INTERGROWTH-21st Curve Research Articles

Mortality Risk in US Neonatal Intensive Care Unit Infants by Birth Size Classifications Comparing Three Growth Curves

Introduction: Three widely referenced growth curves classify infant birth anthropometric measurements as small (SGA), appropriate (AGA), or large (LGA) for gestational age (GA) differently. We assessed how these differences in assignment affect the identification and prediction of neonatal intensive care unit (NICU) mortality risk in US preterm infants. Methods: Birth data of infants admitted to NICUs from the Pediatrix Clinical Data Warehouse (2013–2018) were analyzed. Birth weight, length, and head circumference of 46,724 singleton infants (24–32 weeks GA) were classified as SGA, AGA, or LGA using the Olsen, Fenton, and INTERGROWTH-21st curves. NICU mortality risk based on birth size classification was analyzed using unadjusted and adjusted logistic regression stratified by GA. Results: Odds of mortality were increased with SGA classification at all GAs, size measurements, and curve sets, compared with AGA infants. LGA classification for weight was associated with lower mortality risk at 24 weeks GA and higher risk at 30 weeks GA. Odds of mortality did not differ significantly across curve sets. Classification of size at birth alone had relatively low predictive ability to identify mortality risk, with unadjusted AUCs near 0.5 for all analyses. Conclusion: There were no significant differences across curve sets in predicting mortality. Classification of size at birth is a relatively imprecise method to identify infants at risk for NICU mortality.

The Prevalence of Small for Gestational Age and Extrauterine Growth Restriction among Extremely and Very Preterm Neonates, Using Different Growth Curves, and Its Association with Clinical and Nutritional Factors.

Monitoring the growth of neonates in the Neonatal Intensive Care Unit (NICU) using growth charts constitutes an essential part of preterm infant care. Preterm infants are at increased risk for extrauterine growth restriction (EUGR) due to increased energy needs and clinical complications. This retrospective study compares the prevalence of small for gestational age (SGA) at birth and EUGR at discharge in extremely and very preterm neonates hospitalized in the NICU of a tertiary hospital in Greece, using different growth curves, and it examines the associated nutritional and clinical factors. Fenton2013 and INTERGROWTH-21st growth curves were used to calculate z-scores of birth weight (BW) and weight, length, and head circumference at discharge. The study includes 462 newborns with a mean BW of 1341.5 g and mean GA of 29.6 weeks. At birth, 6.3% of neonates were classified as SGA based on Fenton2013 curves compared to 9.3% with INTERGROWTH-21st growth curves. At discharge, 45.9% of neonates were characterized as having EUGR based on the Fenton2013 weight curves and 29.2% were characterized based οn INTERGROWTH-21st curves. Nutritional factors such as the day of initiation, attainment of full enteral feeding, and the duration of parenteral nutrition were associated with EUGR by both curves. The prevalence of SGA and EUGR neonates differs between the two growth references. This shows that further evaluation of these charts is needed to determine the most appropriate way to monitor infant growth.

Prediction of Perinatal and Neurodevelopmental Outcomes in Newborns with a Birth Weight below the 3rd Percentile: Performance of Two International Curves - Prospective Cohort from a Brazilian City.

To evaluate the performance of Intergrowth-21 st (INT) and Fetal Medicine Foundation (FMF) curves in predicting perinatal and neurodevelopmental outcomes in newborns weighing below the 3rd percentile. Pregnant women with a single fetus aged less than 20 weeks from a general population in non-hospital health units were included. Their children were evaluated at birth and in the second or third years of life. Newborns (NB) had their weight percentiles calculated for both curves. Sensitivity, specificity, positive (PPV) and negative predictive value (NPV), and area under the ROC curve (ROC-AUC) for perinatal outcomes and neurodevelopmental delay were calculated using birth weight < 3rd percentile as the cutoff. A total of 967 children were evaluated. Gestational age at birth was 39.3 (±3.6) weeks and birth weight was 3,215.0 (±588.0) g. INT and FMF classified 19 (2.4%) and 49 (5.7%) newborns below the 3rd percentile, respectively. The prevalence of preterm birth, tracheal intubation >24 hours in the first three months of life, 5th minute Apgar <7, admission to a neonatal care unit (NICU admission), cesarean section rate, and the neurodevelopmental delay was 9.3%, 3.3%, 1.3%, 5.9%, 38.9%, and 7.3% respectively. In general, the 3rd percentile of both curves showed low sensitivity and PPV and high specificity and NPV. The 3rd percentile of FMF showed superior sensitivity for preterm birth, NICU admission, and cesarean section rate. INT was more specific for all outcomes and presented a higher PPV for the neurodevelopmental delay. However, except for a slight difference in the prediction of preterm birth in favor of INT, the ROC curves showed no differences in the prediction of perinatal and neurodevelopmental outcomes. Birth weight below the 3rd percentile according to INT or FMF alone was insufficient for a good diagnostic performance of perinatal and neurodevelopmental outcomes. The analyzes performed could not show that one curve is better than the other in our population. INT may have an advantage in resource contingency scenarios as it discriminates fewer NB below the 3rd percentile without increasing adverse outcomes.

