________________________________________________________________ _Fall 2010 /Winter 2010__________

This is the Final Edition of ONNews!

To finalize our transition from print to web, the Ohio Neonatal Nutritionists group will no longer be publishing a

biannual newsletter. In place of ONNews, monthly practice update articles will be featured on our website,

www.ohioneonatalnutritionists.homestead.com. This change allows ONN to disseminate current NICU evidence-

based information to you faster. Thank your for your continued support of the Ohio Neonatal Nutritionists!

Nutrition Care Process 2011 Updates

The 3rd edition of the International Dietetics and Nutrition Terminology Reference Manual and Pocket Guide is now available.

(http://www.eatright.org/members/ncp/ ) The Neonatal Nutrition Toolkit to the Nutrition Care Process has been revised as well and

will be available in December 2010 to purchase on line.

The Nutrition Care Process and Standardized Language Committee (http://www.eatright.org/Members/content.aspx?id=8456 ) is

charged with developing standardized language that most appropriately defines nutrition care for coding and recognition of

nutrition intervention. For revision there have been some updates to more closely identify nutrition practice. The updates are

listed here and are categorized by the Nutrition Assessment and Monitoring and Evaluation, Nutrition Diagnosis, and

Nutrition Intervention sections. First will be the change in the order of data categories and second, the new terminology

which is underlined.

Nutrition Assessment and Monitoring and Evaluation Terminology- Order of data categories

The new order is as follows: (new terminology is underlined)

Food/Nutrition-Related History (FH)

Food and Nutrient Intake (1)

Food and Nutrient Administration (2)

Medication and Herbal Supplement Use (3)

Knowledge/Beliefs/Attitudes (4) Behavior (5)

Factors Affecting Access to Food and Food/Nutrition-Related Supplies (6)

Physical Activity and Function (7)

Nutrition-Related Patient/Client-Centered Measures (8)

ONNews

Newsletter of the Ohio Neonatal Nutritionists www.ohioneonatalnutritionists.homestead.com

Nutrition Assessment and Monitoring and Evaluation Terminology- New Terms

- Enteral nutrition intake (1.3.1) now separated from parenteral

- Parenteral nutrition intake (1.3.2)

- Bioactive substance intake now includes: Food additives (specify) (FH 1.4.2.4) and Other (specify) (FH1.4.2.5)

- Carbohydrate intake now includes: Insulin-to-carbohydrate ratio (FH1.5.3.7)

- Eating environment now includes: Eats alone (FH2.1.3.5)

*NICU NOTE: this would only be applicable when assessing a breastfeeding mother

- Enteral and parenteral nutrition administration (2.1.4)

- Beliefs and attitudes now includes: Food preferences (specify) (FH4.2.12) and Emotions (specify) (FH4.2.13)

*NICU NOTE: this would only be applicable when assessing a breastfeeding mother

- Physical activity now includes: NEAT (non-exercise activity thermogenesis) (FH 7.3.11)

- Protein Profile now includes: Antibody level, specify (BD 1.11.7)

- Patient/Client/Family Medical/Health History now includes: Other (specify) (CH2.1.14 P or F)

- Treatments/therapy/complimentary/alternative medicine now includes: Palliative/end-of-live care (specify) (CH 2.2.4)

- Comparative Standards are now listed.

Nutrition Diagnostic Terminology- Order of data categories

The order of Categories remain the same: Intake, Clinical and Behavioral-Environmental

Nutrition Diagnostic Terminology- New Terms

Energy Balance now includes: Predicted suboptimal energy intake (NI 1.6) and Predicted excessive energy intake (NI 1.7)

Oral or Nutrition Support Intake now has Enteral and Parenteral separated as well as 3 new additions:

Inadequate enteral nutrition infusion (NI 2.3)

Excessive enteral nutrition infusion (NI 2.4)

Less than optimal enteral nutrition (NI 2.5) Inadequate parenteral nutrition infusion (NI 2.6)

Excessive parenteral nutrition infusion (NI 2.7)

Less than optimal parenteral infusion (NI 2.8)

*NOTE: Inappropriate infusion of enteral/parenteral nutrition has been removed

Multi-nutrient (5.11) includes: Predicted suboptimal nutrient intake (NI 5.1.11.1) and Predicted excessive nutrient intake (NI

5.11.2)

