Journal of Tropical Pediatrics, 2018, 64, 126–131

doi: 10.1093/tropej/fmx038
Advance Access Publication Date: 3 June 2017
Original paper

Postnatal Weight Gain Patterns in Preterm

Very-Low-Birth-Weight Infants Born in a
Tertiary Care Center in South India

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by Georgie Mathew1, Vijay Gupta1*, Sridhar Santhanam1
and Grace Rebekah2
1
Department of Neonatology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004, India
2
Department of Biostatistics, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004, India
*Correspondence: Vijay Gupta, Department of Neonatology, Christian Medical College and Hospital, Vellore, Tamil Nadu 632004, India.
E-mail <[email protected]>.

ABSTRACT
Background: Extrauterine growth retardation is a common problem in preterm, very-low-birth-
weight (VLBW) babies, as well as paucity of growth charts that follow their postnatal growth.
Aim: To evaluate and plot postnatal weight gain patterns of preterm VLBW babies of <34 weeks’
gestation born at a tertiary care neonatal unit in South India.
Methods: Weight gain patterns of all preterm (27 to < 34 weeks’ gestation) and VLBW (<1500 g)
neonates were used for plotting the centile curves by retrospective review of electronic medical re-
cords. The growth velocity was calculated from birth and from the time baby regained their birth
weight.
Results: Mean growth rate (6SD) of these babies was 16.2 6 2.4 g/kg/day and average time to re-
gain birth weight was 14.2 days (range 12.0–17.6).
Conclusion: The recommended growth velocity of 10–15 g/kg/day can be achieved using unforti-
fied expressed breast milk, though at higher feeding volumes of 200 ml/kg/day. These centile curves
can be useful for monitoring postnatal growth.

K E Y W O R D S : preterm, very low birth weight, newborn, postnatal growth charts

INTRODUCTION extrauterine environment, varied nutritional require-

Rapid strides in the field of neonatology have ments and morbidity associated with both prematur-
increased the survival of more and more premature ity and low birth weight. The general target of
infants born at lower gestational ages than ever be- weight gain in the neonatal intensive care unit is
fore [1]. Postnatal nutrition of very-low-birth-weight to replicate the intrauterine growth in the third tri-
(VLBW) babies remains a challenge to the practicing mester, which equates to daily weight gain of nearly
neonatologist especially in low- and middle-income 15 g/kg/day with infants receiving 120 kcal/kg/day
countries like India, where not much feeding alterna- [2].
tives are available. In-utero growth charts (like Modified Fenton
Postnatal growth of infants is different from in- 2013 [3], Babson and Benda 1976 [4] and
utero growth for various reasons, including Lubchenco 1963 [5]) do not account for the initial

C The Author [2017]. Published by Oxford University Press. All rights reserved. For Permissions, please email: [email protected]
V  126
 Postnatal Weight Gain Patterns in Preterm Very-Low-Birth-Weight Babies  127

weight loss of neonates and project growth under measurements were taken. To calculate the weight
ideal conditions (intrauterine environment). Hence, gain velocity, each day weight gain was calculated,
postnatal growth charts like Ehrenkranz 1999 [6], divided by previous day weight or the birth weight
Dancis 1948 [7], etc. are needed to study the growth (whichever was higher). The growth velocity of the
pattern of these infants. There are few intrauterine baby was calculated as mean of each day growth vel-
growth charts (e.g. Kandraju et al. [8]) available for ocity from the time of regain of birth weight until
plotting growth from the Indian population. Only discharge as well as from birth until discharge.
few postnatal growth charts (Saluja et al. [9] and
Kumar et al. [10]) are available from northern India