Differing prevalence of microcephaly and macrocephaly in male and female fetuses.

To compare the proportion of female and male fetuses classified as microcephalic (head circumference [HC] < 3rd percentile) and macrocephalic (>97th percentile) by commonly used sex-neutral growth curves. For fetuses evaluated at a single center, we retrospectively determined the percentile of the first fetal HC measurement between 16 and 0/7 and 21-6/7 weeks using the Hadlock, Intergrowth-21st, and NICHD growth curves. The association between sex and the likelihood of being classified as microcephalic or macrocephalic was evaluated with logistic regression. Female fetuses (n = 3,006) were more likely than male fetuses (n = 3,186) to be classified as microcephalic using the Hadlock (0.4% male, 1.4% female; odds ratio female vs. male 3.7, 95% CI [1.9, 7.0], p < 0.001), Intergrowth-21st (0.5% male, 1.6% female; odds ratio female vs. male 3.4, 95% CI [1.9, 6.1], p < 0.001), and NICHD (0.3% male, 1.6% female; odds ratio female vs. male 5.6, 95% CI [2.7, 11.5], p < 0.001) curves. Male fetuses were more likely than female fetuses to be classified as macrocephalic using the Intergrowth-21st (6.0% male, 1.5% female; odds ratio male vs. female 4.3, 95% CI [3.1, 6.0], p < 0.001) and NICHD (4.7% male, 1.0% female; odds ratio male vs. female 5.1, 95% CI [3.4, 7.6], p < 0.001) curves. Very low proportions of fetuses were classified as macrocephalic using the Hadlock curves (0.2% male, < 0.1% female; odds ratio male vs. female 6.6, 95% CI [0.8, 52.6]). Female fetuses were more likely to be classified as microcephalic, and male fetuses were more likely to be classified as macrocephalic. Sex-specific fetal head circumference growth curves could improve interpretation of fetal head circumference measurements, potentially decreasing over- and under-diagnosis of microcephaly and macrocephaly based on sex, therefore improving guidance for clinical decisions. Additionally, the overall prevalence of atypical head size varied using three growth curves, with the NICHD and Intergrowth-21st curves fitting our population better than the Hadlock curves. The choice of fetal head circumference growth curves may substantially impact clinical care.

Comparison of different growth curves in the assessment of extrauterine growth restriction in very low birth weight preterm infants

