Classify fying growth appropriateness at t bir irth: Fenton v - - PowerPoint PPT Presentation

Classify fying growth appropriateness at t bir irth: Fenton v vs In Intergrowth 21 growth charts

Manisha Mehta ,Manoj Modi, Anup Thakur, Pankaj Garg , Arun Soni , Neelam Kler , Satish Saluja

Introduction

• 26 million neonates born in India every year
• 12 to 30% are Small for gestational age
• Appropriateness of growth at birth is usually described based
• n Intrauterine growth charts
• Two common types of growth charts used
• Growth references (descriptive)
• Growth standards (prescriptive)

Introduction

• Preterm infants are at risk for poor growth during hospital stay

and beyond

• No consensus regarding how to monitor the growth of preterm

infants

• We can use growth charts which are:
• Cross sectional
• Longitudinal
• Fetal–infant growth charts
• Indian data on size at birth compared with international data

shows that our birth weights are lower

• Chance of misclassifying the infants at birth

Fenton’s and Intergrowth’s charts still are two commonly used

Revised Fenton 2013 Growth charts

• Based on large cross-sectional

data of approximately 4 million infants (1991 and 2007)

• From 6 developed countries

(Germany, Italy, United States, Australia, Scotland and Canada)

• Gender specific
• Does not take postnatal weight

loss into consideration

Intergrowth-21st Growth Charts

• Intergrowth 21 project (2009-2014)
• Prescriptive standards for growth

between pregnancy and early infancy

• Data from 8 geographic locations

(developed and developing countries ), multiethnic population, including India

• Developed growth standards for fetal

growth, postnatal growth in preterm and standards for assignment of size for gestational age at birth in new born

• Gender specific

Recently published and not yet implemented in many countries

Objective

• To compare Fenton and Intergrowth-21 for classification of

anthropometric parameters of newborns at birth and at discharge

Materials and Methods

• Study design
• Retrospective Observational study (during January 2008 to

December 2018)

• Settings
• Level III NICU
• Study population
• Newborns admitted in NICU
• Excluding major malformations/Deaths/Transfer/LAMA

Anthropometry

• Anthropometric measurements performed by a trained

labour room nurses at birth and at discharge

• Birth weight recorded within 10 min of birth
• Birth weight and discharge weight were performed with

digital electronic scales (accuracy of ± 5 g)

• The length and the Head Circumference (HC) documented

within 24 h of birth

• Length at birth and discharge recorded with an

infantometer to the nearest 0.1 cm

• HC at birth and discharge measured at the maximum

circumference of the head (i.e. occipito-frontal) with a non- stretchable tape to the nearest 0.1 cm

Materials and methods: Data Collection

• Gestational age and anthropometric parameters at birth and discharge

were retrieved from database

• Neonates were classified as <10th centile, 10-90th centile and >90th

centile on Fenton’s as well as on Intergrowth-21 charts

• Agreement between two charts for above classification was checked

using kappa statistics

• Among VLBW neonates, incidence of EUGR (defined as discharge weight

less than 10th centile) during NICU stay was also evaluated using Fenton’s charts and Intergrowth preterm postnatal follow up charts

Results: Birth weight-Fenton versus Intergrowth-21

Intergrowth Kappa 0.887 AGA (70%) SGA (23.6%) LGA (6.4%) Total Fenton AGA (73%) 7975 (94.6%) 267 3.2% of Fenton’s AGA) 186 (2.2% of Fenton’s AGA) 8428 SGA (22.2%) 99 (3.9%) 2467 (96.1%) 2566 LGA (4.8%) 13 (2.3%) 3 (0.5%) 539 (97.1%) 555 Total 8087 2737 725 11549

During study period 11549 neonates were analyzed Shaded area represents agreement

Results: Birth Length-Fenton versus Intergrowth-21

Intergrowth Kappa 0.709 AGA (19.7%) SGA (60.6%) LGA (19.7%) Total Fenton AGA (15.4%) 1457 (97.5%) 37 (2.5%) 1494 SGA (72.6%) 472 (6.7%) 5769 (81.5%) 835 (11.8%) 7076 LGA (12%) 92 (7.8%) 1085 (92.2%) 1177 Total 1929 5898 1920 9747

