NICU Best Practice: NICU Best Practice: Recommended vs. RealityRecommended vs. Reality

Analysis 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

Background

The last published extensive survey on neonatal feeding practices was in 1985 (n=269). Churella HR, Bachhuber WL, and MacLean

WC. Pediatrics. (1985). 76: 243-249.

We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).

Methods

775 surveys were sent via e-mail and mail NICU Unit Directors as listed in AAP Directory (n=434) Neonatal-Perinatal Fellowship Directors (n=96) Past Ross Nutrition Conference attendees (n=245)

A total of 176 responses (23% returned) MD (staff or fellow) – 70% RD – 24% NNP – 3% Other or Unknown – 3%

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.

DOMAIN IParenteral and Enteral Feeding

Strategies

In 3 preterm infant weight groups

1. On what day of life is TPN started?

N= 1 2 3 4 5 6 Later

<1000g 167 80% 20% <1%

1001-1500g 168 75% 24% <1% <1%

1501-2500g 156 52% 39% 4% 2% <1% <1% 1%

Patti’s slide:

What is the science behind when to start TPN.

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

<1000g 150 7% 28% 51% 13% 1%

1001-1500g

154 4% 29% 55% 11% 1%

1501-2500g

153 1% 30% 55% 12% 1%

Patti’s slide

Recommended parenteral protein intakes at different gestational ages

3. Do you advance protein daily?

N= 0.25 0.5 1 >1

<1000g 148 1% 49% 49% 1%

1001-1500g

151 <1% 37% 59% 3%

1501-2500g

150 <1% 32% 63% 4%

YES 91% NO 9% (N=174)

If yes, what increment (g/kg) do you advance by?

Patti

Comment on the need/rationale for protein advancement

4. What is your maximum protein (g/kg/day) when at full TPN?

N= <2 2 2.5 3 3.5 4 >4

<1000g 164 2% 18% 49% 29% 1%

1001-1500g

166 2% 22% 55% 20% 1%

1501-2500g

164 3% 29% 54% 13% 1%

Patti

Once again emphasize Zeigler’s work on protein intake at different gest ages.

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

<1000g 164 26% 34% 32% 7% 1%

1001-1500g

167 22% 22% 46% 10% 1%

1501-2500g

170 20% 18% 47% 13% 1%

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

<1000g 161 25% 36% 30% 7% 1%

1001-1500g

166 22% 25% 43% 9% 1%

1501-2500g

168 20% 20% 47% 13% 1%

6. Do you give different amounts of lipid to infants who have lung disease? (N=168)YES 7% NO 62% SOMETIMES 31%

7. Are there any contraindications to starting lipids? (N=174)

YES 40% NO 60%

N=70 YES NOLung disease 17% 83%Jaundice 50% 50%PPHN 43% 57%Hyperglycemia 23% 77%

8. How fast do you advance your lipids (g/kg/day)?

N= 0.25 0.5 1 2 3Based on TG

<1000g 133 56% 28% 17%

1001-1500g

142 42% 44% <1% 13%

1501-2500g

142 37% 51% <1% 11%

Patti

2-3 slides on lipid safety, contraindications, what we know and don’t know about lipid aministration, rate of advancement

9a. On what day do you start enteral feeds in non-ventilated infants?

N= 0 1 2 3 4 5 6 7

<1000g 153 3% 35% 34% 16% 4% 4% <1% 2%

1001-1500g

156 8% 49% 32% 8% 2% <1%

1501-2500g

152 25% 54% 16% 5%

9b. On what day do you start enteral feeds in ventilated infants?

N= 0 1 2 3 4 5 6 7

<1000g 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%

10. Do you initially use continuous or bolus method of enteral feedings?

N= BOLUS CONTINUOUS

<1000g 170 81% 19%

1001-1500g

172 95% 5%

1501-2500g

173 99% 1%

?Patti review scientific data on bolus vs continuous feeds?

11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)?

N= 5 10 15 20 ≥30

<1000g 146 8% 33% 15% 43% <1%

1001-1500g

153 3% 12% 19% 64% 3%

1501-2500g

154 1% 5% 9% 69% 16%

11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)?

N= 5 10 15 20 ≥30

<1000g 144 15% 35% 13% 36% 1%

1001-1500g

153 5% 20% 20% 53% 2%

1501-2500g

153 4% 13% 14% 62% 10%

12a. How do you define “early small feeds”? Is it less than, equal to, or more than 20 cc/kg/day?

