Nutritional Strategies in the NICU (What we learned in the Neonatal Nutrition Survey) Nutritional Strategies in the NICU (What we learned in the Neonatal Nutrition Survey) Pediatrics 123:51-57, 2009 Michael K. Georgieff, MD Professor of Pediatrics University of Minnesota Amplatz Childrens Hospital University of Minnesota

What is the problem?

Ehrenkranz et al. Reproduced with permission from Pediatrics, Vol 104: , Copyright 1999 by the AAP

1.Transition 2. Catch-up 3. Post-discharge CPS phase 1: Transition 0-10 days Sick Catabolic CPS Phase 2: Catch-up 10d-34 wks PCA Well Anabolic Immature Physio CPS Phase 3: Post-dischargeWellAnabolic Mature 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 (1985). 76: We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).

Methods 775 surveys were sent via 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? TYPEN=169 Private39% University53% Public or Military 8% NUMBER OF BEDS N=175 <102% % % % >5023%

DOMAIN I Parenteral and Enteral Feeding Strategies In 3 preterm infant weight groups

1. On what day of life is TPN started? N=123456Later <1000g 167 x g 168 x g 156 x

1. On what day of life is TPN started? N=123456Later <1000g %20%<1% g %24%<1% g %39%4%2%<1% 1%

2. How much protein (g/kg/day) do you prescribe on the first day of TPN? N= <1000g150x g 154x g 153x

2. How much protein (g/kg/day) do you prescribe on the first day of TPN? N= <1000g1507%28%51%13%1% g 1544%29%55%11%1% g 1531%30%55%12%1%

3. Do you advance protein daily? N= >1 <1000g g g 150 YESNO (N=174) If yes, what increment (g/kg) do you advance by?

3. Do you advance protein daily? N= >1 <1000g g g 150 YES91%NO 9%(N=174) If yes, what increment (g/kg) do you advance by?

3. Do you advance protein daily? N= >1 <1000g1481%49% 1% g 151<1%37%59%3% g 150<1%32%63%4% YES91%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=< >4 <1000g164x g 166x g 164x

4. What is your maximum protein (g/kg/day) when at full TPN? N=< >4 <1000g1642%18%49%29%1% g 1662%22%55%20%1% g 1643%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= <1000g g g 170

5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the non- ventilated infant? N= <1000g16426%34%32%7%1% g 16722% 46%10%1% g 17020%18%47%13%1%

5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the ventilated infant? N= <1000g g g 168

5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the ventilated infant? N= <1000g16125%36%30%7%1% g 16622%25%43%9%1% g 16820% 47%13%1%

7. Are there any contraindications to starting lipids? (N=174) YES NO N=70YESNO Lung disease Jaundice PPHN Hyperglycemia

7. Are there any contraindications to starting lipids? (N=174) YES 40%NO 60% N=70YESNO Lung disease Jaundice PPHN Hyperglycemia If Yes, what are they?

7. Are there any contraindications to starting lipids? (N=174) YES 40%NO 60% N=70YESNO Lung disease 17%83% Jaundice 50% PPHN 43%57% Hyperglycemia 23%77% If Yes, what are they?

8. How fast do you advance your lipids (g/kg/day)? N= Based on TG <1000g g g 142

8. How fast do you advance your lipids (g/kg/day)? N= Based on TG <1000g13356%28%17% g 14242%44%<1%13% g 14237%51%<1%11%

9a. On what day do you start enteral feeds in non-ventilated infants? N= <1000g153x g 156x g 152x

9a. On what day do you start enteral feeds in non-ventilated infants? N= <1000g1533%35%34%16%4% <1%2% g 1568%49%32%8%2%<1% g 15225%54%16%5%

9b. On what day do you start enteral feeds in ventilated infants? N= <1000g142X? g 148X? g 147X?

