By Tammi Jantzen, Co-founder & CFO
Last week, I had the pleasure of attending the Baylor College of Medicine Neonatal Nutrition Conference in Houston, along with over 160 attendees from 29 states. All participants came together to learn about the latest research and trends related to nutritional strategies for babies born too soon. Preterm infants have greater nutritional needs in the neonatal period than at any other time of their lives. The nutrient needs are inherently high at this stage of development to match the high rates of nutrient deposition achieved by infants in utero. In order to achieve appropriate rates of weight gain – almost twice that of a term infant – and to avoid postnatal growth failure, early and adequate nutritional support is needed. Yet, growth failure remains a major problem.
Growth Assessment of Preterm Infants
Postnatal growth failure is a universal problem among very low birthweight infants and is associated with adverse neurodevelopmental and growth outcomes in early childhood. Postnatal growth failure is defined as weight <10th percentile on the growth chart. The implications of growth failure include an increased risk of chronic lung disease, sepsis, necrotizing enterocolitis (NEC), cerebral palsy and school difficulties. Some of the factors that drive poor growth and poor cognitive outcomes include social determinants of health, prenatal factors, morbidities, and NICU stress.
So, what rate of growth should we aim for? The goal for preterm infants is to achieve rates of growth and nutrient accretion that match those achieved by infants of similar gestational age in utero. That goal rate is 15-20 g/kg/day. Let’s break that down in an example:
- Baby is born at 28 weeks gestational age weighing 900 grams (2 lbs)
- Assume Baby consistently gains weight at a rate of 20 g/kg/day
- In just 5 weeks, Baby will weigh 1800 grams (4 lbs) – doubling in size!
- The neonatal period is the fastest period of growth of their lifetime
Important Role of Human Milk in the NICU
How can we best achieve good growth? According to the American Academy of Pediatrics, all preterm infants should receive human milk. The nutritional and immunological properties unique to mom’s breastmilk help protect babies from infection and illness. Mom’s breastmilk contains a variety of nutrients, growth factors and hormones that are vital for early brain development. In addition, preterm infants have immature intestines – digestion, absorption, and motility are all still developing at 24 weeks gestational age. Human milk interacts with and shapes the intestinal microbiome by providing the good gut bacteria as well as the human milk oligosaccharides (HMOs) which are food for the good bacteria.
Fortifiers also play an important role. Human milk should be fortified with protein, minerals, and vitamins to ensure optimal nutrient intake and appropriate growth for infants weighing <1500 grams at birth. Pasteurized donor human milk, appropriately fortified, should be used if mother’s own milk is unavailable or its use is contraindicated. Fortifiers ensure growth and help meet the critical nutrient needs of preterm infants.
Quality Improvement and Nutrition
Quality Improvement (QI) initiatives are important in every hospital. Quality improvement requires an intentional change in a methodical and systematic way. A successful QI project will lead to improved patient outcomes, improved efficiencies, decreased waste, improved morale, and can give hospitals a competitive advantage. One of the speakers said they have over 35 QI projects in their NICU currently ongoing.
Some domains of quality are safety, effectiveness, efficiency, avoiding waste, and consistency in care. Practice variability among clinicians is common. In fact, the speaker talked about residents carrying around folders for each of the attending physicians for rounds. Each folder contained the care preferences for each attending as they were all very different. Variation between clinicians is a source of frustration to staff and parents and can lead to decreased quality of care and potentially increased costs and waste.
Current quality problems with nutrition include: suboptimal nutritional intakes that lead to poor growth; delayed achievement of feeding milestones; poor long-term outcomes; and errors in nutrition delivery. Some of the patient safety errors related to neonatal nutrition are:
- Administration of wrong breastmilk – mistakenly feeding an infant breastmilk from another mom
- Gavage tube placed inadvertently into trachea, infusion of feeds into lungs
- Parenteral nutrition composition and infusion rate errors
- Intravenous infusion of milk – yes this does happen!
Ideally, a “nutrition dashboard” can help with quality monitoring and quality improvement. Nutrition is a data-rich field with so much data already being captured in the electronic medical record. There are hundreds of data points per day on each baby – it isn’t humanly possible to track all this data in a meaningful way without an analytical dashboard. A nutrition dashboard could streamline and integrate data collection systems for analysis and visual display of key data. It would help measure and monitor key quality indicators, track trends, and benchmark performance against industry standards.
Because people are resistant to change, it’s important to overlay practices and outcomes to help clinical teams see what is best and why change is needed. However, it was noted that things don’t change because you send an email or put a policy in place. We have to do more. We have to do better.
“Everyone in healthcare really has two jobs when they come to work every day: to do their work and to improve it.”
– Paul Batalden, MD, Senior Fellow, Institute for Healthcare Improvement
This was my third year attending this conference, and I am always amazed at how much there is to learn. There were so many great presentations, unfortunately I couldn’t write about them all… the impact of nutrition on the microbiome, the latest NEC research, the use of probiotics in the NICU, PN guidelines and calculations, and racial disparities to name a few.
In closing, I think it’s important to remember that, thirty years ago, extremely preterm infants didn’t survive. Today, we can survive infants at just 22 weeks gestational age. That is just a little over halfway through a term pregnancy. These tiny fighters are really a new clinical population.
Huge strides have been made in research to try and understand the best strategies to help these tiny babies not just survive, but to grow and thrive. Proper nutrition early in life plays an essential role. Let the voice of nutrition be heard!