N=62

Minimal Enteral Nutrition (MEN)

6%

Gut priming 8%

Trophic 86%

N=86

Less than

20 cc/kg/day90%

Equal to

20 cc/kg/day10%

More than

20 cc/kg/day

12b. Do you use “trophic feeds”…?

With RDS? N=174

YES 90%

NO 10%

In Absence of RDS?

N=173

YES 87%

NO 13%

13. What is the composition of the first enteral feed for infants?

<1000g

(N=173)

1001-1500g

(N=174)

1501-2500g

(N=173)Sterile water 2% 1% <1%

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 <1% 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%

14. How many days do you maintain babies on “trophic feeds”?

N= 1 2 3 7 OtherNot

Used

<1000g 127 20% 24% 29% 17% 9%

1001-1500g

146 42% 19% 18% 5% 6% 8%

1501-2500g

148 61% 11% 5% 1% 1% 19%

Patti

1-3 slides on MEF

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%

Patti-brief comments on prior slide

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?

N=81 Energy Fat Calcium Protein

YES 64% 21% 22% 51%

NO 36% 79% 78% 49%

Patti

2 slides on feeding SGA infant

17. Who is a candidate for elemental formula (e.g. Pregestamil)? (N=171)

Poor Growth

S/P NEC

Gut Surgery

GERDMicro-premie

Diarrhea

5% 68% 61% 8% 7% 39%

Other candidates?

Bloody StoolsFormula

IntoleranceMalabsorption

Milk Protein Intolerance

1% 4% 1% 2%

18. How long do you keep an infant on premature formula or supplemented breast milk? (N=149)

34 weeks 6%

35 weeks 8%

36 weeks 23%

37 weeks 8%

40 weeks 9%

1 month 4%

2 months 3%

3 months 6%

>3 months 34%

19. Do you prescribe a post-discharge nutritional strategy? (N=171)YES 84% NO 16%

N=144 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% <1%

20. If yes, what percent of preterm infants are on…?

Patti

2 slides on formula enrichment and post-discharge nutrition

21. In the 24-26 week gestation infants, do you target a specific GIR?YES 60% NO 40%

Initial GIR N=96

4 14%

4.5 5%

5 40%

5.5 10%

6 20%

7 8%

7.5 1%

8 2%

Goal GIR N=835 1%

6 6%

7 8%

8 3%

9 31%

10 4%

11 21%

12 7%

13 7%

14 6%

15 2%

Patti

1-2 slides on max ox glucose capacity

DOMAIN IIParenteral and Enteral Nutritional

Additives and Supplements

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%

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%

patti

Brief comment on each of these additives

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%

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%

Patti

1-2 slides on risks and benefits of these supplements

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%

DOMAIN IIIDemographics of Your Institution

1. What best describes your Level II-III nursery?

TYPE N=169

Private 39%

University 53%

Public or Military

8%

NUMBER OF BEDS

N=175

<10 2%

10-20 15%

21-30 19%

31-50 40%

>50 23%

2. Who writes your TPN orders? (N=176)

Attending 49%

Fellow 26%

Resident 60%

NNP 66%

Pharmacist 10%

Dietician 15%

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? (N=168)

YES 46%

NO 54%

5. Do you have TPN protocols or does each practitioner have their own feeding strategies? (N=175)

Unit TPN protocols 31%

Individualized 31%

Both 36%

Neither <1%

6. Do you have a pharmacist in your unit? (N=175)

YES 76% NO 24%

Full-time 66%

Part-time 34%

7. Do you have a dietician or nutrition support service in your unit? (N=175)

YES 79% NO 21%

Full-time 56%

Part-time 44%

8. Do you have standing TPN labs or are they individualized? (N=174)

Standardized 28%

Individualized 42%

Both 30%

9. Do you use a stock or “starter” TPN (glucose and protein) on day of life 1? (N=175)

YES 55%

NO 45%

10. Where is your TPN prepared? (N=175)

Unit pharmacy 6%

Hospital pharmacy 76%

Another pharmacy in town <1%

Commercial outsource 18%

11. Do you follow up the long-term growth of IUGR babies? (N=172)

YES 58%

NO 42%