30-30-60: A Quality Improvement Project on Faster Enteral Feed Advancement and Early Fortification

Early nutrition for premature infants is a crucial determinant of postnatal growth, neurodevelopment, and survival. Concerns about necrotizing enterocolitis (NEC) have led to delays in the introduction and advancement of enteral feeding. Our quality improvement (QI) project aimed to decrease the time to achieve full enteral feeds and central line duration in infants born between 27 to 32 weeks and 6 days' gestation.

We conducted this QI initiative from August 2023 to December 2024. We designed a simplified feeding guideline, 30-30-60, which involved initiation of enteral feeds at a volume of 30 ml/kg/d, advancement by 30 ml/kg/d, and earlier fortification at 60 ml/kg/d. Statistical control charts were used to study changes over time. We measured days to full enteral feeds and central line days as primary outcomes. Balancing measures were rates of feeding intolerance and usage of donor breast milk. Clinical outcomes (late-onset sepsis, NEC) were also tracked.

A total of 84 infants were included. The mean time to achieve full enteral feeds decreased by 25.5%, from 11 days to 8.2 days, whereas the mean duration of central line days decreased by 34%, from 8.9 days to 5.9 days. The percentage of infants requiring peripherally inserted central catheter placement decreased by 67%, from 42.9% at baseline to 14%. Episodes of feeding intolerance decreased over time, whereas the donor human milk usage, late-onset sepsis, and NEC rates remained stable.

QI methodology was successfully used to implement new feeding guidelines, thereby reducing days to full enteral feeds and central line duration.