Incidence of and Risk Factors for Extrauterine Growth Restriction in  Preterm Infants with Gestational Age Less Than 32 Weeks or Birth Weight Less Than 1,500 Grams

Mallika Pomrop; Nawinda  Rueang-amnat

Authors

Mallika Pomrop Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand https://orcid.org/0000-0001-7203-5067
Nawinda Rueang-amnat Department of Pediatrics, Faculty of Medicine, Chiang Mai University, Thailand

Keywords:

extrauterine growth restriction, preterm infant, very low birth weight

Abstract

Objective To determine the incidence and risk factors for extrauterine growth restriction (EUGR) in preterm infants with gestational age (GA) less than 32 weeks or birth weight (BW) less than 1,500 grams.

Methods A retrospective cohort study reviewed preterm infants admitted at Chiang Mai University Hospital between January 1, 2017, and December 31, 2020. EUGR was defined as weight below the 10^th percentile at 36 weeks postmenstrual age based on the Fenton growth chart. Data were analyzed, with a p-value of less than 0.05 considered statistically significant. Multivariate regression analysis was adjusted for confounding variables.

Results Among 310 eligible infants, 201 (64.8%) were diagnosed with EUGR. All of 76 SGA infants (100.0%) were EUGR. Significant risk factors included proven sepsis (OR 3.90, 95%CI 1.13-13.45, p = 0.03), diuretic use (OR 3.62, 95%CI 1.47-8.91, p = 0.005), definite NEC (OR 3.54, 95%CI 1.60-7.83, p = 0.002), maternal gestational hypertension (OR 2.36, 95%CI 1.28-4.35,
p = 0.006), and multiple births (OR 1.85, 95%CI 1.04-3.28, p = 0.04). Nutritional risk factors were delayed full enteral feeding (OR 1.08, 95%CI 1.03-1.12, p = 0.001) and higher initial glucose infusion rate (GIR) in TPN (OR 1.28, 95%CI 1.11-1.48, p = 0.001). Infants with EUGR had longer hospital stays and higher hospital costs than non-EUGR infants. Multivariate analysis showed significant risks including definite NEC (OR 2.45, 95%CI 1.01-5.96, p = 0.049), maternal gestational hypertension (adjusted OR 2.79, 95%CI 1.46-5.33, p = 0.002), and multiple births (adjusted OR 2.29, 95%CI 1.24-4.24, p = 0.008).

Conclusions Multiple births, maternal gestational hypertension, SGA status, and NEC were associated with a higher risk of EUGR in preterm infants less than 32 weeks or VLBW. Providing proper antenatal care for mothers with multiple pregnancies or gestational hypertension, along with optimized postnatal care, can help improve growth outcomes and reduce the incidence of EUGR in these infants.

References

Liao W, Lin M, Wang T, Chen C; Taiwan Premature Infant Follow-up Network. Risk factors for postdischarge growth retardation among very-low-birth-weight infants: A nationwide registry study in Taiwan. Pediatr Neonatol. 2019;60:641-7.

Ruth VA. Extrauterine growth restriction: a review of the literature. Neonatal Netw. 2008;27:177-84.

De Curtis M, Rigo J. Extrauterine growth restriction in very-low-birthweight infants. Acta Paediatr. 2004; 93:1563-8.

Radmacher PG, Looney SW, Rafail ST, Adamkin DH. Prediction of extrauterine growth retardation (EUGR) in VVLBW infants. J Perinatol. 2003;23:392-5.

Collaborative Group for the Nutritional, Growth and Developmental Study on Very Low Birth Weight Infants. [Postnatal growth of very low birth weight infants during hospitalization]. Zhonghua Er Ke Za Zhi. 2013;51:4-11. Chinese. PubMed PMID: 23527924.

Hsu CT, Chen CH, Lin MC, Wang TM, Hsu YC. Correction: Post-discharge body weight and neurodevelopmental outcomes among very low birth weight infants in Taiwan: A nationwide cohort study. PLoS One. 2019;14(1):e0211526. PubMed PMID: 30682164.

Clark RH, Thomas P, Peabody J. Extrauterine growth restriction remains a serious problem in prematurely born neonates. Pediatrics. 2003;111:986-90.

Peila C, Spada E, Giuliani F, Maiocco G, Raia M, Cresi F, Bertino E, Coscia A. Extrauterine growth restriction: definitions and predictability of outcomes in a cohort of very low birth weight infants or preterm neonates. Nutrients. 2020;12(5):1224. PubMed PMID: 32357530.

