debbie hans md, fellow, university of mn mary pylipow md, university of ……………
DESCRIPTION
NICU Best Practice: Recommended 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. - PowerPoint PPT PresentationTRANSCRIPT
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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
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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We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).
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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%
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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 IParenteral 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
<1000g 167 80% 20% <1%
1001-1500g 168 75% 24% <1% <1%
1501-2500g 156 52% 39% 4% 2% <1% <1% 1%
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Patti’s 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
<1000g 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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Patti’s slide
Recommended parenteral protein intakes at different gestational ages
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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?
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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= <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%
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Patti
Once again emphasize Zeigler’s 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
<1000g 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
<1000g 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? (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%
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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%
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Patti
2-3 slides on lipid safety, contraindications, what we know and don’t 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
<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%
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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
<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%
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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%
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?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
<1000g 146 8% 33% 15% 43% <1%
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
<1000g 144 15% 35% 13% 36% 1%
1001-1500g
153 5% 20% 20% 53% 2%
1501-2500g
153 4% 13% 14% 62% 10%
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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
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12b. Do you use “trophic feeds”…?
With RDS? N=174
YES 90%
NO 10%
In Absence of RDS?
N=173
YES 87%
NO 13%
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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%
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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%
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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?
N=81 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)? (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%
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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%
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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…?
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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 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%
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Patti
1-2 slides on max ox glucose capacity
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DOMAIN IIParenteral 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 IIIDemographics of Your Institution
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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%
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2. Who writes your TPN orders? (N=176)
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? (N=168)
YES 46%
NO 54%
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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%
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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%
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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%
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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%