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A standardized nutrition approach for very low birth weight neonates improves outcomes, reduces cost and is not associated with increased rates of necrotizing enterocolitis, sepsis or mortality

Journal of Perinatology volume 33, pages 851–857 (2013)Cite this article

Subjects

Abstract

OBJECTIVE:

To assess how a standard practice for nutrition support in very low birth weight (VLBW) neonates would impact on their hospital course.

STUDY DESIGN:

This was a prospective, single center, before vs after comparison of a non-standardized approach to nutrition in VLBW neonates to a standardized approach. Standardization of feeding initiation, feeding volume and caloric advancement, management of feeding aspirates (residuals), use of starter parenteral nutrition (PN), use of breast milk and donor breast milk, initiation and discontinuation of intravenous (IV) intralipids, documentation of protein use, and utilization of percutaneously inserted central venous catheters were performed. Multiple outcome measures were evaluated. Fisher’s exact, Mann–Whitney U-tests and χ2 tests were used for statistical analysis.

RESULT:

Sixty-nine infants in the pre-standardization (non-standardized) group were compared with 154 infants in the standardized approach group. Analysis was performed for each group as a whole. Statistically significant improvements were seen in multiple areas for the standardized group including the day of life birth weight was regained (P<0.0005), use of breast milk as the initial feeding (P<0.0001), use of starter PN on admission (P<0.0001), earlier time for initiation of PN (P<0.0001), decreased use of PN overall (P<0.0001), enteral protein use (P<0.0001), earlier time for initiation of IV intralipids (P<0.002), day of life for full enteral feeds (P<0.0005) and first day for initiation of enteral feeds (P<0.0001). Fewer infants born microcephalic at birth remained so at discharge in the standardized group as compared with the pre-standardized group (P<0.02). Similarly, less infants born small for gestational age at birth remained so at discharge in the standardized group as compared with the pre-standardized group (P<0.05). Two cases of necrotizing enterocolitis (NEC) occurred in the pre-standardization group and one in the standardized group. No coagulase-negative Staphlococcal infections or line infections occurred during the entire study period. Two cases of sepsis occurred in the pre-standardization group, both in infants <750 g. No cases of sepsis occurred in the standardized group. Cost savings were remarkable from decreased PN usage in the standard group.

CONCLUSION:

Implementation of a standardized approach to nutrition in VLBW infants reduces the use of PN thereby reducing cost, causes a more rapid regain of birth weight, decreases the number of babies that are small for gestational age and microcephalic at discharge, and decreases the time to full enteral feeds. No adverse increases in mortality, sepsis, NEC, coagulase-negative Staphlococcal infections or line infections occurred.

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References

  1. Guthrie SO, Gordan PV, Thomas V, Thorp JA, Peabody J, Clark RH . Necrotizing enterocolitis among neonates in the United States. J Perinatol 2003; 23: 278–285.

    Article  Google Scholar 

  2. Boyd CA, Quigley MA, Brocklehurst P . Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis. Arch Dis Child Fetal Neonatal Ed 2007; 92: F169–F175.

    Article  Google Scholar 

  3. McQuire W, Anthony MY . Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review. Arch Dis Child Fetal Neonatal Ed 2003; 88: F11–F14.

    Article  Google Scholar 

  4. Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawöger R, Kiechl-Kohlendorfer U et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatrics 2010; 156: 562–567 e 561.

    Article  CAS  Google Scholar 

  5. Lucas A, Cole TJ . Breast milk and neonatal necrotising enterocolitis. Lancet 1990; 336: 1519–1523.

    Article  CAS  Google Scholar 

  6. Berseth CL, Bisquera JA, Paje VU . Prolonging small feeding volumes early in life decreases the incidence of necrotizing enterocolitis in very low birth infants. Pediatrics 2003; 111: 529–534.

    Article  Google Scholar 

  7. Kennedy KA, Tyson JE, Chamnanvanakij S . Rapid versus slow rate of advancement of feedings for promoting growth and preventing necrotizing enterocolitis in parenterally fed low-birth infants. Cochrane Database Syst Rev 2000; 2: CD001241.

    Google Scholar 

  8. Cobb BA, Carlo WA, Ambalavanan N . Gastric residuals and their relationship to necrotizing enterocolitis in very low birth weight infants. Pediatrics 2004; 113 (1): 50–53.

    Article  Google Scholar 

  9. Cohen S, Mandel D, Mimouni FB, Solovkin L, Dollberg S . Gastric residual in growing preterm infants: effect of body position. Am J Perinat 2004; 21 (3): 163–166.

    Article  Google Scholar 

  10. Kenton AS, Fernandes CJ, Berseth CL . Gastric residuals in prediction of necrotizing enterocolitis in very low birth weight infants. Pediatrics 2004; 113 (6): 1848–1849.

