Optimizing Nutrition at Birth in VLBW Infants
Robin Bissinger, PhD, NNP-BC; Dave Annibale, MD; Annette Crull, RN;
John Cahill, MD; Lauree Pearson MSN, NNP-BC; Sarah Taylor, MD, Carolyn Finch, MS, RD
Medical University of South Carolina
BACKGROUND
Adipose tissue accretion begins at 25 weeks
gestation and continues at 1-3 g/kg/day in utero.
At birth fat becomes the main source of energy.
Failure to provide sufficient non-protein energy
leads to fatty acids being oxidized to produce
energy instead of providing membrane
deposition. Altering critical membrane
development in the brain may lead to abnormal
neurological function and poor long term
outcomes.
•Critical appraisal of the literature for AA and IL on the
first day and hours of life
•Review all aspects of concern in administering AA and
IL in the first few hours of life including
hyperbilirubinemia, infection, hyperkalemia, hyper and
hypoglycemia, acidosis, BUN
•Ensure osmolality of PN with 4% AA is not over 1000
mOSml to ensure safety in peripheral lines.
•Change initial TPN (after hours bag) from 2.5% AA to
4% AA by 11/09
•Ensure TPN is first fluid for all VLBW infants via PIV or
UVC including transported babies.
•Work with pharmacy to provide AA solution in the
delivery room (DR) 24 hours a day
•Develop on-line admission orders with direct fax to
pharmacy for TPN administration
•Provide TPN for transport team for all VLBW transports
•Developed Standardized guidelines for AA and IL
advancement and triglyceride monitoring.
Monitor: Time of AA and IL administration in all VLBW
infants based on time of birth. Document gm/kg/day of
AA in first 24 hours of life.
RESULTS
The goal of this project was to start total
parenteral nutrition (TPN) at birth with AA within
2 hours and IL within 24 hours in VLBW infants.
1) To have 90% of inborn VLBW infants receive at least
2 gm/kg/day of protein in the first 24 hours of life by
1/09 and increase this to 3gm/kg/day by 11/09.
2) To have 80% of outborn VLBW infants receive at least
2 gm/kg of protein in the first 24 hours of life by 1/09
and increase this to 3 gm/kg/day by 11/09
3) To have 90% of all VLBW infants receive intralipids
within the first 30 hours of life by 4/10 and within 24
hours by 6/10.
Figure 1: VLBW Protein Delivery on DOL 1
35
30
25
20
15
Inborn
Outborn
30 Hr Goal
24 HR GOAL
10
5
0
Dec
08
Jan
09
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Month
Jan
10
Feb
Figure 3: Percent of VLBW infants Avoiding
Extrauterine Growth Restriction at Discharge
100
95
90
85
80
75
70
65
60
55
50
AGA at Discharge
Linear (AGA at Discharge)
NEXT STEPS
Although lipid delivery for inborn infants has been
stable at <24 hrs, further interventions to reduce
individual variation are underway (on line orders) and
approaches to reduce delivery time for outborns are
under consideration.
CONCLUSIONS
An aggressive TPN program (coupled with
attention to enteral nutrition) resulted in
improved protein delivery and reduced postnatal growth failure without adverse events.
3.5
Gm/Kg/day Protein Delivery (Initial Order)
MEASURABLE AIMS
4
40
Percent of AGA at Birth
Protein intakes of 3-4 gm/kg/day are required to
overcome obligate protein loss, efficiency of
protein retention and goal of protein accretion in
VLBW infants.
Figure 2: Average IL Start Time
45
Hours
Postnatal growth restriction remains a significant
problem in very low birth weight (VLBW) infants
(<1500gms). It is estimated that almost 50% of
postnatal growth failure is related to energy and
protein deficits. Recent studies have shown that
amino acids (AA) immediately after birth is safe
and prevents loss of protein mass. The delivery of
early intralipids (IL) have not been well studied.
METHODS
3
2.5
REFERENCES
2
1.5
1
"Inborn"
Outborn
0.5
Goal
0
Infant (By Months)
•Te Brakke, F. et al. Amino Acid Administration to Premature Infants directly after
birth. J Pediatr, 2005.
•Poindexter, B. et al. Early Provision of Parenteral Amino Acids in ELBW infants:
relation to growth and development outcome. J Pediatr.148:300-5, 2006.
•Dinerstein, A. et al. Early and Aggressive nutritional strategy decreases postnatal
growth failure in VLBW infants. Journal of Perinatol. 26: 436.442, 2006
•Simmer, K, Rao S. Early introduction of lipids to parenterally-fed preterm infants.
Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.
CD005256.DOI:10.1002/14651858. CD005256.
•Ehrenkranz, R. Early, Aggressive Nutritional Management for Very Low Birth
Weight Infants: What is the Evidence? Semin Perinatol. 31: 48-55, 2007