Putting The NeonatalPreterm MalnutritioIndicators Into Practice

Putting the Neonatal/Preterm Malnutrition
Indicators into Practice

Tuesday, September 25, 2018 • 4:00 - 5:00 PM ET
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1. Define the criteria by which infants are classified as neonate that purpose.
and/or preterm
2. Provide detailed discussion of each recommended indicators of Faculty and Planning Committee Commercial Relationship
malnutrition Disclosures and Conflicts of Interest (COI)
3. Outline the thresholds used to define mild, moderate, and severe In relation to the topic being presented.
malnutrition
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Putting the Neonatal/Preterm
Malnutrition Indicators into
Practice
September 25, 2018
4:00 – 5:00 PM ET
Malnutrition Awareness Week TM Schedule

Monday, Tuesday, Wednesday, Thursday, Friday,
September 24 September 25 September 26 September 27 September 28
4:00 – 5:00 PM 4:00 – 5:00 PM 4:00 – 5:00 PM 4:00 – 5:00 PM 12:00 – 1:00 PM
ET ET ET ET ET
Diagnosing Putting the Community Adult and Pediatric Virtual Lunch with
Malnutrition in the Neonatal/Preterm Nutrition Nutrition the Experts:
Obese Patient: A Malnutrition Resources: What Screening Legislation for
General Approach Indicators into is Available for the Systematic Malnutrition
Practice Discharged Review: Updates Prevention
Patient? from the Academy
of Nutrition and
Dietetics
5
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Session Moderator Topics & Faculty

Diane Barsky, MD Putting the Neonatal/Preterm Putting the Neonatal/Preterm

Infant Malnutrition Indicators Infant Malnutrition Indicators
Physician Nutrition Specialist into Practice into Practice
Division of Gastroenterology, Dena Goldberg, PhD, RD
Hepatology, and Nutrition, Susan Carlson, MMSc RD,
Neonatal Nutrition Specialist,
Children’s Hospital of Carilion Clinic Children’s Hospital
CSP, LD
Philadelphia, Philadelphia, PA Neonatal Dietitian
Assistant Professor,
University of Stead Family
Department of Pediatrics, Virginia
Children’s Hospital, Iowa City,
Tech Carilion School of Medicine,
IA
Roanoke, VA
6
Malnutrition Indicators into Practice
Dena Goldberg, PhD, RD

Carilion Children’s
Roanoke, VA
Disclosures
No conflicts of interest related to this presentation
7
Learning Objectives
Upon completion of this session, the learner will be able to….
1. Describe the development of the recommended indicators for

identifying malnutrition in preterm infants and neonates and why
identifying malnutrition is important
2. Use the recommended indicator days to regain birth weight to identify
malnutrition
3. Use the recommended indicator nutrient intake to identify malnutrition
Development of the Indicators

• Academy of Nutrition and Dietetics Pediatric Nutrition Practice Group response to
member request
• Modeled the process of evidence-informed, consensus driven recommendation, but
is not an interdisciplinary consensus statement

• Provide an objective/standardized method to describe malnutrition based on a
comprehensive review of the literature and consensus of the authors
• Provide a starting point with objective criteria to begin to collect data and evaluate
outcomes with the goal of facilitating a multidisciplinary effort to begin identifying
preterm infants and neonates at risk for deleterious outcomes form suboptimal
nutrition
• Anticipated modification of the indicators over time as experience helps fine tune
the criteria, new malnutrition assessment techniques become available, and validity
is confirmed
8
Preterm/Neonatal vs. Pediatric Indicators
Preterm/Neonatal Recommended PEDIATRIC Consensus Statement2

Indicators1
Term Infants greater than one month

Preterm infants born before 37 weeks of age
and are less than 37 weeks
Term infants born at 37 weeks and

older who are less than one month of
age
Why Diagnose and Document Malnutrition?

