is the infants bmi important ? sonya misra mbbs mph oct 17 2014

IS THE INFANTS BMI IMPORTANT ?Sonya Misra MBBS MPH

Oct 17 2014

Disclosures• Nothing to Disclose

• except

• I think growth is very important.

Objectives • Define BMI components and Growth Charts• Discuss the differences between growth pattern of

Preterm Infants and Term babies• Discuss some of the evidence demonstrating importance

of growth on Neurodevelopmental Outcomes

Wikipedia

What is mothers first question ?

BMI• Formula : weight (kg) / [height (m)]2 • BMI is a fairly reliable screening indicator of body fatness

for most adults.• BMI does not measure body fat directly, but research has

shown that BMI correlates to direct measures of body fat, such as underwater weighing and dual energy x-ray absorptiometry (DXA).

Air Displacement Plethysmography

vMeasure of Adiposity and Lean body mass

Gestation TermBody Weight 3.3 kgOFC 34 cmLength 50 cmFat Free mass normalBody fatness 10 %

Gestation 26 weeks now termBody Weight 2.5 kgOFC 33 cmLength 46 cmFat free mass lowBody fatness 20 %

So far our Primis have been showing a lack of lean body mass and more abdominal fat

1. Term Infants of Diabetic mothers have a higher body fat percent compared to infants of mother without diabetes 2. This increase of body fat is also seen in a cohort of babies from 30 to 36 weeks

At SCVMCResearch

Gestation TermBody Weight 5 kgOFC 33 cmLength 50 cmBody fatness 25 %

Gestation 26 weeks now termBody Weight 2.5 kgOFC 33 cmLength 46 cmBody fatness 20 %

So far our Primis show a lack of lean body mass and more abdominal fat

Disproportionate growth reduced length

reduced fat free mass

Abdominal Fat

Too little lean body mass

2010 NICHD 79 % of VLBW weigh < 10th at 36 weeks

Abdominal fat in Adults• Linked to lower muscle mass• Possibly due to lower estrogen• Visceral fat has been linked to

• Cardiovascular disease • Type 2 diabetes• Colorectal Cancer

• Low Physical Activity and High calorie diets

3.5 weeks and 5lb 7oz vs. 12 months and 17lb 13oz

By Spencer Lacy

Growth and Neurological Outcomes

The Course of Postnatal Growth in VLBW Infants predicts neurological outcomes better than the weight for age at birthBeatrice Latal-Hajnal et al J Pediatr2003:143:163-70

Birth 9 months 2 years

10%ile

AGA

SGA

MDI 101.7PDI 101.8

MDI 94.9PDI 89.9

Length of SGA stayed SGA had 10 point lower MDI than those that recovered.OFC did not predict outcomes

Weight Gain• Many different studies • Franz 2008 Correlation between weight at discharge and

outcomes at 5 years of age• Children with Catch up growth also less problems• Better Growth to discharge associated with better

motor development and cognitive development

American DataGrowth Velocity with outcomes 18 -22 monthsEhrenkranz et al Pediatrics 2006;117;1253

NICHD network 1994-1995 600 babiesChildren Less than 1000 gm

1st Quartile

2nd Quartile 3rd Quartile 4th Quartile

Weight gain gm/kg/day

12 15.6 17.8 21.2

MDI 75.7 77.7 79.7 80.9PDI < 70 % 35 32 18 14Normal Neuro Exam

70 77 76 86

Neurodevelopmental Impairment %

55 49 41 29

3.5 weeks and 5lb 7oz vs. 12 months and 17lb 13oz

By Spencer Lacy

Growth

500 children 1974 to 79 rainbow babies VLBW

Normal Head

Subnormal head < 2 SD

IntelligenceVerbal IQ

97 84.1

Performance IQ 95.9 82.1

Academic Achievementa. Reading

93.7 77.2

b. Math 94.3 86.1

c. Spelling 90.6 78.6

8 year old outcomes based on HC at 8 Months Hack et al continued

Failure of Length or linear growth and Outcomes

• Lean Body mass• Hardest hit of all the measurements• Most nutritional strategies have failed to help• Non nutritional factors ?

• Stress hormones ? • Inflammation

Same Factors responsible for both Shorter Lengths and Poor outcomes• Nutritional -

• Protein 4.2 -4.8 g/kg/day normal neurogenesis dendritic arborization synaptogenesis and myelin production

• Carbohydrates • Fat • Zn

• Inflammatory chronic - IL6 and TNF alpha • Affect neurons and white matter• Suppressing GH/IGF-1 axes

Summary• Good Growth cannot be considered to be weight gain

alone• Changes in HC or Length are also associated with long

term neurodevelopmental changes• Best outcomes in better grown babies• Important to monitor closely with growth charts and body

composition• Enhance Fat Free Mass by

Minimize inflammation

Adequate Protein Intake

Exercise

Massage ?

Pro Growth Interventions New Directions

• OLD Make sure you have enough calories and protein and micronutrients

• Massage – several studies have shown up to a 20 % increase in weight gain.

• Reduce inflammation. Work on ways to decrease CLABSI• Breast milk feeding better bacteria ?• Increase parasympathetic tone

• Decrease pain • Reduce anxiety/stress – Skin to skin• Frequent family visits

CARING FOR THE FAMILYYou can make a difference !