nutritional strategies in the nicu (what we learned in the neonatal nutrition survey) nutritional...

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

What is the problem?

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

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

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)

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We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).

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%

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%

DOMAIN IParenteral and Enteral Feeding

Strategies

In 3 preterm infant weight groups

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

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%

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

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%

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?

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?

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?

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

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%

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

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%

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

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%

7. Are there any contraindications to starting lipids? (N=174)

YES NO

N=70 YES NOLung disease

Jaundice

PPHN

Hyperglycemia

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?

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?

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

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%

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

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%

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?

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%

10. Do you initially use continuous or bolus method of enteral feedings?

N= BOLUS CONTINUOUS

<1000g 170

1001-1500g

172

1501-2500g

173

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%

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

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%

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

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%

12b. Do you use “trophic feeds”…?

With RDS? N=174

YES

NO

In Absence of RDS?

N=173

YES

NO

12b. Do you use “trophic feeds”…?

With RDS? N=174

YES 90%

NO 10%

In Absence of RDS?

N=173

YES 87%

NO 13%

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%

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

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%

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

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%

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%

DOMAIN IIParenteral and Enteral Nutritional

Additives and Supplements

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

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

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%

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

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%

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

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%

3b. Do you add any of the following to breast milk?

N= YES NO

Polycose 165

Microlipid 164

MCT oil 161

Promod/Propac 166

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%

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

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%

DOMAIN IIIDemographics of Your Institution

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%

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%

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