Food and Safety Access now includes: Intake of unsafe food NB 3.1

*NICU NOTE: this could be applicable to formula/water to make formula

Nutrition Intervention Terminology- Order of data categories

The order of the categories remains the same, but Nutrition Education has new names:

Food and/or Nutrient Delivery

Nutrition Education:

Nutrition Education-Content

Nutrition Education-Application

Nutrition Counseling

Coordination of Nutrition Care

Nutrition Intervention Terminology New Terms

FOOD AND/OR NUTRIENT DELIVERY

Enteral Nutrition (2.1)

Formula/solution (ND 2.1.1)

Insert enteral feeding tube (ND 2.1.2)

Site care (ND 2.1.3)

Feeding tube flush (ND 2.1.4)

Parenteral Nutrition/IV Fluids (2.2)

Formula/solution (ND 2.2.1)

Site Care (ND 2.2.2) IV fluids (ND 2.2.3)

Under Bioactive Substance Management (3.3)

Plant sterol and stanol esters (ND 3.3.1)

Soy protein (ND 3.3.2)

Psyllium and β-glucan (ND3.3.3)

Food Additive (ND 3.3.4)

Other (specify) (ND3.3.5)

Under Nutrition-Related Medication Management

Medications (ND 6.1)

Herbal/complimentary products (specify) (ND6.2)

Under Nutrition Education-Content (1) Nutrition relationship to health/disease (E-1.4)

Recommend modifications (E-1.5)

Other or related topics (E-1.6)

Other (specify) (E-1.7)

Under Nutrition Education-Application

Result interpretation (E-2.1)

Skill development (E-2.2)

Other (specify) (E-2.3)

Here are some examples of using the new NCP terminology:

Example 1

Nutrition Assessment: Emotions: Mother is overcome with condition of infant and is producing low amounts of expressed

breastmilk and does not want to use a substitute feeding (Donor breastmilk or formula)

Nutrition Diagnosis: Less than optimal enteral nutrition related to low volume expression by mother evidenced by 50% of

ordered/needed daily volume for weight and age

Nutrition Intervention: Nutrition Education Content: Nutrition relationship to health/disease – session with mom to discuss/educate

on enteral needs and to review options of enteral substitute

Intervention agreed upon: Use donor expressed maternal breastmilk with expressed breastmilk and support mother to increase milk

supply.

Goal: 100% mother’s breastmilk by DOL 10

Indicator: % of mother’s milk daily and mom’s compliance with pumping plan

Criteria: volume of breastmilk equal to infant’s need; mom pumping q 3 hrs except overnight

Example 2

Nutrition Assessment: Parenteral Nutrition formula/solution is lower nutrient prescription on DOL 4 than unit guidelines

Nutrition Diagnosis: Inadequate parenteral solution related to protein gram/kg prescription evidenced by weight loss > 10% of

birth weight

Nutrition Intervention: Parenteral Nutrition formula/solution: Increase protein gram/kg to 3.5

Goal: Patient is receiving established unit nutrition guidelines by DOL 6

Indicator: Weight, TPN labs

Criteria: weight loss subsides and TPN labs are WNL

Example 3

Nutrition Assessment: a surgical baby has a peripheral IV line on DOL 8

Nutrition Diagnosis: Less than optimal parenteral nutrition related to line access evidenced by lower nutrients than needed for

weight and age

Nutrition Intervention: Parenteral nutrition formula solution nutrient prescription per weight and age post central line placement

Goal: ~ 100 kcal/kg parenteral nutrition daily intake

Indicator: Weight, TPN labs

Criteria: TPN labs WNL and weight gain > 15 g/day (premature growth charts)

Example 4

Nutrition Assessment: Palliative end of life care (Trisomy 18)

Nutrition Diagnosis: Predicted suboptimal nutrient intake related to parenteral nutrition DC’d with only breastmilk enteral delivery

per parents wishes evidenced by intake 30% of nutrient needs.

Nutrition Intervention: Discharge and transfer of Nutrition Care to Hospice

Goal: Collaboration with Hospice staff for storage/use of expressed breastmilk

Indicator: Safe storage and delivery of breastmilk

Criteria: Frozen breastmilk stored at -20°C, -4°F; fresh breastmilk stored at 4°C, 39°F; milk delivered by bottle or breast ad lib. (Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in Health Care Facilities. Robbins ST, Beker LT.

Chicago, IL: American Dietetic Association. 2004.)

