o battisti, vevey 2010 1 thoughts on fetal and neonatal growth: tissues and nutrition professor...

O Battisti, Vevey 2010 1

Professor Oreste Battisti,Professor Oreste Battisti,

ULg Faculty of MedicineULg Faculty of Medicine

Pediatrics and neonatologyPediatrics and neonatology


The Fetal and postnatal growth : the analysis of commonly used anthropometric charts

CM Drillien and F Cockburn:« Neonatal medicine »Churchill Livingstone


Growth contains different dimensions or vectors It can be assessed by - absolute indices: Weight, length, HC, skinfolds, circumferences,…- relative indices (ratios between indices):-The velocity of indices

Difficulties of growth in utero and afterwards changes the relative importance of vectors

And also can have lately consequences


The charts The nutrients

O Battisti, 555

Périods in weeks d BW g d BL cm d HC cm dBWg/dBLcm dBWg/dHCcm dBLcm/dHCcm

26-28 115( 70- 160 )

1 (.85-1.15) 1.1( 0.9 -1 .2 )

115( 35-115 )

110( 100-133)

0.9( 0.95-1 )

28-30 145( 100- 190 )

1.13( 0.63-1.63)

0.9( 0.7 – 1.3 )

125( 90-160 )

164( 115-213 )

1.34( 0.44-2.24 )

30-32 170( 108-232 )

1.2(.94– 1.54)

0.7( 0.7-1.3 )

182( 86-288 )

242( 117-376 )

1.35( 0.9-1.79 )

32-34 208( 148-268 )

1.23(.94- 1.54 )

0.8( 0.65-0.95 )

178( 70-286 )

253( 153-353 )

1.56( 0.97-2.15 )

34-36 242( 167-317 )

1( 0.6 – 1.4 )

0.7( 0.15-0.9 )

272( 174-370 )

392( 184-600 )

1.5( 1.1-2.5 )

36-38 213( 129 – 297 )

0.8( 0.3 – 1.3 )

0.5( 0.2-0.8 )

273( 166-380 )

459( 87-731 )

1.8( 1.1-2.5 )

38-40 143( 43-243 )

0.7( 0.1 – 1.3 )

0.33( 0.13-0.53 )

310( 0- 645 )

621( 0-1321 )

2.4( 0.5-0.34 )

40-42 70( 0 – 168 )

0.25( 0 – 0.6 )

0.17( 0 – 0.48 )

280( 0 – 583 )

420( 0 – 400 )

1.47( 0- 1.25 )

Mean 170( 57 – 283 )

0.9(.15 – 1.65 )

0.6( 0.04-1.1 )

223( 82-366 )

355( 14-686 )

1.66( 0.88 – 2.44 )


Stage I (Hyperplasia) - 4 to 20 weeks - Rapid mitosis - Increase of DNA content Stage II (Hyperplasia &

Hypertrophy) - 20 to 28 weeks - Declining mitosis. - Increase in cell size.


Stage III ( Hypertrophy) - 28 to 40 weeks - Rapid increase in cell size. - Rapid accumulation of fat, muscle and

connective tissue. 95% of fetal weight gain occurs during

last 20 weeks of gestations.

MRO2: 6 – 8 ml/kg/m BMR and MRO2

increase with GA CH: glucose ( proportional to

mother ) and lactate ( from the placenta )

High de novo synthesis of lipids

lipids glycogen proteins

NEFA,glycerol glucose Am acids

CO2 + ATP

hGH, E, NEGlucagon, ACTH,T4

Icortisol

Glucagon,E, NE,T4

I, hGH Cortisol

Insulin

Insulin

Cortisol,glucagon

cortisol

IhGH,Gucagon,E, NE, ACTHT4

ATP and 5-Pentose; In- and out-cells

composition Defenses against FR and

EAA BMR Muscles ( FFA ) and

intestines ( glutamine and KB ) have alternatives

- secretion + secretion

+ resistance

Catecholamines, somatostatin

Glucose, fructose

hGH, ACTH, cortisol, T4, HPL, glucagon, endorphins

Hypo-K+ AA, Leu, ILeu KB, acidosis, hypoxia, FFA

Beta-blockers, chlorpromazine,DPH, diazoxide

Kupfer cells, Xth nerve, beta-stimulators

Prematurity,

Glucagon, pancreozymin

rest exercise


The secretion of insulin in utero The role of insulin in utero The receptors to insulin in utero The secretion and role of HGH in utero


