Defining Malnutrition in the NICU: The Beginning Emily Trumpower RD, CSP, CNSC Brie Carlson, MPH, RD, CSP University of Michigan C.S. Mott Children’s Hospital Ann Arbor, MI

Goals and Objectives Goal: Objectives: To provide a better understanding of what our NICU is doing in terms of diagnosis of malnutrition and how we are doing it Objectives: Learn what criteria we use for diagnosis Know what type of data collection may be necessary in order to move closer to collective process for diagnosis

Pediatric Malnutrition MTool™ BMI (Wt/Lt Z-score) MUAC Z-score Height/Lt Z-score Weight Degree of possible malnutrition (above -1) None -1 to -1.99 At Risk/Mild -2 to -2.99 Moderately wasted Moderate Below -3 Severely Wasted Severe

Means ± SD of the population A.S.P.E.N Abstract- 2015 CNW Why? We wanted benchmarking and comparison data What were we interested in evaluating? Comorbidities Malnutrition (using MTool™) Methods: Inclusion: Vermont Oxford Network database Inborn, 2012-2013 <1500g at birth Weights included only Comparisons: Weight z-scores at birth, discharge, and then delta z-score (change from birth to discharge) Values compared to MTool™ criteria for malnutrition -1 to -1.99 (at risk/mild), -2 to -2.99 (moderate), and <=-3 (severe) Example: z-score of -2.5=> moderate Z-scores vs. CLD, PDA, NEC/bowel surgery, and PIH Means ± SD of the population N=142 Gestational Age (Weeks) 29 ± 2.77 Birthweight (g) 1151 ± 270 LOS (days) 69.5 ± 47 Weight Gain (g/day) during LOS 22.8 ± 5.6 Admit Z-Score for weight -0.51 ± 0.93 Discharge Z-Score for weight -1.37 (calculated value) Delta Z-score for weight (DZ) -0.86 ± 0.98

ASPEN Abstract- 2015 CNW Other results using MTool™ Correlation results Using malnutrition diagnosis coding based on delta z-scores and discharge z-scores, there was less weight gain (g/d) overtime in the malnutrition diagnosis group P-value 0.01 Using malnutrition diagnosis coding based on delta z-score, there was a longer LOS associated in the malnutrition diagnosis group P-value 0.024 Using malnutrition diagnosis coding based on delta z-score, there were more NEC/bowel surgery diagnoses in the malnutrition group P-value 0.021 Using malnutrition diagnosis coding based on lower birth z-score, there was a longer LOS associated with a malnutrition diagnosis P-value 0.006 CLD, PIH, & PDA did not correlate w/any malnutrition data Other results using MTool™ Were more diagnosed cases of malnutrition using discharge z-score for weight vs. delta z-score for weight 52% of mild, moderate, or severe malnutrition at discharge using z-score vs. 38% using delta z-score P value of <0.01

Our current usage of the MTool™ in the NICU Mehta paper did not include preterm infants or any infants < 1mo old We track z-scores and delta z-scores weekly after 1 month At 44 weeks CGA, we will diagnose malnutrition using the MTool™ for illness related malnutrition Former 25 weeker who is now corrected to 44 weeks could confer a severe malnutrition diagnosis based on a length z-score of -3 Exclusionary criteria that we use right now are congenital disorders

How can we define malnutrition in the preterm infant population??

Questions yet to answer Is there a z-score or a delta z-score that would correlate with poor outcomes (increased co-morbidities)? Would a Delta z-score be more appropriate for assessing malnutrition in NICU patients? How would this affect the current practices of using MTool™ at 44 weeks correction? At what point during life is the most appropriate time to consider “nadir” of growth loss in order to calculate an appropriate Delta-Z? Do we use the “nadir” weight z-score or the birth weight z-score? How do intakes of energy and protein, specifically in the first 28 days, effect overall growth through out NICU admission, and later admissions when they are older?

