Improving Neonatal nutrition in the NICU

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Title: Improving Neonatal Nutrition in the NICU

Authors: Margarita Dionysiou, MD1, Hannah Pfohl, MS, RD, LDN2, Manuel Peregrino, MD, MBA1, Samuel Carchidi, RN1, Maureen McGinnis, RN1

Sharon Sauer, RN1, Maryann Malloy, RN1, Laura Dougherty, RD2, Diane Kenealy, NNP1, Kathleen Lechowicz, PA-C1, Gail Cameron, MD1. Tracey Harris, DO1

1Division of Neonatal-Perinatal Medicine, Einstein Medical Center Philadelphia, Philadelphia

2Department of Food and Nutrition, Einstein Medical Center Philadelphia, Philadelphia

Background: Optimal nutrition in preterm neonates is linked to improved developmental outcomes. Following a standardized feeding guideline has been linked to decreased rates of neonatal morbidities including necrotizing enterocolitis (NEC). Currently, there is a great variation in feeding management among providers in the EMCP NICU and the incidence of mild malnutrition is elevated in VLBW infants at discharge (weight-for-age z-score decline of 0.8-1.2 SD in infants >2 weeks old).

Objective: To institute a feeding guideline in the EMCP NICU to allow for more consistency among providers and to improve neonatal nutritional in the NICU by reducing the median change in weight-for-age z-score between birth and discharge in VLBW infants to 0.7.

Design/Methods: The new feeding guideline was instituted in a stepwise manner: first by addressing how quickly we advance the feeds (cycle 1) and then by addressing fortification to increase the nutritional value (cycle 2). Information was obtained with chart review. The study included neonates of GA <34 0/7 weeks, birth weight < 1.5 kg and length of stay > 14 days. We excluded neonates with congenital anomalies or known/suspected metabolic disorders. Outcome measures were median birth-to-discharge weight-for-age z-score change and median central line days. Process measure was day of life (DOL) of full enteral feeds (140 ml/kg/day) and balancing measure the incidence of necrotizing enterocolitis (NEC).

Results: Implementation of the new feeding advancement guideline led to decreased weight-for-age z-score change from birth to discharge from 1.1 to 0.8decreased central line days from 9 to 7 days and decreased day of life of full enteral feeds from 10 to 9 daysNo feeding intolerance was noted. No infants developed NEC >2 weeks of life. One infant died of NEC during PDSA cycle 1 at <2 weeks of age; feeds advanced per guideline with formula rather than donor milk per parental request.

Discussion: Feeding advancement guideline (PDSA cycle 1) led to reduced incidence of mild malnutrition at discharge but short of 0.7 goal. Barriers to feeding advancement guideline were vasopressors, hypermagnesemia, and NPO for blood transfusions. Future efforts will focus on the implementation of the new enteral feeding fortification guideline (PDSA cycle 2 ) that will include earlier fortification of feeds to allow for higher calorie feeds within first week of life.

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Einstein Medical Center Philadelphia

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