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Benenson S, Cohen MJ, Greenglick N, Schwartz C, Eventov-Friedman S, Ergaz Z. The Validity of Positive Coagulase-Negative Staphylococcus Cultures for the Diagnosis of Sepsis in the Neonatal Unit. Am J Perinatol 2022. [PMID: 35381607 DOI: 10.1055/a-1817-5698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
OBJECTIVE Coagulase-negative Staphylococcus (CoNS) is the most frequent pathogen causing late-onset sepsis (LOS) in neonatal intensive care units (NICUs). Technical difficulties hinder blood culture (BC) collection and obtaining only one culture before initiating antibiotic therapy is a common practice. We sought to assess specific clinical information and CoNS cultures for the diagnosis of true bacteremia in the NICU. STUDY DESIGN This historical cohort study was conducted in NICUs at the Hadassah-Hebrew University Medical Center of Jerusalem in Israel. Clinical and laboratory data in every CoNS bacteremia were collected and compared between bacteremia groups as follows: true positive, two positive BCs; contaminant, one positive BC out of two; undefined, one BC obtained and found positive. RESULTS For 3.5 years, CoNS was isolated in 139 episodes. True positive was identified in 44 of 139 (31.7%), contaminant in 42 of 139 (30.2%), and the event was undefined in 53 of 139 (38.1%). Vancomycin treatment was more frequent in the true positive and undefined groups than the contaminant group (100, 90.6, and 73.8% respectively, p = 0.001); treatment was also prolonged in these two groups (p < 0.001). No clinical variables were associated with true bacteremia on multivariable analysis. CONCLUSION Diagnosis should definitely be based on at least two positive BCs, despite objective difficulties in obtaining BCs in neonates. KEY POINTS · CoNS is a frequent pathogen causing LOS in neonates.. · Due to technical difficulties, often only one culture is collected prior to antibiotic therapy.. · No clinical/laboratory variables were associated with the diagnosis of true CoNS bacteremia.. · Diagnosis should definitely be based on at least two positive BCs..
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Affiliation(s)
- Shmuel Benenson
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Matan J Cohen
- Jerusalem district, Clalit Health Services, Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Nofar Greenglick
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Carmela Schwartz
- Department of Clinical Microbiology and Infectious Diseases, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Zivanit Ergaz
- Department of Neonatology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Linam WM, Trivedi KK, Schaffzin JK. Don't just do it-Conducting and publishing improvement science in infection prevention and antibiotic stewardship. ANTIMICROBIAL STEWARDSHIP & HEALTHCARE EPIDEMIOLOGY : ASHE 2022; 2:e33. [PMID: 36310783 PMCID: PMC9614962 DOI: 10.1017/ash.2021.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 12/11/2021] [Indexed: 06/16/2023]
Affiliation(s)
- W. Matthew Linam
- Department of Pediatrics, Emory University School of Medicine and Children’s Healthcare of Atlanta, Atlanta, Georgia
| | - Kavita K. Trivedi
- Division of Communicable Disease Control and Prevention, Alameda County Public Health Department, San Leandro, California
| | - Joshua K. Schaffzin
- Division of Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
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Piazza AJ, Brozanski B, Grover T, Chuo J, Mingrone T, Rao R, Smith J, Soliman D, Rintoul N, Bellflower B, Richardson T, Holston M, McClead R, Guidash J, Pallotto EK. STEPP IN: A Multicenter Quality Improvement Collaborative Standardizing Postoperative Handoffs. Pediatrics 2021; 148:183430. [PMID: 34851419 DOI: 10.1542/peds.2020-016402] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/30/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE To reduce care failures by 30% through implementation of standardized communication processes for postoperative handoff in NICU patients undergoing surgery over 12 months and sustained over 6 months. METHODS Nineteen Children's Hospitals Neonatal Consortium centers collaborated in a quality improvement initiative to reduce postoperative care failures in a surgical neonatal setting by decreasing respiratory care failures and all other communication failures. Evidence-based clinical practice recommendations and a collaborative framework supported local teams' implementation of standardized postoperative handoff communication. Process measures included compliance with center-defined handoff staff presence, use of center-defined handoff tool, and the proportion of handoffs with interruptions. Participant handoff satisfaction was the balancing measure. Baseline data were collected for 8 months, followed by a 12-month action phase and 7-month sustain phase. RESULTS On average, 181 postoperative handoffs per month were monitored across sites, and 320 respondents per month assessed the handoff process. Communication failures specific to respiratory care decreased by 73.2% (8.2% to 4.6% and with a second special cause signal to 2.2%). All other communication care failures decreased by 49.4% (17% to 8.6%). Eighty-four percent of participants reported high satisfaction. Compliance with use of the handoff tool and required staff attendance increased whereas interruptions decreased over the project time line. CONCLUSIONS Team engagement within a quality improvement framework had a positive impact on the perioperative handoff process for high-risk surgical neonates. We improved care as demonstrated by a decrease in postoperative care failures while maintaining high provider satisfaction.
