Improved Use of Human Milk, Growth, and Central Line Utilization With Standard Feeding Roadmap in an Academic NICU

Feeding volume advancement in preterm neonates: A level 4 neonatal intensive care unit quality improvement initiative

INTRODUCTION

Because of provider variability in feeding guideline application, a quality improvement (QI) initiative was begun to better standardize feeding initiation and advancement for preterm infants. Our specific, measurable, achievable, relevant, and timely aims included decreasing the time to reach full feeds by 35% and reducing the duration of central lines by 30% over 12 months in infants born between 25 and 30 weeks' gestation or with birth weight between 600 and 1250 g.

METHODS

Registered dietitians tracked central line days, parenteral nutrition (PN), enteral nutrition, fortification, guideline adherence, anthropometrics, necrotizing enterocolitis (NEC) cases, and central line-associated bloodstream infections (CLABSIs). QI progress charts were reviewed monthly.

RESULTS

Mean central line days decreased from 7.3 to 5.8. Days of PN decreased from 6.7 to 5.1. The day of life that enteral feeds were started decreased from 1.1 to 0.5. The number of days between starting enteral feeds and adding fortification decreased from 3.4 to 2.3 days. Full enteral feeds were achieved on average 2 days earlier. Birth weight was regained at around 10.2 days of life before the guideline was implemented and at a mean of 9.6 days after the guideline. There was no increase in cases of CLABSI or diagnoses of NEC.

CONCLUSION

After implementation of this feeding QI initiative at a level 4 neonatal intensive care unit, central line duration and PN use were decreased and infants reached full enteral feeds earlier without changes in cases of NEC, CLABSI, or time to regain birth weight.

Development of necrotizing enterocolitis after blood transfusion in very premature neonates

BACKGROUND

Prior studies report conflicting evidence on the association between packed red blood cell (PRBC) transfusions and necrotizing enterocolitis (NEC), especially in early weeks of life where transfusions are frequent and spontaneous intestinal perforation can mimic NEC. The primary objective of this study was to evaluate the association between PRBC transfusions and NEC after day of life (DOL) 14 in very premature neonates.

METHODS

A retrospective cohort analysis of very premature neonates was conducted to investigate association between PRBC transfusions and NEC after DOL 14. Primary endpoints were PRBC transfusions after DOL 14 until the date of NEC diagnosis, discharge, or death. Wilcoxon ranked-sum and Fisher's exact tests, Cox proportional hazards regression, and Kaplan-Meier curves were used to analyze data.

RESULTS

Of 549 premature neonates, 186 (34%) received transfusions after DOL 14 and nine (2%) developed NEC (median DOL = 38; interquartile range = 32-46). Of the nine with NEC after DOL 14, all were previously transfused (P < 0.001); therefore, hazard of NEC could not be estimated. Post hoc analysis of patients from DOL 10 onward included five additional patients who developed NEC between DOL 10 and DOL 14, and the hazard of NEC increased by a factor of nearly six after PRBC transfusion (hazard ratio = 5.76, 95% confidence interval = 1.02-32.7; P = 0.048).

CONCLUSIONS

Transfusions were strongly associated with NEC after DOL 14. Prospective studies are needed to determine if restrictive transfusion practices can decrease incidence of NEC after DOL 14.