nutritional needs of preterm infants: outcomes assessment … › upload › userfiles › pdfs ›...

1

Nutritional Needs of Preterm Infants: Feeding Choices and Dietary Transitions

Final Outcomes AssessmentAugust 2017

Abbott Nutrition Grant ID: 25831283

Activity Page

2

Program Information

Activity Title: Nutritional Needs of Preterm Infants: Formula Choices and Dietary Transitions

Launch Date: July 29, 2016Expiration Date: July 29, 2017

Credit: 1.0 AMA PRA Category 1 Credit(s)TM

1.0 Continuing Professional Education units (CPEU) for dietitians 0.10 IACET approved CEU’s for nurses

Sponsored By: The Academy for Continued Healthcare LearningSupported by: Supported by an educational grant from Abbott Nutrition

Audience Generation:FreeCME: https://learning.freecme.com/attendee/view_program.jsp?programCode=21682PAPcNnCACHL site: http://achlcme.org/Infant‐nutrition‐webcast

Faculty:Sharon Groh‐Wargo, PhD, RD, LDProfessor, Nutrition and PediatricsCase Western University School of MedicineCleveland, Ohio

Executive Summary

Level 1‐2 OutcomesParticipation Learners: 1,178 Clinicians (guarantee 1,000) Certificates: 998

Satisfaction Quality of educational content was highly rated for this activity 84% of learners noted that the faculty’s ability to effectively convey the subject

matter and expertise on the subject matter was Good/Excellent.

95% of learners would recommend this activity to a colleague.

Over 75% of participants were either physicians, physician assistants, or nurses/NPs. Participants agreed that all learning objectives were met with an average rating of 3.51/4.00 or higher, supporting the high rating of the educational quality. Participants feel that the education is of value and the majority would recommend this activity to a colleague.

3

Executive Summary

Level 3‐5 Outcomes Changes made based on participation in this activity may impact up to 3,060 pre‐term/early

pre‐term infants each month.

This activity was highly effective, with 63% of learners indicating that patient outcomes would be positively impacted.

Learners improved performance on all post‐test questions, with an average of 85% of participants answering post‐test questions correctly, compared to only 39% on the pre‐test.

Learners demonstrated increases in both knowledge, competence and performance by:

– Demonstrating an increased ability to formulate nutrition care plans which foster optimal growth Participants demonstrated increased knowledge of guidelines and peer‐reviewed literature

– Differentiating between preterm and standard term formulas in terms of nutrient composition Participants also demonstrated knowledge of preterm vs very low birth weight infants and can

correlate these differences with appropriate nutritional practices– Correctly advising parents to alter both their diet (if breastfeeding) and the infant’s when the child

experiences a milk allergy Participants recognize the differences between supplementing feedings, and enriched vs

fortified formulas and are better prepared to counsel parents on which formulas to select for their infants

– Transitioning preterm infants to standard term formula when both growth and weight gain are sustained

Executive Summary

Level 3‐5 Outcomes (cont)

Participants increased their self‐rating of confidence as a result of participation in this activity and with respect to:

– Designing nutritional care plans which support a healthy lifestyle in infants (an increase of 18% in confidence)

– Appropriately prescribing preterm formula or human milk fortifier (HMF) for very low birth weight (VLBW) or low birth weight (LBW) infants

– Transitioning infants from preterm formulas to standard‐term formulas following sustained growth and nutrient intake

– Educating parents and caregivers with respect to differences between supplemented, fortified, and enriched formulas.

Increases in participant confidence endured for at least 45 days following the activity (ie, duration could possibly be longer)

Portions of this educational activity were directly translated into clinical practice as more than two‐thirds of participants frequently or always engage in parent education to help them optimally select infant formulas

4

Future Education

Considerations for Future Education

Long‐term outcomes of preterm infants

Parenteral/NICU nutrition for premature infants

Best practices for breastfeeding

Infant brain growth and development

Reinforcement of the nutritional differences between preterm discharge and standard term formulas

Profession

26%

27%18%

5%

17%

7% Profession

Physician

Physician Assistant

Nurse

Nurse Practitioner

Other

Unknown

Total Participants Certificates

1,178 998

“Other” included students, medical technicians, technologists, residents, and pharmacists.

