NICU Best Practice: Recommended vs. Reality Analysis of 2006 Neonatal Nutrition Survey October 12, 2006

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NICU Best Practice Recommended vs.
RealityAnalysis of 2006 Neonatal Nutrition
Survey October 12, 2006

• Debbie Hans MD, Fellow, University of MN
• Mary Pylipow MD, University of ..
• Michael Georgieff MD, University of MN
• Patti Thureen, MD, University of Colorado

2
Background

• The last published extensive survey on neonatal
  feeding practices was in 1985 (n269).
• Churella HR, Bachhuber WL, and MacLean WC.
  Pediatrics. (1985). 76 243-249.
• We conducted a similar survey on a smaller scale
  (n25) in 2001 (unpublished data).

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Methods

• 775 surveys were sent via e-mail and mail
• NICU Unit Directors as listed in AAP Directory
  (n434)
• Neonatal-Perinatal Fellowship Directors (n96)
• Past Ross Nutrition Conference attendees (n245)
• A total of 176 responses (23 returned)
• MD (staff or fellow) 70
• RD 24
• NNP 3
• Other or Unknown 3

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Methods

• For each individual question, the response rate
  was determined by subtracting the number of no
  response and inappropriate response from the
  total number of surveys
• Inappropriate response was defined as
• Multiple responses to a given question
• Responses that did not correspond to a provided
  choice
• e.g. responding 1.5 when choices were 0, 1, 2,
  etc.

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DOMAIN I

• Parenteral and Enteral Feeding Strategies
• In 3 preterm infant weight groups

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1. On what day of life is TPN started?
N 1 2 3 4 5 6 Later
lt1000g 167 80 20 lt1
1001-1500g 168 75 24 lt1 lt1
1501-2500g 156 52 39 4 2 lt1 lt1 1
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Pattis slide

• What is the science behind when to start TPN.

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2. How much protein (g/kg/day) do you prescribe
on the first day of TPN?
N 0.5 1 2 3 3.5 4
lt1000g 150 7 28 51 13 1
1001-1500g 154 4 29 55 11 1
1501-2500g 153 1 30 55 12 1
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Pattis slide

• Recommended parenteral protein intakes at
  different gestational ages

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3. Do you advance protein daily?
YES 91 NO 9 (N174) If yes, what increment
(g/kg) do you advance by?
N 0.25 0.5 1 gt1
lt1000g 148 1 49 49 1
1001-1500g 151 lt1 37 59 3
1501-2500g 150 lt1 32 63 4
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Patti

• Comment on the need/rationale for protein
  advancement

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4. What is your maximum protein (g/kg/day) when
at full TPN?
N lt2 2 2.5 3 3.5 4 gt4
lt1000g 164 2 18 49 29 1
1001-1500g 166 2 22 55 20 1
1501-2500g 164 3 29 54 13 1
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Patti

• Once again emphasize Zeiglers work on protein
  intake at different gest ages.

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5a. How much IV lipid (g/kg/day) do you
prescribe on first day TPN for non-ventilated
infant?
N 0 0.5 1 2 3
lt1000g 164 26 34 32 7 1
1001-1500g 167 22 22 46 10 1
1501-2500g 170 20 18 47 13 1
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5b. How much IV lipid (g/kg/day) do you
prescribe on first day TPN for ventilated infant?
N 0 0.5 1 2 3
lt1000g 161 25 36 30 7 1
1001-1500g 166 22 25 43 9 1
1501-2500g 168 20 20 47 13 1
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6. Do you give different amounts of lipid to
infants who have lung disease? (N168)YES 7
NO 62 SOMETIMES 31

• 7. Are there any contraindications to starting
  lipids? (N174)
• YES 40 NO 60

N70 YES NO
Lung disease 17 83
Jaundice 50 50
PPHN 43 57
Hyperglycemia 23 77
17
8. How fast do you advance your lipids
(g/kg/day)?
N 0.25 0.5 1 2 3 Based on TG
lt1000g 133 56 28 17
1001-1500g 142 42 44 lt1 13
1501-2500g 142 37 51 lt1 11
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Patti