BackgroundPreterm infants are at risk of extrauterine growth restriction (EUGR) and associated complications in the long term. Growth curves are important in assessing postnatal growth in these infants. The aim of this study was to determine the prevalence of EUGR in preterm infants and the factors associated with EUGR using two different growth curves. MethodsWe retrospectively evaluated 596 preterm infants with birth weight ≤1500 g. Small for gestational age (SGA) was defined as birth weight <10th percentile for gestational age. EUGR was defined as discharge weight z score <−2. All z scores were determined using both the Fenton 2013 and Intergrowth-21st (IG-21) growth curves. ResultsThe infants’ median gestational age was 28 weeks (27–29) and median birth weight was 1080 g (900–1243). The prevalence of SGA was 9.2% with IG-21 curves and 5% with Fenton curves (p < 0.001). The median discharge weight was 2060 g (1860–2363). The prevalence of EUGR was significantly higher with the Fenton curves than with the IG-21 curves (38% vs. 31.7%, p < 0.001). The mean discharge weight z score was −1.82±1.29 with Fenton and −1.44±1.49 with IG-21 curves. In multivariate analysis, significant risk factors for EUGR according to the Fenton curves were SGA (odds ratio [OR]: 19.15, 95% confidence interval [CI]: 4.4–82.59), respiratory distress syndrome (RDS) (OR 1.64, 95% CI 1.12–2.4), late neonatal sepsis (LNS) (OR: 2.27, 95% CI: 1.5–3.44), and >16 days to full enteral feeding (OR: 1.8, 95% CI: 1.22–2.68). Similarly, independent risk factors for EUGR according to the IG-21 curve were SGA (OR: 16.3, 95% CI: 7.23–36.9), RDS (OR: 1.81, 95% CI: 1.16–2.83), LNS (OR: 2.29, 95% CI: 1.43–3.68), and >16 days to full enteral feeding (OR: 2.11, 95% CI: 1.38–3.23). ConclusionThe growth curves used for diagnosis may lead to differences in EUGR rates in intensive care units and the factors identified as associated with EUGR. At-risk infants should be evaluated for EUGR and their weight and nutritional support should be monitored carefully. Comparisons of long-term outcomes are needed to assess the suitability of growth curves used for EUGR follow-up.

A New Birthweight Reference by Gestational Age: A Population Study Based on the Generalized Additive Model for Location, Scale, and Shape Method

BackgroundIt is important to choose a suitable birthweight reference to assess newborns, especially those that are small for gestational age (SGA). Currently, there is no regional standard reference for the north of China or for Shandong province.MethodsA total of 130,911 data records of singleton, live neonates born at 24–42 weeks of gestation were collected from 2016 to 2018 in Shandong province. A new birthweight-for-gestational age percentile reference was constructed based on the Generalized Additive Model for Location, Scale and Shape (GAMLSS) package in R version 3.5. The established gestational age weight curve was compared separately with the Fenton curve, INTERGROWTH−21st curve, and the Chinese Neonatal Network Standard curve of 2015.ResultsWe established the reference values of birthweight by gestational age at the 3rd, 10th, 25th, 50th, 75th, 90th, and 97th percentiles. Newborns had much heavier birthweights than those in the INTERGROWTH-21st and Fenton curves at most gestational ages. Although the newborns' birthweight references were closer to the Chinese Neonatal Network Standard except a few for gestational age, this study and INTERGROWTH-21st had similar birthweight curve shapes.ConclusionsThere are obvious differences among the criteria for newborn birthweights. Therefore, it is more accurate to assess newborns using the local birthweight reference.

Comparação das curvas de intergrowth-21st e de Fenton para avaliação de recém-nascidos prematuros

Abstract Objectives: to compare the intrauterine and postnatal growth of preterm infants according to the Intergrowth-21st and Fenton curves. Methods: study carried out in a maternity hospital, reference in high-risk pregnancy, with preterm infants born in 2018 who were hospitalized in the neonatal units of the institution. Preterm newborns weighed at least twice after birth were included in the sample and those that were syndromic, malformed or presented fluid retention were excluded. Proportions and means were compared using Pearson’s chi-square and Student’s t tests for paired samples, respectively. The McNemar test was used to compare categorical variables and the Kappa test to verify the degree of agreement between birth weight classifications obtained by the curves. Results: one hundred and fifty three infants with a median gestational age of 34.4 weeks were included. The incidences of the categories of nutritional status at birth did not differ between the curves. There was perfect agreement between the curves, except when newborns born under 33 weeks of gestational age were evaluated, in which case the agreement was substantial. About 21% of the babies classified as small for gestational age (SGA) by Intergrowth-21st were adequate for gestational age (AGA) according to Fenton and, on average, 20% of cases that had postnatal growth restriction (PNGR) according to Fenton standards were categorized as adequate weight by Intergrowth-21st. Postnatal weight classifications obtained by the evaluated curves had perfect agreement. Conclusions: the differences in theclassifications found between the charts reveal the importance of choosing the growth curve for monitoring preterm infants since behaviors based on their diagnoses can impact the life of this population.