• Establish nutrition priorities and document response to nutrition
therapy
• Add Malnutrition to the Problem List for post discharge follow-up
10
9
Assumption
• Poor growth and malnutrition are related
o Variations in growth rates between NICUs can be attributed to variation in
nutrition practices3-11
o Improved nutrition reduces the difference between birth and discharge

weight z scores12
• However, poor growth can be due to complications of prematurity

• Clinical judgement is required to distinguish between poor growth due
to malnutrition and poor growth due to complications of prematurity
11
Prematurity, Nutrition, Growth and

Neurodevelopment Outcomes
• Preterm birth alters normal brain growth and development 13,14
• Research indicates a link between poor growth and neurocognitive development up to 19 years of
age15-30
• Aggressive nutrition during the first 2 weeks of life promotes better brain development and
growth31-35
• Very low birth weight infants with better growth, greater fat mass and fat free mass have
larger cerebellar volumes36
• Poor head growth during NICU stay and post discharge has been associated with motor and
cognitive delays37
• The link between linear growth, brain development, and neurocognitive outcome is
strong20,21,24,38,39
• Early monitoring of growth to detect deficits improves growth outcomes 40
12
10
Furthermore,
• Preterm birth increases the risk of cardiovascular disease and metabolic
syndrome41-44
• Excessive catch-up growth increases risk of chronic disease45-47

• Optimal nutrition and growth can decrease the risk of chronic disease 48,49
13
Days to Regain Birthweight as an Indicator

• Use in conjunction with nutrient intake
• Less meaningful after the first few months of life
Mild Malnutrition Moderate Severe

Malnutrition Malnutrition
15-18 days 19-21 days > 21 days
14
11
Background: Days to Regain Birth Weight
• Most but not all infants demonstrate a weight loss of 7-20% of birth
weight during the first 3-5 days of life50
• Most but not all infants regain birth weight by 7-14 days51-55
• Optimal fluid balance and nutrition mitigate the weight loss and poor
growth56-58
• Thus, delayed return to birth weight may indicate malnutrition
15
Days to Regain Birthweight Case Study

• Hx: Baby Jetson is a 1837 gram 33 0/7 week infant born to a mother
with uncontrolled type II diabetes and PIH. Infant started on TPN and
trophic feeds of donor breast milk at admission
• DOL 8: Weight 1749 (5% below birth weight). TPN d/c as infant
reached full feeds of 24 kcal donor breast milk with HMF
• DOL 15: Weight 1821 (1% below birth weight). Infant receiving 158 ml
per kg 24 kcal donor breast milk with HMF providing 128 kcal and 4.2
g protein per kg
• Does infant meet criteria for malnutrition based on days to regain birth
weight?
16
12
And the Answer is
• NO!!!
• Days to regain birthweight requires a second indicator.
Recommended indicator nutrient intake
17
Background: Nutrient Intake as an Indicator of

Malnutrition
• During the first few weeks, weight changes often reflect postnatal fluid
shifts. Thus, comparing intake to recommendations is useful in
identifying malnutrition
• During this time nutrition intakes are often prescribed the health care
provider making assessing the adequacy of intake relatively
straightforward
• Thus, during the first two weeks of life, nutritional status is best
assessed by comparing nutrient intake to recommendations
18
13
Recommended parenteral and enteral energy
and protein goals
Parenteral Enteral
Infant age (wk) Energy goals Protein goals Energy goals Protein goals
(kcal/kg) (g/kg) (kcal/kg) (g/kg)
Preterm59,60 85-110 3-4 110-130 3.5-4.5

< 34 0/7
Late preterm61 100-110 3-3.5 120-135 3-3.2
34 0/7-36 6/7
Term59,60 90-108 2.5-3 105-120 2-2.5
> 37 0/7
Reprinted with permission from Journal of the Academy of Nutrition and Dietetics. Goldberg DL,
Becker PJ, Brigham K, et al. Identifying malnutrition in preterm and neonatal populations:
recommended indicators. 2017. DOI: 10.1016/j.jand.2017.10.006.
19
Case Study: Nutrient Intake

• Hx: Baby Koala is a 714 g 25 1/7 week male with RDS, rule out
sepsis
• DOL 2 peritoneal drains were placed due to a SIP
• DOL 51 exploratory lap, reduction of internal hernia, SBR with

anastomosis, omentectomy
• DOL 61 weight at 7th percentile, z score -1.18 with gain past week
37% of expected
• DOL 66 On full feeds of donor breast milk 26 kcal beginning
transition to formula
20
14
Case Study Nutrient Intake Continued
• DOL 66 34 4/7 weeks Made NPO for persistent emesis. TPN not
restarted due to expected rapid feed advance. D 10 at 130 ml per kg
o 44 kcal/kg; 0 g protein/kg
• DOL 67-68 Nutramigen at 40 ml per kg, D 10 at 100 ml per kg

o 61 kcal/kg; 0.8 g protein/kg
• DOL 69 Nutramigen at 73 ml/kg, D10 at 70 ml per kg
o 74 kcal/kg; 1.4 g per kg protein
• DOL 70 Nutramigen at 105 ml per kg, D 10 at 35 ml per kg
o 83 kcal/kg; 2 g/kg protein
• Does this infant meet criteria for malnutrition based on nutrient intake?
21
And the Answer is

