title: Very low birth weight infant care: adherence to a new nutrition protocol improves growth outcomes and reduces infectious risk.
abstract: BACKGROUND
  Very low birth weight (VLBW) infants are at risk for postnatal growth restriction due to inadequate nutrient delivery and concomitant illness. Integrated clinical pathways or protocols can improve growth outcomes by decreasing practice variability.
  
  
  METHODS
  A comprehensive nutrition bundle comprising standardized recommendations for initiating, advancing, and fortifying enteral feedings, and timely discontinuation of central lines was implemented in July 2012. Eligible were infants with a birth weight of <1500 g and <34 weeks gestation who were born over a 1-year period pre- and post-intervention, respectively. The primary aim was to determine if the intervention improved anthropometric parameter delta z scores at 36 weeks PMA. Secondary aims included time to first and full enteral feedings, central line-days, and rates of necrotizing enterocolitis (NEC) and sepsis/sepsis-like episodes.
  
  
  RESULTS
  A total of 299 infants were included, of which 156 received the proposed intervention (Nutrition bundle group), and 143 received non-standardized nutrition practices (Conventional group). Median delta z scores for length (-1.2 versus -1.71; p=0.01) and head circumference (-0.73 versus -1.21; p=0.03) but not weight at 36 weeks PMA (-1.42 versus -1.58; p=0.74) were significantly higher in the Nutrition bundle group as compared to the Conventional group. Fewer infants in the intervention group had severe growth restriction. Time to first feed, full feeds, and central line duration were significantly shorter in the intervention period. The incidence of NEC and sepsis/sepsis-like episodes decreased with the intervention.
  
  
  CONCLUSIONS
  A strategy using a comprehensive nutrition bundle improved linear and head circumference growth, reduced postnatal growth restriction, and decreased comorbidities in VLBW infants.
authors.affiliation: Department of Pediatrics, Division of Neonatology, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. Electronic address: bstefanescu@salud.unm.edu.
authors.forename: Beatrice M
authors.initials: BM
authors.lastname: Stefanescu
authors.affiliation: Department of Pediatrics, Division of Neonatology, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. Electronic address: maria.krakauer@vanderbilt.edu.
authors.forename: Maria
authors.initials: M
authors.lastname: Gillam-Krakauer
authors.affiliation: Department of Biostatistics, University of Michigan, 1415 Washington Heights, Ann Arbor, MI 48109, USA. Electronic address: stefanes@umich.edu.
authors.forename: Andrei R
authors.initials: AR
authors.lastname: Stefanescu
authors.affiliation: Department of Pediatrics, Division of Neonatology, University of New Mexico School of Medicine, 1 University of New Mexico, Albuquerque, NM 87131-0001, USA. Electronic address: melinda.markham@vanderbilt.edu.
authors.forename: Melinda
authors.initials: M
authors.lastname: Markham
authors.affiliation: Department of Clinical Nutrition, Monroe Carell Jr. Children's Hospital at Vanderbilt, 2200 Children's Way, Nashville, TN 37232-9544, USA. Electronic address: Jennifer.L.Kosinski@vanderbilt.edu.
authors.forename: Jennifer L
authors.initials: JL
authors.lastname: Kosinski
mesh_terms: D016022:Case-Control Studies; D004750:Enteral Nutrition / Q000379:methods*; D020345:Enterocolitis, Necrotizing / Q000517:prevention & control*; D005260:Female; D019983:Guideline Adherence; D006801:Humans; D007227:Infant Nutritional Physiological Phenomena; D007231:Infant, Newborn; D019102:Infant, Very Low Birth Weight / Q000254:growth & development / Q000502:physiology*; D015931:Intensive Care, Neonatal / Q000379:methods*; D008297:Male; D018805:Sepsis / Q000517:prevention & control*
keywords: Breast milk; Growth; Growth restriction; Nutrition; Preterm infants