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and none from other parts of India. The Intergrowth Statistical analysis
21st chart [11] has to some extent addressed this
issue. However, it provides a reference standard and Distribution and smoothing
not the actual weight gain of preterm babies in a spe- Box-Cox t distribution was assumed to get over with
cific region. skewness in the modeling. Cubic Spline smoothing
Paucity of appropriate growth charts, especially to has been used for generation of graphs using the
follow postnatal growth of the preterm VLBW popu- Generalized Additive Models for Location Scale and
lation in these regions, is a definitive problem. This Shape (GAMLSS) method using the R software
study aims to plot the weight gain patterns (growth [12]. These are semi-parametric regression-type
curves) of premature VLBW infants born in a ter- models, where the response variable follows param-
tiary care center in South India. etric distribution. The R software was used in gener-
ating the 3rd, 10th, 50th, 90th and 97th percentiles,
mean and standard deviations.
MATERIAL AND METHODS
Settings and subjects
This retrospective study was conducted at a tertiary Fluid and nutrition policy
care neonatal unit in South India between January VLBW infants were started on 80 mL/kg/d of fluid
2013 and December 2014. The Institutional Review (5–10% dextrose) on first day of life and daily incre-
Board and hospital Ethics Committee approved the ments of 10–20 ml/kg/day at the clinical discretion
study. The postnatal weight patterns of all new- of the physician. The total fluid intake was regulated
born babies who were of <34 weeks of gestation to allow physiological weight loss. All VLBW infants
and <1500 g at birth were recorded from admission were started on parenteral nutrition (PN) from the
until discharge. Newborn babies with life-threatening second day of life with protein intake of 1–2 g/kg/d
morbidities and/or major congenital malformations and lipid intake of 1 g/kg/d. Daily increments of
and babies who needed fortification due to inad- 1 g/kg/d were made, with a maximum intake of
equate weight gain were excluded from the study. 3.5 g/kg/d of amino acid and 3 g/kg/d of lipid, tar-
Newborn babies who stayed for less than 7 days geting a parenteral caloric intake of 70–90 kcal/kg/d.
(168 h) in the hospital or those whose complete Enteral feeds were initiated as soon as possible,
growth parameters were not available were also preferably on the first day of life, if the baby was
excluded from the study. hemodynamically stable. Increments of 10–30 mL/
Gestational age was recorded as per obstetrical es- kg/day were planned and increased if tolerated
timates based on first trimester ultrasonography and enterally till a maximum of 200 ml/kg/day. As far as
if it was not available, by date of last menstrual possible, expressed breast milk (EBM) from the
period. Nude baby weight was taken once daily by mother was preferred for enteral feeding and any
using an electronic weighing scale (Essae DS 852, extra volume of milk, if ever needed, was obtained
EssaeTeroka Limited India) with error 65 g. If there from a pool of expressed milk from the screened
was a large discrepancy with respect to previous day mothers of all the infants after their informed
weight (usually more than 50 g,) repeat consent.
128  Postnatal Weight Gain Patterns in Preterm Very-Low-Birth-Weight Babies

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Fig. 1. Flow diagram depicting flow of the study.

Table 1. Distribution of newborn based on birth weight was in 28-week gestational age (17 days) and
weights minimum time noted in 33-week gestational age.
Average weight gain (g/kg/day) calculated from
Birth weight (g) Number n (%) birth until discharge ranged from 9.5 to 10.8 g/kg/
800 7 (3.4) day in newborns of all gestations, except in newborns
801–900 2 (1.0) of 27 weeks’ gestation, where weight gain was
901–1000 21 (10.1) 5.3 g/kg/day. Inconsistent weight gain in babies
1001–1100 27 (13.0) of  27 weeks’ gestation may be due to enrollment
1101–1200 34 (16.4) of fewer babies. The growth velocity from the time
1201–1300 32 (15.5) babies regained their birth weight until dis-
1301–1400 40 (19.3) charge ranged from 15.9 to 18.3 g/kg/day (mean:
1401–<1500 44 (21.3) 16.24 6 2.4 g/kg/day). The number of babies en-
Total 207 rolled for plotting growth curves (Supplementary
Figs S2–S7) for each gestational age gradually
declined with increase in postnatal day especially
after 3–4 weeks of age because of discharges
RESULTS
(Supplementary Tables S3–S8).
A total of 207 newborn babies were included in the
final analysis (Fig. 1). There were 106 (51.2%) males
and 101(48.8%) females. There were 44 (21.3%) DISCUSSION
babies who were small for gestational age (SGA), Preterm VLBW infants are at an increased risk of
159 (76.8%) were appropriate for gestational age postnatal growth failure due to hostile ex-utero envir-
(AGA) and 4 (1.9%) were large for gestational age onment and impaired postnatal nutrition [9]. This
(LGA), as per Fenton’s (2013) growth charts [3]. poor postnatal growth has significant bearing on
Distribution based on weight and gestational age is long-term neuro-developmental outcome and hence
given in Tables 1 and 2. defies the concept of intact survival [13, 14].
Mean birth weight 6 SD was 1226.7 6 191.7 g. To ensure optimal postnatal growth, we need the
Mean time (6 SD) to reach full volume feeds population-specific robust postnatal growth charts to
was8.6 6 2.6 days. Average time to regain birth monitor their growths and to intervene appropriately
weight was 14.2 days (2 weeks), with range from12.0 if it falters. There are many growth charts available
to 17.6 days. A serial reduction in time to regain like Babson and Benda [4], UK WHO NICM
birth weights was observed with increasing gesta- growth chart [15], Gairdner and Pearson chart [16],
tional age. Maximum mean time to regain birth Fenton 2003 [17], Fenton 2013 [3], PPFS study
 Postnatal Weight Gain Patterns in Preterm Very-Low-Birth-Weight Babies  129

