Generating longitudinal growth charts from preterm infants fed to current recommendations.

OBJECTIVE: To use repeated measurements of weight, length and head circumference to generate growth centile charts reflecting real-world growth of a population of very preterm infants with a well-described nutritional intake close to current recommendations. DESIGN: Infants born before 30 weeks gestational age (GA) were recruited. Infants received nutrition according to an integrated care pathway, with nutrient intake recorded daily, weight recorded twice-weekly and length and head circumference weekly. The LMS method was used to construct growth centile charts between 24 and 36 weeks corrected GA for each parameter. SETTING: A single tertiary neonatal unit in England. PATIENTS: 212 infants (124 male) (median GA at birth: 27.3 weeks, median birth weight: 900 g). RESULTS: Median daily energy, protein, carbohydrate and fat intake were within 3% of published recommendations. The total number of measurements recorded was 5944 (3431 for weight, 1227 for length and 1286 for head circumference). Centile charts were formed for each parameter. Data for male and female infants demonstrated similar patterns of growth and were pooled for LMS analysis. A web application was created and published (bit.ly/sotongrowth) to allow infants to be plotted on these charts with changes in SD score of measurements reported and graphically illustrated. CONCLUSIONS: These charts reflect growth in a real-world cohort of preterm infants whose nutrient intakes are close to current recommendations. This work demonstrates the feasibility of forming growth charts from serial measurements of growing preterm infants fed according to current recommendations which will aid clinicians in setting a benchmark for achievable early growth.

Handheld 3D scanning as a minimally invasive measuring technique for neonatal anthropometry.

BACKGROUND: Measurement of length and head circumference (HC) in addition to weight is vital in assessing the nutritional status of preterm infants. Current anthropometry represents an interruption to preterm infants, and may not be possible in unstable infants. Handheld 3D scanning has the potential to perform bedside anthropometry (length and HC) in a less invasive manner. We aimed to evaluate the feasibility and performance of 3D scanning as a 'non-touch' measuring technique for routine anthropometry. METHODS: Preterm infants born before 30 weeks gestation were recruited from a single neonatal unit. HC and length were measured both manually and by a handheld 3D scanner at recruitment and weekly until discharge. The two methods were compared using the Bland-Altman method and linear regression. RESULTS: Seventeen infants had manual and 3D-scan measurements (67 HC, 87 length). The mean difference (95%CI) between manual and 3D-scan measures, as a percentage of the manual value, was 2.87% (2.27-3.47%) for HC and 3.10% (2.65-3.54%) for length. Correlation between manual and 3D measures was high; HC r = 0.957 and length 0.963. Bland-Altman plots showed reasonable agreement between the two methods, and there was a high correlation between scanner and manual measurements. CONCLUSIONS: These data show a high correlation between measurements gathered from 3D scan images and standard anthropometry. However, 3D measures are not yet precise enough for routine clinical use. Refinement of technique/technology may translate into practical monitoring the growth of preterm infants with minimal handling and without interruption to developmental care.

Early postnatal growth failure in preterm infants is not inevitable.

BACKGROUND: Previously published data have demonstrated that preterm infants experience a fall across marked centile lines for weight in early life with early poor head growth also reported. This study describes a single neonatal unit's experience of longitudinal change in weight, head circumference (HC) and length in a cohort of preterm infants born <32 weeks' gestation. METHODS: Data were collected from a single neonatal unit between July 2012 and June 2017. This period followed the introduction of improved nutritional guidelines. Patients were grouped according to their gestational age at birth. Growth lines were constructed for weight, HC and length in each gestational age group from the median measures and compared with reference centile lines. RESULTS: Data were analysed from 396 patients consisting of 2808, 1991 and 2004 measures for weight, HC and length, respectively. Longitudinal growth plots did not show an initial absolute weight loss in any of the subgroups. Across all groups, the mean change in SD score between birth and 36 weeks was -0.27 (95% CI -0.39 to -0.15). CONCLUSIONS: This description of longitudinal growth in a cohort of preterm infants demonstrates that early postnatal growth failure is not inevitable, with most infants growing along a trajectory close to their birth centile. There is no evidence of a 2 marked centile line weight decrease or weight loss. These data provide evidence to suggest that extrauterine weight gain tracking centile lines can be achieved.

Home use of breast milk fortifier to promote postdischarge growth and breast feeding in preterm infants: a quality improvement project.

To improve the postdischarge growth of exclusively breastfed preterm infants, born weighing ≤1.8 kg, by using breast milk fortifier (BMF) supplements postdischarge until 48 weeks' gestational age. A quality improvement (QI) project involving plan-do-study-act (PDSA) cycles. A tertiary surgical neonatal unit. Preterm infants weighing ≤1.8 kg at birth. We completed four PDSA cycles to develop and improve an electronic patient information sheet to promote the use BMF beyond discharge. Safety, feasibility and attitudes of parents to home BMF were assessed using questionnaires. A retrospective audit (July 2015-September 2017) was completed investigating the effects of home BMF on growth up to 1 year of age. Change in SD scores for weight for age, length for age and head circumference of age at various time points compared with those at birth were calculated. Compared with baseline measurements (infants born October 2012-November 2013), the QI project resulted in improved growth (measured as the change in SD score from birth, cSDS) at discharge for weight (cSDS -0.7), head circumference (cSDS 0.4) and length (cSDS-0.8), and at 1 year for weight (cSDS 0.9) and length (cSDS 0.8). Home BMF appeared to be safe, and parents found its use acceptable. QI methods facilitated the successful integration of BMF into routine clinical care after discharge, improving the growth trajectory of exclusively breastfed preterm infants discharged home, as well as supporting breast feeding in this vulnerable population group.

