1. 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

2. What is the problem?

3. Ehrenkranz et al. Reproduced with permission from Pediatrics, Vol 104:280-289, Copyright 1999 by the AAP

4. 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

5. 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)

6. 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: 243-249. We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).

7. Methods 775 surveys were sent via e-mail 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%

8. 1. What best describes your Level II-III nursery? TYPEN=169 Private39% University53% Public or Military 8% NUMBER OF BEDS N=175 <102% 10-2015% 21-3019% 31-5040% >5023%

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

10. 1. On what day of life is TPN started? N=123456Later <1000g 167 x 1001- 1500g 168 x 1501- 2500g 156 x

11. 1. On what day of life is TPN started? N=123456Later <1000g 167 80%20%<1% 1001- 1500g 168 75%24%<1% 1501- 2500g 156 52%39%4%2%<1% 1%

12. 2. How much protein (g/kg/day) do you prescribe on the first day of TPN? N=0.51233.54 <1000g150x 1001- 1500g 154x 1501- 2500g 153x

13. 2. How much protein (g/kg/day) do you prescribe on the first day of TPN? N=0.51233.54 <1000g1507%28%51%13%1% 1001- 1500g 1544%29%55%11%1% 1501- 2500g 1531%30%55%12%1%

14. 3. Do you advance protein daily? N=0.250.51>1 <1000g148 1001- 1500g 151 1501- 2500g 150 YESNO (N=174) If yes, what increment (g/kg) do you advance by?

15. 3. Do you advance protein daily? N=0.250.51>1 <1000g148 1001- 1500g 151 1501- 2500g 150 YES91%NO 9%(N=174) If yes, what increment (g/kg) do you advance by?

16. 3. Do you advance protein daily? N=0.250.51>1 <1000g1481%49% 1% 1001- 1500g 151<1%37%59%3% 1501- 2500g 150<1%32%63%4% YES91%NO 9%(N=174) If yes, what increment (g/kg) do you advance by?

17. 4. What is your maximum protein (g/kg/day) when at full TPN? N=<222.533.54>4 <1000g164x 1001- 1500g 166x 1501- 2500g 164x

18. 4. What is your maximum protein (g/kg/day) when at full TPN? N=<222.533.54>4 <1000g1642%18%49%29%1% 1001- 1500g 1662%22%55%20%1% 1501- 2500g 1643%29%54%13%1%

19. 5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the non- ventilated infant? N=00.5123 <1000g164 1001- 1500g 167 1501- 2500g 170

20. 5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the non- ventilated infant? N=00.5123 <1000g16426%34%32%7%1% 1001- 1500g 16722% 46%10%1% 1501- 2500g 17020%18%47%13%1%

21. 5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the ventilated infant? N=00.5123 <1000g161 1001- 1500g 166 1501- 2500g 168

22. 5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for the ventilated infant? N=00.5123 <1000g16125%36%30%7%1% 1001- 1500g 16622%25%43%9%1% 1501- 2500g 16820% 47%13%1%

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

24. 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?

25. 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?

26. 8. How fast do you advance your lipids (g/kg/day)? N=0.250.5123 Based on TG <1000g133 1001- 1500g 142 1501- 2500g 142

27. 8. How fast do you advance your lipids (g/kg/day)? N=0.250.5123 Based on TG <1000g13356%28%17% 1001- 1500g 14242%44%<1%13% 1501- 2500g 14237%51%<1%11%

28. 9a. On what day do you start enteral feeds in non-ventilated infants? N=01234567 <1000g153x 1001- 1500g 156x 1501- 2500g 152x

29. 9a. On what day do you start enteral feeds in non-ventilated infants? N=01234567 <1000g1533%35%34%16%4% <1%2% 1001- 1500g 1568%49%32%8%2%<1% 1501- 2500g 15225%54%16%5%

30. 9b. On what day do you start enteral feeds in ventilated infants? N=01234567 <1000g142X? 1001- 1500g 148X? 1501- 2500g 147X?

31. 9b. On what day do you start enteral feeds in ventilated infants? N=01234567 <1000g1423%16%27%29%9% 1%6% 1001- 1500g 1482%24%42%17%8%5%1% 1501- 2500g 1475%31%34%18%7%4%1%

32. 10. Do you initially use continuous or bolus method of enteral feedings? N=BOLUSCONTINUOUS <1000g170 1001- 1500g 172 1501- 2500g 173

33. 10. Do you initially use continuous or bolus method of enteral feedings? N=BOLUSCONTINUOUS <1000g17081%19% 1001- 1500g 17295%5% 1501- 2500g 17399%1%

34. 11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)? N=510152030 <1000g146x 1001- 1500g 153x 1501- 2500g 154x

35. 11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)? N=510152030 <1000g1468%33%15%43%<1% 1001- 1500g 1533%12%19%64%3% 1501- 2500g 1541%5%9%69%16%

36. 11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)? N=510152030 <1000g144x 1001- 1500g 153x 1501- 2500g 153x

37. 11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)? N=510152030 <1000g14415%35%13%36%1% 1001- 1500g 1535%20% 53%2% 1501- 2500g 1534%13%14%62%10%

38. 12b. Do you use trophic feeds…? With RDS?N=174 YES NO In Absence of RDS? N=173 YES NO

39. 12b. Do you use trophic feeds…? With RDS?N=174 YES90% NO10% In Absence of RDS? N=173 YES87% NO13%

40. 13. What is the composition of the first enteral feed for infants? <1000g (N=173) 1001- 1500g (N=174) 1501- 2500g (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%

41. 14. How many days do you maintain babies on trophic feeds? N=1237Other Not Used <1000g127 1001- 1500g 146 1501- 2500g 148

42. 14. How many days do you maintain babies on trophic feeds? N=1237Other Not Used <1000g12720%24%29%17%9% 1001- 1500g 14642%19%18%5%6%8% 1501- 2500g 14861%11%5%1% 19%

43. 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

44. 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%

45. 21. In the 24-26 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%

46. DOMAIN II Parenteral and Enteral Nutritional Additives and Supplements

47. 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

48. 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

49. 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%

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

51. 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%

52. 3a. Do you use any of the following to enhance your enteral formula? N=YESNO Polycose171 Microlipid164 MCT oil168 Promod/Propac161

53. 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%

54. 3b. Do you add any of the following to breast milk? N=YESNO Polycose165 Microlipid164 MCT oil161 Promod/Propac166

55. 3b. Do you add any of the following to breast milk? N=YESNO Polycose16525%75% Microlipid16418%82% MCT oil16142%58% Promod/Propac16642%58%

56. 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

57. 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%

58. DOMAIN III Demographics of Your Institution

59. 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%

60. 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%

61. 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