A Quality Improvement Targeted at Improving Growth in Low Birth Weight Infants with an Expanded Donor Milk Program

Purpose/Objectives: Due to rising medical costs, the use of donor milk and human-milk-based fortifiers was restricted to infants less than 900gm in our level 3 NICU. With these restrictions, our only option was to use preterm formula as a supplement to feeds, contrary to the AAP guidelines. We subsequently observed an increase in NEC rates in infants with weight of 1000 gm and 1250 gm at birth following these restrictions. After presenting the data to the hospital administration, the NICU was granted the ability to expand our supplemental donor milk use in infants up to 1500 gm at birth. To determine whether the modification of our previous feeding protocol to include earlier fortification of human-milk feeds would reduce the length of time to return to birth weight following initiation of feeds. To determine whether the expanded use of donor milk would result in a higher percentage of infants with birth weights 1500 gm and less, with head circumference (HC) and weights greater than the 10%ile for postconceptual-age at discharge .

Design/Methods: The nutrition quality improvement team modified the NICU's standard feeding protocol to include fortification of human milk at 60ml/kg/day. Appropriate educational information was disseminated, and daily rounds were made with physicians, nurse practitioners, nurses, and the NICU dieticiation to review daily weights and weekly HCs. Fortification was increased weekly until target growth velocity was achieved; the rate of which varies for each infant. Weight and head circumference at discharge were reviewed and recorded in the Vermont-Oxford database. Run charts were shown to a multidisciplinary group after each cycle to evaluate processes and areas for improvement.

Results: Two PDSA cycles showed decrease in the time to return to birth weight from 14 days to 6 days; and an average time to achieve full feeds decreased from 16 days to 10 days. Review of the discharge metrics for each infant have showed no obvious improvements in discharge metrics compared to when the improvement project was initiated. Approximately 50% of infants in our NICU continue to be discharged from our NICU with weight and HC < 10%ile for postconceptual age. No cases of necrotizing enterocolitis were documented in our target group. Balancing measures that could not be studied include the nutritional composition of the milk.

Conclusion/Discussion: Expanded donor milk program can be implemented safely without significant adverse impact to growth. We were, however, unable to show an effect on discharge metrics, despite implementing early fortification. The optimal caloric intake to achieve better growth rates may also depend on many factors that could not be evaluated during this project. Our quality improvement team will continue to monitor growth metrics for all infants born < 1500 gm to determine whether these metrics will improve over time.