Resources:

International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care

Process.3rd Ed. Chicago, IL; American Dietetic Association; 2011.

Pocket Guide for the International Dietetics and Nutrition Terminology Reference Manual, 3rd Ed. Chicago, IL: American Dietetic

Association; 2011.

American Dietetic Association, Neonatal Nutrition Toolkit and IDNT Pocket Guide. Chicago, IL: American Dietetic Association.

Available at the EAL store: (DEC 2010) www.adaevidencelibrary.com

American Dietetic Association. Electronic Health Record Toolkit (download). Chicago, IL: American Dietetic Association; 2008.

Available at the EAL store: www.adaevidencelibrary.com

Nancy Nevin-Folino, MEd, RD, CSP, LD FADA; Dayton Children’s Medical Center, Dayton, OH

Donor Milk: Survey of Pediatric Dietitians

A survey was developed and administered October 18 – 20, 2010 via the Pedi-RD listserve. The purpose of the survey was to

ascertain more information related to donor milk use and practice. Listed below are some of the survey results:

84 RDs responded to the survey; 72.6% provided the names of their hospitals. Hospitals were all over the US and Canada.

The majority of respondents work in NICUs; over 30 work in 26 – 50 bed NICUs.

48 RDs said that donor milk was used in their hospitals.

The top 3 reasons for use of donor milk were VLBW, prevention of NEC, and as a bridge to mother’s milk.

Donor milk has been used >3 years in 18 hospitals.

The donor milk is paid for by the NICU budget in 90% of cases.

o The majority of hospitals do not charge for the milk; 9 RDs stated that they do charge the patient.

o Charges range from $0.53/mL fed (or $15.90/oz fed) to $21.00/ounce fed.

The majority of respondents indicated that their hospitals order the milk in bulk and dispense it as needed for patients.

o The RN/IBCLC orders the milk in the majority of cases. 34% of respondents said RDs order the milk.

o The majority order 20 Cal/oz term milk, but prefer preterm if it is available.

86% or 37 hospitals have specific criteria for using donor milk. Most use the milk for infants <1500 grams, require parental

consent, and a physician’s order.

o 72% use milk as a bridge until mother’s milk comes in.

o 90% of respondents require informed consent.

o 95% fortify donor milk in a variety of ways.

The top 3 nutrients that concern Pediatric RDs are protein, minerals and Calories

83.7% have observed poor growth even in infants fed fortified donor milk.

The majority of respondents only use thawed donor milk for 24 hours even though the milk bank personnel recommend 48

hours.

o 63% document the lot number in the medical record.

o The majority re-label donor milk with a hospital-specific label.

For RDs who answered that they do not use donor milk in their hospitals (n=37), the top reasons it is not used are: cost,

logistics and MD does not want to use.

Amy Sapsford, RD, CSP, LD; Cincinnati Children’s Hospital, Cincinnati, OH

Evidence-Based Resources

The following resources will provide assistance to develop a clinical question and to search and evaluate evidence in order to

support the practice of evidence-based medicine.

ADA Evidence Analysis Library

Free to members at www.eatright.org

By subscription for non-members

Tutorial 1 CPE

Patient Protection and Affordable Care Act www/effectivehealthcare.ahrq.gov/index.cfm

Evidence Based Medicine www.ahrq.gov/clinic/epcix.htm

Academy of Neonatal Nursing member only tools for evidence based practice www.Academyonline.org

USDA , HHS nutrition evidence library http://www.nutritionevidencelibrary.com

Centre for evidence-based medicine, Oxford University www.cebm.net

Designed to develop, teach and promote EBM. Site includes worksheets, tutorials, power-point presentations.

Duke University Medical Center tutorial for EBM www.hsl.unc.edu/services/tutorials/ebm/index.htm

Book:

Evidence-Based Medicine: How to Practice and Teach EBM. 3rd Edition. Strauss, SE et al. Philadelphia, Pa, Churchill-

Livingstone 2005.

