An Initiative to Reduce Preterm Infants Pre-discharge Growth Failure Through Time-specific Feeding Volume Increase

Abstract

Very low birth weight infants often demonstrate poor postnatal longitudinal growth, which negatively impacts survival rates and long-term health outcomes. Improving extrauterine growth restriction (EUGR) among extremely premature infants has become a significant focus of quality improvement initiatives. Prior efforts in the University of Massachusetts Memorial Medical Center neonatal intensive care unit were unsuccessful in improving the EUGR rate at discharge.

Methods: The primary aim of this initiative was to improve EUGR at discharge [defined as weight less than 10th percentile for postmenstrual age (PMA)] for infants born ≤32 0/7 weeks from a baseline of 25% to 20% by June 2019. We excluded all small for gestational age infants due to the limitation in the EUGR definition. A multidisciplinary team implemented evidence-based nutritional guideline changes using the Institute of Healthcare Improvement methods. The most notable change was the time-specific feeding volume advancement that increased the goal feeding volume between 31 0/7 and 34 0/7 weeks PMA from 150-160 to 170-180 milliliters per kilogram per day. The team monitored nutritional intake, weight, necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD), and length of stay (LOS).

Results: The EUGR rate improved from 25% to 12% after initiation of increased time-specific, enteral feeding guidelines at 31-34 weeks PMA. NEC rate, BPD rate, and LOS remained unchanged throughout the initiative.

Conclusions: By implementing a time-specific volume increase guideline from 31 0/7 to 34 0/7 weeks PMA, the EUGR rate improved from baseline of 25% to 12% without increasing NEC rate, BPD rate, and LOS.

Fig. 1.

Nutrition guideline history: how to increase the caloric content of breast milk using human milk fortifier and liquid protein. ¹Similac, Abbott Laboratories, Columbus, OH; ²Abbott Nutrition, Abbott Laboratories, Columbus, OH; ³Nestle Health Science, Nestle HealthCare Nutrition, Inc, Bridgewater, NJ.

Fig. 2.

Key driver diagram to reduce EUGR at discharge for infants born less than or equal to 32 0/7 weeks. Gray indicates prior initiatives. TPN, total parenteral nutrition.

Fig. 3.

PDSA ramp cycles to establish enteral feeding guideline changes.

Fig. 4.

P chart of extrauterine growth failure rate at discharge at UMMMC for infants born less than or equal to 32 0/7 weeks GA. ¹PDSA cycle timeline, please refer to Figure 2 for full list of PDSA cycles included and their initiation dates.

Fig. 5.

P chart of volume increase guideline compliance for all infants born less than or equal to 32 0/7 weeks GA.

Fig. 6.

Balancing measures for feeding volume increase. A, P chart of infants born less than or equal to 32 0/7 weeks GA diagnosed with BPD at UMMMC. B, T chart displaying duration (days) between each incidence of NEC occurring in infants born less than or equal to 32 0/7 weeks.