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Affiliation(s)
- Anthony J Piazza
- Department of Pediatrics, Emory University and Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia
| | - Beverly Brozanski
- School of Medicine, Washington University and St Louis Children's Hospital, St Louis, Missouri
| | - Theresa Grover
- Department of Pediatrics, Children's Hospital of Colorado, Aurora, Colorado
| | - John Chuo
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Rakesh Rao
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Joan Smith
- Department of Pediatrics, St Louis Children's Hospital, St Louis, Missouri
| | - Doreen Soliman
- Department of Anesthesia, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Natalie Rintoul
- Division of Neonatology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | | | - Margaret Holston
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Richard McClead
- Department of Neonatology, Nationwide Children's Hospital, Columbus, Ohio
| | - Judy Guidash
- Nemours Children's Health System, Wilmington, Delaware
| | - Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, School of Medicine, University of Missouri-Kansas City and Children's Mercy Kansas City, Missouri
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Preventing Central Line Blood Stream Infections in Critical Care Patients. Crit Care Nurs Clin North Am 2021; 33:419-429. [PMID: 34742498 DOI: 10.1016/j.cnc.2021.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Currently, the Centers for Disease Control reports close to 40,000 central line-associated bloodstream infections (CLABSI) occur in acute care facilities in the United States each year. Most are considered preventable. Evidence-based practices such as the CLABSI bundle and central line maintenance bundles have demonstrated their effectiveness in reducing CLABSI. This article reviews these best practices and provides a framework for consistent implementation.
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Ceylan G, Topal S, Turgut N, Ozdamar N, Oruc Y, Agin H, Devrim I. Assessment of potential differences between pre-filled and manually prepared syringe use during vascular access device management in a pediatric intensive care unit. J Vasc Access 2021; 23:885-889. [PMID: 33983076 DOI: 10.1177/11297298211015500] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Central line-associated bloodstream infection is one of the four primary health-care-associated infections applicable to pediatric intensive care units defined by The Centers for Disease Control and Prevention. According to current guidelines, it is essential to flush vascular access devices before each infusion to assess catheter function and prevent catheter-related complications. OBJECTIVE This prospective trial aimed to assess the potential differences between pre-filled and manually prepared saline syringe use during vascular access device management in a pediatric intensive care unit. METHODS Volunteered registered pediatric intensive care unit nurses were asked to implement the flushing solution to an extension line of a central venous catheter in vitro. After the randomization process with opaque sealed envelopes, they have started either with manual preparation or used sterile pre-filled saline syringes. Sterile application steps forms were used for monitoring the manual preparation of saline syringes versus the pre-filled saline syringes phase. Each volunteer repeated the steps for 3, 5, and 10 mL syringe volumes with the manually prepared and pre-filled saline syringes. After completing the procedures, failed steps and durations were transferred into a database to be analyzed by a blinded investigator. RESULTS A total of 41 nurses volunteered and 123 forms for three attempts per one nurse were filled for each group. In the manual preparation group, the number of at least one failure in the necessary steps was 89 (72.3%) and the same number in the pre-filled syringe group was 6 (4.9%), and significantly lower in the pre-filled saline syringe group (p < 0.001). The overall time for preparing to flush was 86.0 ± 22.3 s (ranging from 46 to 173 s) for manual prepared syringes and 35.2 ± 9.4 s (ranging from 18 to 100 s) (p < 0.001) for pre-filled saline syringes. CONCLUSION Our results demonstrate that the risk for breaking the aseptic no-touch technic was higher in the manual preparation group. We have also demonstrated that the flushing time was shorter with pre-filled syringes compared to manually prepared ones, which may contribute to decreasing the workload of the nurses and may increase the quality of care in the intensive care units. The use of pre-filled saline syringes may decrease the central line-associated bloodstream infections incidence and may increase the quality of care by saving extra time in the pediatric intensive care unit.
