CLINICAL CONDITIONS ASSOCIATED

WITH POST NATAL GROWTH

FAILURE IN PRETERM INFANTS
Dinerstein N A1, Solana C L1, NietoR M1, Perez G P1, Carrara M2, Kelmansky D3, Chan D3.
Neonatology, Maternidad Sarda1, Fresenius Kabi2 Argentina, Instituto del Cálculo, University of Buenos Aires3, Argentina.

ABSTRACT RESULTS
BACKGROUND: Among our preterm newborn infants, at 40 weeks post menstrual age From 08/2001 to 11/2005, 339 infants were born and 238 patients who met inclusion criteria
(PMA) 52 % are below the 10th percentile for body weight, 47% for body length and 8% for were included in the study.
head circumference (HC). OBJECTIVE: to evaluate the influence of each perinatal clinical Clinical and growth characteristics are shown in Tables 1 and 2.
condition on the frequency of post natal growth retardation (PNGR), low head circumfer- Multivariate analysis showed that the following variables were predictive for PNGF: gesta-
ence (HC) and short body length at 40 PMA. DESIGN/METHODS: cohort study. Inclusion tional age, combined morbidity, birth weight and caloric deficit at 28 days of life (Table 3).
criteria: in-born infants, <32 weeks GA, birth weight <1500 g and surviving up to 40 weeks Predictive variables for short length were: gestational age, combined morbidity, birth
of PMA. Exclusion criteria: major congenital malformations, intrauterine infections and in- weight and male gender (Table 4).
fants transferred before 40 weeks. Three explicative logistical regression models were Predictive variables for low HC were: birth weight and male gender (Table 5).
constructed estimating in each case the 95% confidence intervals for the odds ratio of the All the mentioned variables have good Hosmer-Lemeshow adjustment and show good ca-
significant factors. RESULTS: From 08/2001 to 11/2005, 339 infants were born, 238 met the pacity of classification (above 72%).
inclusion criteria and were studied. Clinical characteristics and outcomes were: mean
birth weight: 1144 g, SD 234; mean GA: 28.4 weeks, SD 1.66; frequency of small for dates:
9.2%; CRIB score >5:11.3%; PNGR: 52%; low HC at 40 PMA: 8%; short length at 40 PMA:
TABLE 1:CLINICAL CHARACTERISTICS
47%; BPD: 36.6%; late onset sepsis: 26.9%; NEC: 1.7%; PDA: 46.6% and combined morbidity
(PDA, RDS,BPD and late onset Sepsis): 60.1%. Multivariate analysis showed that the fol- Birth weight g mean (SD) 1144 g (± 234)
lowing variables were predictive for PNGF: gestacional age (OR:2.01, 95%CI 1.52-2.66), Mean Gestational Age in w (SD) 28.4 w (± 1.66)
combined morbidity (OR:2.85, 95%CI 1.43-5.69), birth weight (OR:0.53, 95%CI 0.43-0.66) and
caloric deficit (OR:1.13, 95%CI 1.04-1.23). Predictive variables for short length were: gesta- Small for Dates n (%) 22 (9.2)
cional age (OR:1.58, 95%CI 1.22-2.03), combined morbidity (OR:3.09, 95%CI 1.6-5.96), birth HC 3rd pc at birth n (%) 25 (10.5)
weight ( OR: 0.54 95%CI 0.44 0.66 ) and male gender (OR:2.39, 95%CI 1.26-4.54). Predictive
variables for low HC were: birth weight (OR:0.62, 95%CI 0.54-0.83) and male gender Body length 3rd pc at birth n (%) 75 (31.5)
(OR:6.39, 95%CI 1.76-23.23). All of the above have good Hosmer-Lemeshow adjustment and
RDS n (%) 130 (54.3)
show good capacity of classification (above 72%). CONCLUSIONS: We found that com-
bined morbidities such us RDS, PDA, late onset sepsis and BPD, associated with lower CRIB score >5 n (%) 27 (11.3)
birth weight, gestacional age, male gender and caloric deficit explain PNGR , shorter body
BPD n (%) 87 (36.6)
length and lower head circumference at 40 PMA weeks in our population. Postnatal
growth failure prevention will only be possible improving nutritional interventions and re- Late-onset sepsis n (%) 64 (26.9)
ducing neonatal co-morbidities.
NEC n (%) 4 (1.7)
PDA n (%) 111 (46.6)
BACKGROUND Combined morbidity* n (%)
Breakthroughs in neonatal care during the last years have improved survival of extremely * RDS, PDA, Late onset sepsis, BPD 143 (60.1)
low birth weight infants. Patients showing an adequate post-natal growth have the great-
est chance of long term optimal health, cognitive skills and academic achievement.
Despite implementing nutritional protocols aimed at achieving or exceeding suggested TABLE 2: GROWTH OUTCOMES
energy and protein requirements, accumulated deficits during the first weeks of life1,2 are
difficult to recover3. PNGR n (%) 124 (52.1)
Among our preterm newborn infants, at 40 week post menstrual age (PMA), 52 % are
below the 10th percentile for body weight, 47% for body length and 8% for head circumfer- Low HC at 40 PMA n (%) 20 (8)
ence (HC). Short length at 40 PMA 113 (47)
Prevalent pathologies of neonatal period also condition growth. In respiratory distress
syndrome (RDS), greater energy comsumption is observed due to greater ventilation effort.
Bronchopulmonary dysplasia (BPD) causes a higher caloric expenditure at rest, inad- TABLE 3: RISK VARIABLES FOR PNGF BY MULTIPLE
equate water management, need of diuretics therapy, plus a restricted intake of energy
and proteins. LOGISTIC REGRESSION MODELS
Newborns with persistent ductus arteriosus (PDA) show some degree of congestive heart
failure and higher caloric requirements, being a real challenge to achive the ideal caloric VARIABLE OR 95 %CI
intake due to high metabolic demands of myocardium and respiratory muscles. Neonatal Birth Weight 0.53 0.43 - 0.66
sepsis generates a significant “catabolic” response, with changes in energy and protein
metabolism due to cytokines increase (tumoral necrosis factor and interleukin-6, among Gestacional Age 2.01 1.52 - 2.66
others) and to sympathetic nervous activity, with increases in the levels of cat- Combined Morbidity 2.85 1.43 - 5.69
echolamines, oxygen comsumption and negative nitrogenous balance.
The sickest patients show slower growth rate during hospitalization. There is evidence of Combined Mobidity 1.13 1.04 - 1.23
a inverse relation in very pretern infants between growth rate during hospitalization and
alterations of neurodevelopmental.4
TABLE 4: RISK VARIABLES FOR SHORT LENGTH BY
MULTIPLE LOGISTIC REGRESSION
OBJETIVES
To assess the influence of each perinatal clinical condition on the frequency of post natal VARIABLE OR 95 %CI
growth retardation (PNGR) defined as body weight below the 10th percentile of the ex- Birth Weight 0.54 0.44 -0.66
pected value, based on postmenstrual age (PMA) intrauterine growth chart and head cir-
cumference (HC) and body length below the 3th percentile at 40 PMA. Gestacional Age 1.58 1.22 -2.03
Male Gender 2.39 1.26 -4.54
Combined Mobidity 3.09 1.6 - 5.96
METHODS
Cohort study. Inclusion criteria: in-born infants, less than 32 weeks GA, birth weight below
1500 g and surviving up to 40 weeks of PMA. Exclusion criteria: major congenital malforma- TABLE 5: RISK VARIABLES FOR LOW HC BY MULTIPLE
tions, intrauterine infections and infants transferred before 40 weeks.
STATISTICAL ANALYSIS: Three explicative logistical regression models for predecting low LOGISTIC REGRESSION MODELS
body weight, length and head circumference at 40 weeks PMA were constructed, estimat-
ing in each case 95% confidence intervals for odds ratio of significant factors.
VARIABLE OR 95 %CI
ETHICAL CONSIDERATIONS:The study was authorized by both, Ethics and Research Com- Birth Weight 0.62 0.54 -0.83
mittee of Materno Infantil Ramón Sarda Hospital.
Gestacional Age 1.58 1.76-23.23

