Breaking Bad Eating Habits in the NICU

I thought I would share my top ten bad eating habits in the NICU. I have deliberately not ordered them in terms of size of the offense but set them down more chronologically as they occur clinically.

1. Not initiating “starter TPN” when a preterm infant is born.

It is amazing that this continues to take time for traction and near complete adoption across the country. The experience of the past when infants underwent significant metabolic derangement when taken from the womb where they were nourished with an almost endless supply of nutrients from the placenta to a simple intravenous dextrose drip seemed drastic now. And yet surveys suggest that this is still a practice.¹ In this survey about half of infants are started on starter TPN. While we can be happy that they reported a majority of NICU’s will start TPN on day 1 of life, this still leaves a large number of infants who struggle on a dextrose drip for up to 24 hours before TPN gets started. Starter TPN can be made well in advance, does not add excessive costs since it is batch prepared, and can be readily stored and retrieved in the middle of the night.

2. Not starting at least 3 grams/kg/day of amino acids of parenteral nutrition.

For the same reasons as in #1, the evidence to support the safety of early parenteral amino acids (AA) should permit a consistent use of at least 3 grams/kg/day of AA. Even in my own unit I have to consistently re-educate our team to give an infant a good start. Generally most starter TPN’s will begin at 2-3 grams/kg/day. When ordering TPN, many places will start at 2 g/kg/day then advance by 0.5g/kg/day instead of jumping to 3 g/kg/day with the next step. When each day is a nutritional crisis for the smallest preterm infants, every small drop of protein matters.

3. Starting lipids too slowly

Like starting AA on day 1, the initiation of lipids now occurs within the first 48 hours of life. The incremental increase of lipids is surprisingly slow everywhere. While the smallest micro preemie will struggle with lipid tolerance, most preterm infants can immediately handle 2 grams/kg/day of Intralipids. Increments of 1 g/kg/day with each day works just fine for many infants as well. Fat is the most energy dense component of TPN, so giving an adequate amount makes a huge difference in energy intake.

4. Not fixing electrolyte imbalances within 24 hours.

This is a big beef of mine. I think many people have become complacent seeing mild derangements of electrolytes such as hyper or hyponatremia, often having these corrections not fully corrected for several days. In fact, sometimes I will see sodium left to hover at 134 -135 mmol/L for days. The body is very tightly regulated and having a balanced homeostatic milieu is critical to staying healthy. My rule in the NICU is full correction of electrolyte disturbances in 24 hours.

5. Not having human milk as the only nutritional source for preterm infants less than 1500 grams birthweight.

For those that know me, this is a primary focus for my own messaging whenever I speak publicly. There is irrefutable evidence now that the exclusive use of human milk (HM) leads to a reduction in necrotizing enterocolitis (NEC) and in particular with surgical NEC.^2-4 A reduction in early onset sepsis has also been re-confirmed.⁵ The dose-dependent effect of the drug called HM is impressive and really is a testament to the power of the multitude of bioactive compounds found in HM.^{6, 7} There are places in the country where about 25% of very low birth weight infants see HM. In this day of cost containment and quality metrics it is unacceptable that we cannot make this practice a strong rule. The lack of mother’s milk is often cited as an excuse. The answer to that is in the next habit.

6. Not using donor human milk in the NICU.

It is true that mothers of preterm infants do not make as much milk as healthy term mothers.⁸ These mothers do require more lactation support, but when provided can often far exceed expectations and generate more than enough milk for their infants to cover the most critical period until they are about 34 weeks gestation. Donor HM (DHM) is a safe and superior product to infant formula that simply lack biologically active components and contain bovine products that are suspected to affect the risk for NEC. DHM is readily available across at least a dozen states in the US. The industry has both non-profit and commercial enterprises and is growing steadily with several banks opening every year. If everyone switched overnight we probably would exceed current capacity, but if greater awareness and better support at higher levels such as the state or federal level, this could be a successful conversion over several years.