Successfully implementing and embedding guidelines to improve the nutrition and growth of preterm infants in neonatal intensive care: a prospective interventional study.

OBJECTIVES: We aimed to improve the nutritional care of preterm infants by developing a complex (multifaceted) intervention intended to translate current evidence into practice. We used the sociological framework of Normalization Process Theory (NPT), to guide implementation in order to embed the new practices into routine care. DESIGN: A prospective interventional study with a before and after methodology. PARTICIPANTS: Infants <30 weeks gestation or <1500 g at birth. SETTING: Tertiary neonatal intensive care unit. INTERVENTIONS: The intervention was introduced in phases: phase A (control period, January-August 2011); phase B (partial implementation; improved parenteral and enteral nutrition solutions, nutrition team, education, August-December 2011); phase C (full implementation; guidelines, screening tool, 'nurse champions', January-December 2012); phase D (postimplementation; January-June 2013). Bimonthly audits and staff NPT questionnaires were used to measure guideline compliance and 'normalisation', respectively. NPT Scores were used to guide implementation in real time. Data on nutrient intakes and growth were collected continuously. RESULTS: There were 52, 36, 75 and 35 infants in phases A, B, C and D, respectively. Mean guideline compliance exceeded 75% throughout the intervention period, peaking at 85%. Guideline compliance and NPT scores both increased over time, (r=0.92 and 0.15, p<0.03 for both), with a significant linear association between the two (r=0.21, p<0.01). There were significant improvements in daily protein intake and weight gain between birth and discharge in phases B and Ccompared with phase A (p<0.01 for all), which were sustained into phase D. CONCLUSIONS: NPT and audit results suggest that the intervention was rapidly incorporated into practice, with high guideline compliance and accompanying improvements in protein intake and weight gain. NPT appears to offer an effective way of implementing new practices such that they lead to sustained changes in care. Complex interventions based on current evidence can improve both practice and clinical outcomes.

Assessing the growth of preterm infants using detailed anthropometry.

AIM: Preterm infants display altered body composition compared to term infants, and weight gain is a crude indicator body composition. Childhood mid-upper arm circumference (MUAC) is a measure of nutritional status. This study investigates MUAC and mid-thigh circumference (MTC) to monitor growth in preterm infants. METHODS: Preterm infants (<30-week gestation) were recruited. MUAC, MTC, weight, length and head circumference (HC) were measured at recruitment and weekly intervals until discharge. Descriptive, correlation and regression analyses were used. RESULTS: Ninety-three infants were recruited. Median measurement duration was eight weeks (1-19). Median gestational age was 27 weeks (23-29). Analysis by curve estimation displayed a mean increase of 2.58 mm/week (left MUAC) (p ≤ 0.0001), 2.56 mm/week (right MUAC) (p ≤ 0.0001), 4.16 mm/week (left MTC) (p ≤ 0.0001), 4.20 mm/week (right MTC) (p ≤ 0.0001). Coefficients of determination (R2 ) were calculated using a growth regression model for MUAC and MTC (0.866-0.917); measures were comparable to growth modelling of weight (0.913), length (0.945) and HC (0.928). High concordance between left and right MUAC and MTC generated a Pearson's correlation coefficient of 0.999 (MUAC) (p ≤ 0.001) and 0.994 (MTC) (p ≤ 0.001). CONCLUSION: Data demonstrate the potential utility of MUAC and MTC as additional measures of growth in preterm infants that are reproducible over time. There is potential to gain insights to improve lean-mass accretion in preterm infants.

How to use: nutritional assessment in neonates.

Adequate nutrition and growth during the neonatal period are important, especially for preterm infants, for whom there is evidence of poor nutrient intakes and growth, and this has important implications for their health in later life. Increased nutritional support while on the neonatal intensive care unit has been shown to improve growth, but such support is not universally available. Being able to carry out and interpret a nutritional assessment is therefore an important skill for paediatricians caring for neonates. This article aims to explain how to use nutritional assessment in neonates and provides some tools to make this process as straightforward as possible.

Milk osmolality: does it matter?

High osmolality of infant feed reflects a high concentration of solute particles and has been implicated as a cause of necrotising enterocolitis. Evidence for direct intestinal mucosal injury as a result of hyperosmolar feeds is scant, and no good evidence has been found to support such an association. High osmolality of enteral substrate may, however, slow down gastric emptying. Osmolality of current infant feeds ranges from around 300 mOsm/kg in human breast milk to just more than 400 mOsm/kg in fully fortified breast milk. Addition of mineral and vitamin supplements to small volumes of milk can increase osmolality significantly and should be avoided if possible.