Improving Nutrition for Very Low Birth Weight Infants:
Toolkits I (2004) & II (2005)
Nancy E. Wight MD, IBCLC, FABM, FAAP

The concept of collaboration among institutions for the purpose of improving overall quality of care is a key component of successful and efficient change in health care. Building on the existing VON (Vermont-Oxford Network) framework, the California Association of Neonatologists (CAN), in association with multiple public and private partners developed the California Perinatal Quality Care Collaborative (CPQCC) to foster benchmark performance by all of the NICUs in California. The three arms of the CPQCC are the Data Center, the Perinatal Quality Improvement Panel (PQIP) and the Research Unit. 1

PQIP regional opinion leaders identify NICU care practices that have the potential for improvement. Practice recommendations are presented in a stand-alone quality improvement "toolkit" and a multidisciplinary quality improvement workshop designed to "jump-start" unit teams. Participants are sent exercises before the workshop that are designed to assess current practice and create "cognitive dissonance" as a force for change. Past quality improvement (QI) initiatives have targeted antenatal steroid use, surfactant use, consistent mechanical ventilation, abandonment of postnatal steroid use, prevention of early-onset sepsis, and prevention of nosocomial infection. I had the privilege of working on "Nutritional Support of the Very Low Birth Weight Infant: Parts I (2004) & II (2005)", which encompass multiple best practice recommendations with extensive reference lists, assessment tools, and multiple, practical appendices. 2,3 Part I was designed to help the NICU care team assess current nutritional practices and outcomes, and to promote and support breastmilk for VLBW infants as part of optimal

nutritional management. Part 2 includes best practices in parenteral and enteral nutrition, plus additional attention to continued support for breastfeeding in the NICU and post-discharge. As an extra bonus, Toolkit II includes discussions and appendices on current nutritional "hot topics" such as misadministration of human milk and cytomegalovirus in human milk for extremely preterm infants. Both Toolkits are currently available as a free downloads (~150 pages each) on the CPQCC site (www.cpqcc.org).

Lactation consultants, NICU nurses and anyone interested in optimal nutrition for NICU patients should review these Toolkits. Neonatal nutrition and the use of breastmilk and breastfeeding in the NICU are extensively addressed, using current research and honestly noting where research support is lacking. A recent expert panel report, presented as a supplement to the May 2005 Issue of the Journal of Perinatology 4, confirmed many of the best practices elucidated in the Toolkits.

  1. Wirtschafter DD, & Powers RJ (2004). Organizing regional perinatal quality improvement: Global considerations and local implementation. NeoReviews, 5(2), e50-59.
  2. CPQCC/PQIP: Nutritional Support of the Very Low Birth Weight Infant: Part I, http://www.cpqcc.org/NutritionToolkit.html
  3. CPQCC/PQIP: Nutritional Support of the Very Low Birth Weight Infant: Part II, http://www.cpqcc.org/NutritionIIToolkit.htm
  4. Bhatia J, Ramanathan R, Sekar, Seri I, Eds. Evidence vs Experience in Neonatal Practice: Proceeding from the Inaugural Conference (Oct 8-9, 2004), Supplement to J Perinatology, June 2005; 25(S2):S1-S18

Ask the Expert: Continued from page 6

of life can be devastating and even fatal. If one child has thrush and the other does not, it would be wise to allot one breast to each child if feasible.

In summary, if a pregnancy is not high risk and there is no uterine bleeding, no history of premature delivery, and good weight gain, the pregnant mother can breastfeed without jeopardizing the pregnancy or her health. The infant and older child who are tandem feeding usually do well as long as the mother is well nourished and the older child has access to good complementary nutrition. The emotional and physical aspects of tandem nursing on the mother are more variable. I agree with Hilary Flower if there is not a high risk situation: "Weigh things carefully. Tune into your body. Be brave. Be honest. And trust yourself to make the most appropriate plan for the health and well-being for your family."

Additional Reading:
Lawrence RA, Lawrence RM, Breastfeeding, A guide for the Medical Profession. 6th Ed. St. Louis: Mosby 2005. 754-757.

References:
  1. Marquis GS, Penny ME, Diaz JM, Marin M. Postpartum Consequences of an Overlap of Breastfeeding and Pregnancy: Reduced Breast Milk Intake and Growth During Early Infancy. Pediatrics. 2002;109(4):e56.
  2. Moscone SR, Moore MJ. Breastfeeding during pregnancy. J Hum Lact 9:83, 1993.
  3. Ramachandran P. Lactation: Nutrition, fertility, interaction. In Women and Nutrition in India. New Delhi, India: Nutrition Foundation of India, 1989, 194.
  4. Flower Hilary, Adventures in Tandem Nursing Breastfeeding during Pregnancy and Beyond. La Leche League Int. 2003. 233.
  5. Bohler E, Bergstrom S. Child growth during weaning depends on whether mother is pregnant again. J Trop Pediatr. 1996. 42:104-109.
  6. Rawlings JS, Rawlings VB, Read JA, Prevalence of low birth weight and preterm delivery in relation to the interval between pregnancies among white and black women. NEJM. 1999; 332:69-74.
  7. Newton N, Theotokatos M. Breastfeeding during pregnancy.J Hum Lact 1993; 9(2):83-88.

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