A comparison of four fetal biometry growth charts within an Australian obstetric population.

The aim of this study was to investigate the applicability of four existing fetal growth charts to a local tertiary hospital obstetric population. Four existing fetal growth charts (the Raine study reference charts, INTERGROWTH-21st charts, World Health Organization (WHO) fetal growth study charts and Australasian Society for Ultrasound in Medicine (ASUM) endorsed Campbell Westerway charts were compared using data from 11651 singleton pregnancy ultrasound scans at King Edward Memorial Hospital (KEMH). The 3rd, 10th, 50th 90th and 97th percentile curves for abdominal circumference (AC) biometry for the KEMH data were calculated and the four primary correlation parameters from fitted 3rd order polynomials (a, b, c and d) were used to generate like-for-like comparisons for all charts. The overall comparisons showed a significant variation with different growth charts, giving different percentiles for the same fetal AC measurement. INTERGROWTH-21st percentile curves tended to fall below those of other charts for AC measurements. Both the Raine Study charts and ASUM charts were the charts of closest overall fit to the local data. Our data show the Raine Study charts are the most appropriate for our population compared with the other three charts assessed suggesting the 'one size fits all' model may not be appropriate. However, additional analysis of biometry measurements, primarily AC, is needed to address the deficiency of data at 14-18 weeks gestation which exists for the Raine Study data.A reasonable alternative may be to adopt the WHO charts with local calibration (including the 14 - 18 week gestation period).

Weight gain speed and z-score behavior in large prematures for gestational age.

Objective: to investigate the speed of weight gain (WG) and the z-score (E-z) of weight in premature neonates large for gestational age (LGA) during four weeks of hospitalization. Methods: a retrospective longitudinal study with premature neonates in a neonatal intensive care unit at a university hospital. Data were obtained from January 2017 to December 2018; 115 babies with gestational age (GA) ≥ 27 and < 37 weeks, non-twin, AGA or LGA were included. The WG (g/kg/day) was obtained from the nadir weight and the E-z was calculated online based on the Intergrowth-21st curves. Repeated-measures ANOVA and multiple linear regression were used to assess the association between WP and E-z and explanatory variables; p < 5 %. Results: mean GA was 32.5 weeks, birth weight was 1910 g and weight loss was 5 % at 7 days. WG was lower in LGA babies, with GI between 32 and 37 weeks (LGA, 9.2 ± 5.6 g/kg/day vs AGA, 13.9 ± 6.0 g/kg/day). The change in WG was explained by protein supply in AGA (B = 2.5 g/kg/day; 95 % CI, 0.7 to 4.3; and β = 0.543) and by GA in LGA (B = -0.05 g/kg/day; 95 % CI, -0.09 to -0.02; and β = -0.574). In the 4th week of hospitalization, weight E-z decreased similarly for LGAs and AGAs, and this variation was explained by growth. Conclusions: premature LGAs had lower WG compared to AGAs during the neonatal period. The linear and brain growth explained the variation in weight E-z among these preterms.

Comparison of growth curves in very low birth weight preterm infants after hospital discharge.

Monitoring preterm infants' growth is essential to ensure the best prognosis for their growth and development. We aimed to compare growth curves in very low birth weight preterm infants after hospital discharge. In this retrospective longitudinal study, 178 preterm infants' growth was assessed by z-scores for weight for age and length to age and compared between Fenton and Kim and Intergrowth-21st charts from hospital discharge until 50weeks postnatal, and between Intergrowth-21st and WHO charts, 50 and 64weeks postnatal. The Kappa test was used to evaluate the agreement of the number of cases classified above or below the -2 Z-score concerning weight-for-age and length-for-age indicators to each proposed curve. Our results found that the agreement between Fenton and Kim and Intergrowth-21st curves was almost perfect for most of the weeks investigated, except 35-38 (k = 0.79) and 47-50 (k = 0.61) weeks postnatal. When evaluating the agreement between WHO and Intergrowth-21st, it was substantial for most of the weeks investigated, except for 55-58 and 69-64weeks postnatal, in which the agreement was almost perfect (k = 0.84; k = 0.81, respectively). Furthermore, we observed that Fenton and Kim curve identified 8.4% and WHO, 5.8% more cases of preterm infants below -2 z than Intergrowth-21st.Conclusion: Although the agreement of the curves was substantial to almost perfect, the Fenton and Kim and WHO curve seem to identify more cases of preterm infants compared to the Intergrowth-21st, a finding that deserves more in-depth investigation in clinical practice. What is Known: • The adequate interpretation of postnatal growth depends on the standard growth chart. • Studies comparing the classification of anthropometric indicators of preterm infants between growth curves consider only the period from birth to hospital discharge. What is New: • This is the first study that compares the classification of weight-for-age and length-for-age indicators of VLBW preterm infants between Intergrowth-21st and Fenton and Kim curves until 64 weeks postnatal. • Substantial to almost perfect agreement of length-for-age indicator was found between the two growth curves of preterm infants during outpatient follow-up.

