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A different strategy, in addition to prolonged trophic feeds, is to advance feeds slowly; however this strategy also prolongs attaining full volume enteral feeds, and thus more days of TPN are required. A Cochrane review done in 2010 compared a slow advancement of feeds (15-20ml/kg/d) versus a faster advancement (30-35ml/kg/d). There was not a difference in the rate of
NEC, and infants who had slow rates of feeding advancement took longer to regain their birth weight and to reach full enteral feeds.11
Clinicians often question what type of feeding is best for VLBW infants. Breast milk alone provides adequate nutrition for the term infant; however breast milk lacks phosphate, carbohydrates, vitamins, and trace minerals appropriate for premature contains these additional nutrients, may fed breast milk. Adding multi-component associated with short-term increase in weight gain, linear, and head growth; evaluate long term neurodevelopmental and growth outcomes.12
One barrier to the advancement of feeds is the concern for feeding intolerance. Often, infants will have partially digested milk, bilious secretions, or a mix of the two in their stomachs before a new feeding is due to begin, and this can lead to feeds being held, possibly unnecessarily. It may be helpful to have guidelines in place that can be used to determine if feedings need to be held or continued, with the goal of maximizing enteral nutrition. Mihatsch looked at
in extremely low birth weight infants, and found that a bilious residual itself,
Implementation of standardized feeding protocol in a large level 3 academic NICU improved growth velocity in our population of VLBW infants.
in absence of other clinical signs and symptoms, should not slow down the advancement of enteral feeds.13
protocols have previously been shown. Corriveau et al. showed an increase in exclusive breastfeeding in the outpatient population with the implementation of a breast-feeding friendly clinical protocol.4 Deindl, et al. found an increased use of opiates and improved staff satisfaction after the implementation of a neonatal pain and sedation protocol.15 Another study in the Emergency Department showed that the implementation of a septic shock protocol and care guideline improved compliance in delivery of antibiotic and oxygen administration
and was associated with a decreased length of stay.16 A Vermont Oxford Network Collaborative showed that the implementation of a protocol for using therapeutic hypothermia for neonatal encephalopathy improved the consistency of care for patients in the NICU.7 Our data are unique in showing an improvement
in growth in infants < 1500 grams birth weight after implementation of a standardized feeding protocol.
In a study by McCallie et al. that looked at outcomes after a standardized feeding protocol was implemented, full enteral feedings were reached earlier and there were fewer days of TPN. They also found a decrease in necrotizing enterocolitis and late-onset sepsis.18 Our institution already had a low baseline of days to full feeds, and incidence of necrotizing enterocolitis, and late-onset sepsis, so perhaps this is why we did not see a difference in these
outcomes after implementation of our feeding protocol.
Our feeding protocol was developed on an evidence-based approach. The above mentioned studies suggest that early enteral feeds, prolonged trophic volume feeds, followed by a standardized advance in volume may lead to improved growth velocity and feeding tolerance, fewer days of TPN, and decreased need for a central of TPN or days to full feeds. The lack of improvement in decreasing TPN days or time to full feedings may have resulted prior to implementation of the protocol.
Following implementation of the protocol, there were no changes in the central venous line (CVL) days, however there was a trend towards an increase
in CVL days (8.7 versus 15.0 days). There are several possible explanations
of the nursing and medical teams that due to the prolonged trophic feeds (3
or 5 days of 20ml/kg/d), the infant will reach full feeds later, and therefore
there will be a need for more reliable
IV access. Since the completion of this project, central line usage guidelines were implemented, that address which infants should have central venous lines placed for TPN or medications and when these lines should be removed. The goals of this ongoing quality improvement central line usage project include standardizing practice, decreasing line days, decreasing incidence of sepsis,
and improving nursing satisfaction. Preliminary data have shown a decrease in number of line days from 15.9 to 12.7
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Del Med J | June 2017 | Vol. 89 | No. 6