    Article  Google Scholar 

  11. Chauhan M, Henderson G, McQuire W . Enteral feeding for very low birth weight infants: reducing the risk of necrotizing enterocolitis. Arch Dis Child Fetal Neonatal Ed 2008; 93: F162–F166.

    Article  CAS  Google Scholar 

  12. Ziegler EE . Meeting the nutritional needs of the low-birth weight infant. Ann Nutr Metab 2011; 58 (Suppl 1): 8–18.

    Article  CAS  Google Scholar 

  13. Stephens BE, Walden RV, Gargus RA, Tucker R, McKinley L, Mance M et al. First-week protein and energy intakes are associated with 18-month developmental outcomes in extremely low birth weight infants. Pediatrics 2009; 123: 1337–1343.

    Article  Google Scholar 

  14. Ernbleton NO, Cooke RJ . Protein requirements in preterm infants: effect of different levels of protein intake on growth and body composition. Pediatr Res 2005; 58 (5): 855–860.

    Article  Google Scholar 

  15. Felderhoff-Mueser U, Buhrer C . Clinical measures to preserve cerebral integrity in preterm infants. Early Hum Dev 2005; 81 (3): 237–244.

    Article  Google Scholar 

  16. Poindexter BB, Langer JC, Dusick AM, Ehrenkranz RA . National Institute of Child Health and Human Development Neonatal Research Network. Early provision of parenteral amino acids in extremely low birth weight infants: relation to growth and neurodevelopmental outcome. J Pediatr 2006; 148 (3): 300–305.

    Article  CAS  Google Scholar 

  17. Rozich JD, Howard RJ, Justeson JM, Macken PD, Lindsay ME, Resar RK . Standardization as a mechanism to improve safety in health care. Jt Comm J Qual Saf 2004; 30 (1): 5–14.

    Article  Google Scholar 

  18. Hasibeder WR . Does standardization of critical care work? Curr Opin Crit Care 2010; 16: 493–498.

    Article  Google Scholar 

  19. Pieltain C, Habibi F, Riga J . Early nutrition, postnatal growth retardation and outcome of VLBW infants. Arch Pediatr 2007; 14 (suppl I): S11–S15.

    Article  Google Scholar 

  20. Geary CA, Fonseca RA, Caskey MA, Malloy MH . Improved growth and decreased morbidities in&lt;1000 g neonates after early management changes. J Perinatol 2008; 28 (5): 347–353.

    Article  CAS  Google Scholar 

  21. Street JL, Montgomery D, Alder SC, Lambert DK, Gerstmann DR, Christensen RD . Implementing feeding guidelines for NICU patients&lt;2000 g results in less variability in nutrition outcomes. J Parenteral Enteral Nutr 2006; 30 (6): 515–518.

    Article  Google Scholar 

  22. Patole SK, de Klerk N . Impact of standardized feeding regimens on incidence of neonatal necrotizing enterocolitis: a systematic review and meta-analysis of observational studies. Arch Dis Child Fetal Neonatal Ed 2005; 90: F147–F151.

    Article  CAS  Google Scholar 

  23. Christensen RD, Henry E, Wiedmeier SE, Burnett J, Lambert DK . Identifying patients, on the first day of life, at high-risk of developing parenteral nutrition associated liver disease. J Perinatol 2007; 27 (5): 284–290.

    Article  CAS  Google Scholar 

  24. Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawöger R, Kiechl-Kohlendorfer U et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr 2010; 156: 562–567.

    Article  CAS  Google Scholar 

  25. Lucas A, Cole TJ . Breast milk and neonatal necrotizing enterocolitis. Lancet 1990; 336 (8730): 1519–1523.

    Article  CAS  Google Scholar 

  26. Ursprung R, Gray J . Random safety auditing, root cause analysis, failure mode and effects analysis. Clin Perinatol 2010; 37 (1): 141–165.

    Article  Google Scholar 

  27. Ursprung R, Gray JE, Edwards WH, Horbar JD, Nickerson J, Plsek P et al. Real time patient safety audits: improving safety every day. Qual Saf Health Care 2005; 14 (4): 284–289.

    Article  CAS  Google Scholar 

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  1. Division of Neonatology, Akron Children’s Hospital, Akron, OH, USA

    T J Butler, L J Szekely & J L Grow

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  1. T J Butler
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Correspondence to T J Butler.

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Butler, T., Szekely, L. & Grow, J. A standardized nutrition approach for very low birth weight neonates improves outcomes, reduces cost and is not associated with increased rates of necrotizing enterocolitis, sepsis or mortality. J Perinatol 33, 851–857 (2013). https://doi.org/10.1038/jp.2013.66

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