5

Specialty

20%

16%8%

7%

4%

4%

4%2%

Specialty

Family Practice, General Practice, or Primary Care

Pediatrics

Unknown

Obstetrics and/or Gynecology

Emergency Medicine

Other

Internal Medicine

Neonatology/Maternal‐Fetal Medicine

Question Topic Pre Post % Change

1 Optimizing preterm infant growth 25% 77% 208%

2 Preterm vs term formula differences 58% 97% 67%

3 Using preterm formulas to aid in catch‐up growth 24% 73% 204%

4 Infant milk allergies 58% 94% 62%

5 Post‐hospital discharge formulas 31% 84% 177%

Overview of correct responses:

Level 3 & 4: Pre/Post‐test Overview

25%

58%

24%

58%

31%

77%

97%

73%

94%86%

0%

25%

50%

75%

100%

1 2 3 4 5

Pre

Post

Learners demonstrated improved knowledge and competence on all five pre/post‐test questions and case vignettes.

6

Level 3 & 4: Pre‐test vs. Post‐test

1. Charlotte was born at 32 weeks. Her corrected age is 6 months, 2 weeks. Her parents have only introduced rice cereal into her diet as her only semi‐solid food. Her pediatrician is talking to her parents about feeding progression. Which of the following elements should the pediatrician highlight when advancing feeding for Charlotte?

A. Withhold cow’s milk until approximately 1 year, 7 weeks

B. Meats cooked at dinner for the household could be introduced as they are a good source of protein, iron, and zinc

C. Breastfeeding for up to 2 years should be encouraged because the infant was premature

D. Extreme caution should be used when introducing Charlotte to solid foods because of her prematurity, and the corresponding slower development of appropriate gut bacteria

25%

10%

25%

40%

77%

9%7% 7%

0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015)

Prior to the activity, over 40% of participants chose a conservative nutritional approach for a very preterm infant. Post‐activity, over 70% of participants recognized that a diet at 6 months of corrected age could

include specific foods but should still include breastmilk or formula as infants less than one year could have trouble processing the protein, sodium, and extra minerals found in cow’s milk.


2. How do preterm discharge formulas differ from standard milk‐based formulas in terms of nutrition?

A. More protein, less vitamin A, less B6

B. More protein, higher levels of zinc and B6

C. More lactose, lower amounts of fat and iron

D. Lower zinc and protein levels but more vitamin A

22%

58%

11% 9%

97%

1%0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015)

Pretest performance on this question was significantly higher than on the previous one showing that participants are familiar with various formula compositions. Post‐activity, almost all participants correctly identified major differences between preterm discharge and milk‐based formulas suggesting that learners are aware of how to

select approved formulas for optimal infant growth.

1% 1%

7


3. From the choices below, select the MOST appropriate definition of preterm infants as well as the corresponding, potential benefits which may result from using a preterm discharge formula for this infant population.

A. Born before 36 weeks and less than 1800 g; greater weight gain and bone mineralization

B. Born before 36 weeks and less than 1250 g; greater weight gain and linear growth

C. Born before 34 weeks and less than 1800 g; greater weight gain and bone mineralization

D. Born before 34 weeks and less than 1250 g; greater weight gain and linear growth

33%

24% 24%19%

15%

73%

5%

0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015)

Pretest performance on this question shows that there is still confusion as to the timeline which is used to define a preterm infant. However, the majority of participants on the post‐test correctly identified gestational cut‐offs for preterm babies. Post‐test performance also allows us to see that participants are aware of the benefits of preterm discharge formulas by allowing preterm infants a chance for growth catch‐up (at 18

months) via the ingestion of specific nutrients in greater amounts than those seen in standard term formulas.


4. Beth, a 4 month old, has been receiving a diet consisting of largely formula with about 1‐2 feedings a day of mother’s milk. Lately, she has been very fussy after feeding and gassy. She has even spit up following her feedings. The parents are concerned about a milk allergy or GERD. If a milk allergy is confirmed, choose the best course of action from the options below:

A. Beth’s mom should stop breastfeeding her daughter and switch to a formula that contains protein hydrolysate.

B. Beth’s mom may choose a formula that contains a protein hydrolysate, as well as a diet for herself that is free from dairy products.

