nicugrowth_app

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