Page 15 - Delaware Medical Journal - June 2017
P. 15
SCIENTIFIC ARTICLE
Introduction
Very Low Birth Weight (VLBW) infants often have extrauterine growth restriction. More than 70 percent of premature infants
at time of discharge. The incidence of extrauterine growth restriction increases with decreasing gestational age and birth weight.1 Severe growth restriction has been associated with poor neurodevelopmental outcomes,2 and may be associated with
an increased risk of long-term medical problems.3
Many clinicians are hesitant to start early enteral feeds due to the association of feeds and necrotizing enterocolitis (NEC). Of infants that develop NEC, 90 percent do
so after enteral feedings are initiated, and only 10 percent of infants diagnosed with NEC have never been fed.4 There are large practice variations between clinicians
and institutions in the timing of feeding initiation, manner of advancing feeding volumes, how quickly feeds are advanced, and type of feeding used in VLBW infants.5 To date, the optimal feeding strategy for this high-risk population remains in question.
The development of consistent approaches to managing preterm infants, including feeding regimens, has been suggested
as a way to improve outcomes.5 The objective of our study was to implement
a performance improvement project to determine if the initiation of a standardized feeding protocol could improve growth velocity in VLBW infants.
METHODS
Study Population
A performance improvement project was conducted at Christiana Care Health System, a large level 3 regional NICU. Preterm infants with BW <1500 grams and <34 weeks gestation born
FIGURE 1
Pre- and Post-Intervention Patients
between January 1, 2012 and December 31, 2012 were included in the study. Infants that were transferred to another facility or died prior to reaching full of 150ml/kg/d, were excluded from
the main analysis. For the analysis of incidence of culture positive sepsis, all infants were included.
Study Design
A standardized feeding protocol was developed by a multidisciplinary team, which included three neonatologists,
a neonatal fellow, a neonatal nurse practitioner, a neonatal nurse, and a nutritionist. A summary of the feeding protocol is as follows:
• Consider early enteral feeds when infant is clinically stable, at discretion of care team
• Exclusive human milk diet is strongly recommended, with the use of donor breast milk if needed
• For infants with BW <1000 grams,
126 Infants
56 Pre-intervention
70 Post-intervention
4 Deaths 3 Transfers
6 Deaths 5 Transfers
49 infants included in analysis
59 infants included in analysis
trophic volume of 20ml/kg/d is held for 5 days without advancement
<1500 grams, trophic volume of 20ml/kg/d is held for 3 days without advancement
• Trophic feedings are acceptable with an umbilical arterial catheter (UAC) in place
• After period of trophic feeding volume, feeds are advanced daily by 20ml/kg/d to goal of 150ml/kg/d
is recommended when enteral feeding volume reaches 120ml/kg/d
and when infants should be made NPO and/or further evaluation is indicated. acute increase in abdominal girth by
Del Med J | June 2017 | Vol. 89 | No. 6
175