Perfil dos recém-nascidos prematuros atendidos no seguimento ambulatorial em uma cidade do sul do Brasil

Objetivo: Analisar o perfil de recém-nascidos prematuros atendidos em um seguimento ambulatorial em uma cidade do sul do Brasil. Métodos: Estudo observacional, retrospectivo, através de análise de prontuários. Foram incluídos todos os pré-termos com idade gestacional inferior a 35 semanas e após alta, tiveram acompanhamento regular até completar doze meses de idade corrigida, no período de janeiro de 2010 a dezembro de 2017. Resultados: Um total de 9419 prontuários foram revisados, entretanto apenas 397 preencheram os critérios de inclusão. Os prematuros acompanhados no ambulatório de pediatria tiveram um crescimento adequado e compatível com as curvas do Intergrowth-21. Na triagem neonatal, o teste da orelhinha apresentou maior alteração (10,3%), seguido do teste do pezinho (3,4%). As comorbidades mais prevalentes foram as alterações cardiológicas (51,1%), alterações no desenvolvimento neuropsicomotor (35,1%) e anemia (30,5%). Prematuridade extrema, baixo peso ao nascer e apgar abaixo de 7 no quinto minuto foram os fatores de risco mais associados as comorbidades encontradas. Conclusão: Os resultados sugerem que os prematuros acompanhados no ambulatório de pediatria da universidade têm um crescimento compatível com as curvas do Intergrowth-21, entretanto, é imprescindível o acompanhamento a médio e longo prazo, especialmente nos casos de prematuridade extrema, baixo peso ao nascer e apgar baixo para diagnóstico e intervenção precoce das morbidades.

INCIDENCE OF SMALL FOR GESTATIONAL AGE NEONATES, ACCORDING TO THE FENTON AND INTERGROWTH-21ST CURVES IN A LEVEL II MATERNITY.

ABSTRACTObjective: To compare the incidence of small for gestational age infants among late preterm and term newborns, using the Fenton and Intergrowth-21st curves.Methods: Observational and retrospective study with newborns in a level II maternity. The study was approved by the Institution’s Ethics Committee. Live births from July 2007 to February 2009 with a gestational age from 34 to 41 weeks and seven days were included. Neonates with incomplete data were excluded. Appropriate weight for gestational age was assessed by the Fenton and Intergrowth-21st intrauterine growth curves, considering birth weight <10th percentile as small for gestational age. The degree of agreement between the two curves was assessed by the Kappa coefficient. Numerical variables were compared using the Student t-test or the Mann-Whitney. Categorical variables were compared using the chi-square test. Statistical analyzes were performed using SPSS17® software, considering significant, p<0.05.Results: We included 2849 newborns with a birthweight of 3210±483 g, gestational age of 38.8±1.4 weeks; 51.1% male. The incidence of small for gestational age in the full sample was 13.0 vs. 8.7% (p<0.001, Kappa=0.667) by the Fenton and Intergrowth-21st curves, respectively. Among late preterm, the incidence of small neonates was 11.3 vs. 10.9% (p<0.001; Kappa=0.793) and among full-term infants it was 13.1% vs. 8.5% (p<0.001; Kappa=0.656), respectively for the Fenton and Intergrowth-21st curves.Conclusions: The incidence of small for gestational age newborns was significantly higher using the Fenton curve, with greater agreement between the Fenton and Intergrowth-21st curves among late preterm, compared to full term neonates.