Figueras-Aloy J, Palet-Trujols C, Matas-Barceló I, Botet-Mussons F, Carbonell-Estrany X. Extrauterine growth restriction in very preterm infant: etiology, diagnosis, and 2-year follow-up. Eur J Pediatr. 2020; 179:1469–79.

Victora CG, Villar J, Barros FC, Ismail LC, Chumlea C, Papageorghiou AT, et al. Anthropometric characterization of impaired fetal growth: risk factors for and prognosis of newborns with stunting or wasting. JAMA Pediatr. 2015;169:e151431. PubMed PMID: 26147058

Black RE, Victora CG, Walker SP, Bhutta ZA, Christian P, de Onis M, et al. Maternal and child undernutrition and overweight in low-income and middle-income countries. Lancet. 2013;382(9890):427-51.

Hedderson MM, Gunderson EP, Ferrara A. Gestational weight gain and risk of gestational diabetes mellitus. Obstet Gynecol. 2010;115:597-604.

Blencowe H, Cousens S, Oestergaard M, Chou D, Moller AB, Narwal R, et al. National, regional, and worldwide estimates of preterm birth rates in the year 2010 with time trends since 1990 for selected countries: a systematic analysis and implications. Lancet. 2012;379(9832):2162-72.

Fenton TR, Kim JH. A systematic review and meta-analysis to revise the Fenton growth chart for preterm infants. BMC Pediatr. 2013;13:59. PubMed PMID: 23601190

Villar J, Cheikh Ismail L, Victora C, Ohuma EO, Bertino E, Altman DG, et al. International standards for newborn weight, length, and head circumference by gestational age and sex: The Newborn Cross-Sectional Study of the INTERGROWTH-21st Project. Lancet. 2014;384:857-68.

Lee A, Kozuki N, Cousens S, Stevens G, Blencowe H, Silveira M, et al. Estimates of burden and consequences of infants born small for gestational age in low- and middle-income countries with INTERGROWTH-21st standard: analysis of CHERG datasets. BMJ. 2017;358. PubMed PMID: 28893769.

Tozzi M, Moscuzza F, Michelucci A, Lorenzoni F, Cosini C, Ciantelli M, et al. ExtraUterine Growth Restriction (EUGR) in preterm infants: growth patterns, nutrition, and epigenetic markers. a pilot study. Front Pediatr. 2018;6:408. PubMed PMID: 30619799.

Zozaya C, Avila-Alvarez A, Arruza L, García-Muñoz Rodrigo F, Fernandez-Perez C, Castro A, et al. The effect of morbidity and sex on postnatal growth of very preterm infants: a multicenter cohort study. Neonatology. 2019;115:348-54.

Reuter S, Moser C, Baack M. Respiratory distress in the newborn. Pediatrics In Review. 2014;35:417–29.

Benitz W; Committee on Fetus and Newborn, American Academy of Pediatrics. Patent ductus arteriosus in preterm infants. Pediatrics. 2016;137. PubMed PMID: 26672023.

Gregory KE, DeForge CE, Natale KM, Phillips M, Van Marter LJ. Necrotizing enterocolitis in the premature infant: neonatal nursing assessment, disease pathogenesis, and clinical presentation. Adv Neonatal Care. 2011;11:155–64.

Smith WL, McGuinness G, Cavanaugh D, Courtney S. Ultrasound screening of premature infants: longitudinal follow-up of intracranial hemorrhage. Radiology. 1983;147:445–8.

Gilfillan M, Bhandari A, Bhandari V. Diagnosis and management of bronchopulmonary dysplasia. BMJ. 2021;375:n1974. PubMed PMID: 34670756

Shan HM, Cai W, Cao Y, Fang B, Feng Y. Extrauterine growth retardation in premature infants in Shanghai: a multicenter retrospective review. Eur J Pediatr. 2009;168:1055-9.

Oh W, Poindexter B, Perritt R, Lemons J, Bauer C, Ehrenkranz R, et al. Association between fluid intake and weight loss during the first ten days of life and risk of bronchopulmonary dysplasia in extremely low birth weight infants. J Pediatr. 2005;147:786-90.

Stewart A, Brion L, Ambrosio-Perez I. Diuretics acting on the distal renal tubule for preterm infants with (or developing) chronic lung disease. Cochrane Database Syst Rev. 2011;2011:CD001817. PubMed PMID: 21901679.