Authors weight length HC « type »:At birthpostnatal -> 60 weeks

parameters

Lubchenco1966

22 % 11% 10 % Diagnostic Ponderal index

Usher-Mc Lean 1969

26 % 8 % 6 % Diagnostic

Babson 1970-1976

14 % 8 % 9 % Diagnostic

Gairdiner1971

17 % 4 % 4 % Diagnostic and postnatal

Battisti1990

13 % 7 % 6 % Diagnostic postnatal

Ponderal index, LAC, LAC/HC, tricipital skf, several organs muscles

Dombrowski1996

13 % 5 % 4 % diagnostic

«normal population» if the CV < 19%, mean = médian = mode


Author(s), year(s) Intervals in weeks , parameters CV : BW CV : BL CV : HC

Babson, 1970,1976 26-42 ; 26-92 ; BW,BL,HC 14 8 9

Battisti, 1992 25-60 ; BW,BL,HC,PI 13 7 6

Dombrowski 1992, 26-42 ; BW,BL,HC 13 5.3 4

Gairdner 1971 26-60 ; BW,BL,HC 17 4.4 4

Lubchenco 1966, 1970 26-42 ; BW,BL,HC, PI 22 11 10

Usher-McLean 1969 25-44 ; BW,BL,HC 26 8 6


Author PCA and BW PCA and BL PCA and HC

Babson * BW= 176 PCA – 3696, SD = 2401 ; r = . 99

BL = 0.8 PCA + 17.5, SD = 10.8 ; r = . 99

HC= 0.48 PCA + 14, SD = 6.63 ; r =. 98

Battisti * =174 APC – 3665, SD = 434 ; r = .99

= 0.9 APC + 11.5, SD = 4; r= . 99

= 0.6 APC + 9.72,SD = 2.4 ; r= . 98

Dombrowski * = 174 APC – 3732, SD = 1262; r=.99

= 1.06 APC + 6.64, SD = 7.8; r=. 99

= 0.721 APC + 5.3, SD = 5.3; r = . 98

Gairdner * = 206 APC – 5051, SD = 2672; r = . 98

= 0.89 APC +13.6, SD = 13; r =. 99

= 0.5 APC + 13.94, SD = 6.5; r = . 98

Lubchenco * = 163 APC – 3375, SD = 1303; r =. 99

= 1.25 APC + 2.5, SD = 7.1; r =. 99

= 0.58 APC + 10.5, DS = 4.8; r =. 97

Usher-McLean * = 177 APC – 3741, SD = 1350; r =. 99

T= 1.11 APC +7, SD = 8.35; r =. 99

= 0.81 APC + 3.1, SD = 6.2; r=.99


Lubchenco curves


Way of characterizing the relationship of height to mass for an individual.

PI = 1000 x

Typical values are 20 to 25. PI is normal in symmetric IUGR. PI is low in asymmetric IUGR.

Mass (kgs) Height (cms)

3


PCA weeks BW g BL cm HC cm

25 560 ( 90 ) 31.6 ( 2.5 ) 22 ( 1.5 )

26 720 ( 115 ) 33.1 ( 2.6 ) 23.1 ( 1.6 )

28 1040 ( 200 ) 36.1 ( 2.8 ) 25.3 ( 1.8 )

30 1360 ( 218 ) 39.1 ( 3 ) 27.4 ( 1.9 )

32 1685 ( 275) 42.1 ( 2.5 ) 29.5 ( 1.8 )

34 2093 ( 335 ) 44 ( 3.5 ) 30.9 ( (2.2 )

36 2500 ( 430 ) 45.9 ( 2.4 ) 32.2 ( 2.3 )

38 2932 ( 469 ) 47.7 ( 3.8 ) 33.2 ( 2.3 )

40 3365 ( 445 ) 49.5 ( 2.6 ) 34.3 ( 1.6 )

42 3798 ( 608 ) 51.3 ( 4 ) 35.4 ( 2.5 )


0

1000

2000

3000

4000

5000

6000

25 26 28 30 32 34 36 38 40 42

PCa in weeks

Bo

dy

wei

gh

t

Body weight

-2 DS

+2 DS


0

10

20

30

40

50

60

70

25 26 28 30 32 34 36 38 40 42

PCA in weeks

Bo

dy

len

gth

Body length

-2 DS

+2 DS

0

5

10

15

20

25

30

35

40

45

25 26 28 30 32 34 36 38 40 42

PCA in weeks

Hea

d c

ircu

mfe

ren

ce Headcircumference

-2 DS

+2 DS

Dombrowski charts



25 800 ( 152 ) 35.6 ( 1.4 ) 26.2 ( 1 )