9b. On what day do you start enteral feeds in ventilated infants? N= <1000g1423%16%27%29%9% 1%6% g 1482%24%42%17%8%5%1% g 1475%31%34%18%7%4%1%

10. Do you initially use continuous or bolus method of enteral feedings? N=BOLUSCONTINUOUS <1000g g g 173

10. Do you initially use continuous or bolus method of enteral feedings? N=BOLUSCONTINUOUS <1000g17081%19% g 17295%5% g 17399%1%

11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)? N= <1000g146x g 153x g 154x

11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)? N= <1000g1468%33%15%43%<1% g 1533%12%19%64%3% g 1541%5%9%69%16%

11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)? N= <1000g144x g 153x g 153x

11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)? N= <1000g14415%35%13%36%1% g 1535%20% 53%2% g 1534%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 YES90% NO10% In Absence of RDS? N=173 YES87% NO13%

13. What is the composition of the first enteral feed for infants? <1000g (N=173) g (N=174) g (N=173) Sterile water2%1%<1% Glucose solution2% ½ strength 20 cal formula3% 1% Full strength 20 cal formula45% 52% ½ strength 24 cal formula4%5%3% Full strength 24 cal formula17%20%17% ½ strength breast milk<1%1% Full strength breast milk88%89% Pedialyte1% ¼ strength 24 cal formula2%1% Full strength 22 cal formula3%

14. How many days do you maintain babies on trophic feeds? N=1237Other Not Used <1000g g g 148

14. How many days do you maintain babies on trophic feeds? N=1237Other Not Used <1000g12720%24%29%17%9% g 14642%19%18%5%6%8% g 14861%11%5%1% 19%

15. Do you feed babies with…? N=YESNO Indwelling UACs174 Indwelling UVCs174 Low-dose dopamine170 Cut off for dopamine34 Indomethacin174 Hydrocortisone166 Clinically significant PDA174 Clinically insignificant PDA174

15. Do you feed babies with…? N=YESNO Indwelling UACs17475%25% Indwelling UVCs17493%7% Low-dose dopamine17037%63% Cut off for dopamine3468%32% Indomethacin17417%83% Hydrocortisone16670%30% Clinically significant PDA17428%72% Clinically insignificant PDA17493%7%

21. In the week gestation infants, do you target a specific GIR? YES 60%NO 40% Initial GIRN=96 414% 4.55% 540% 5.510% 620% 78% 7.51% 82% Goal GIRN=83 51% 66% 78% 83% 931% 104% 1121% 127% 137% 146% 152%

DOMAIN II Parenteral and Enteral Nutritional Additives and Supplements

1. Do you use insulin in your NICU? N=YESNO Use insulin?173 If yes, for hyperglycemia? 154 If yes, to enhance weight gain? 147

1. Do you use insulin in your NICU? N=YESNO Use insulin?17388%12% If yes, for hyperglycemia? 154 If yes, to enhance weight gain? 147

1. Do you use insulin in your NICU? N=YESNO Use insulin?17388%12% If yes, for hyperglycemia? 15498%2% If yes, to enhance weight gain? 14712%88%

2. Do you add any of the following to your TPN solution? N=YESNO Erythropoeitin173 H2 Antagonists171 Albumin170 Iron Dextran171 Carnitine172

2. Do you add any of the following to your TPN solution? N=YESNO Erythropoeitin17313%87% H2 Antagonists17164%36% Albumin17026%74% Iron Dextran17132%68% Carnitine17265%35%

3a. Do you use any of the following to enhance your enteral formula? N=YESNO Polycose171 Microlipid164 MCT oil168 Promod/Propac161

3a. Do you use any of the following to enhance your enteral formula? N=YESNO Polycose17153%47% Microlipid16429%71% MCT oil16874%26% Promod/Propac16155%45%

3b. Do you add any of the following to breast milk? N=YESNO Polycose165 Microlipid164 MCT oil161 Promod/Propac166

3b. Do you add any of the following to breast milk? N=YESNO Polycose16525%75% Microlipid16418%82% MCT oil16142%58% Promod/Propac16642%58%

4. Do you use any of the following supplements? N=YESNO Iron174 Folic acid159 Vitamin E (with EPO) 154 Vitamin E (without EPO) 161 Vitamin A161 Vitamin D159

4. Do you use any of the following supplements? N=YESNO Iron17491%9% Folic acid15911%89% Vitamin E (with EPO) 15419%81% Vitamin E (without EPO) 16138%62% Vitamin A16146%54% Vitamin D15943%57%

DOMAIN III Demographics of Your Institution

6. Do you have a pharmacist in your unit? (N=175) YES 76%NO 24% Full-time66% Part-time34% 7. Do you have a dietician or nutrition support service in your unit? (N=175) YES 79%NO 21% Full-time56% Part-time44%

8. Do you have standing TPN labs or are they individualized? (N=174) Standardized28% Individualized42% Both30% 9. Do you use a stock or starter TPN (glucose and protein) on day of life 1? (N=175) YES55% NO45%

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