Sustaining improved nutritional support for very low birthweight infants
Mitchell Kresch1, Kashish Mehra2, Richard Jack2
1Department of Pediatrics, Penn State Health Children's Hospital, Hershey, Pennsylvania, USA mkresch@pennstatehealth.psu.edu.
Insights
Postnatal growth failure (PGF) in very low birthweight (VLBW) infants was reduced by improving nutritional support. This quality improvement project successfully decreased PGF rates in VLBW infants to below 50%.
Area of Science:
- Neonatal intensive care
- Pediatric nutrition
- Quality improvement science
Background:
- Postnatal growth failure (PGF) affects a significant majority (84%) of appropriately grown very low birthweight (VLBW) infants.
- Contributing factors include prematurity, acute illness, and inadequate nutritional support.
- A quality improvement initiative was launched to address high PGF rates in VLBW infants.
Purpose of the Study:
- To reduce the incidence of PGF in VLBW infants to less than 50% at discharge within two years.
- To sustain PGF rates below 50% long-term.
- To enhance nutritional support strategies for VLBW infants.
Main Methods:
- Inclusion criteria: All inborn VLBW infants without congenital anomalies.
- Intervention: Implemented evidence-based practices including earlier initiation of starter total parenteral nutrition (TPN), aggressive advancement of regular TPN, and timely human milk fortification.
- Methodology: Utilized three Plan-Do-Study-Act (PDSA) cycles to test and refine interventions.
Main Results:
- Significantly reduced time to initiation of starter TPN from 5.5 hours to under 3 hours.
- Increased frequency of achieving amino acid and lipid goals with regular TPN.
- Improved rates of human milk fortification at 80 mL/kg/day intake.
Conclusions:
- Achieved a sustained reduction in PGF for VLBW infants, decreasing from 84% to below 50% starting in 2010-2011.
- Reported a PGF rate of 23.1% in 2016, demonstrating long-term success.
- Validated the effectiveness of the model for improvement in enhancing nutritional support for VLBW infants.
Background:
Postnatal growth failure (PGF) in very low birthweight (VLBW) infants is a result of factors such as prematurity, acute illness and suboptimal nutritional support. Before this project began, 84% of appropriately grown VLBW infants in our neonatal intensive care unit experienced PGF. The aims of this quality improvement project were to reduce the percentage of infants discharged with PGF to less than 50% within 2 years and to maintain a rate of PGF under 50%.
Methods:
All inborn VLBW infants were eligible for this study. Infants with congenital anomalies were excluded. We determined key drivers for optimal nutrition and identified potentially better practices (process measures) based on a review of the literature, which included more rapid initiation of starter total parenteral nutrition (TPN), aggressive use and advancement of regular TPN, and fortification of human milk when the volume of intake reached 80 mL/kg/day. Three Plan-Do-Study-Act (PDSA) cycles were tested.
Results:
Time to initiation of starter TPN was significantly reduced from 5.5 hours to under 3 hours. Regular TPN provided the goals for amino acids and lipids at increased frequency after the first two PDSA cycles. The proportion of infants whose milk was fortified at 80 mL/kg/day increased after the third PDSA cycle.
Conclusions:
We found a sustained decrease in the percentage of infants discharged with PGF from 84% at baseline to fewer than 50% beginning in 2010-2011 through 2016, with 23.1% of infants experiencing PGF in 2016. We have achieved improved nutritional support for VLBW infants using the model for improvement.
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