Marsha Dumm, MS, RD, LD Nationwide Children’s Hospital at Riverside, Columbus, Ohio

Kayexalate Administration in a NICU

Have you ever had a baby in your unit who required Kayexalate for elevated serum potassium levels? If you have not, you may not

be aware that Kayexalate can be given different ways. It can be given enterally, per rectum, and also mixed in the formula. When it

is mixed in the formula the resin actually settles out and the baby is fed only the formula that is decanted off the top. Some doctors

recommend that Kayexalate be mixed like this for neonates since enteral administration of Kayexalate is contraindicated in

neonates. Drugs.com included the following message for pediatric patients:

“The effectiveness of Kayexalate in pediatric patients has not been established. In neonates, Kayexalate should not be given by the

oral route. In both children and neonates particular care should be observed with rectal administration, as excessive dosage or

inadequate dilution could result in impaction of the resin.

Due to the risk of digestive hemorrhage or colonic necrosis, particular care should be observed in premature infants or low birth

weight infants.” (http://www.drugs.com/pro/kayexalate.html Accessed November 11, 2010)

Kayexalate is a medication not often used in our unit and when it was ordered for a baby in renal failure, there was confusion

regarding how to order and administer it from pharmacists, to dietitians, the ordering provider, and the bedside nurses. When a

safety problem nearly occurred, a step-by-step guide including photos was made to help explain the process to parents and staff.

Please see Kayexalate Handout PDF under the Fall/Winter 2010 Newsletter tab.

Amy Sapsford, RD, CSP, LD; Cincinnati Children’s Hospital, Cincinnati, OH

Formula Room Technician Training

The American Dietetics Association (ADA) publication Infant Feedings: Guidelines for Preparation of Formula and Breastmilk in

Health Care Facilities outlines the standards for equipment, infection control, and mixing practices in hospital formula rooms.

Implementation of these guidelines pose problems for the technicians who often have a background in food service. To improve

the quality and safety of the patient formulas, Nationwide Children’s Hospital in Columbus, Ohio partnered with Columbus State

Community College to develop a formal training program for formula room staff with a curriculum based on ADA

recommendations. Participants attended 12 classes and were required to pass an examination to demonstrate proficiency in

crucial areas including infection control, inventory control, use of weights and measures, and mathematics. Technician training

resulted in decreased formula errors and a stable formula rooms staffing.

1. Dumm MD et al. Technician training reduces formula preparation errors. ICAN. 2010;2(4):258-260.

Marsha Dumm, MS, RD, LD; Nationwide Children’s NICU at Riverside Hospital, Columbus, OH

Colostrum Oral Care

While there is consensus on the benefits of human milk - and in particular colostrum - little research is published regarding the use

of colostrum for oral care for infants in neonatal intensive care. It is theorized that some of the immunoprotective properties of

human milk may be extended oropharyngeal administration to infants who are unable to take enteral nutrition. Oral care is

performed using sterile water on extremely low birth weight infants and other NICU infants who are NPO due to a variety of

diagnoses. A pilot study by Rodriguez et al. supports the use of colostrum in oral care for prevention of ventilator-assisted

pneumonia; they found no adverse effects of this practice. Swabbing mucosal surfaces allows for use of the first drops of

colostrum and may provide positive reinforcement for pumping mothers. The potential benefits of this practice warrant further

research. Below is a sample policy for the oropharyngeal administration of colostrum or human milk.

Sample Policy

Subject: Use of colostrum or human milk for oral care in the NICU.

Purpose: To provide the anti-bacterial and other protective properties in colostrum and human milk to infants unable to take

enteral feedings.

Policy Statement: All infants who would normally be fed enterally with mother’s own or donor milk will receive the benefits of

human milk through oral care.

Instructions:

1. Target population includes, but is not limited to infants who are NPO for pre- or post-operative care, medical NEC,

prophylactic or treatment indomethecin, treatment of hypotension, sepsis, ECMO.

2. Oral care may be performed with each care time, but at least twice daily. 3. Use an approved hospital swab appropriate to infant size.

4. If there is a small amount of colostrum, swab can be dipped into collection vessel. For greater volumes, a small amount

should be decanted into a sterile Volu-Feed.

5. Swab will be saturated with colostrum or human milk and used to swab the entire buccal mucosal surface.

6. Mother’s own colostrum or expressed milk may be used - or donor milk for infants whose parents have consented to the

use of donor milk.

Equipment: Sterile, hospital approved swab, Sterile volufeed

Reference:

1. Tarmow-Mordi W, Isaacs D, Dutta S. Adjunctive immunologic interventions in neonatal sepsis. Clinics Perinatol.

2010;37(2):481.