Table 2. Time to regain birth weight, reach full volume feeds and average growth velocity of new-
born based on gestational age
Gestational Number Mean 6 SD Mean 6 SD Time Mean time to Average weight Average weight
age (% SGA) Birth weight (g) to reach full volume regain birth gain per kg gain per kg per day
feeds 150 (ml/kg/day) weight (days) per day(g) after regaining
birth weight (g)

 27 weeks 6 (0) 1073.336436.72 12.063.7 14.6766.74 5.28 11.12

28 weeks 28(7.1) 1049.116152.54 10.663.7 17.5764.45 9.65 15.85
29 weeks 22 (9.1) 1154.326202.49 8.962.1 15.163.48 9.48 16.95

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30 weeks 38 (2.6) 1192.896171.39 8.462.0 13.9765.28 10.81 17.07
31 weeks 46 (15.2) 1261.856185.3 8.162.1 13.263.31 10.00 17.10
32 weeks 39(23.1) 1326.926140.02 7.962.0 12.7263.68 10.29 18.29
33 weeks 28(82.1) 1344.116141.3 7.662.5 11.9663.86 9.57 17.31
Mean 6 SD growth velocity 9.3061.83 16.2462.37

[18] and Intergrowth 21st [11]. There are very few and may not reflect the actual postnatal growth
postnatal growth charts to suit the Indian population achieved in any preterm population. Hence, we
[9, 10], in spite of the high number of VLBW babies should have a growth chart specific to our population
born in India. We thus tend to use standards from without excluding the antenatal risk factors leading
the Western population, which may not be justified, to intrauterine growth retardation/premature deliv-
as the growth pattern of Indian fetuses may not ap- ery and should try to achieve the growth between
proximate with their Western counterparts [19]. 10th and 90th percentile.
Hence, using the Western growth standards for our The currently used longitudinal postnatal growth
VLBW babies may be imprecise and not appropriate. charts [6] that accounted for physiological weight
Application of intrauterine growth curves to loss are somewhat outdated in terms of huge turn-
monitor postnatal growth of preterm infants may be around in preterm nutrition practices in the past two
inadequate in the first week of postnatal life due to decades. Kumar et al. [10] also stressed the need of
physiological weight loss after birth and even after population-specific growth charts, as our newborn
that due to different morbidities, different ex-utero babies were smaller at birth and were growing at a
environment and nutritional factors [6, 20]. slower growth velocity.
Approximating postnatal growth of babies with intra- In our study, mean age to regain birth weight
uterine growth standards may not be realistic and ranged from 12.0 days for 33 weeks’ gestation to
may be physiologically biased. Attempting to achieve 17.6 days for 28 weeks’ gestation, which was quite
the intrauterine growth rates after physiological comparable with other studies. Mean age (6SD) to
weight loss may be achieved by increased body fat, regain birth weight was 10.0 (3.7) in AGA and 8.7
predisposing the baby to metabolic syndrome later (3.5) days in SGA babies in a study by Saluja et al.
in life [21]. Pereira-da-Silva et al. suggested reassign- [9]. The cohort in the Pre MGS study [23] reached
ing a new z score trajectory target after physiological their birth weight by 10–12 days and cohort of the
weight loss appropriate for postnatal environment ra- NICHD study [6] reached their birth weight by
ther than approximating their postnatal growth with mean of 13–17 days.
birth z score trajectory [22]. Growth velocity of our babies (Supplementary
Intergrowth 21st [11] has developed preterm Figs S2–S7, Supplementary Tables S3–S8) was not
growth charts for babies of  33 weeks’ gestation much different from the available fetal and postnatal
taking the population with lowest risk factors. This growth standards. The weight gain velocity from the
will serve as a reference standard for ideal growth day of regaining birth weight was maximum of
130  Postnatal Weight Gain Patterns in Preterm Very-Low-Birth-Weight Babies

18.3 g/kg/day in 32 weeks’ gestation and minimum ACKNOWLEDGEMENTS

of 11.1 g/kg/day in  27 weeks’ gestation. The The authors thank and acknowledge the Medical Record
weight gain velocity from birth ranged from a min- Department at Christian Medical College Vellore for their
imum of 5.3 g/kg/day in  27 weeks to a maximum help and support in retrieving the inpatient medical records
of 10.8 g/kg/day in 30 weeks of gestation. The usual of enrolled patients for the study.
postnatal weight loss is not evident in lower percent-
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