Quality improvement project in a neonatal intensive care unit reduced the prevalence and duration of hypophosphatemia with significant and sustainable results.

BACKGROUND: Hypophosphatemia is associated with prolonged mechanical ventilation and may affect growth, bone mineralization, nephrocalcinosis, and mortality in preterm infants. Optimal nutrition practices may decrease risk for hypophosphatemia and improve outcome. METHODS: A quality improvement project was established to improve parenteral and enteral phosphorus intake with the goal to decrease prevalence and duration of hypophosphatemia in the first 14 days in infants <32 weeks' gestation. RESULTS: Among 406 preterm infants, the prevalence of moderate hypophosphatemia decreased from 44% to 19% (P < 0.01) over 4 years. The median duration of moderate hypophosphatemia decreased from 72 h (48-128) to 24 (24-53) (P < 0.01). Daily intakes of parenteral calcium and phosphorus on the fourth day of life increased from 1.5 to 2.5 mEq/kg/day (P < 0.01) and 0.6 to 1.3 mmol/kg/day (P < 0.01), respectively. The median postnatal age of first serum phosphorus concentration assessment decreased from 53 h (41-64) to 32 (24-40) (P < 0.01). CONCLUSION: During this quality improvement project, reduced prevalence and duration of hypophosphatemia in infants <32 weeks' gestation in the first 14 days of life was achieved through the optimization of parenteral and enteral phosphorus intake and improved response to acute hypophosphatemia.

Growth after implementing a donor breast milk program in neonates <33 weeks gestational age or birthweight <1500 grams: Retrospective cohort study.

BACKGROUND: Donor breast milk (DBM) feeding has been associated with less growth than formula in preterm infants. Zinc content in DBM is insufficient to support growth in preterm infants. OBJECTIVE: To compare growth from birth to discharge, macro- and micronutrient intake and the frequency of poor growth before (Epoch-1) and after (Epoch-2) implementing a DBM program. METHODS: Retrospective cohort study of 1069 infants born at < 33 weeks' gestational age or birthweight < 1500 g and fed using our adjustable feeding protocol with accurate serial length measurements. Growth was assessed by changes in Z-scores of weight, length and fronto-occipital circumference from birth to discharge. RESULTS: Growth did not decrease significantly in Epoch-2. However, energy and protein intake increased by 5% and frequency of zinc and vitamin D supplementation increased by >30%. CONCLUSIONS: DBM implementation did not significantly decrease growth from birth to discharge using our adjustable feeding protocol.

Zinc deficiency limiting head growth to discharge in extremely low gestational age infants with insufficient linear growth: a cohort study.

OBJECTIVE: To assess the relationship of size for age with zinc deficiency in extremely low gestational age (GA) infants (23-28 weeks, ELGANs) who had insufficient linear growth despite optimizing other nutrients and to analyze changes in fronto-occipital circumference (FOC), weight and length with zinc supplementation. STUDY DESIGN: Retrospective cohort study. RESULTS: Among 302 ELGANs, a serum zinc concentration was obtained in 52 with insufficient linear growth (17%). Zinc deficiency (serum concentration <0.74 mcg/ml) was diagnosed in 8 of 24 (33%) small for GA (SGA) compared to 35 of 278 (13%) non-SGA infants (P = 0.01). Zinc supplementation for >2 weeks improved FOC growth to discharge or 50 weeks postmenstrual age in infants with Zn deficiency. However, neither linear growth nor weight gain improved with Zn supplementation. CONCLUSION: Zinc deficiency was diagnosed in 14% ELGANs in this cohort. Zinc supplementation for >2 weeks improved FOC growth but not linear growth or weight gain.

Preparedness for students and staff with anaphylaxis.

BACKGROUND: Schools are responsible for handling life-threatening events due to a variety of conditions, including anaphylaxis. California is one of a few states that permits school districts to stock emergency epinephrine auto-injectors and to train unlicensed assistive personnel to administer epinephrine for a life-threatening event. We surveyed school nurses in California to explore their experience with life-threatening anaphylaxis, implementation of allowable stock epinephrine auto-injector programs, and the barriers to program implementation. METHODS: An exploratory, cross-sectional, descriptive design was used for this study. Data was obtained from a convenience sample of 171 credentialed California school nurses via an online survey service. Descriptive statistics and Pearson's chi-square were used to analyze the data. RESULTS: Thirty percent of school nurses reported using 1 student's prescribed medication to rescue another student in distress. Despite the frequency of using another student's rescue medication and California's permissive policy, only 13% of nurses reported having stock epinephrine programs. Barriers to stock epinephrine programs included: (a) limited availability of school nursing services, (b) lack of policies or guidelines, (c) inadequate funding for training and medication, and (d) lack of education. Limited awareness of susceptibility and the immediate life-threatening nature of anaphylaxis were also contributing factors. CONCLUSIONS: Legislative initiatives are sufficient to develop safe, effective policies and protocols to manage life-threatening allergic reaction in schools. The findings indicate that more education is needed for school personnel and research is needed to determine an effective mechanism to remove barriers for emergency care during school hours.