7. Not providing enough enteral protein.

Yes, even after you fortify HM with human milk fortifiers we still have infants who are not getting enough protein to grow. This is a result of two major factors, one is that current fortifiers were not designed for our micro preemies. The second is that HM is hugely variable in nutrient components and protein content wanes over time in all mothers. Therefore many preterm infants are given meals that are far short of their optimal protein. I really like and endorse the adjustable fortification strategy that pushes fluids and fortification using BUN as a target indicator of protein status.⁹

8.  Waiting for infants to show poor growth before pushing feeds higher.

This is a harder one to convey as many places have set practices that reach a certain fluid target and concentration target. The team then waits for poor growth or growth failure before then responding to this with a higher amount of volume or increased concentration of feeds depending on the infant’s tolerance to fluid. Repeated bouts of poor growth end up with a bit of a staircase effect in growth. Given the great needs of the smallest preemies, I would much rather predetermine a caloric target that exceeds the amounts needed for most (say 80-90%) of the infants so that most infants are growing successfully most of the time, instead of the larger percentage of infants that are tweaked upwards every week before the growth trajectory is met.

9. Discharging VLBW infants home without fortification

The evidence for optimal postdischarge nutrition is very limited and confusing, particularly for HM fed preemies going home. The available evidence and common sense would indicate that our smallest infants probably still require some additional nutritional support after being discharged home. These infants have been shown to grow better if this support is added.¹⁰ Many are discharged home before term due date and are still in a rapid growth period when bone and brain development are critical. Until we get more large scale evidence, I am a huge fan of a consistent practice to support good growth and development after discharge. At UCSD we consistently aim for at least 3 months of additional nutritional fortification after VLBW infants go home.

10. Finally I am including an already broken bad habit in the NICU. I have to admit that I miss the days when we could have a cup of coffee walking around in the NICU. If someone could figure out a safe way to have this accomplished, a lot of happy smiles await you. 🙂

 

References

1. Hans DM, Pylipow M, Long JD, Thureen PJ, Georgieff MK. Nutritional practices in the neonatal intensive care unit: analysis of a 2006 neonatal nutrition survey. Pediatrics. 2009;123(1):51-7.

2. Lucas A, Cole TJ. Breast milk and neonatal necrotising enterocolitis. Lancet. 1990;336(8730):1519-23.

3. Sullivan S, Schanler RJ, Kim JH, Patel AL, Trawoger R, Kiechl-Kohlendorfer U, et al. An exclusively human milk-based diet is associated with a lower rate of necrotizing enterocolitis than a diet of human milk and bovine milk-based products. J Pediatr. 2010;156(4):562-7.

4. Cristofalo EA, Schanler RJ, Blanco CL, Sullivan S, Trawoeger R, Kiechl-Kohlendorfer U, et al. Randomized Trial of Exclusive Human Milk versus Preterm Formula Diets in Extremely Premature Infants. J Pediatr. 2013.

5. Patel AL, Johnson TJ, Engstrom JL, Fogg LF, Jegier BJ, Bigger HR, et al. Impact of early human milk on sepsis and health-care costs in very low birth weight infants. J Perinatol. 2013;33(7):514-9.

6. Meinzen-Derr J, Poindexter B, Wrage L, Morrow AL, Stoll B, Donovan EF. Role of human milk in extremely low birth weight infants’ risk of necrotizing enterocolitis or death. Journal of perinatology : official journal of the California Perinatal Association. 2009;29(1):57-62.

7. Kim JH, Froh EB. What Nurses Need To Know Regarding Nutritional and Immunobiological Properties of Human Milk. J Obstet Gynecol Neonatal Nurs. 2011;41(1):122-37.

8. Henderson JJ, Hartmann PE, Newnham JP, Simmer K. Effect of preterm birth and antenatal corticosteroid treatment on lactogenesis II in women. Pediatr. 2008;121(1):e92-100.

9. Arslanoglu S, Moro GE, Ziegler EE. Adjustable fortification of human milk fed to preterm infants: does it make a difference? J Perinatol. 2006;26(10):614-21.

10. O’Connor DL, Weishuhn K, Rovet J, Mirabella G, Jefferies A, Campbell DM, et al. Visual development of human milk-fed preterm infants provided with extra energy and nutrients after hospital discharge. JPEN J Parenter Enteral Nutr. 2012;36(3):349-53.