Shaded area represents agreement

Results : Head Circumference- Fenton versus Intergrowth-21

Intergrowth Kappa 0.753 AGA (14.6%) SGA (70.7%) LGA (14.7%) Total Fenton AGA (15.5%) 1268 (82.1%) 280 (17.9%) 1568 SGA (64.9%) 198(3%) 6274 (95.2%) 116 (1.8%) 6588 LGA (19.6%) 631 (31.7%) 1359 (68.3%) 1990 Total 1486 7175 1475 10146

Shaded area represents agreement

Results :Discharge data-Fenton

VLBW babies born AGA by Fenton Classification n VLBW babies born AGA by Intergrowth Classification n <10th centile 388 (46%) <10th centile 410 (50.2%) 10th -90th centile 430 (51%) 10th -90th centile 379 (46.4%) >90th centile 25 (3%) >90th centile 27(3.3%) Total 843 Total 816 Kappa=0.894

Discussion

• Reddy et al studied 603 babies <=32 weeks
• Found 3% of infants who were AGA (weight) on Fenton charts

identified as SGA by Intergrowth charts (3.2% of Fenton’s in our study)and 2.3% of infants who were AGA (weight) on Intergrowth charts were identified as SGA by Fenton charts (3.9% in our study)

Discussion

• Tuzun et al(n=248 very preterm) compared the Intergrowth

standards and Fenton 2013 references to classify birth size and incidence of EUGR at discharge

• Incidence of IUGR (weight) at birth was higher (12% versus

15%)(23.6% versus 22.2%)and EUGR (weight) at discharge was lower 40.2% versus 31.5%) (50.2% versus 46%)with Intergrowth when compared to Fenton references

• Difference in proportions of EUGR with these 2 charts maybe

because of differences in the intrauterine and extrauterine environment and nutrition

• None of the study assessed agreement between the two groups

Strengths and Limitations

• Strengths:
• Reasonable sample size
• Exact weeks and days to classify
• Limitation:
• Retrospective design
• Anthropometry taken by different observers

Conclusions

• There is good agreement between Fenton’s and Intergrowth-

21 chart for centiles categories for birth weight

• For head circumference and length, agreement is moderate

(70-75%)

• Approximately 50% of VLBW neonates experience EUGR by

discharge

Conclusions

• Despite good agreement,a proportion of babies may be

misclassified in either of the charts

• Can have clinical implications in managing these babies

Implications

• Need for evaluation of new standards against currently used
• ne
• NNF should come with recommendations stating which

chart to use to classify based on size at birth

• EUGR definition as well as charts for classification need to

be stated for nationwide use

• Further studies needed to evaluate functional impact of

differences on long term outcomes

References

• Fenton TR, Kim JH. A systematic review and metaanalysis to

revise the Fenton growth chart for preterm infants. BMC

• Pediatr. 2013;13(1):59.
• Villar J, Giuliani F, Bhutta ZA, et al. Postnatal growth

standards for preterm infants: the preterm Postnatal Follow- up Study of the INTERGROWTH-21(st) Project.Lancet Glob

• Health. 2015;3(11):e681–e691.
• Villar J, Giuliani F, Fenton TR, et al. INTERGROWTH- 21st very

preterm size at birth reference charts.Lancet. 2016;387(10021):844–845. 2019 Oct 27:1-8.

References

• Villar J, Cheikh Ismail L, Victora CG, et al. International

standards for newborn weight, length, and head circumference by gestational age and sex: the newborn Cross-Sectional Study

• f the INTERGROWTH-21st Project. Lancet.

2014;384(9946):857–868.

• Reddy KV, Sharma D, Vardhelli V, Bashir T, Deshbotla SK, Murki
• S. Comparison of Fenton 2013 growth curves and Intergrowth-

21 growth standards to assess the incidence of intrauterine growth restriction and extrauterine growth restriction in preterm neonates ≤32 weeks. J Matern Fetal Neonatal Med

• Tuzun F, Yucesoy E, Baysal B, Kumral A, Duman N, Ozkan H.

Comparison of INTERGROWTH-21 and Fenton growth standards to assess size at birth and extrauterine growth in very preterm

• infants. J Matern Fetal Neonatal Med. 2018 Sep;31(17):2252-

2257.

Thank You!