• YES!!!
• Infant meets criteria for mild malnutrition.
o Kcal intake 70% of recommended intake (120-135 g/kg) for 4 days (DOL
67-70
o Protein intake 42% of recommended intake (3-3.2 g/kg) for 4 days (DOL67-
70)
22
15
Summary
• Days to regain birth weight is an indicator appropriate for the first
weeks of life that should be used in conjunction with nutrient intake
• Nutrient intake is a useful indicator during the first 2 weeks of life and
can also be used in older infants when medical complications prevent
the provision of adequate nutrition
23

Malnutrition Indicators into Practice
Susan J. Carlson, MMSc, RDN, CSP, LD

Neonatal Dietitian
University of Iowa Stead Family Children’s Hospital at the
University of Iowa Hospitals and Clinics
Iowa City, Iowa
16
Disclosures
No conflicts of interest related to this presentation
25
Learning Objectives
Upon completion of this session, the learner will be able to….
1. Describe weight based indicators used to assess for premature /

neonatal malnutrition
2. Describe length based indicators used to assess for premature /
neonatal malnutrition
3. Identify factors that must be considered when using the recommended
indicators to assess for premature / neonatal malnutrition
26
17
Change in weight for age z - score
• Calculated using z-scores defined on hospital ELM growth charts or using
peditools.org website. Z-score comparisons should be made using the
same growth chart (e.g. Fenton or Olsen)

Decline of Decline of Decline of
0.8 – 1.2 SD 1.2 – 2 SD >2 SD
• Parameter should not be used in first 2 weeks of life when weight loss is
expected. After DOL #14, it may be used for a variety of time intervals (e.g.
change in z-score from birth, over the past week, or an interval of nutritional
concern).
27
Weight Gain Velocity

• Weight gain velocity compared to goal
o Weight gain velocity is
- Calculated as weight gain in g/d

- Compared to an established g/d goal
- Goal should be sufficient to maintain weight for age at the current z-score (goal rate may
be increased promote catch-up growth if indicated)
Use of g/kg/d is not recommended secondary to variability

in measurement based on the weight used for calculation.
28
18
Growth Velocity Calculations
• Systematic review of 1543 preterm infant growth studies:
o 40% reported growth as g/kg/d
o 32% reported growth as g/d
o 29% reported growth as change in z-score

• In studies using g/kg/d, the kg denominator was calculated from:
o Not identified (64%).
o Average of study start and study end weights
o Exponential calculation
o Birth weight Fenton TR et al. Pediatrics.
2017;139(3):e20162045
o Early weight that wasn’t birth weight.
29
Weight gain velocity (g/d)

• Weight gain velocity may be determined by using NICU specific
established standards for weight gain or calculated using weekly
weight gain column on peditools.org website.

<75% <50% <25%
of expected rate of weight gain to maintain growth rate
• Weight gain velocity is used for short term weight changes (weekly,
monthly). It should not be used in the first two weeks of life or used
when comparing current weight to birth weight.
30
19
Change in length for age z - score
• Calculated using z-scores defined on hospital ELM growth charts or
using peditools.org website.

Decline of Decline of Decline of
0.8 – 1.2 SD 1.2 – 2 SD >2 SD
• Not appropriate in first two weeks of life

• May be deferred in critically ill / unstable infants
• Use in conjunction with another indicator when accurate length
measurement available
31
Linear growth velocity (cm/wk)

• Linear growth velocity may be determined by using NICU specific
established standards for linear growth or calculated using weekly weight
gain column on peditools.org website.

