1. 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

2. 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

3. 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

4. Means ± SD of the population
A.S.P.E.N Abstract 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,
<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 (at risk/mild), -2 to (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

5. 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

6. 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

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

8. 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?

9. 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

10. 2003 Fenton Growth Chart
Example # 1
2 months old, Delta Z = -1.47

11. 2003 Fenton Growth Chart Example # 2
1 month of age, Delta Z score = -1.36

12. 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

13. 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

14. 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

15. 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

16. 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.