Outcomes of early nutrition support in extremely low-birth-weight infants

Ramona Donovan, Bhagya Puppala, Denise Angst, Bryan W Coyle
Nutrition in Clinical Practice 2006, 21 (4): 395-400

BACKGROUND: Early nutrition intervention, both parenteral and enteral, is becoming a standard of care for the extremely low-birth-weight infant (ELBW; <1,000 g) in many neonatal intensive care units (NICU) across the United States. However, there are no published or widely accepted guidelines regarding nutrition support strategies for this population. Most NICU clinicians have developed their own guidelines, so nutrition practices vary widely. In an effort to standardize our practice, we implemented nutrition support guidelines for ELBW infants, initiating both parenteral nutrition (PN) and minimal enteral feedings (MEFs) within the first 24 hours of life, whenever possible. The purpose of this study was 2-fold: (1) to evaluate the adherence to the nutrition guidelines and (2) to compare pre- and postguideline outcomes such as time to regain birth weight, time to reach full enteral feedings, and average daily weight gains.

METHODS: The study was conducted at a level III NICU from January 2002 until February 2003. Charts of 70 infants with a birth weight <or=1,250 g were reviewed as part of a quality-assurance project to monitor adherence to the newly established guidelines. Another 23 charts of ELBW infants who were admitted and cared for in the NICU before the initiation of the nutrition guidelines were reviewed as a control group. Data collected from the charts included the hour of life PN and MEFs were started, the day of life infants reached full enteral feedings, infant weights for the first 4 weeks of life, incidence of early hyperglycemia, occurrence of necrotizing enterocolitis, and length of neonatal birth hospital stay. Student's t-tests were used to compare clinical outcomes between infants receiving early nutrition support (<or=24 hours of life) vs those who were started later.

RESULTS: Of eligible infants, 82.6% began receiving nutrition support within 24 hours of life. The average time to begin PN was 22 hours after the adoption of the guidelines vs 64.4 hours before guideline implementation (p < .01). In the postguideline group, MEFs were initiated at mean 27.1 hours of age vs 80.4 hours in the preguideline group (p < .01). Those who were started on early nutrition support reached full enteral feedings significantly sooner than those who received delayed nutrition support (12.7 days vs 45.8 days; p < .01). Early nutrition support also resulted in earlier regain of birth weight (day 13.3 vs 15.4 days, p < .05). Although not statistically significant, infants who received earlier nutrition support showed trends toward greater overall weight gain in weeks 3 and 4 of life and a lower incidence of elevated serum blood glucose.

CONCLUSIONS: The implementation of early nutrition support guidelines influenced the timeliness of initiating nutrition support in our unit. Early initiation of nutrition support in ELBW infants produces a rapid regain of initial weight loss, improves weight gain, and enhances earlier achievement of full enteral feedings.

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