26 900 ( 175 ) 36.5 ( 1.5 ) 26.7 ( 1 )

30 1300 ( 245 ) 40.3 ( 1.6 ) 28.7 ( 1.15 )

34 2500 ( 475 ) 44.1 ( 1.5 ) 30.6 ( 1.2 )

38 2900 ( 550 ) 47.9 ( 1.9 ) 32.5 ( 1.6 )

42 4300 ( 815 ) 51.7 ( 2 ) 34.6 ( 1.4 )

46 4700 ( 890 ) 55.5 ( 2.2 ) 36.7 ( 1.5 )

50 5100 ( 970 ) 59.3 ( 2.4 ) 38.8 ( 1.6 )

54 5500 ( 1045 ) 63.1 ( 2.5 ) 40.9 ( 1.6 )

60 5900 (1120 ) 66.9 ( 2.7 ) 42.8 ( 1.7 )

O Battisti, Vevey 2010 22, , 2222

0

1000

2000

3000

4000

5000

6000

7000

8000

9000

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Bo

dy

wei

gh

t

Body weight

-2 DS

+2 DS


0

10

20

30

40

50

60

70

80

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Bo

dy

len

gth

Body length

-2 DS

+2 DS

0

5

10

15

20

25

30

35

40

45

50

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Hea

d c

ircu

mfe

ren


-2 DS

+2 DS

Gairdiner


PCA Measures at birth Measures afterwards Total

25 –28 468 225 693

29 – 31 1252 598 1850

32- 35 1092 518 1610

36 – 39 2494 1190 3684

40-42 2344 1118 3462

43- 60 1199 1199

Total 7650 4848 12498



25 686 ( 89 ) 35.3 ( 2.5 ) 25 ( 1.5 )

26 860 ( 112 ) 36.2 ( 2.5 ) 25.6 ( 1.5 )

30 1555 ( 202 ) 40 ( 2.8 ) 28 ( 1.7 )

34 2250 ( 293 ) 43.8 ( 3 ) 30.5 ( 1.8 )

38 2950 ( 384 ) 47.6 ( 3.3 ) 32.9 ( 1.97 )

42 3645 ( 474 ) 51.4 ( 3.6 ) 35.3 ( 2.1 )

46 4340 ( 564 ) 55.2 ( 3.9 ) 37.8 ( 2.25 )

50 5035 ( 654 ) 59 ( 4.1 ) 40.2 ( 2.4 )

54 5730 ( 745 ) 62.8 ( 4.4 ) 42.6 ( 2.55 )

60 6775 ( 880 ) 68.5 ( 4.8 ) 46.3 ( 2.78 )

262626O Battisti, Vevey, 2010O Battisti, Vevey, 2010

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1000

2000

3000

4000

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7000

8000

9000

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Bo

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Body weight

-2 DS

+2 DS

272727O Battisti, Vevey, 2010O Battisti, Vevey, 2010

0

10

20

30

40

50

60

70

80

90

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Bo

dy

len

gth

Body length

-2 DS

+2 DS

0

10

20

30

40

50

60

25 26 30 34 38 42 46 50 54 60

PCA in weeks

Hea

d c

ircu

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-2 DS

+2 DS

Battisti


Brain: 15%

Muscles: 25%


previous aspect ofIUGR

Actual aspect ofprematurity

In Growth retardation:- increase their hemoglobin;- Relative high cerebral mass;- Decrease of P-pyruvate kinase In very low birthweight:- lower effect of insulin on glycogenesis and on

glycogenosis; these activities increase afer 34-40 w;- Limited gluconeogenesis;- Inappropriate ( in excess ) endogenous adrenergic

activity;