2. Rodriguez NA, Meier PP, Groer MW, Zeller JM. Oropharyngeal administration of colostrum to extremely low birth

weight infants: a theoretical perspective. J Perinatol. 2009;29(1):1-7.

3. A pilot study to determine the safety and feasibility of oropharyngeal administration of own mother’s colostrum to

extremely low birth weight infants. Advances in Neonatal Care. 2010;10(4):206.

Marsha Dumm, MS, RD, LD; Nationwide Children’s Hospital at Riverside, Columbus, OH

New Publications

Neonatal Nutrition Toolkit

As the International Dietetics and Nutrition Terminology (IDNT) Reference Manual is updated and revised, the

Neonatal Nutrition Toolkit is updated and revised as well. The ADA Nutrition Care Process/Standardized Language (NCP/SL) Committee and the Pediatric Nutrition DPG have collaborated to ensure that this toolkit is consistent with

the current edition of the IDNT and neonatal practice - including case studies using the new terminology. The updated

Neonatal Nutrition Toolkit: A Practical Application of the Nutrition Care Process and Standardized Language to the NICU Setting 2011 edition is now available on the ADA Evidence Library Store and is available for purchase at:

https://www.adaevidencelibrary.com/store.cfm?category=8 . Individuals can also link to this resource from ADA as

well at http://www.eatright.org/Shop/Product.aspx?id=6442452819&CatID=385

Price: $75 Member Price: $35 Student Price: $20

Nancy Nevin-Folino, MEd, RD, CSP, LD FADA; Dayton Children’s Medical Center; Dayton, OH

Infant Feedings: Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, 2nd Ed

Does this book look familiar to you? It sits on many of our bookshelves as it contains much-needed information to provide safe administration of feedings for infants. Members of the Pediatric Nutrition Practice Group and ADA have revised the book and it is

due out in the Spring, 2011. The book is edited by Sandra Robbins and Robin Meyers and is entitled: Infant Feedings:

Guidelines for Preparation of Human Milk and Formula in Health Care Facilities, 2nd Ed. Notice that human milk was placed

before formula in the title to reflect the importance of human milk in infant nutrition. For more information, watch for marketing

information from ADA or go to www.eatright.org.

Amy Sapsford, RD, CSP, LD; Cincinnati Children’s Hospital, Cincinnati, OH

New Product Update

Mead Johnson Nutrition has announced upcoming products that are of special interest to those working in the NICU setting.

These products include Enfamil Premature High Protein 24 Cal, Enfamil Premature 30 Cal, and Enfamil Liquid Human Milk

Fortifier.

Enfamil Premature High Protein 24 is a 24 cal per ounce preterm ready to feed formula with 3.5 g protein/ 100 calories. In

contrast, to original Enfamil Premature formulations that provides 3 g protein /100 calories. Osmolality remains at around 300

mOmsm/kg/water, offers a higher protein formulation to meet the needs of growing premature infants.

Enfamil Premature 30 Cal is a ready to feed 30 calorie per ounce premature ready to feed formula that is due to be available in

2011.

Enfamil Liquid Human Milk Fortifier is a commercially sterile bovine source concentrated liquid human milk fortifier with

increased protein content (4 g per 100 calories of fortified preterm human milk). Comes in single unit dose packaging Advantages

include increased protein, Vit D, and iron content and easy to mix 26 cal per ounce formulation. Data from Clinical Trials are

pending and due to be available early next year.

Trayce Garner, MEd, RD, CSP, LD; Good Samaritan Hospital, Cincinnati, OH

Mixing

To make 30 mL of 24 cal

per ounce Human Milk

Enfamil Liquid Human Milk Fortifier

1 vial (5mL)

Preterm Human Milk 25mL

Nutrients per 100 cal

Energy, Cal 100

Protein, g 4

Fat, g 6

CHO, g 8.1

Vit A, IU 1250

Vit D, IU 210

Vit E, IU 6.2

Folate, mcg 35

Calcium, mg 145

Phos, mg 80

Potassium, mg 98

Magnesium, mg 5.3

Iron, mg 1.91

Zinc, mg 1.37

Manganese, mcg 10.7

Copper, mcg 101

Selenium, mcg 2.5

Sodium, mg 57

Sodium, mEq 2.48

Osmolality, mOsm/kg water 326

Case Study: Poor Growth and Feeding Intolerance

JJ is a former 26 week premie with RDS transferred from an outside hospital on his day of birth. When JJ arrived in NICU he

weighed 760gms (25th %ile), length 31cm (50th %ile) and HC 24.5cm (50th %ile). He was immediately started on TPN of Dextrose