<75% <50% <25%
of expected rate of length gain to maintain growth rate
• Not appropriate in first two weeks of life

• May be deferred in critically ill / unstable infants
• Use in conjunction with another indicator when accurate length
measurement available
32
20
Other screening tools not incorporated
in preterm / neonatal malnutrition screen
• Body composition
• Body mass index

• Mid upper arm circumference
• Head circumference
• Nutrition focused physical exam
33
Case Study
• 28 6/7 week gestation male now DOL #20
• Infant received TPN from DOL # 0 – 14
• Enteral Feeds initiated DOL #1

• HMF added to breast milk feeds on DOL #7
• Goal enteral feeds achieved on DOL #18
• Average nutrient intakes over past 7 days were ~110 kcal/kg/d
• Urine sodium measured on DOL#20 was 17 mEq/L (goal >40 mEq/L)
34
21
Wt for age Goal Wt
Date Weight Change in Z-
%ile Wt changes Gain
(gest) (g) score from birth
Z-score (g/d)
8/20/18 1255 g 58th Regained B Regain B Wt
(28 6/7) Z= +0.21 SD Wt DOL #10 DOL #7 - 15
8/27/18 1155 g 24th -0.91 SD -100 g (8%) 24 g/d
(29 6/7) Z= -0.70 SD from B Wt
9/2/18 1300 g 25th -0.89 SD 24 g/d x 6 d 23 g/d
(30 5/7) Z= -0.68
9/9/18 1400 18%ile -1.11 SD 14 g/d x 7 d 26 g/d
(31 5/7) Z= -0.90
28 g/d
Is this infant malnourished?
Criteria Patient
Value
Decline in weight for age Z-score -1.11 SD from birth, - 0.22 SD past week
Weight gain velocity (% of goal) 54% of goal over past week
Days to regain B Wt 10 d
Nutrient Intake >80% of intake every day x past week
36
22
Is this infant malnourished?
Criteria Patient Patient Mild Moderate Severe

Value Criteria Malnutrition Malnutrition Malnutrition
Weight for -1.11 SD mild Decline of Decline of Decline of

age Z-score 0.8 – 1.2 SD 1.2 – 2 SD >2 SD
Weight gain 54% mild <75% <50% <25%
velocity
Regain B Wt 10 d WNL 15-18 d 18 – 21 d >21 d
Nutrient >80% WNL >3 – 5 d >5–7d >7 d
Intake of <75% of <75% of <75%
37
Factors to consider when completing malnutrition

assessment in preterm infants and neonates
• Comprehensive volume of data available for preterm infants makes
assessment of malnutrition simpler than pediatric / adult patients.
o Daily weights
o Nutrients provided by TPN / tube feedings makes daily intake easier to
quantify
• Serial malnutrition screens over time will help caregivers identify

response to nutrition therapy; need for adjustment to nutrient intake
goals.
38
23
Factors to consider when completing malnutrition
assessment in preterm infants and neonates
• First two weeks of life
o Nutrient intake is the primary method to evaluate nutritional status. Growth is not
an accurate measure
• After the first two weeks of life.

o Days to regain birthweight is an acceptable measure in the first few months but
becomes less meaningful the older the infant becomes
o Medical practices that affect fluid status / growth (e.g. diuretics, steroids, initiation of
IV fluids) need to be considered when evaluating adequacy of growth
o Length growth should only be considered when length measures are accurate
39
References
1. Goldberg DG et al. Identifying malnutrition in preterm and neonatal
populations: Recommended indicators. J Acad Nutr Dietet. 2018;
118 (9): 1571-1582. https://doi.org/10.1016/jand.2017.10.006
2. Fenton TR et al. Pediatrics. 2017;139(3):e20162045

3. Fenton TR and Kim JH. A systematic review and meta-analysis to
revise the Fenton growth chart for preterm infants. BMC Pediatrics
2013 13:59 https://doi.org/10.1186/1471-2431-13-59
4. Olsen IE et al. New intrauterine growth curves based on U.S.
population data. Pediatrics. 2010, 125; e214-e244.
40
24
Malnutrition Indicators in Preterm and Neonatal
Populations Reference Card
You can find this on page 27 in the handout or follow the link below:
https://www.nutritioncare.org/guidelines_and_clinical_resources/Mal
nutrition_Solution_Center/
41
Questions
Submit your questions using the interactive panel on the left.
Click Questions to submit your questions
42
25
2018 ASPEN Clinical Nutrition Webinar Series
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44
26
Malnutrition Indicators in Preterm and Neonatal Populations 1
Primary Indicators Requiring One Indicator