Is particular in very preterm babies But also in case of cardiac dysfunction or

malformation In case of NEC In case of bowel malformation

Pt g Lp g Kcal

SGA 2.8-4 4.2-6 82

AGA 2.1-3 3.2-4.5 67

GA TMR kcal BMR kcal needs g Pt syn g

24 82 35 3.42 1.43

28 84 38 3.40 1.54

32 86 41 3.38 1.65

36 88 44 3.36 1.76

40 90 47 3.34 1.87

44 92 50 3.32 1.98

% retained Expended lost

Kcal 46 42 12

CH 11 88 1

Pt 60 23 17

Lp 70 10 20


120

6-8

120

6-8

Kcal/kg/d

QO2 l/kg/m

50-6060-70% carbohydrates

25-30< 5% Lipids

10-1520-30% Proteins

In utero after

Proteins are the main component in nutrition;

Even if proteins are done of aminoacids, proteins and aminoacids need to be considered in different ways;

Proteins turnover is linked to metabolic rate and to oxygen consumption

Proteins have a central role in nutrition and in growth. There is none storage, even if their turnover is high.

d BW g/kg/d = 3.44 Pt intake g/kg/d + 7.34 ( Rahia, 1994 ) Pt needs g/kg/d = 3.5 – 0.00354 GA ( Rahia, 1994 ) Pt synthesis = 0.0269 GA + O.785 ( Widdowson, 1977 ) Pt synthesis = 0.173 BMR – 2.56 ( Beaufrère, 1990 ) d BW g = 3.6 Pt intake + 0.095 Energy intake – 0.0047 + 1.7 ( Heird, 1989 ) d PC = 0.1598 Pt intake + 0.253 ( Battisti, 1990 ) d BL = 0.336 Pt intake + 0.253 ( Battisti, 1990 ) Pt content % BW = 0.7 GA + 1.86 ( Widdowson, 1977 ) VO2 = 62 + 2 ml/kgProtein/min ( Battaglia, 1997 )

Aminoacids coming from mother: the sources are her intakes and her muscles;

From these sources, 70 % go to the fetus and 20 % to the placenta;

[ Fetus / Mother ] AA ratio is 1.5 - 2 Three types of transporters for AA in the placenta = A, L,

ASC; This transport is depending on delivery of O2 to the fetus;

when O2 delivery t the fetus decreases, AA delivery decreases also.

A : GABA, glycine ( return from serine*, leucine, isoleucine and valine ), serine*, threonine*, gutamine* and alanine*;

L: proline, serine*, threonine*, glutamine*, alanine*, leucine, isoleucine,valine, phenylalanine;

ASC: serine*, threonine*, glutamine*, alanine* * use the three types of transporters; Remember that « fetal milk « contains 25-30 % of AA, 60-

70 % of carbohydrates ( glucose and lactate ) and less than 3 % of EFA; and that fetal milk is passing essentialy through the liver.

IQ global at 7.5 – 8 years= dBWg/kg/day + 84.5 ; this should be comprised between 14.5 and 17 g / kg / day.

IQ verbal at 7.5 – 8 years = 1.29 dBW/kg/day + 79. But also other parameters … ( i.e. head

circumference at 9 months, mother status, …)

3 Purposes of that turnover: - primary protection, - losses replacements, - degradations of peptides; Within tissues: in fetus and neonate, the proteins turnover is very high in the

liver ( 50 % ) and in the brain ( 44 % );Proteins turnover is low in the other tissues ( in muscles= 3.2 % ).

These values are different in the adult: 57 % in liver, 50 % in kidney, 17 % in brain, 18 % in heart, 15 % in skeletal muscles.

Within body: proteins turnover is mainly represented by the muscles and

intestines;

Overall: 1 g tissue growth = 3 – 3.5 kcal; 0.086 g PT 0.105 G Lp; Protein synthesis: is correlated to activities of hormones ( hGH, somatomedins,

insulin , T4), to a caloric intake well proportionated and higher than 70 kcal/kg/d, and activities of skeletal muscles.

The quantitative needs of proteins can be estimated to values comprised between 2.5 ( TPN ) to

3.5 ( EN ) g/kg/d and these should be accompanied by 35 kcal/g of proteins;

The qualitative needs of proteins should contain 48 % essential AA ( mixture of casein and

albumin ).


