Optimizing Neonatal Nutrition
The Vermont Oxford Network (VON) is a non-profit voluntary collaboration of health care professionals dedicated to improving the quality and safety of medical care for newborn infants and their families. Established in 1988, the Network is comprised of over 700 Neonatal Intensive Care Units around the world. In support of its mission, the Network maintains a Database including information about the care and outcomes of high-risk newborn infants. The Database provides unique, reliable and confidential data to participating units for use in quality management, process improvement, internal audit and peer review.
Health care professionals from member institutions participate actively in clinical trials, long-term follow-up studies and epidemiologic and outcomes research. Members may also participate in quality improvement collaboratives for Neonatology consisting of multidisciplinary improvement teams working together to identify and implement better practices aimed at achieving measurable improvements in quality and safety. Teams attend face-to-face meetings that include interactive plenary presentations, small and large group exercises, and learning fairs in which teams share their improvement stories. Each team has joined a Learning and Improvement Community, a multi-hospital group that focuses on improving key NICU processes. Between meetings of the collaborative, teams work together through conference calls and email discussion lists.
Carrie Finch, RD, CNSC, and Cecilia Kennedy, RD, have participated as team members with the Neonatology group at MUSC, focusing on optimizing nutrition in very low-birthweight infants (VLBW) (infants born weighing < 1.5 kg). Through our Learning and Improvement Community, we have identified 6 “potentially better practice” (PBP) areas at MUSC:
1. Monitor nutritional intake and nutritional outcome measures into medical management of
prematures infants.
2. Start parenteral nutrition (PN) soon after birth, with amino acids within two hours and lipids
within 24 hours of birth, in infants < 1.5 kg.
3. Promote and use human milk as the preferred nutritional substrate for premature infants
4. Implement feeding guidelines which include early trophic feeds, an algorithm for managing
residuals, and systematic advancement for infants < 1.5 kg.
5. Supplement human milk with additional protein, calories, minerals, and micronutrients to
achieve at least 3.5 grams/kg/day of protein delivery and adequate growth.
6. Promote post-discharge breastfeeding with appropriate nutrient fortification.
Our quality improvement poster presented at the VON Collaborative in Austin, TX, in April focused on the second PBP. By increasing early protein administration to our VLBW infants from 2 grams/kg to 3.2 grams/kg and ensuring administration within 2 hours of birth in our inborn patients, we have seen a corresponding decrease in extrauterine growth restriction in this population at discharge.
Currently, our percent of VLBW infants avoiding extrauterine growth restriction at discharge is 7-10%, decreased from 35% in early 2009. In 2009, there were 232 VLBW births at MUSC. This compares to 889 VLBW births admitted to Level III Neonatal ICU’s in SC in 2008. Our next improvement poster will be presented in September and likely focus on our progress with PBP 5.