A Quality Improvement Project to Reduce Time to Full Enteral Feeds for Very Low Birth Weight Neonates.

BACKGROUND: Adherence to standardized feeding guidelines has been proposed as a strategy to limit morbidity in very low birth weight neonates. Fostering adherence limits the variability in medicine that affects the quality of patient care. The aim of this study was to reduce by 20% the time to full enteral feeds in very low birth weight neonates in the NICU within a 12-month period. METHODS: In a level IV regional perinatal center with low utilization of its feeding protocol, a 12-month quality improvement project was conducted with a key intervention of a feeding schedule calculator based on the unit standardized feeding protocol. Through studied education and implementation cycles, these feeding schedules were used to reduce time to full enteral feeds while monitoring adverse events related to their use. RESULTS: During the course of this quality improvement project, our time to full enteral feeds of 160 ml/kg/day of feeds reduced from 24.7 days to 17.7 days after process changes with special-cause variation noted on control charts. We also showed a significant reduction in mean central line duration over the course of the project from a baseline of 19 days to 14.5 days. CONCLUSION: Through a key intervention of a feeding volume calculator, we were able to reduce the time to full enteral feeds in neonates without any increase in adverse events of necrotizing enterocolitis or poor weight gain.

Educational Perspectives: Palliative Care Education in Neonatal-Perinatal Medicine Fellowship.

The neonatal period from birth to less than or equal to 28 days is one of increased risk of death. Congenital anomalies and prematurity are 2 of the most common risk factors for death at this early age. Many of these neonates will die in an intensive care unit, some with full resuscitative efforts being undertaken despite the understanding that these actions are highly unlikely to yield an outcome different from death. Palliative care allows curative therapies to be provided alongside supportive techniques such as enhanced family communication, attention to spirituality and the psychosocial health of the family, management of symptoms other than those specific to the underlying disease process, and enhancing comfort. The American Academy of Pediatrics has set forth recommendations related to pediatric palliative care for the various pediatric subspecialties; however, much of the focus is on disease processes and curing or mitigating various illnesses. Given the high preponderance of death in the neonatal period, neonatal-perinatal medicine training programs should be tasked with generating formal palliative care training. Such training should be geared to providing better care for neonatal patients with a life-limiting or life-altering illness, and better equipping future neonatologists with the tools needed to provide truly comprehensive care for their sickest patients at risk for death and disability. This article serves to review the concept of palliative care in neonates, discuss the paucity of formal education in palliative care, explore the general trend in palliative care education, review various ways in which palliative care education can be formalized, and define metrics of a successful educational program.

Neonatal Hypoglycemia.

Lower blood glucose values are common in the healthy neonate immediately after birth as compared to older infants, children, and adults. These transiently lower glucose values improve and reach normal ranges within hours after birth. Such transitional hypoglycemia is common in the healthy newborn. A minority of neonates experience a more prolonged and severe hypoglycemia, usually associated with specific risk factors and possibly a congenital hypoglycemia syndrome. Despite the lack of a specific blood glucose value that defines hypoglycemia, concern for substantial neurologic morbidity in the neonatal population has led to the generation of guidelines by both the American Academy of Pediatrics (AAP) and the Pediatric Endocrine Society (PES). Similarities between the 2 guidelines include recognition that the transitional form of neonatal hypoglycemia likely resolves within 48 hours after birth and that hypoglycemia that persists beyond that duration may be pathologic. One major difference between the 2 sets of guidelines is the goal blood glucose value in the neonate. This article reviews transitional and pathologic hypoglycemia in the neonate and presents a framework for understanding the nuances of the AAP and PES guidelines for neonatal hypoglycemia.