• 2-3 slides on lipid safety, contraindications,
  what we know and dont know about lipid
  aministration, rate of advancement

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9a. On what day do you start enteral feeds in
non-ventilated infants?
N 0 1 2 3 4 5 6 7
lt1000g 153 3 35 34 16 4 4 lt1 2
1001-1500g 156 8 49 32 8 2 lt1
1501-2500g 152 25 54 16 5
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9b. On what day do you start enteral feeds in
ventilated infants?
N 0 1 2 3 4 5 6 7
lt1000g 142 3 16 27 29 9 9 1 6
1001-1500g 148 2 24 42 17 8 5 1 1
1501-2500g 147 5 31 34 18 7 4 1
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10. Do you initially use continuous or bolus
method of enteral feedings?
N BOLUS CONTINUOUS
lt1000g 170 81 19
1001-1500g 172 95 5
1501-2500g 173 99 1
22
?Patti review scientific data on bolus vs
continuous feeds?
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11a. How quickly are enteral feedings advanced
for non-ventilated infants (cc/kg/day)?
N 5 10 15 20 30
lt1000g 146 8 33 15 43 lt1
1001-1500g 153 3 12 19 64 3
1501-2500g 154 1 5 9 69 16
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11b. How quickly are enteral feedings advanced
for ventilated infants (cc/kg/day)?
N 5 10 15 20 30
lt1000g 144 15 35 13 36 1
1001-1500g 153 5 20 20 53 2
1501-2500g 153 4 13 14 62 10
25
12a. How do you define early small feeds? Is
it less than, equal to, or more than 20 cc/kg/day?
N62
Minimal Enteral Nutrition (MEN) 6
Gut priming 8
Trophic 86
N86
Less than 20 cc/kg/day 90
Equal to 20 cc/kg/day 10
More than 20 cc/kg/day
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12b. Do you use trophic feeds?
With RDS? N174
YES 90
NO 10
In Absence of RDS? N173
YES 87
NO 13
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13. What is the composition of the first enteral
feed for infants?
lt1000g (N173) 1001-1500g (N174) 1501-2500g (N173)
Sterile water 2 1 lt1
Glucose solution 2
½ strength 20 cal formula 3 3 1
Full strength 20 cal formula 45 45 52
½ strength 24 cal formula 4 5 3
Full strength 24 cal formula 17 20 17
½ strength breast milk lt1 1 1
Full strength breast milk 88 89 89
Pedialyte 1 1 1
¼ strength 24 cal formula 2 1
Full strength 22 cal formula 3
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14. How many days do you maintain babies on
trophic feeds?
N 1 2 3 7 Other Not Used
lt1000g 127 20 24 29 17 9
1001-1500g 146 42 19 18 5 6 8
1501-2500g 148 61 11 5 1 1 19
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Patti

• 1-3 slides on MEF

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15. Do you feed babies with?
N YES NO
Indwelling UACs 174 75 25
Indwelling UVCs 174 93 7
Low-dose dopamine 170 37 63
Cut off for dopamine 34 68 32
Indomethacin 174 17 83
Hydrocortisone 166 70 30
Clinically significant PDA 174 28 72
Clinically insignificant PDA 174 93 7
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Patti-brief comments on prior slide
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16. Do you feed SGA infants differently than AGA
infants?
N YES NO
ENTERAL 175 46 54
PARENTERAL 174 21 79
If yes, which nutrients differ?
N81 Energy Fat Calcium Protein
YES 64 21 22 51
NO 36 79 78 49
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Patti

