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 on 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-21 st Growth Charts • Intergrowth 21 project (2009-2014) • Prescriptive standards for growth between pregnancy and early infancy Recently published and not yet implemented in many countries • 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
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 AGA SGA LGA Total (70%) (23.6%) (6.4%) AGA 7975 267 186 8428 (73%) (94.6%) 3.2% of (2.2% of Kappa Fenton’s Fenton’s 0.887 AGA) AGA) Fenton SGA 99 2467 0 2566 (22.2%) (3.9%) (96.1%) LGA 13 3 539 555 (4.8%) (2.3%) (0.5%) (97.1%) Total 8087 2737 725 11549 During study period 11549 neonates were analyzed Shaded area represents agreement
Results: Birth Length-Fenton versus Intergrowth-21 Intergrowth AGA SGA LGA Total (19.7%) (60.6%) (19.7%) Fenton AGA 1457 37 0 1494 (15.4%) (97.5%) (2.5%) Kappa SGA 472 5769 835 7076 0.709 (72.6%) (6.7%) (81.5%) (11.8%) LGA 0 92 1085 1177 (12%) (7.8%) (92.2%) Total 1929 5898 1920 9747 Shaded area represents agreement
Results : Head Circumference- Fenton versus Intergrowth-21 Intergrowth AGA SGA LGA Total (14.6%) (70.7%) (14.7%) Fenton AGA 1268 280 0 1568 (15.5%) (82.1%) (17.9%) Kappa 0.753 SGA 198(3%) 6274 116 6588 (64.9%) (95.2%) (1.8%) LGA 0 631 1359 1990 (19.6%) (31.7%) (68.3%) Total 1486 7175 1475 10146 Shaded area represents agreement
Results :Discharge data-Fenton Classification n Classification n <10 th centile <10 th centile 388 410 (46%) (50.2%) VLBW VLBW 10 th -90 th centile 10 th -90 th centile 430 379 (46.4%) babies babies (51%) born born AGA >90 th centile >90 th centile AGA by by 25 (3%) 27(3.3%) Fenton Intergrowth 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 one • 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 of the INTERGROWTH-21 st 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.
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