title: Identifying Barriers to Initiating Minimal Enteral Feedings in Very Low-Birth-Weight Infants: A Mixed Methods Approach.
abstract: OBJECTIVE
  This study aims to elicit physician and nursing perceptions about initiation of minimal enteral feedings (MEF) in very low-birth-weight (VLBW) infants.
  
  
  METHODS
  A three-phase, mixed methods study including a quantitative chart review of 37 VLBW infants, followed by 26 qualitative observations of morning rounds, 26 interviews of neonatal intensive care unit (NICU) medical team members, tailored interventions based on the identified barriers to MEF, and finally a postintervention chart audit of 50 VLBW infants.
  
  
  RESULTS
  The main barriers to initiation of MEF were failure to appreciate the differences between the goals of MEF versus nutritive feedings, inconsistent definition of "sick" infant, indomethacin for intraventricular hemorrhage prophylaxis, awaiting mother's own milk, complicated feeding protocols/algorithms for feeding intolerance, and lack of buy-in from nurses/nurse practitioners. The compliance with early initiation of MEF per the feeding guidelines rose from 25 to 92% after our interventions.
  
  
  CONCLUSIONS
  Understanding the complex interplay of provider, system and patient-based factors that interfere with initiation of MEF may enable NICUs to develop consensus guidelines and targeted interventions and to achieve timely initiation of nonnutritive feedings.
authors.affiliation: Division of Neonatology, Department of Pediatrics, Montefiore Medical Center, Bronx, New York.
authors.forename: Yogangi
authors.initials: Y
authors.lastname: Malhotra
authors.affiliation: Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
authors.forename: Nneka
authors.initials: N
authors.lastname: Nzegwu
authors.affiliation: Department of Pediatrics, Columbia University Medical Center, New York, New York.
authors.forename: Jamie
authors.initials: J
authors.lastname: Harrington
authors.affiliation: Section of Neonatal Perinatal Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Richard A
authors.initials: RA
authors.lastname: Ehrenkranz
authors.affiliation: Department of Pediatrics, Yale University School of Medicine, New Haven, Connecticut.
authors.forename: Janet P
authors.initials: JP
authors.lastname: Hafler
mesh_terms: D004750:Enteral Nutrition / Q000379:methods*; D006282:Health Personnel / Q000193:education*; D006801:Humans; D007213:Indomethacin / Q000627:therapeutic use*; D007223:Infant; D062071:Infant, Extremely Premature / Q000254:growth & development*; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight / Q000254:growth & development*; D007363:Intensive Care Units, Neonatal / Q000458:organization & administration; D007407:Interviews as Topic; D020300:Intracranial Hemorrhages / Q000517:prevention & control; D008895:Milk, Human; D017410:Practice Guidelines as Topic; D036301:Qualitative Research
chemical_list: D007213:Indomethacin