C. Beth could conceivably be introduced to more foods sooner in order to lessen exposure to milk‐based formulas.

D. Beth’s mom should stop breastfeeding her daughter and switch to a formula that is soy‐based.

19%

58%

10% 13%

3%

94%

1% 2%

0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015)

More than half of the participants taking the pretest correctly identified the best course of action for an infant who has a milk allergy as well as her mother. The number of correct responses increased by 62% on the post‐test with over 90% of participants choosing the correct response. Thus, activity content provided clinicians with a strategy of how to choose a new formula type when dealing with infant milk allergies as well as helpful diet

changes for breastfeeding mothers.

8


5. George is now chronologically 5 months old. However, he was born 2 months premature. For how long should he be fed a post‐discharge formula, especially since at his last growth assessment, he exhibited appropriate growth?

A. Until he reaches 1 year as his post‐conception age

B. He can stop the PTDF now and transition to a standard term formula

C. He should continue on PTDF indefinitely

D. Until he gains at least 10 oz. a week, he should continue receiving PTDF

39%31%

7%

23%

86%

3% 5%

0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015)

Participants initially split their choices between an age cut‐off, and a growth and weight achievement. Post‐activity, 86% of participants correctly identified that guidelines recommend a transition to standard formula

on a case‐by‐case basis, especially when growth is sustained and on‐track.

Level 5 Outcomes

A 45‐day follow‐up survey was sent to participants who completed this activity. One knowledge question and two confidence‐based questions were used to gather information on if and how participants are applying activity content in practice (slides 17‐19).

9

Level 5: Follow‐up SurveyConfidenceBefore/following participation in this activity, how confident are you in transitioning pre‐term infants to term formula, when appropriate?

5%

5%

63%

27%

3%

21%

54%

22%

10%

47%

38%

5%

0% 25% 50% 75%

Not at all confident

Not very confident

Very confident

Extremely confident

Pre (N=196) Post (N=1,015) Follow‐Up Survey (N=19)

Prior to activity completion, almost half of the participants rated themselves as “not very confident” when transitioning infants from pre‐term to term formula. Post‐activity, 76% of participants identified as either “very or extremely confident” in their

ability to gauge when/how to adjust the nutritional care plan for these patients. Forty‐five days post‐activity, 90% of participants felt very or extremely confident in their capability to do so. Because participants plan to refer to growth curves more and also have an increased awareness of formulas and their differences, this knowledge may help them feel more

confident.

*The data for the pre‐test was gathered via a polling question within the activity

Level 5: Follow‐up SurveyCaregiver Education

10%

16%

37%

37%

9%

13%

42%

36%

23%

32%

29%

16%

0% 10% 20% 30% 40% 50% 60%

Never

Rarely

Frequently

Always

Pre (N=217)

Post (N=1,015)

Follow‐Up Survey (N=19)

How often do you currently/plan to take the time to educate parents/caregivers on the difference between supplemented, fortified, and enriched preterm formulas?

Seventy‐eight percent of participants, post‐activity, stated that they would always or frequently engage with parents and/or caregivers to provide education on the array of formula choices available and the

differences between them. Forty‐five days later, this trend held, with 74% of survey respondents responding that the knowledge gained was of use when educating parents such that clinicians are

retaining the ability to select the most appropriate nutritional choices for their infants.

10

Level 5: Follow‐up SurveyKnowledge

Beth, a 4 month old, has been receiving a diet consisting of largely formula with about 1‐2 feedings a day of mother’s milk. Lately, she has been very fussy after feeding and gassy. She has even spit up following her feedings. The parents are concerned about a milk allergy or GERD. If a milk allergy is confirmed, choose the best course of action from the options below.

A. Beth’s mom should stop breastfeeding her daughter and switch to a formula that contains protein hydrolysate.

B. Beth’s mom may choose a formula that contains a protein hydrolysate, as well as a diet for herself that is free from dairy products.

C. Beth could conceivably be introduced to more foods sooner in order to lessen exposure to milk‐based formulas.

D. Beth’s mom should stop breastfeeding her daughter and switch to a formula that is soy‐based.

19%

58%

10% 13%

3%

94%

1% 2%5%

79%

11%5%

0%

25%

50%

75%

100%

A B C D

Pre (N=1,119) Post (N=1,015) Follow‐Up Survey (N=19)

This same pre/post question was also used on the follow‐up survey. Post‐activity, 94% of participants correctly identified the best course of action from the choices provided. Performance fell slightly 45 days post‐activity,

but was still robust with nearly 80% of respondents answering this question correctly.