CONCLUSIONS
In our population, we found that neonatal com- during postnatal period might reduce the severity
bined morbidities (RDS, PDA, late onset sepsis of the most frequent morbidities like late onset
and BPD), gestational age and caloric deficit ex- sepsis and BPD.
plain low body weight at 40 weeks PMA. Prevention of postnatal growth failure will only be
Shorter body length was explained by gestational possible by improving nutritional interventions al-
age, combined morbidities and male gender. lowing gradual growth rechannelling and reducing
Lower head circumference at 40 PMA weeks was neonatal co-morbidities. An adequate nutritional
explained by birth weight and male gender. support may also reduce morbidities that have a
We speculate that avoiding early undernutrition negative impact on growth and neurodevelopment.

REFERENCES
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2006 Jul;26(7):436-42. 2.- Emblenton,N E, N. Pang, and R.J Cooke, Postnatal malnutrition and growth retardation: an inevitable consequence of current recommendations in preterm infants? Pediatrics
2001; 107 (2): p. 270-3. 3.- Nieto R, Perez G, Dinerstein A, Solana C et al. Avoiding Energy and Protein Deficits According to AAP Nutritional Recommendations for VLBW Infants Reduces Postnatal Undernu-
trition at 36 Weeks of Corrected Gestational Age? E-PAS2006: 5571.426. 4.- Ehrenkranz RA et al Growth in the neonatal intensive care unit influences neurodevelopment and growth or outcomes of ex-
tremely low birth weight infants. Pediatrics 2006; 117: 1253-61.