An Introduction to the UK-WHO Neonatal and Infant Close Monitoring (NICM) Growth Chart

1. An Introduction to the UK-WHO Neonatal and Infant Close Monitoring (NICM) Growth Chart

2. Definitions and Terminology Gestational age: time elapsed between the first day of the last menstrual period and the day of delivery Preterm: birth date before 37 completed weeks gestation Number of weeks preterm: 40 weeks minus gestational age Chronological age: time elapsed since birth Postmenstrual age: gestational age plus chronological age in weeks Corrected age: chronological age minus number of weeks preterm American Academy of Pediatrics, Pediatrics 2004;114:1362-4

3. Special features of the NICM Chart A date box system to aid accurate calculation of gestational age Calculating corrected age is difficult and prone to mistakes Arrow drawn back method of gestational age correction not practical for very early gestations Large scale Extra low reading (-3, -4, -5 SD) lines to allow assessment of very small infants Does not require gestational age correction as time axis is continuous from birth

4. When to use the NICM chart Infants born before 32 weeks gestation Unwell infants born 32-36 weeks gestation Term unwell neonates needing close monitoring e.g. those with cardiac or renal disease Infants with significant growth or weight faltering

5. Data sources for the NICM Chart 23 weeks gestation to 42 weeks: Reanalysed UK1990 data Describes size at birth only Does not describe how preterm infants should grow 2 weeks to 2 years corrected age charts: WHO growth standard

6. Head and length curves in reverse order to fit on page Special features: • Large scale • SD lines for assessment of very small infants • Date boxes Birth weight, and HC for gestation from 23 weeks to 42 weeks, length from 26 weeks Infancy chart starts at 2 weeks

7. Preparing the chart using date boxes Start with either a) estimated date of delivery (EDD) or b) date of birth and known or estimated gestational age Use the calendar to fill in the date boxes Mark boxes up in pencil

8. Use of the calendar to fill in the date boxes Nearest completed week of gestation Arrow 1 (working backwards from known EDD to birth date) • Move up or down column to find dates for each preceding (arrow 1) or succeeding (arrow 2) week on page 1 or fortnight on page 2 • At the end of year start again in same column at the top or bottom • Ignore December 31st and leap years EDD Date of birth Arrow 2 (working forwards from exact gestational age to EDD) EDD

9. 1) Preparing the 23-42 weeks gestation chart using EDD (working backwards) Write expected date of delivery into EDD box Work up calendar column to identify preceding dates for each completed week of gestation until first completed week after birth date is reached Write dates into date boxes (day and month only) Plot birth measurements at exact gestational age (weeks and days)

10. Example of preparing the 23 to 42 week chart from EDD (working backwards) EDD 29/9, date of birth 3/7 = 27 weeks 3 days gestation, birthweight 800g 1/9 8/9 15/9 22/9 29/9 6/10 13/10 27/10 10/11 7/7 14/7 21/7 28/7 4/8 11/8 18/8 25/8 1/9 8/9 15/9 22/9 29/9

11. 2) Preparing the 23 to 42 week chart from gestational age (working forwards) Write date of birth in box under exact gestational age Calculate date of next completed week of gestation Work down calendar column to identify date for each subsequent completed week of gestation until EDD box is reached

12. Example of preparing the 23-42 week chart from known gestation in completed weeks (working forwards) Find date of first completed week of gestation then write in the date at each completed week of gestation until EDD Date of birth 4/9/09 28 weeks 3 days gestation 8/9 15/9 22/9 29/9 6/10 13/10 20/10 27/10 3/11 10/11 17/11 24/11

13. Preparing the 2 weeks to 6 months chart Date boxes are per fortnight Preterm infants Starting from date in 42 weeks/ 2 weeks box Mark the date of each fortnight ofage in successive boxes Term infants Write date of birth in EDD box Enter weekly dates up to 42 weeks / 2 weeks box Then mark the date of each fortnight in successive boxes

14. Preparing the 2 weeks to 6 months chart 22/9 29/9 6/10 13/10 27/10 10/11 24/11 8/12 22/12 6/1 20/1 3/2 17/2 3/3 17/3 31/3

15. Date boxes are per calendar month Enter date at corrected age 6 months For preterm infants use date in EDD box + 6 months For term infants use date of birth + 6 months e.g. EDD/dob = 24/11/09  enter 24/5/10 Check that this date is within 2 days of last date box on 2 weeks to 6 months chart Mark up remaining date boxes 24/6 at 7 months, 24/7 at 8 months etc… Preparing the 2 weeks to 6 months chart

16. Preparing the 2 weeks to 6 months chart

17. SummaryUK-WHO Neonatal and Infant Close Monitoring (NICM) chart Use for all extremely preterm (<32 weeks) infants and any neonate or infant needing close monitoring Provides larger plotting area and low reading lines No need for gestational age correction Use date boxes for speed and accuracy Mark up before plotting Use to find exact gestational and corrected age Use calendar to work out dates up to age 6 months After 6 months use calendar months

18. Date box group exercise: Jason Date of birth 08/06/2006, approximately 26 weeks gestation Expected Date of Delivery (EDD) 10/09/2006 Mark up the 23-42 week chart date boxes What was his exact gestation in weeks and days? Mark up the 2 week to 6 month chart date boxes for What is the date in the 6 month (26 weeks) box? Mark up the 6-24 month chart What date will you enter at 6 months? Why is it different from the 6 month date on the last page?

19. 1. Exact gestational age: 26 weeks 4 days 2. Postmenstrual age at discharge: 40 weeks 3 days

20. Date in 26 week box: 12/3 3. Corrected age when admitted with RSV: 10 weeks (chronological age: 23 weeks and 3 days)

21. Date in 6 month box: 10/3 4. Current corrected age ; 20 months 1 week (Chronological age: 23 months)