A quality-improvement project to standardise feeding practices for micro preemies helped to boost weight and nearly quadrupled the frequency of lactation consultations ordered in the neonatal intensive care unit (NICU), a multi-disciplinary team from Children’s National Health System finds.
According to the US Centres for Disease Control and Prevention, about 1 in 10 infants in 2016 was pre-term, born prior to completing 37 gestational weeks of pregnancy. Micro preemies are the tiniest infants in that group, weighing less than 1,500 grams and born well before their brain, lungs and organs like the liver are fully developed.
As staff reviewed charts for very low birth weight preterm infants admitted to Children’s NICU, they found dramatic variation in nutritional practices among clinicians and a mean decline in delta weight Z-scores, a more sensitive way to monitor infants’ weight gain along growth percentiles for their gestational age. A multidisciplinary team that included dietitians, nurses, neonatologists, a lactation consultant and a quality-improvement leader evaluated nutrition practices and determined key drivers for improving nutrition status.
“We tested a variety of strategies, including standardising feeding practices; maximizing intended delivery of feeds; tracking adequacy of calorie, protein and micronutrient intake; and maximising use of the mother’s own breast milk,” says Dr Michelande Ridoré, a Children’s NICU quality-improvement lead who will present the group’s findings during the Virginia Neonatal Nutrition Association conference this fall.
“We took nothing for granted: We re-educated everyone in the NICU about the importance of the standardised feeding protocol. We shared information about whether infants were attaining growth targets during daily rounds. And we used an infographic to help nursing moms increase the available supply of breastmilk,” Ridoré says.
On top of other challenges, very low birth weight preterm infants are born very lean, with minimal muscle. During the third trimester, pregnant women pass on a host of essential nutrients and proteins to help satisfy the needs of the foetus’ developing muscles, bones and brain. “Because preterm infants miss out on that period in utero, we add fortification to provide preemies with extra protein, phosphorus, calcium and zinc they otherwise would have received from mom in the womb,” says Dr Victoria Catalano, a paediatric clinical dietitian in Children’s NICU and study co-author.
Babies’ linear growth is closely related to neurocognitive development, Catalano says. A dedicated RN is assigned to length boards for Children’s highest-risk new-borns to ensure consistency in measurements.
Infants who were admitted within the first seven days of life and weighed less than 1,500 grams were included in the study. At the beginning of the quality-improvement project, the infants’ mean delta Z-score for weight was -1.8. By December 2018, that had improved to -1.3. And the number of lactation consultation ordered weekly increased from 1.1 to four.
“We saw marked improvement in micro preemies’ nutritional status as we reduced the degree of variation in nutrition practices,” says Dr Mary Revenis, NICU medical lead on nutrition and senior author for the research. “Our goal was to increase mean delta Z-scores even more. To that end, we will continue to test other key drivers for improved weight gain, including zinc supplementation, updating infants’ growth trajectories in the electronic medical record and advocating for expanded use of birth mothers’ breast milk,” Revenis says.
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