Performance of a local reference curve for predicting small for gestational age fetuses in pregnant women with HIV/AIDS.

To compare the performance of a local estimated fetal weight curve with curves established for other populations to predict small for gestational age (SGA) fetuses. A retrospective and cross-sectional study involving 231 fetuses in which the performance of a local curve (proposed model) was compared with the Hadlock and Intergrowth-21st curves in the prediction of SGA fetuses, by applying them to a population of high-risk pregnant woman with HIV/AIDS. For each model, a receiver operating characteristic curve was adjusted, considering the SGA classification by the neonatal Intergrowth method as the gold standard, and the area under the curve (AUC) was calculated. The models presented linear correlations with each other. The agreement of the proposed model with Hadlock was very good (kappa = 0.83), whereas the proposed model and Intergrowth-21st had moderate agreement (kappa = 0.44). The SGA fetus detection sensitivities of the proposed model and Hadlock were 61.9% and 57.1%, with specificity of 84.1% and 86.2% and accuracy of 80.1% and 81%, respectively, without statistical difference. The sensitivity of the Intergrowth-21st model was 33.3%, while the accuracy was 85.7% and the specificity was 97.4%. The AUC estimated values for the Hadlock, proposed, and Intergrowth-21st models were 0.834, 0.832, and 0.835, respectively. The proposed model and Hadlock were interchangeable in the prediction of SGA fetuses and superior to the Intergrowth-21st model.

Prevalence and diagnostic accuracy of microcephaly in a pediatric cohort in Brazil: a retrospective cross-sectional study

ObjectiveWe sought to describe the prevalence of microcephaly and to compare the different cutoff points established by the Brazilian Ministry of Health at various times during a Zika virus epidemic. As a secondary aim, we investigated the possible etiology of the microcephaly. MethodThis retrospective study utilized newborn participants in the Zika Cohort Study Jundiaí. Newborns from the Zika Cohort Study Jundiaí with an accurate gestational age determination and complete anthropometric data were analyzed, and microcephaly was diagnosed according to the INTERGROWTH-21st curve. At delivery, fluids were tested for specific antibodies and for viruses. Brain images were evaluated for microcephaly. Receiver Operating Characteristic curves were plotted to define the accuracy of different cutoff points for microcephaly diagnosis. ResultsOf 462 eligible newborns, 19 (4.1%) were positive for microcephaly. Cutoff points corresponding to the curves of the World Health Organization yielded the best sensitivity and specificity. Three of the microcephaly cases (15.8%) were positive for Zika virus infections; nine (47.4%) had intrauterine growth restriction; one had intrauterine growth restriction and was exposed to Zika virus; three had a genetic syndrome (15.8%); and three had causes that had not been determined (15.8%). ConclusionsMicrocephaly prevalence was 4.1% in this study. Cutoff values determined by the World Health Organization had the highest sensitivity and specificity in relation to the standard IG curve. The main reason for microcephaly was intrauterine growth restriction. All possible causes of microcephaly must be investigated to allow the best development of an affected baby.

Generation of a malaria negative Ugandan birth weight standard for the diagnosis of small for gestational age.

ObjectivePlacental malaria is a known risk factor for small for gestational age (SGA) neonates. However, currently utilized international and African birthweight standards have not controlled for placental malaria and/or lack obstetrical ultrasound dating. We developed a neonatal birthweight standard based on obstetrically dated pregnancies that excluded individuals with clinical malaria, asymptomatic parasitemia, and placental malaria infection. We hypothesized that current curves underestimate true ideal birthweight and the prevalence of SGA.Study designParticipants were pooled from two double-blind randomized control trials of intermittent preventive therapy during pregnancy in Uganda. HIV-negative women without comorbidities were enrolled from 12–20 weeks gestation. Gestational age was confirmed by ultrasound dating. Women were followed through pregnancy and delivery for clinical malaria, asymptomatic parasitemia, and placental malaria. Women without malaria, asymptomatic parasitemia, or placental malaria formed the malaria negative cohort and generated the Ugandan birthweight standard. The Ugandan standard was then used to estimate the prevalence of SGA neonates in the malaria positive cohort. These findings were compared to international (Williams, World Health Organization (WHO), and INTERGROWTH-21st) and regional standards (Tanzanian and Malawi).Results926 women had complete delivery data; 393 (42.4%) met criteria for the malaria negative cohort and 533 (57.6%) were malaria positive. The Ugandan standard diagnosed SGA in 17.1% of malaria positive neonates; similar to the INTERGROWTH-21st and Schmiegelow curves. The WHO curve diagnosed SGA in significantly more neonates (32.1%, p = <0.001), and the Malawi curve diagnosed SGA in significantly fewer neonates (8.3%, p <0.001).ConclusionExclusion of women with subclinical placental malaria in malaria-endemic areas created birth weight norms at higher values and increased the detection of SGA. Birth weight standards that fail to account for endemic illness may underestimate the true growth potential of healthy neonates.