(D) 7.5 and 25 gms pro/L. TPN was advanced to reach D 12.5 and 35 gms pro/L at 120 mLs/kg and 3gms intravenous fat

emulsion/kg. Trophic feedings of maternal breastmilk (MBM) were started on DOL #3 and advanced slowly per protocol with

minimal aspirates. Feedings had not yet been fortified when he developed abdominal distention and was made NPO; parenteral

nutrition was again maximized. He was a R/O NEC, his x-ray (KUB) was negative for NEC and he was restarted on MBM. At 120

mLs/kg feeds were fortified with human milk fortifier to 22 Cals/oz. He had large aspirates and feeds were changed to MBM

mixed 4:1 with Similac Special Care (SSC) 30 for 22 Cals/oz. He appeared to show better tolerance with SSC mixture vs

powdered HMF. When he reached MBM with SSC 30 to provide a 24 Cals/oz, stool output increased and he still was unable to

demonstrate weight gain despite receiving 148 kcals/kg and 3.7 gms pro/kg.

He failed Indocin therapy and at 6 weeks had a PDA ligation. He was treated with diuril and lasix; however respiratory status

worsened and he was found to have a pseudomonas aeruginosa infection. At this point, the infant had multiple medical problems

including: CLD, hyponatremia, cholestasis, rickets, feeding intolerance, and FTT. Cardiology service was consulted since diuretic

therapy was contributing to decreased sodium levels and poor growth; sodium supplementation was recommended. GI service was

consulted to help sort out his many GIT problems. They ordered a fecal fat study which showed split fat in the stool which

indicated a fat malabsorption, but could also reflect a milk protein allergy. They suggested that the infant’s feedings be changed to

Neocate.

Mom had been pumping and had a good supply of breast milk; she was very anxious and wanted the infant to receive her breast

milk. We attempted to mix MBM with Pregestimil powder to make a 24 Cal/oz product. Infant again had increased stool output

and no improvement in weight gain. It was suggested to Mom to follow a milk-free diet and we would change feeds to Neocate for

2 weeks while she continued to pump. Infant showed improvement with change to Neocate, stool output decreased and he started

to demonstrate weight gain even on 20 Cals/oz. He is currently on Neocate 24 to provide 120 kcals/kg and is gaining wt

appropriately. He is now 43 wks GA. Mom would like infant to return to the breast milk pumped while she was on a milk-free

diet. Infant is finally growing on Neocate and labs have improved with Neocate. Mom is aware that even if we returned to MBM

as a base it would need to be supplemented in order to provide adequate nutrition. This case may be one in which continuing to

feed breast milk may not be in the best interest of the infant. Long term plan is to attempt to re-introduce breast milk when infant’s

weight improves on the growth chart.

Significant Labs 1 month 2 moths Current (4 mo. 1 wk.)

Sodium mEq/L 132 130 138

D. Bili, mg/dL 2.4 5.6 0.5

Albumin, g/dL 2.9 2.2 2.8

Alk Phos, U/L 560 999 663

Calcium, mg/dL 8.8 7.5 9.2

Phosphorus, mg/dL 5.2 2.4 4.3

Medications: ADEK, Sodium chloride, sodium phosphorous, calciferol, Mylecon and Ursodiol

Mary Jo Fink, MEd, RD, L; Rainbow Babies and Children’s Hospital, Cleveland, OH

ONNews Editors:

Jodi Bender, MS, RD, LD; Mercy Children’s Hospital, Toledo, Ohio

Melody Thompson MS, RD, LD; Abbott Nutrition Pediatric Medical Dept. and Nationwide Children’s Hospital, Columbus, Ohio

Disclaimer:

**Content in this newsletter is provided by members of the Ohio Neonatal Nutritionists and by non-member contributors, each of

whom is cited by name and affiliation beneath the associated published piece. The views expressed in this newsletter are those of

the authors of each individual piece - and may not necessarily reflect positions of the Ohio Neonatal Nutritionists' group or its

individual members. Mention of product names in this newsletter does not necessarily constitute endorsement by the authors or by

the Ohio Neonatal Nutritionists. The authors and the Ohio Neonatal Nutritionists hereby disclaim responsibility for the

application of the information contained in this newsletter.