Indian Pediatr 2010;47: 843-844
Improving Growth Outcomes of VLBW Infants: How
Richard A Ehrenkranz
Professor of Pediatrics and Obstetrics, Gynecology &
Reproductive Sciences, Yale University School of Medicine,
New Haven, CT 06520-8064.
n 1977, the American Academy of
Pediatrics Committee on Nutrition first stated that the goal of
nutritional management of VLBW infants should be to permit the rate of
extrauterine growth and the composition of weight gain to approximate that
of a normal fetus of the same postmenstrual age, if the infant had
remained in utero(1). However, it has become clear that such a goal
is more often not reached, especially by ELBW infants(2). The paper by
Saluja and colleagues published in this issue of Indian Pediatrics(3)
is the first report to confirm that observation on the Indian
subcontinent. Although not an unsurprising finding, this report enumerates
several issues that should be considered by investigators studying growth
of VLBW infants.
Whenever possible, reference intrauterine growth curves
should reflect the population studied. Although the authors noted this
limitation to their study, they selected Fenton’s intrauterine growth
reference(4) to determine AGA vs SGA and to calculate z-scores.
Unfortunately, Fenton’s data do not reflect one population; birth weight
data are from a Canadian birth cohort and the length and head
circumference data are from Swedish and Australian cohorts. In addition,
given the high incidence (48%) of SGA in Saluja’s study population, the
reader might question the accuracy of gestational age assessment, which
was not defined, or the extent that race/ethnicity, life style differences
or prenatal care affected birth weight. Therefore, establishing
intra-uterine growth reference curves for the Indian subcontinent should
be a perinatal research priority. An example of new intrauterine growth
curves based on a large cohort based on US data was recently published(5).
Second, while the described fluid and nutrition policy
appeared quite reasonable and comparable to currently recommended "early
aggressive" nutritional support regimes, several aspects would be subject
to significant practice variation. For example, the authors state: "Enteral
feeds were initiated as soon as possible, preferably on the first day of
life, if haemodynamically stable. Increments of 20-30 mL/kg/d were made as
tolerated. Human milk was preferred and once infants reached an enteral
intake of 100 mL/kg/d, human milk fortifier ….were added to increase the
calories to 80 kcal/100mL with an additional protein intake of 0.6
g/kg/d." The early initiation and rate of advancement of enteral feeding,
especially with human milk, are admirable. How-ever, early parenteral
nutrition support was only offered to those infants not expected to be on
full enteral nutrition within the first 5 days of life, increasing the
potential for protein and energy deficits, which are difficult to overcome
prior to hospital discharge(6). Therefore, fluid and nutrition policies
that optimize the transition of nutritional support from initiation to
achievement of full enteral nutrition and during maintenance enteral
nutrition should be recommended and encouraged.
It is hoped that promoting growth of VLBW infants
should lead to improved long term neuro-developmental outcomes(7). In
order to change practices that support that goal, an understanding of the
growth outcomes achieved with current practices is essential. Saluja and
colleagues should be commended for initiating that process.
Competing interests: None stated.
1. American Academy of Nutrition Committee on
Nutrition. Nutritional needs of low-birth-weight infants. Pediatrics 1977;
2. Ehrenkranz RA. Early, aggressive nutritional
management for very low birth weight infants: What is the evidence? Semin
Perinatol 2007; 31: 48-55.
3. Saluja S, Modi M, Kaur A, Batra A, Soni A, Garg P,
et al. Growth of very low birth-weight Indian infants during
hospital stay. Indian Pediatr 2010; 47: 851-856.
4. Fenton TR. A new growth chart for preterm babies:
Babson and Benda’s chart updated with recent data and a new format. BMC
Pediatr 2003; 3: 13-22.
5. Olsen IE, Groveman SA, Lawson ML, Clark RH, Zemel
BS. New intrauterine growth curves based on United States data. Pediatrics
2010; 125: e214-e224.
6. Embleton NE, Pang N, Cooke RJ. Postnatal
malnutrition and growth retardation: An inevitable consequence of current
recommendations in preterm infants? Pediatrics 2001; 107: 270-273.
7. Ehrenkranz RA, Dusick AM, Vohr BR, Wright LL, Wrage
LA, Poole WK, et al. Growth in the neonatal intensive care unit
influences neurodevelopmental and growth outcomes of extremely low birth
weight infants. Pediatrics 2006; 117: 1253-1261.