Indicator Mild Malnutrition Moderate Malnutrition Severe Malnutrition Use of Indicator
Decline in
Decline of 0.8-1.2 SD Decline of >1.2-2 SD Decline of >2 SD Not appropriate for first 2 weeks of life
weight-for-age z score
Weight gain velocity <75% of expected rate of <50% of expected rate of <25% of expected rate of Not appropriate for first 2 weeks of life
weight gain to maintain weight gain to maintain weight gain to maintain
growth rate growth rate growth rate
Nutrient intake ≥3-5 consecutive days of ≥5-7 consecutive days of ≥7 consecutive days of Preferred indicator during first 2 weeks of life
protein/energy intake protein/energy intake protein/energy intake
≤75% of estimated needs ≤75% of estimated needs ≤75% of estimated needs
Primary Indicators Requiring Two or More Indicators

Indicator Mild Malnutrition Moderate Malnutrition Severe Malnutrition Use of Indicator
Days to regain birthweight 15-18 19-21 >21 Use in conjunction with nutrient intake
Linear growth velocity <75% of expected rate <50% of expected rate <25% of expected rate Not appropriate for first 2 weeks of life
of linear gain to maintain of linear gain to maintain of linear gain to maintain May be deferred in critically ill, unstable infants
expected growth rate expected growth rate expected growth rate
Use in conjunction with another indicator when
accurate length measurement available
Decline in Decline of 0.8-1.2 SD Decline of >1.2-2 SD Decline of >2 SD Not appropriate for first 2 weeks of life
length-for-age z score May be deferred in critically ill, unstable infants
Use in conjunction with another indicator when
accurate length measurement available
Recommended Parenteral and Enteral Energy and Protein Intakes

Parenteral Enteral
Infant Age Week Energy Goals (kcal/kg) Protein Goals (g/kg) Energy Goals (kcal/kg) Protein Goals (g/kg)
Preterm <34-0/7 85-111 3-4 110-130 3.5-4.5
Late Preterm 34-0/7 to 36-6/7 100-110 3-3.5 120-135 3-3.2
Term ≥37-0/7 90-108 2.5-3 105-120 2-2.5
SD=standard deviation. Expected weight gain velocity, expected linear growth velocity, and z scores can be determined using the online calculator PediTools (www.peditools.org). Supported by
Reference: 1. Reprinted from Journal of the Academy of Nutrition and Dietetics, Goldberg DL, Becker PJ, Brigham K, et al. Author(s),
Identifying Malnutrition in Preterm and Neonatal Populations: Recommended Indicators. Article in Press https://doi.org/10.1016/j.jand.
27
2017.10.006 Pages 1-11, 2018, with permission from Elsevier and Academy of Nutrition and Dietetics.
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28
Putting the Neonatal/Preterm Malnutrition Indicators Into Practice

Clinical Dietitian II Carilion Children’s Hospital, Roanoke, Virginia
Disclosures
I have no commercial relationships to disclose
Presentation Overview/Summary
This presentation discusses the development of the recommended indicators for diagnosing
preterm/neonatal malnutrition, the reason for developing the criteria, and the rationale behind their
development. The use of days to regain birth weight and nutrition intake as indicators for malnutrition is
reviewed with case studies.
Learning Objectives
At the conclusion of the presentation, the learner will be able to:
1. Describe the development of the recommended indicators for identifying malnutrition in preterm
infants and neonates and why identifying malnutrition is important
2. Use the recommended indicator days to regain birth weight to identify malnutrition
3. Use the recommended indicator nutrient intake to identify malnutrition
Key Takeaways/Fast Facts

• Documenting malnutrition with its addition to the problem list focuses attention on the nutrition
deficits and the need for monitoring post discharge
• Days to regain birthweight and nutrient intake are the recommended indicators for diagnosing
malnutrition during the first two weeks of life.
• Nutrient intake can be used as an indicator in older preterm infants when medical complications
prevent provision of optimal nutrition
Learning Assessment Questions

1. Dragon is a 26 4/7 week infant now 37 4/7 weeks old. Which set of indicators are appropriate to
use to diagnosis malnutrition:
A. Preterm/Neonatal
B. Pediatric
2. The Preterm/Neonatal indicators are based on which of the following assumptions:

A. Growth and malnutrition are related
B. Poor growth can be due to complications of prematurity
C. Clinical judgement is required to distinguish from poor growth due to malnutrition and
poor growth due to complications of prematurity
D. All of the above
3. Baby Jetson is a 15 day old premature infant who is 1% below birth weight and is receiving 90%
of estimated kcal and protein needs. He meets the criteria for mild malnutrition based on days to
regain birth weight.
A. True
B. False
4. Baby Koala has received an average of 64% of recommended kilocalories and 33% of
recommended protein over the past 5 days. She meets the criteria for mild malnutrition.
A. True
B. False
29
5. Which of the following is not true:
A. The recommended indicators for diagnosing malnutrition in preterm infants and
neonates is an interdisciplinary consensus statement
B. The recommended indicators will change as experience fine tunes the indicators, new
assessment techniques become available and validity is confirmed
C. The recommended indicators provide an objective/standardized method to describe
malnutrition based on a comprehensive review of the literature and consensus of the
authors
D. The recommended indicators provide a starting point with objective criteria to begin to
collect data and evaluate outcomes with the goal of facilitating a multidisciplinary effort to
begin identifying preterm infants and neonates at risk for deleterious outcomes form
suboptimal nutrition
Learning Assessment Answers:

1. Answer = B; Rationale: Infant is over one month old and is now term
2. Answer = D; Rationale: All are assumptions the authors agreed upon
3. Answer = False: Rationale: Days to regain birth weight requires inadequate nutrition as a
second indicator
4. Answer = True; Rationale: Infant has received less than 75% of recommended kilocalorie and
protein intake
5. Answer = A; Rationale: The recommended indicators is not an interdisciplinary consensus
statement
References
Goldberg DL, Becker PJ, Brigham K, et al. Identifying Malnutrition in Preterm and Neonatal
Populations: Recommended Indicators. J Acad Nutr Diet. February 2018.
doi:10.1016/j.jand.2017.10.006.
30
Putting the Neonatal/Preterm Malnutrition Indicators into Practice
Susan J Carlson MMSc, RDN, CSP, LD

Neonatal Dietitian, University of Iowa Stead Family Children’s Hospital at the University of Iowa
Hospitals and Clinics, Iowa City, Iowa
Disclosures
I have no commercial relationships to disclose
Presentation Overview/Summary
This presentation will discuss the background and rationale for the development of a malnutrition
screen for preterm infants and neonates. The recommended indicators used to diagnose malnutrition in
preterm infants and neonates will be described and application of the malnutrition screening process
will be demonstrated through case studies.
Learning Objectives
At the conclusion of the presentation, the learner will be able to:
1. Describe weight-based indicators used to assess for premature / neonatal malnutrition
2. Describe length-based indicators used to assess for premature / neonatal malnutrition
3. Identify factors that must be considered when using the recommended indicators to assess for
premature / neonatal malnutrition
Key Takeaways/Fast Facts

• Z-scores allow the clinician a measurable method to evaluate adequacy of growth over time in
premature infants.
• Goal growth velocity is a rate of weight or length gain sufficient to achieve or maintain goal
weight for age or length for age z-scores.
Learning Assessment Questions

1. A 26 week gestation male infant is born with a weight of 870 g (58th %ile, z-score +0.18). At 30
days of life (PMA 30 2/7 weeks), he weighs 1080 g (13th %ile, z-score of -1.12 SD). Is this
infant malnourished based on the recommended indicators for preterm and neonatal
malnutrition.
A. Yes, infant with mild malnutrition
B. Yes, infant with moderate malnutrition
C. Yes, infant with severe malnutrition
D. No, infant is not malnourished
2. Change in weight for age z-score may be used to assess for malnutrition in preterm infants
during the first 2 weeks of life.
A. True
B. False
3. A male infant was born at 24 weeks weighing 650 g. He is now DOL #35. Weight has
increased from 940 g to 1052 g over the past 2 weeks with goal weight gains of 18 g/d. Which
of the following is incorrect?
A. Weight gains have averaged 8 g/d
B. Weight gain velocity should be measured as g/kg/d
C. Rate of weight gain is 44% of goal growth velocity
D. Current weight gain velocity is consistent with moderate malnutrition
31
4. A six week old infant born at 25 weeks gestation currently weighs 1420 g. She weighed 1300 g
one week (7 days) ago. Goal weight gain based on her PMA / size is ~26 g/d. Is this infant
malnourished based on her weight gain velocity over the past week?
A. Yes, infant with mild malnutrition
B. Yes, infant with moderate malnutrition
C. Yes, infant with severe malnutrition
D. No, infant is not malnourished
5. Which of the following is not true about length gain / linear growth velocity indicators?
A. These indicators are not appropriate for use in the first two weeks of life
B. Length measurements may be deferred in critically ill or unstable infants.
C. Decline in length for age z-score or linear growth velocity is typically the first indicator of
malnutrition identified in the preterm infant.
D. It is necessary to have two people and a length board in order to measure length
accurately in neonates.
Learning Assessment Answers:

1. Answer = B; Rationale: This infant demonstrates a decline in weight for age z-score of -1.30 SD
which is consistent with moderate malnutrition.
2. Answer = False; Rationale: Change in weight for age Z-score is not an accurate measure in the
first two weeks of life as all infant undergo an initial postnatal diuresis taking 7 – 15 days to
regain birthweight and establish stable and consistent growth.
3. Answer = B; Rationale: While weight gains have historically been described as g/kg/d, there is
no consensus on the appropriate weight to use in this calculation. In the question above, the
calculated rate of weight gain would vary from 12.3 g/kg/d (using birth weight) to 7.6 g/kg/d
(using current weight).
4. Answer = A; Rationale: Infant has averaged weight gains of 17 g/d over the past week or 65%
of goal growth velocity which is consistent with mild malnutrition.
5. Answer = C; Rationale: In preterm infants as in older infants and children - Length growth is
initially spared in instances of malnutrition with a decline in weight gain velocity occurring as the
initial growth marker of malnutrition
References
1. Goldberg DG et al. Identifying malnutrition in preterm and neonatal populations: Recommended
indicators. J Acad Nutr Dietet. 2018; 118 (9): 1571-1582.
https://doi.org/10.1016/jand.2017.10.006
2. Fenton TR et al. Pediatrics. 2017;139(3):e20162045
3. Fenton TR and Kim JH. A systematic review and meta-analysis to revise the Fenton growth
chart for preterm infants. BMC Pediatrics 2013 13:59 https://doi.org/10.1186/1471-2431-13-59
4. Olsen IE et al. New intrauterine growth curves based on U.S. population data. Pediatrics. 2010,
125; e214-e244.
32
Putting the Neonatal/Preterm Malnutrition Indicators Into Practice References
Malnutrition Week Webinar 9/26/18
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38
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Putting The NeonatalPreterm MalnutritioIndicators Into Practice

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Putting The NeonatalPreterm MalnutritioIndicators Into Practice

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Putting the Neonatal/Preterm Malnutrition

Indicators into Practice

WEBINAR ATTENDEE PACKET

Special Malnutrition Awareness Week Offer

This program is supported in part by Mead Johnson Nutrition

Dietitians may post comments on this program on www.cdrnet.org.

Deadline for claiming CE Credits: October 25, 2018

*IMPORTANT NOTE: DO NOT LOG IN TO YOUR ACCOUNT FROM THE MAIN

Site and Chapter Participants

Site and Chapter Coordinator Instructions

*IMPORTANT NOTE: DO NOT LOG IN TO YOUR ACCOUNT FROM THE MAIN

Access Handout and Webinar Recording

How to Create Your ASPEN Account

Malnutrition Awareness Week TM Schedule

Resources, simply click the header to expand

Session Moderator Topics & Faculty

Diane Barsky, MD Putting the Neonatal/Preterm Putting the Neonatal/Preterm

Dena Goldberg, PhD, RD

1. Describe the development of the recommended indicators for

Development of the Indicators

is not an interdisciplinary consensus statement

Preterm/Neonatal Recommended PEDIATRIC Consensus Statement2

Term Infants greater than one month

Term infants born at 37 weeks and

Why Diagnose and Document Malnutrition?

• Add Malnutrition to the Problem List for post discharge follow-up

o Improved nutrition reduces the difference between birth and discharge

• However, poor growth can be due to complications of prematurity

Prematurity, Nutrition, Growth and

• Excessive catch-up growth increases risk of chronic disease45-47

Days to Regain Birthweight as an Indicator

Mild Malnutrition Moderate Severe

Days to Regain Birthweight Case Study

Recommended indicator nutrient intake

Background: Nutrient Intake as an Indicator of

Preterm59,60 85-110 3-4 110-130 3.5-4.5

Case Study: Nutrient Intake

• DOL 51 exploratory lap, reduction of internal hernia, SBR with

• DOL 67-68 Nutramigen at 40 ml per kg, D 10 at 100 ml per kg

And the Answer is