• 2 slides on feeding SGA infant

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17. Who is a candidate for elemental formula
(e.g. Pregestamil)? (N171)
Poor Growth S/P NEC Gut Surgery GERD Micro-premie Diarrhea
5 68 61 8 7 39
Other candidates?
Bloody Stools Formula Intolerance Malabsorption Milk Protein Intolerance
1 4 1 2
35
18. How long do you keep an infant on premature
formula or supplemented breast milk? (N149)
34 weeks 6
35 weeks 8
36 weeks 23
37 weeks 8
40 weeks 9
1 month 4
2 months 3
3 months 6
gt3 months 34
36
19. Do you prescribe a post-discharge
nutritional strategy? (N171)YES 84 NO 16
20. If yes, what percent of preterm infants are
on?
N144 0 25 50 75 100
Breast milk 24 40 35 6
Fortified breast milk 13 39 22 15 4
Transitional (22cal/oz) formula 8 23 35 15 10
Standard formula 42 17 3 lt1
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Patti

• 2 slides on formula enrichment and post-discharge
  nutrition

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21. In the 24-26 week gestation infants, do you
target a specific GIR?YES 60 NO 40
Initial GIR N96
4 14
4.5 5
5 40
5.5 10
6 20
7 8
7.5 1
8 2
Goal GIR N83
5 1
6 6
7 8
8 3
9 31
10 4
11 21
12 7
13 7
14 6
15 2
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Patti

• 1-2 slides on max ox glucose capacity

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DOMAIN II

• Parenteral and Enteral Nutritional Additives and
  Supplements

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1. Do you use insulin in your NICU?
N YES NO
Use insulin? 173 88 12
If yes, for hyperglycemia? 154 98 2
If yes, to enhance weight gain? 147 12 88
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2. Do you add any of the following to your TPN
solution?
N YES NO
Erythropoeitin 173 13 87
H2 Antagonists 171 64 36
Albumin 170 26 74
Iron Dextran 171 32 68
Carnitine 172 65 35
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patti

• Brief comment on each of these additives

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3a. Do you use any of the following to enhance
your enteral formula?
N YES NO
Polycose 171 53 47
Microlipid 164 29 71
MCT oil 168 74 26
Promod/Propac 161 55 45
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3b. Do you add any of the following to breast
milk?
N YES NO
Polycose 165 25 75
Microlipid 164 18 82
MCT oil 161 42 58
Promod/Propac 166 42 58
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Patti

• 1-2 slides on risks and benefits of these
  supplements

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4. Do you use any of the following supplements?
N YES NO
Iron 174 91 9
Folic acid 159 11 89
Vitamin E (with EPO) 154 19 81
Vitamin E (without EPO) 161 38 62
Vitamin A 161 46 54
Vitamin D 159 43 57
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DOMAIN III

• Demographics of Your Institution

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1. What best describes your Level II-III nursery?
TYPE N169
Private 39
University 53
Public or Military 8
NUMBER OF BEDS N175
lt10 2
10-20 15
21-30 19
31-50 40
gt50 23
50
2. Who writes your TPN orders? (N176)
Attending 49
Fellow 26
Resident 60
NNP 66
Pharmacist 10
Dietician 15
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3. Do you have standing TPN orders or are they
individualized for each patient?
Standing 7
Individualized 90
Both 3
4. If individualized, do you use a computerized
TPN program to calculate each component? (N168)
YES 46
NO 54
52
5. Do you have TPN protocols or does each
practitioner have their own feeding strategies?
(N175)
Unit TPN protocols 31
Individualized 31
Both 36
Neither lt1
53
6. Do you have a pharmacist in your unit?
(N175) YES 76 NO 24
Full-time 66
Part-time 34
7. Do you have a dietician or nutrition support
service in your unit? (N175) YES 79 NO 21
Full-time 56
Part-time 44
54
8. Do you have standing TPN labs or are they
individualized? (N174)
Standardized 28
Individualized 42
Both 30
9. Do you use a stock or starter TPN (glucose
and protein) on day of life 1? (N175)
YES 55
NO 45
55
10. Where is your TPN prepared? (N175)
Unit pharmacy 6
Hospital pharmacy 76
Another pharmacy in town lt1
Commercial outsource 18
11. Do you follow up the long-term growth of
IUGR babies? (N172)
YES 58
NO 42