Differential classification of infants in United States neonatal intensive care units for weight, length, and head circumference by United States and international growth curves

Background Clinicians and researchers use a variety of intrauterine growth curves to classify NICU infants as small (SGA), appropriate (AGA), or large for gestational age (LGA). Since curve creation methods and samples vary, SGA/AGA/LGA cut-offs and resulting subgroups of infants vary among curves and impact outcome study findings - limiting generalisability. Aim Determine how two international and two US-specific curves classified US NICU infants. Subjects and methods Classified 192,888 infants from US NICUs (2013–2016) as SGA or LGA for birthweight, length, and head circumference, using the international Fenton and INTERGROWTH-21st curves and US-specific Olsen and Lubchenco (historical) curves. Results Modern curves classified approximately 10% of infants as SGA up to 32 weeks, but older infants had increased variability. The INTERGROWTH-21st curves consistently had rates above 10% for LGA after 32 weeks. Conclusions While Olsen and Fenton both fit, the Olsen curves had overall best-fit for our sample of US NICU infants. The INTERGROWTH-21st curves fit the definitions for SGA and LGA for younger ages, but inferences outside of these definitions are unwarranted due to limited sample size. The INTERGROWTH-21st sample used for 33 weeks and older infants was physically smaller at the upper percentiles than our sample of US infants.

Colostrum oropharyngeal immunotherapy for very low birth weight preterm infants: protocol of an intervention study

BackgroundThe oropharyngeal colostrum administration protocol to treat premature newborns is a possible and plausible strategy in neonatal health services, since the immunoprotective components of colostrum can be absorbed by the lymphoid tissues of the oropharynx. In this context, this study aims to describe the implementation of oropharyngeal colostrum immunotherapy in very low birth weight preterm newborns in a neonatal unit, as well as to test an algorithm in a public hospital.MethodsThe protocol is applied in a non-randomized, superiority clinical trial with historical control. In the treatment group, 0.2 mL of raw colostrum is dripped into the right and left oropharyngeal mucosa, totaling 8 administrations every 24 h until the 7th complete day of life interruptedly. The control group consists of very low birth weight preterm newborns born in the same hospital in previous years (historical control). The clinical progression of 60 newborns until hospital discharge is recorded on standardized forms. A total of 350 participants are estimated to complete the survey in 4 years. The occurrence of continuous outcomes between the groups are compared through the paired t-test or Wilcoxon’s two-sample test. The chi-square test or Fisher’s exact test, and survival analysis are used for binary outcomes. The nutritional status is assessed through Intergrowth-21st growth curves for preterm newborns.DiscussionThe flows of the protocol’s actions is sorted by an algorithm, compatible with the Brazilian reality of a public hospital. This measure facilitates and systematizes clinical care, organizes the team’s work process, speeds up the intervention steps, standardizes decision-making and unifies the quality of care, besides showing the feasibility of oropharyngeal colostrum immunotherapy.Trial registrationReBEC, U1111–1222-0598, Registered 09 October 2018, http://www.ensaiosclinicos.gov.br/rg/RBR-2cyp7c/.

