nutritional strategies in the nicu (what we learned in the neonatal nutrition survey) nutritional...
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Nutritional Strategies in the NICUNutritional Strategies in the NICU
(What we learned in the Neonatal Nutrition Survey)(What we learned in the Neonatal Nutrition Survey)Pediatrics 123:51-57, 2009
Michael K. Georgieff, MD
Professor of Pediatrics
University of Minnesota Amplatz Children’s Hospital
University of Minnesota
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What is the problem?
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Ehrenkranz et al. Ehrenkranz et al. Reproduced with permission from Pediatrics, Vol 104:280-289, Copyright Reproduced with permission from Pediatrics, Vol 104:280-289, Copyright 1999 by the AAP 1999 by the AAP
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1.Transition
2. Catch-up
3. Post-discharge3. Post-discharge
CPS phase 1:“Transition”0-10 daysSickCatabolic
CPS Phase 2:“Catch-up”10d-34 wks PCAWellAnabolicImmature Physio
CPS Phase 3:CPS Phase 3: ““Post-discharge”Post-discharge”WellWellAnabolicAnabolicMature PhysioMature Physio
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Possible Causes
Lack of knowledge of current nutritional recommendations Survey (Hans et al, Pediatrics 2009)
Failure to prescribe what is known “NEC-ophobia” (Joe Neu)
Failure to deliver what is prescribed Current NIH sponsored trial (Patti Thureen, PI)
Failure to grow in spite of adequate delivery Can sick babies grow?
Failure to assimilate (absorb, traffic) Failure to translate (growth factors, mTOR)
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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We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).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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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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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 x
1001-1500g 168 x
1501-2500g 156 x
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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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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 x
1001-1500g
154 x
1501-2500g
153 x
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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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3. Do you advance protein daily?
N= 0.25 0.5 1 >1
<1000g 148
1001-1500g
151
1501-2500g
150
YES NO (N=174)
If yes, what increment (g/kg) do you advance by?
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3. Do you advance protein daily?
N= 0.25 0.5 1 >1
<1000g 148
1001-1500g
151
1501-2500g
150
YES 91% NO 9% (N=174)
If yes, what increment (g/kg) do you advance by?
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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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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 x
1001-1500g
166 x
1501-2500g
164 x
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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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5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the non-ventilated infant?
N= 0 0.5 1 2 3
<1000g 164
1001-1500g
167
1501-2500g
170
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5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the 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 the ventilated infant?
N= 0 0.5 1 2 3
<1000g 161
1001-1500g
166
1501-2500g
168
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5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the 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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7. Are there any contraindications to starting lipids? (N=174)
YES NO
N=70 YES NOLung disease
Jaundice
PPHN
Hyperglycemia
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7. Are there any contraindications to starting lipids? (N=174)
YES 40% NO 60%
N=70 YES NOLung disease
Jaundice
PPHN
Hyperglycemia
If Yes, what are they?
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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%
If Yes, what are they?
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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
1001-1500g
142
1501-2500g
142
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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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9a. On what day do you start enteral feeds in non-ventilated infants?
N= 0 1 2 3 4 5 6 7
<1000g 153 x
1001-1500g
156 x
1501-2500g
152 x
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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 X?
1001-1500g
148 X?
1501-2500g
147 X?
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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
1001-1500g
172
1501-2500g
173
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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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11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)?
N= 5 10 15 20 ≥30
<1000g 146 x
1001-1500g
153 x
1501-2500g
154 x
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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 x
1001-1500g
153 x
1501-2500g
153 x
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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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12b. Do you use “trophic feeds”…?
With RDS? N=174
YES
NO
In Absence of RDS?
N=173
YES
NO
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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
1001-1500g
146
1501-2500g
148
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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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15. Do you feed babies with…?
N= YES NO
Indwelling UACs 174
Indwelling UVCs 174
Low-dose dopamine 170
Cut off for dopamine 34
Indomethacin 174
Hydrocortisone 166
Clinically significant PDA 174
Clinically insignificant PDA 174
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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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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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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
If yes, for hyperglycemia?
154
If yes, to enhance weight gain?
147
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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
If yes, to enhance weight gain?
147
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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
H2 Antagonists 171
Albumin 170
Iron Dextran 171
Carnitine 172
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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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3a. Do you use any of the following to enhance your enteral formula?
N= YES NO
Polycose 171
Microlipid 164
MCT oil 168
Promod/Propac 161
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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
Microlipid 164
MCT oil 161
Promod/Propac 166
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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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4. Do you use any of the following supplements?
N= YES NO
Iron 174
Folic acid 159
Vitamin E (with EPO)
154
Vitamin E (without EPO)
161
Vitamin A 161
Vitamin D 159
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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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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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Where do we stand?
Knowledge base appears to be very good Significant changes from 2001
More aggressive protein• Esp. in ELBWs
Earlier feeding initiation Less Epo Less Insulin as nutritional adjuvant
Still a lot of variability in fat administration Good knowledge not translated into practice Or, practice is not effective Current Trials