Improving Time to First Feeding for Preterm Infants: A Quality Improvement Approach

Abstract

Introduction: Early initiation of enteral feeding is reported to reduce sepsis and mortality in preterm infants. Less than half of stable infants born <35 weeks gestational age with birth weight <2,000 g are fed within 24 hours of birth at our center.

Methods: The Specific, measureable, achievable, relevant, timely aim of this quality improvement project was to increase the initiation of enteral feeding within 24 hours of birth from 49% (baseline) to 75% among infants born <35 weeks gestational age with birth weight <2,000 g between November 2022 and December 2023. We identified the unavailability of a mother's own milk as a major barrier to early feeding initiation. Project interventions included antenatal lactation consultation, patient-dedicated breast pumps, standardized feeding orders, and multidisciplinary education. The outcome measure was the time to first enteral feeding, and the balancing measures were the diagnosis of necrotizing enterocolitis (NEC) and the use of formula for first feeding.

Results: The proportion of infants with feeding initiated within 24 hours of birth increased from 49% to 80% during the project period. The incidence of NEC was unchanged (1.9% before and during the project period). Both before and during the project, feedings were most frequently initiated with pasteurized donor human milk (49.7% versus 58.7%), followed by mother's own milk (37.8% versus 35.6%) and formula (12.5% versus 5.8%).

Conclusions: This quality improvement project increased the proportion of eligible infants fed within 24 hours of birth without a change in the incidence of NEC or an increase in formula use as first feeding.

Fig. 1.

Fishbone Diagrams. Problem statement listed on the right-hand side and potential root causes contributing to the problem listed in categories. APU: antepartum unit; EHR, electronic health record; ICN, intensive care nursery; ICU, intensive care unit; IV, intravenous; HE, hand expression; OB, obstetrics.

Fig. 2.

Percentage lactation consults completed before delivery p chart. The y-axis represents the percentage of lactation consults that were completed before delivery. The x-axis shows the date and number of antenatal consults completed for patients <35 weeks at consult.

Fig. 3.

Statistical process control charts. A, Percentage time to first feeding less than 24 hours p Chart. The y-axis represents the percentage of infants in the cohort that were fed within 24 hours of birth. The x-axis shows the date and number of infants. B, Average time to first feeding by month X chart. The y-axis represents the average time in hours:minutes. The x-axis shows the date and number of infants.