Performance of local reference curve on the diagnosis of large for gestational age fetuses in diabetic pregnant women

Objective To evaluate the performance of a local fetal weight curve based on the prediction for large gestational age (LGA) newborns in diabetic pregnant women and to compare it to reference curves established for other populations. Method A reference model for estimated fetal weight was created from a local sample of 2211 singleton low-risk pregnancies. The estimated fetal weight from 194 women with gestational diabetes mellitus was then plotted on this curve, and the results were compared to those obtained by Intergrowth 21st and Hadlock curves. Results The sensitivity of the proposed model to predict LGA fetuses was 55.6%, the specificity was 82.1%, and the accuracy was 74.7%. The sensitivity, specificity, and accuracy for the Intergrowth 21st curve were 46.3%, 87.9%, and 76.3%, respectively, and no statistically significant difference was observed compared to the proposed model. Conversely, significant differences were observed for the Hadlock curve, which presented a lower sensitivity (24.1%), higher specificity (97.1%), and similar accuracy (76.8%). Conclusion The sensitivity of the proposed model was higher compared to the Hadlock curve for the screening of LGA newborns in diabetic pregnant women. However, no significant differences were observed in comparison to the Intergrowth 21st curve.

Local References for Ultrasound-Estimated Fetal Weight Based on 2,211 Singleton Pregnancies in the City of Curitiba, South of Brazil.

To develop reference curves of estimated fetal weight for a local population in Curitiba, South of Brazil, and compare them with the curves established for other populations. An observational, cross-sectional, retrospective study was conducted. A reference model for estimated fetal weight was developed using a local sample of 2,211 singleton pregnancies with low risk of growth disorders and well-defined gestational age. This model was compared graphically with the Hadlock and Intergrowth 21st curves. Reference curves for estimated fetal weight were developed for a local population. The coefficient of determination was R2 = 99.11%, indicating that 99.11% of the fetal weight variations were explained by the model. Compared with Hadlock curves, the 50th, 90th, and 97th percentiles in this model were lower, whereas the 10th percentile nearly overlapped, and the 3rd percentile was slightly higher in the proposed model. The percentiles were higher in the proposed model compared with the Intergrowth 21st curves, particularly for the 3rd, 10th, and 50th percentiles. We provide a local reference curve for estimated fetal weight. The proposed model was different from other models, and these differences might be due to the use of different populations for model construction.

\u201cINTERGROWTH21st vs customized fetal growth curves in the assessment of the neonatal nutritional status: a retrospective cohort study of gestational diabetes\u201d

BackgroundGestational diabetes mellitus is associated with increased incidence of adverse perinatal outcomes including newborns large for gestational age, macrosomia, preeclampsia, polyhydramnios, stillbirth, and neonatal morbidity. Thus, fetal growth should be monitored by ultrasound to assess for fetal overnutrition, and thereby, its clinical consequence, macrosomia. However, it is not clear which reference curve to use to define the limits of normality. Our aim is to determine which method, INTERGROWTH21st or customized curves, better identifies the nutritional status of newborns of diabetic mothers.MethodsThis retrospective cohort study compared the risk of malnutrition in SGA newborns and the risk of overnutrition in LGA newborns using INTERGROWTH21st and customized birth weight references in gestational diabetes. The nutritional status of newborns was assessed using the ponderal index. Additionally, to determine the ability of both methods in the identification of neonatal malnutrition and overnutrition, we calculate sensitivity, specificity, positive predictive value, negative predictive value and likelihood ratios.ResultsTwo hundred thirty-one pregnant women with GDM were included in the study. The rate of SGA indentified by INTERGROWTH21st was 4.7% vs 10.7% identified by the customized curves. The rate of LGA identified by INTERGROWTH21st was 25.6% vs 13.2% identified by the customized method. Newborns identified as SGA by the customized method showed a higher risk of malnutrition than those identified as SGA by INTERGROWTH21st. (RR 4.24 vs 2.5). LGA newborns according to the customized method also showed a higher risk of overnutrition than those classified as LGA according to INTERGROWTH21st. (RR 5.26 vs 3.57). In addition, the positive predictive value of the customized method was superior to that of INTERGROWTH21st in the identification of malnutrition (32% vs 27.27%), severe malnutrition (22.73% vs 20%), overnutrition (51.61% vs 32.20%) and severe overnutrition (28.57% vs 14.89%).ConclusionsIn pregnant women with DMG, the ability of customized fetal growth curves to identify newborns with alterations in nutritional status appears to exceed that of INTERGROWTH21st.