Pilot Data Began collecting in the beginning of 2015 Hoping for a n = 50 before the end of the year All patients <28 weeks at birth Collecting: Demographic data Z-scores at birth for all parameters Z-scores at 14 and 28 days of life Z-scores at the time of discharge Delta Z between Birth-Discharge, 14-DOL and discharge, and 28-DOL and discharge Co-morbidities including BPD; home w/O2, IVH, ROP, NEC, extrauterine growth failure as defined by <10th% at discharge Compounding factors: Persistent hyperglycemia, receiving hydrocortisone in the first 28 days, use of DART protocol, TPN days, days to full feedings, existence of PDA or other CHD (such as ASD/VSD), multiple gestations

2003 Fenton Growth Chart Example # 1 2 months old, Delta Z = -1.47

2003 Fenton Growth Chart Example # 2 1 month of age, Delta Z score = -1.36

Points to consider… Wt/age Length/age FOC/age Birth -0.18 -0.09 -0.13 Week 1 +0.02 -0.31 -0.92 Week 2 -0.74 -0.89 -1.59 Week 3 -0.85 -1.06 -1.77 Week 4 -0.64 (DZ -0.46) -0.98 (DZ -0.89) -1.6 (DZ -1.47) Week 8 -1.65 (DZ-1.47) -2.34 (DZ -2.25) -3.12 (DZ -2.99) Week 10 -2.16 -1.63 -2.48 Week 12 -2.99 -2.84 -3.42 Week 14 -3.13 -3.71 -3.59 Week 15/DC -3.08 -3.63 -3.54 Delta Z-score (DZ) -2.9 -3.41

Preliminary Data of Z-Scores and Delta Z-Scores N= 34 Growth Parameters: (Avg) Birth 14-day Birth-14 day Delta Z-score 28-day Birth-28 days Delta Z-score Discharge Birth-Discharge Delta Z 14 day-discharge Delta Z 28 day- discharge Delta Z Wt 0.33 -0.55 -0.88 -0.77 -1.1 -0.66 -0.99 -0.26 0.17 Lt -0.17 -0.92 -0.75 -1.32 -1.15 -1.41 -0.46 -0.05 FOC -0.03 -1.52 -1.49 -1.37 -1.34 -0.53 -0.73 0.74 0.59

Preliminary ROP Data Any ROP No ROP N= 9 N=16 GA Birth 25 1/7 26 3/7 Nadir % wt loss 9.1% 11% Avg kcal intake for 14 days 69.8 81.5 Avg kcal intake for 28 days 92 97.8 Avg protein intake for 14 days 3.6 3.5 Avg protein intake for 28 days 3.7 Wt Z-score at birth 0.33 0.38 Wt Z-score at 14 days -0.7 -0.35 Wt Z-score at 28 days -0.77 Wt Z-score at discharge -0.74 -0.53

Summary Goal is to have the data finalize by beginning 2016 Hoping to develop a tool that will help to evaluate malnutrition in the specialized population Will need validation studies with use of the tool in other NICUs

References Senterre T. and Rigo J. Reduction in postnatal cumulative nutritional deficit and improvement of growth in extremely preterm infants. Acta Pediatrica. 2011 Stephens BE, Walden RV, et al. First-week protein and energy intake are associated w/18-month developmental outcomes in ELBW’s. Pediatrics 2009. Senterre T. and Rigo J. Optimizing early nutritional support based on recent recommendatoin in VLBW infants allows abolishing postnatal growth restriction. Jpeds Gastroenterology and Nutrition, 2011. Bloom BT, Mulligan J, et al. Improving growth of VLBW infant in the first 28 days. Pediatrics 2003. Martin CR, Brown YF, Ehrenkranz RA. Nutritional practices and growth velocity in the first month of life in extremely preterm infants. Pediatrics 2009. Uberos J, Lardon-Fernandez M, et al. Nutrition in VLBW infant: Impact on BPD. Minerva Pediatrica, 2014.