-Weight in g =175 PCA weeks – 3665 ( SD = 13 % )-Length in cm = PCA weeks + 11 ( SD = 8 %)-HC in cm = 0.6 PCA weeks + 10 ( SD = 6 % )

Corrected correlations in the assessment of Postnatal growth in premature babies


[ d W g / d HC cm ] per week = 44 PCA – 1138 (SD = 13 %, r = 0.973)

[ d L cm / d HC cm ] per week = 0.094 PCA – 1.543 (SD 14 %, r = 0.88)


BW g without IUGR = 174 PCA – 3665 ( 13 % ) BW g with RCIU = 148 PCA – 3894 ( 18 % ) L cm = 0.95 PCA + 11.53 ( 7 % ) HC cm = 0.61 PCA + 9.72 ( 6 % ) LAC cm = 0.26 PCA – 1.685 ( 2% ) LAC / HC = 0.56 APCs + 6.5 ( 4% ) dWg / dL cm = 18.5 APCs – 404 ( 10 % ) dWg / dHCcm = 44 PCAs – 1138 ( 9.5 % ) dLcm / dHCcm = 0.094 APCs – 1.543 ( 6.5 % ) dHC cm = 0.1598 Pt in g/kg/j + 0.253 dLcm = 0.336 Pt in g/kg/j + 0.253Ponderal index: only at birthBody mass Index: only after 34 PCA

! Protein intakes

O Battisti, Vevey 2010

474747

intakes AA = 25-30 %

Glucose+lactate

= 70 %Lip = essentials FA

< 2 %

Mean Mean values/weekvalues/week

dBWdBW

= 170 g= 170 gdBLdBL

= 1 cm= 1 cmdHC dHC

= 0.6 cm= 0.6 cm

< 30 w 145g 1.13 cm 0.9 cm

30-32 170 g 1.2 0.7

32-34 208 1.23 0.8

34-36 242 1 0.7

36-38 213 0.8 0.5

38-40 143 0.7 0.33

40-42 70 0.25 0.17

dBW: variable DL: variable dHC: variable


1 cm HC 1200 ( 250 ) kcal 1 mm Lobe frontal

1 g brain 13.3 (9 ) kcal 18.6 ( 12 ) si retard croissance

1 g muscle 8.7 ( 1.6 ) kcal 19.5 ( 9 ) si rc

1 g weight 4.8 (0.6) kcal 8.9 ( 1 ) si rc

1 cm length 800 ( 40 ) kcal 1280 ( 145 ) si rc

1 mm tsf 395 ( 108 ) g weight 25-30 fat

1 cm LAMC 445 ( 94 ) g weight 98 ( 21 ) g muscles

1 g weight 0.086 g protein 0.15 g weight


For length:- dL cm = 0.587 +0.796 Ptin – 0.0888 CHin – 0.124 Lpin

( r=0.908) 82 %- = 0.336 Ptin +0.253 (r=0.743) 49 %

For body weigth:- dW g = 243.44 + 12.06 CHin – 59.22 Ptin – 17.65 Lpin (r=0.852)- = 297.71 – 23.9 Lpin (r=0.793) 62 %- = 4.744 Calin – 101.3 Ptin (r=0.608) 36 %

For head circumference- dHC cm =0.2836 +0.244 Ptin + 0.0062 Lpin – 0.186 CHin (r=0.995) 99 %- = 0.1598 Ptin +0.253 (r=0.952) 90 %


Mother milk(not modified):CEPW = 10.5 (2.3)CEPL = 4 (1)CEPHC = 3.9 (0.5) PT formulaCEPW = 10.9 (4.3) CEPL = 4.8 (1.5)CEPHC = 3.3 (1) T formulaCEPW = 8.2 (3.3)CEPL = 5 (2.5)CEPHC = 3.4 (0.8)

ns

P < 0.05


Type of baby

- Kcal /gW- Kcal/ cm L- Kcal/cm HC

None G Retardation G retardation

4.8 (0.6) < 0.001 8.9 (1)

798 (40) < 0.001 1276 (145)

1145 (64) ns 1167 (52 )

Non growing growing

BMR kcal/kg/d 51.6 ( 2.3 ) 64.5 ( 4.9 )

CH % 66.6 ( 2.5 )

80.2 ( 4.6 )

Lp % 24.1 ( 3.9 )

13 ( 5 )

Pt % 9.1 ( 2 ) 6.6 ( 0.8 )


Conclusions:Considering biochemical facts concerning different parameters ofGrowth:There are charts for making a diagnosis at birth, Not all are equivalent, mainly for body weigth;There are charts for postnatal growth, but better are the relative indices for harmonious postnatal growth;

In the postnatal growth, it is very important to be precise About What tissues is being assessedAbout the type and amount of proteins intakes

o battisti, vevey 2010 1 thoughts on fetal and neonatal growth: tissues and nutrition professor...

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