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Affiliation(s)
- Gokhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Sevgi Topal
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Nuriye Turgut
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Nihal Ozdamar
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Yeliz Oruc
- Infections Control Committee, Dr. Behcet Uz Children's Disease, and Surgery Training and Research Hospital, Izmir, Turkey
| | - Hasan Agin
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
| | - Ilker Devrim
- Department of Pediatric Infectious Diseases, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Izmir, Turkey
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Kaplan HC, Kuhnell P, Walsh MC, Crowley M, McClead R, Wexelblatt S, Ford S, Provost LP, Lannon C, Macaluso M. Orchestrated Testing of Formula Type to Reduce Length of Stay in Neonatal Abstinence Syndrome. Pediatrics 2020; 146:peds.2019-0914. [PMID: 32913133 DOI: 10.1542/peds.2019-0914] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/15/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Despite the standardization of care, formula feeding varied across sites of the Ohio Perinatal Quality Collaborative (OPQC). We used orchestrated testing (OT) to learn from this variation and improve nonpharmacologic care of infants with neonatal abstinence syndrome (NAS) requiring pharmacologic treatment in Ohio. METHODS To test the impact of formula on length of stay (LOS), treatment failure, and weight loss among infants hospitalized with NAS, we compared caloric content (high versus standard) and lactose content (low versus standard) using a 22 factorial design. During October 2015 to June 2016, OPQC sites joined 1 of 4 OT groups. We used response plots to examine the effect of each factor and control charts to track formula use and LOS. We used the OT results to revise the nonpharmacologic bundle and implemented it during 2017. RESULTS Forty-seven sites caring for 546 NAS infants self-selected into the 4 OT groups. Response plots revealed the benefit of high-calorie formula (HCF) on weight loss, treatment failure, and LOS. The nonpharmacologic treatment bundle was updated to recommend HCF when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC. CONCLUSIONS OT revealed that HCF was associated with shorter LOS in OPQC sites. Implementation of a revised nonpharmacologic care bundle was followed by additional LOS improvement in Ohio. Despite some challenges in the implementation of OT, our findings support its usefulness for learning in improvement networks.
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Affiliation(s)
- Heather C Kaplan
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio; .,Perinatal Institute.,James M. Anderson Center for Health Systems Excellence, and
| | - Pierce Kuhnell
- Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Michele C Walsh
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Moira Crowley
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio.,Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Richard McClead
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, Ohio; and
| | - Scott Wexelblatt
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Perinatal Institute
| | - Susan Ford
- Division of Neonatology, Department of Pediatrics, Rainbow Babies and Children's Hospital, Cleveland, Ohio
| | | | - Carole Lannon
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,James M. Anderson Center for Health Systems Excellence, and
| | - Maurizio Macaluso
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio.,Division of Epidemiology and Biostatistics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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Falciglia GH, Murthy K, Holl JL, Palac HL, Woods DM, Robinson DT. Low prevalence of clinical decision support to calculate caloric and fluid intake for infants in the neonatal intensive care unit. J Perinatol 2020; 40:497-503. [PMID: 31813935 PMCID: PMC7042157 DOI: 10.1038/s41372-019-0546-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 10/08/2019] [Accepted: 10/28/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND Clinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown. METHODS Online surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children's Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar's test. RESULTS Clinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%, p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%, p < 0.001). DISCUSSION Most CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.
