Clinical Research: Assessment,Prevention and Management of Metabolic Bone Disease in Very Low Birthweight Infants: The Role of the Neonatal Nutritionist

Abstract

Very-low-birth-weight (VLBW) preterm infants have an increased risk of developing metabolic bone disease (MBD) over term infants because of their decreased opportunity for intrauterine bone mineralization. Neonatal nutritionists are playing an increasingly important role in the prevention and management of MBD. The purpose of this survey study was to assess their role in the assessment, prevention, and management of MBD in VLBW infants. A total of 49 neonatal nutritionists primarily working in Level III Newborn Intensive Care Units (NICU) were surveyed to determine their clinical practice in the assessment and management of MBD. A total of 83.7% of the respondents assessed skeletal health at an average of 2.3 weeks of life with 16.3% assessing within the first week of life. The majority (93.9%) used serum phosphorus and alkaline phosphatase values in skeletal health assessment. Neonatal nutritionists tended to underestimate the incidence of MBD in their NICUs, with 79.2% estimating the incidence to be 5% or less. Parenteral nutrition (PN) was initiated by days 0 to 3 of life by 95.9% of the respondents, whereas enteral nutrition (EN) was begun on day 4 to 7 by 55.1% of respondents or on days 0 to 3 of life by 28.6% of the respondents. Optimal goals for ratios of calcium to phosphorus were reported as 1.3 to 1.7: 1 for PN by 84.7% and 1.8 to 2:1 in EN by 73.8% of the NICU nutritionists. Enteral vitamin supplements were used routinely by 70.2% of the respondents, with 53.2% using a pediatric multivitamin. Neutra-Phos (44.8%), providing phosphate, and Neo-Calglucon (37.9%), which provides calcium gluconate, were the most commonly used mineral supplements. The neonatal nutritionists surveyed played an active role in educating members of the health care team. Respondents were primarily responsible for documenting recommendations in medical records and direct communication with the NICU team on rounds (98.0%). The most common educational activities the respondents performed included: developing and revising PN order forms (77.1%), NICU handbook development (64.6%) and regular lectures to interns/residents (58.3%) and neonatologists (41.7%). The descriptive survey found that neonatal nutritionists played an increasingly proactive role in a variety of direct patient care activities, ie, risk assessment, initiation of early PN and EN, optimizing calcium and phosphorus intake and education of residents and NICU staff to promote optimal bone mineralization rates.

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