Extrauterine Growth Retardation In Very Low Birth Weight Infants And Its Relationship With Nutritional Management In The Neonatal Intensive Care Unit:a Multicenter Study

ObjectiveTo investigate the incidence and risk factors of extrauterine growth retardation(EUGR)in very low birth weight infants(VLBWI),explore the relationship between the occurrence of EUGR and nutritional management of NICU and construct the risk prediction model of EUGR.The severity of EUGR was quantified and compared at the level of the Neonatal Intensive Care Unit(NICU)to evaluate the quality of nutritional management in different NICUs,so as to provide a clinical basis for quality improvement of nutritional management in NICU.MethodsThis prospective,multicenter observational cohort study was conducted based on Shandong Neonatal Network(SNN).The clinical data of the VLBWI(n=2979),who were admitted to 40 neonatal intensive care units from January 1,2018 to December 31,2020,were collected and analyzed.According to the weight at discharge or 36 weeks of postmenstrual age,all the enrolled VLB WI were assigned into EUGR group and non-EUGR group.Univariate and multivariate logistic regression analyses were used to detect the risk factors for EUGR and construct the risk prediction model of EUGR in preterm small for gestational age(SGA)and non-SGA infants.Weight Z scores at birth and discharge were calculated by the method of Fenton.Using data from one NICU as the reference,a linear regression model of change in weight Z score from birth to discharge was developed as a quantification of EUGR to evaluate the severity of EUGR in 6 NICU.Results1.The current status of EUGR:a total of 2979 VLBWI were enrolled,with 49.8%(1485/2979)male and 12.1%(360/2979)SGA.The incidence of EUGR in the whole group was 57.7%(1270/2979),and were 78.3%(90/115)and 46.9%(53/113)in extremely preterm infants(EPI)and extremely low birth weight infant(ELBWI),respectively.The incidence of EUGR and severe EUGR in SGA and non-SGA infants were 93.1%(335/360)and 52.9%(1385/2979),73.3%(264/360)and 52.9%(1385/2979),respectively.2.Risk factors of EUGR:logistic regression analysis showed that,withholding feeds(OR=1.220,1.092,95%CI:1.018-1.461,1.060-1.124,both P=0.032,<0.001)and time to achieve full enteral feeding(OR=1.043,1.030,95%CI:1.000-1.089,1.020-1.040,P=0.049,<0.001)were independent risk factors of EUGR in both SGA and non-SGA infants.For non-SGA infants,gestational age(OR=1.963,95%CI:1.628-2.303,P<0.001),hypertensive disorders during pregnancy(OR=1.277,95%CI:1.013-41.609,P=0.039),the duration of invasive ventilation(OR=1.044,95%CI:1.029-1.059,P<0.001)and feeding intolerance(OR=1.270,95%CI:1.048-1.539,P=0.015)were independent risk factors of EUGR.3.The prediction model of EUGR:for SGA was established as logit(P)=2.387-1.723×IVF(1 or 0)+0.199×withholding feeds(d)+0.043×time to achieve full enteral feeding(d),for non-SGA infants was logit(P)=-14.837+0.661 ×gestational age(w)-0.004×birth weight(g)-0.017× birth weight centile+0.244×hypertensive disorders during pregnancy(1 or 0)+0.043×the duration of invasive ventilation(d)+0.088×withholding feeds(d)+0.030×time to achieve full enteral feeding(d)+0.239×feeding intolerance(1 or 0).4.Evaluate the quality of nutrition management of different NICUs by quantifying EUGR:a total of 1166 VLBWI were enrolled from six level 3 NICU(A,B,C,D,H,I)with more than 100 cases in SNN,with 51.7%(603/1166)male and 48.3%(563/1166).The incidence of EUGR was 57.6%(672/1166),range from 48.3%-74.3%.By quantifying the EUGR,significant differences were found in the quality of nutrition management in 6 NICUs.The quality care indexes of NICU-A,B,C,D,H and I were 0.000±0.249,-1.777±2.283,-0.211± 1.844,0.246±1.745,-1.082±2.189,-1.494±2.6,respectively.The incidence of EUGR and quality care index for NICU-D were 43.8%(84/192)and 0.246±1.745,this suggested that the nutritional management quality of NICU-D was the highest among the 6 NICUs.Conclusions1.The incidence of EUGR is high in VLBWI.In addition to the prevention of maternal perinatal complications and improving the basis of intrauterine growth,avoiding delaying feeds after birth and achieve full enteral feeding early may reduce the incidence of EUGR.2.Nutritional management levels were significantly different among different NICUs.Establishing benchmarking units and conducting evidence-based quality improvement to narrow the gap in nutritional management levels between NICUs are expected to improve the overall growth outcome of VLBWI.