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Affiliation(s)
- Gustave H. Falciglia
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
| | - Karna Murthy
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA ,Children’s Hospital Neonatal Consortium, Kansas City, MO USA
| | - Jane L. Holl
- 0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA ,0000 0001 2299 3507grid.16753.36Center for Health Services & Outcomes Research, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | | | - Donna M. Woods
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0001 2299 3507grid.16753.36Center for Health Services & Outcomes Research, Northwestern University, Feinberg School of Medicine, Chicago, IL USA
| | - Daniel T. Robinson
- 0000 0001 2299 3507grid.16753.36Department of Pediatrics, Northwestern University, Feinberg School of Medicine, Chicago, IL USA ,0000 0004 0388 2248grid.413808.6Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, USA
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8
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Multi-level Intervention Program - A Quality Improvement Initiative to Decrease Central Line-Associated Bloodstream Infections in the Pediatric Acute and Hematology/Oncology Units. J Pediatr Nurs 2019; 48:106-113. [PMID: 31377635 DOI: 10.1016/j.pedn.2019.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Revised: 07/04/2019] [Accepted: 07/04/2019] [Indexed: 11/20/2022]
Abstract
INTRODUCTION Central Venous Catheters (CVCs) are placed in pediatric patients that require frequent and/or long-term access for intravenous treatments and increase the risk for Central line-associated bloodstream infections (CLABSIs). The specific aims of the study were to evaluate adherence to the intervention components and rates of Central Line Associated Bloodstream Infections (CLABSIs) over five years. METHODS Implementation occurred on the acute care and hematology-oncology pediatric units of a quaternary health care setting in Southern California. Adherence rates were quantified using a CVC audit sheet and CLABSI rates were obtained quarterly before, and at year 1, 2, 3, 4, 5 of implementation. RESULTS CLABSI rates for both pediatric units decreased over the five-year period. Adherence rates were 90% to 100% on the different features of the intervention; the lowest was adherence to Patient Protective Equipment (PPE). A total of 41 incidents of hospital-acquired CLABSIs were reported the year prior to the Bug Buster Committee, which decreased steadily to 9 incidents after implementation. The quarterly CLABSI rates in the Pediatric Acute Care ranged from 2.8 to 6.6/1,000 catheter days and in Pediatric Hematology-Oncology from 2.1 to 4.3/1,000 catheter days the year prior to implementation. CONCLUSIONS While adherence for staff remains high, parent/family adherence was low. We recommend including in the multi-level intervention, procedures targeting parent adherence such as patient education handouts, reviewing content on admission, placing signs on doors indicating PPE requirements, and promptly providing PPE to non-adherent family members.
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Preventable Harm Reduction: A Balancing Act to Zero Harm. J Perinat Neonatal Nurs 2019; 33:283-284. [PMID: 31651623 DOI: 10.1097/jpn.0000000000000447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Falciglia GH, Murthy K, Holl JL, Palac HL, Oumarbaeva Y, Woods DM, Robinson DT. Energy and Protein Intake During the Transition from Parenteral to Enteral Nutrition in Infants of Very Low Birth Weight. J Pediatr 2018; 202:38-43.e1. [PMID: 30195557 DOI: 10.1016/j.jpeds.2018.07.010] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 05/18/2018] [Accepted: 07/03/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To evaluate the association between nutrition delivery practices and energy and protein intake during the transition from parenteral to enteral nutrition in infants of very low birth weight (VLBW). STUDY DESIGN This was a retrospective analysis of 115 infants who were VLBW from a regional neonatal intensive care unit. Changes in energy and protein intake were estimated during transition phase 1 (0% enteral); phase 2 (>0, ≤33.3% enteral); phase 3 (>33.3, ≤66.7% enteral); phase 4 (>66.7, <100% enteral); and phase 5 (100% enteral). Associations between energy and protein intake were determined for each phase for parenteral nutrition, intravenous lipids, central line, feeding fortification, fluid restriction, and excess non-nutritive fluid intake. RESULTS In phases 2 and 3, infants receiving feeding fortification received less protein than infants who were unfortified (-1.1 and -0.3 g/kg/d, respectively; P < .001). However, this negative association was not observed after adjusting for relevant nutrition delivery practices. Despite greater enteral protein intake during phases 2 and 3 (0.3 and 0.8 g/kg/d, respectively; P < .001), infants with early fortification received less parenteral protein than infants who were unfortified (-1.4 and -1.1 g/kg/d, respectively; P < .001). Similar patterns were observed for energy intake. Protein intake declined during phases 3 and 4. CONCLUSIONS Infants paradoxically received less protein and energy on days with early fortification, suggesting that clinicians may lack easily accessible data to detect the association between nutrition delivery practices and overall nutrition in infants who are VLBW.
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Affiliation(s)
- Gustave H Falciglia
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago.
| | - Karna Murthy
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago; Children's Hospitals Neonatal Consortium, Kansas City, MO
| | - Jane L Holl
- Ann & Robert H. Lurie Children's Hospital of Chicago; Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Hannah L Palac
- Department of Preventive Medicine, Feinberg School of Medicine, Northwestern University
| | - Yuliya Oumarbaeva
- Department of Pediatrics, Pritzker School of Medicine, University of Chicago, Chicago, IL
| | - Donna M Woods
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Daniel T Robinson
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL; Ann & Robert H. Lurie Children's Hospital of Chicago
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