1. NICU Best Practice: Recommended vs. Reality NICU Best Practice: Recommended vs. Reality Analysis of 2006 Neonatal Nutrition Survey October 12, 2006 Debbie Hans MD, Fellow, University of MN Mary Pylipow MD, University of …………….. Michael Georgieff MD, University of MN Patti Thureen, MD, University of Colorado

2. 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 We conducted a similar survey on a smaller scale (n=25) in 2001 (unpublished data).

3. 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%

4. Methods For each individual question, the response rate was determined by subtracting the number of “no response” and “inappropriate response” from the total number of surveys “Inappropriate response” was defined as  Multiple responses to a given question  Responses that did not correspond to a provided choice e.g. responding “1.5” when choices were 0, 1, 2, etc.

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

6. 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%

7. Patti’s slide: What is the science behind when to start TPN.

8. 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%

9. Patti’s slide Recommended parenteral protein intakes at different gestational ages

10. 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?

11. Patti Comment on the need/rationale for protein advancement

12. 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%

13. Patti Once again emphasize Zeigler’s work on protein intake at different gest ages.

14. 5a. How much IV lipid (g/kg/day) do you prescribe on first day TPN for non- ventilated infant? N=00.5123 <1000g16426%34%32%7%1% 1001- 1500g 16722% 46%10%1% 1501- 2500g 17020%18%47%13%1%

15. 5b. How much IV lipid (g/kg/day) do you prescribe on first day TPN for ventilated infant? N=00.5123 <1000g16125%36%30%7%1% 1001- 1500g 16622%25%43%9%1% 1501- 2500g 16820% 47%13%1%

16. 6. Do you give different amounts of lipid to infants who have lung disease? (N=168) YES 7% NO 62% SOMETIMES 31% 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%

17. 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%

18. Patti 2-3 slides on lipid safety, contraindications, what we know and don’t know about lipid aministration, rate of advancement

19. 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%

20. 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%

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

22. ?Patti review scientific data on bolus vs continuous feeds?

23. 11a. How quickly are enteral feedings advanced for non-ventilated infants (cc/kg/day)? N=5101520≥30 <1000g1468%33%15%43%<1% 1001- 1500g 1533%12%19%64%3% 1501- 2500g 1541%5%9%69%16%

24. 11b. How quickly are enteral feedings advanced for ventilated infants (cc/kg/day)? N=5101520≥30 <1000g14415%35%13%36%1% 1001- 1500g 1535%20% 53%2% 1501- 2500g 1534%13%14%62%10%

25. 12a. How do you define “early small feeds”? Is it less than, equal to, or more than 20 cc/kg/day? N=62 Minimal Enteral Nutrition (MEN) 6% Gut priming8% Trophic86% N=86 Less than 20 cc/kg/day 90% Equal to 20 cc/kg/day 10% More than 20 cc/kg/day

26. 12b. Do you use “trophic feeds”…? With RDS?N=174 YES90% NO10% In Absence of RDS? N=173 YES87% NO13%

27. 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%

28. 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%

29. Patti 1-3 slides on MEF

30. 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%

31. Patti-brief comments on prior slide

32. 16. Do you feed SGA infants differently than AGA infants? N=YESNO ENTERAL17546%54% PARENTERAL17421%79% If yes, which nutrients differ? N=81EnergyFatCalciumProtein YES64%21%22%51% NO36%79%78%49%

33. Patti 2 slides on feeding SGA infant

34. 17. Who is a candidate for elemental formula (e.g. Pregestamil)? (N=171) Poor Growth S/P NEC Gut Surgery GERD Micro- premie Diarrhea 5%68%61%8%7%39% Other candidates? Bloody Stools Formula Intolerance Malabsorption Milk Protein Intolerance 1%4%1%2%

35. 18. How long do you keep an infant on premature formula or supplemented breast milk? (N=149) 34 weeks6% 35 weeks8% 36 weeks23% 37 weeks8% 40 weeks9% 1 month4% 2 months3% 3 months6% >3 months34%

36. 19. Do you prescribe a post-discharge nutritional strategy? (N=171) YES 84%NO 16% N=1440%25%50%75%100% Breast milk24%40%35%6% Fortified breast milk13%39%22%15%4% Transitional (22cal/oz) formula 8%23%35%15%10% Standard formula42%17%3%<1% 20. If yes, what percent of preterm infants are on…?

37. Patti 2 slides on formula enrichment and post- discharge nutrition

38. 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%

39. Patti 1-2 slides on max ox glucose capacity

40. DOMAIN II Parenteral and Enteral Nutritional Additives and Supplements

41. 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%

42. 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%

43. patti Brief comment on each of these additives

44. 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%

45. 3b. Do you add any of the following to breast milk? N=YESNO Polycose16525%75% Microlipid16418%82% MCT oil16142%58% Promod/Propac16642%58%

46. Patti 1-2 slides on risks and benefits of these supplements

47. 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%

48. DOMAIN III Demographics of Your Institution

49. 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%

50. 2. Who writes your TPN orders? (N=176) Attending49% Fellow26% Resident60% NNP66% Pharmacist10% Dietician15%

51. 3. Do you have standing TPN orders or are they individualized for each patient? Standing7% Individualized90% Both3% 4. If individualized, do you use a computerized TPN program to calculate each component? (N=168) YES46% NO54%

52. 5. Do you have TPN protocols or does each practitioner have their own feeding strategies? (N=175) Unit TPN protocols31% Individualized31% Both36% Neither<1%

53. 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%

54. 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%

55. 10. Where is your TPN prepared? (N=175) Unit pharmacy6% Hospital pharmacy76% Another pharmacy in town<1% Commercial outsource18% 11. Do you follow up the long-term growth of IUGR babies? (N=172) YES58% NO42%