During daily rounds in the neonatal intensive care unit (NICU), physicians need to balance many considerations in their decision-making about nutrition plans for premature infants. Often, instead of discussing how much energy, carbohydrates, fats and protein the baby has received, physicians tend to focus on how much fluid was delivered, according to a study published in Pediatric Research .
"Neonatal fluid intake is easier to calculate quickly, but it is not completely interchangeable with nutrition. Proper nutrition is essential for promoting growth in the premature infant but is more challenging to calculate during rounds," said lead author Gustave Falciglia, MD , a neonatologist at Ann & Robert H. Lurie Children's Hospital of Chicago and Associate Professor of Pediatrics at Northwestern University Feinberg School of Medicine. "Growth, however, is critically important, and many issues faced by premature infants will resolve with proper growth, so we need to consider nutrition plans carefully."
"Parents especially are very invested in their baby's nutrition. They want to know why we decide to place a central line for intravenous nutrition or when to advance feeds and why not," added Dr. Falciglia. "We consider a lot of factors during rounds. Automation with real-time data highlighting tradeoffs would help neonatologists enormously when considering nutrition adjustments during rounds."
Dr. Falciglia and colleagues point out that insufficient nutrition intake in preterm infants is associated with poor growth throughout the NICU stay. Half of preterm infants leave NICU with a weight for age under the tenth percentile. Lower energy and protein intake are also associated with an increased risk of neurodevelopmental impairment and retinopathy of prematurity.
In the current study, researchers observed 20 bedside rounds for 16 infants in two NICUs, in order to describe how clinicians review and analyze patient data during daily rounds to develop nutrition delivery plans for preterm infants. They identified four themes specific to nutrition and growth that were associated with the nutrition decision-making process on rounds:
- Clinicians understand the importance of nutrition; however, they discuss nutrition in language focused on fluid and prioritization of fluid delivery.
- Discussions about nutrition delivery reflect uncertainty and a lack of specificity that benefit from dietitian and pharmacist expertise.
- Infant fluid allowance and feeding tolerance, and the desire to promote healthy growth and metabolism are the primary drivers of nutrition and fluid plans.
- Clinicians struggle to distinguish between growth, fluid shifts, and measurement error.
"Our study supports the concept that developing nutrition plans require clinicians to balance many tradeoffs related to nutrition, as for example when we need to lower fluids but keep the nutrition intake at the same level," explained Dr. Falciglia. "Dieticians and pharmacists help to keep the focus on nutrition, as opposed to simply discussing fluid intake. They, however, are not always present on rounds in the NICU."
The study found that to determine the impact of nutrition on growth and ensure that nutrition delivery was adequate, clinicians relied on growth charts. Observing plotted data over weeks allowed them to correctly identify trends that were less influenced by a single day of measurement error or fluid status. Yet this required clinicians to wait for clear patterns to emerge which may manifest over weeks. Developing and using automated tools may identify poor growth sooner. Highlighting the relationship between short term nutrition intake and growth may help clinicians to intervene sooner by increasing nutrition delivery.
"Automated tools would help with clinical decision-making, as well as track data to be used for quality improvement initiatives and for research," said Dr. Falciglia, who received NIH funding to develop an automated system for calculating total nutrition in the NICU.
His next steps include validating the automated system and evaluating it at other institutions. He also hopes to incorporate parental input in his research, to study how parental beliefs and attitudes influence clinical decision-making in the NICU.
Ann & Robert H. Lurie Children's Hospital of Chicago is a nonprofit organization committed to providing access to exceptional care for every child. It is the only independent, research-driven children's hospital in Illinois and one of less than 35 nationally. This is where the top doctors go to train, practice pediatric medicine, teach, advocate, research and stay up to date on the latest treatments. Exclusively focused on children, all Lurie Children's resources are devoted to serving their needs. Research at Lurie Children's is conducted through Stanley Manne Children's Research Institute, which is focused on improving child health, transforming pediatric medicine and ensuring healthier futures through the relentless pursuit of knowledge. Lurie Children's is the pediatric training ground for Northwestern University Feinberg School of Medicine. It is ranked as one of the nation's top children's hospitals by U.S. News & World Report.