Another question that would also gauge participant understanding would be to find out if learners were aware that milk allergies typically resolve in 75% of infants by age three.

Evaluation Data

11

Learning Objectives

Please rate the following objectives to indicate if you are better able to:

Analysis of Respondents

Rating Scale:

4 = Strongly Agree

1 = Strongly Disagree

Illustrate the differences between preterm and term formulas 3.53

Formulate strategies to transition preterm infants to post‐discharge feeding practices 3.52

Utilize scientific evidence, recommendations by experts and emerging data in infant nutrition to create nutrition care plans that support optimal preterm infant growth

3.51

Provide examples of healthful diets that link how diet impacts disease 3.51

Describe evidence‐based diets for late preterm infants, and for infants with milk allergies or with neonatal abstinence syndrome (NAS)

3.52

N=986

Learners strongly agree/agree that all learning objectives were met, with an average rating of 3.52.

Ninety‐five percent of learners would recommend this activity to a colleague!

Impact of Activity

This activity will improve my patient outcomes:

Yes: 63% No: 20% Validated Practice: 17%

• Able to provide effective parental education on preterm infants’ nutritional needs (4)

• Better prepared to explain the rationale of feeding decisions.

• Healthier babies• It will improve my knowledge with a better impact on my

patients• This will enhance your knowledge and improve your skills in

dealing with premature babies. And awareness especially when it comes to their nutritional status

• Improved nutritional counseling for parents of pre‐term infants

• I will be able to explain to patients the benefits/risks of breastfeeding vs formula in preterm & term babies

• Enhanced my communication with patients• Help answer questions• Better understanding• Continue preterm discharge formula for 1 year• Criteria adjustment• To select milk• Discuss with patients the importance of using discharge

formula or fortifiers

• I can give instructions on infant nutrition based from patient's level of understanding and preference.

• Better formula choices (2)• Help me better to answer new mother's questions regarding

a feeding problem• Better understand when/how to transition formula• Help me in practical work • I will be aware of more dietary concerns that I can bring to

the team taking care of the infant and express any concerns that I do have (if any)

• Discussions with parents and feedings• Experience• Less fussy babies; babies who will gain weight and continue

with their growth mentally and physically• Better understanding of preterm infants, nutrition needs,

and better growth and brain development• More information available/more knowledge (4)• Consulting with other MDs

N=986

12

Impact of Activity (cont)

• Proper care of preterm child• It will increase survival• Proper way of giving formula for pre‐term.• Increases knowledge base of formulas and donor milk.• Will consider changing of formulas currently used• I was not aware of how to appropriately choose formulas

for pre‐terms prior to this activity.• Gave me a wider knowledge base to work from and better

understand. • By advising parents to continue PDTF for better growth and

BMC • Further recognizing nutritional needs of preterm infants• I work in a level 4 NICU and dc babies on all types of feeding

plans (mom wants to nurse, feed pumped milk, formula, etc...)

• Make recommendations to general pediatricians on continued post discharge formula depending on GA

• This activity is very informative making the expected goal reach by following guidelines.

• More up‐to‐date info• Better understanding of preterm nutrition• Better understanding of maternal milk usage and the dread

of online maternal milk

• Formulating diets for all babies with milk allergies• It will create new strategies.• Better approach choosing proper nutrition • When seeing a preterm infant, I will be better able to

educate the mother on feeding.• Improved nutrition for preterm infant’s post discharge.• Greater awareness• Can provide education and resources discussed • Be more aware of the different formulas• By putting pre‐term infants on fortified human milk for

better gain in weight and over all development instead of relying on human milk only.

• To give better nutritional advice • Transition to regular formula• I am clearer on how to treat preterm infants • Will help premature infants get formula regimens better

tailored to their individual needs for the best growth options

• Using more PTDF• More confident in managing preterm formulas• The more you learn about pre‐term babies the more you

understand the baby and the mother.

N=986


Impact of Activity (cont)

• Help us managing nutritional status for preterm infant

• Better growth/development• More aware of nutritional needs • Better understand transitioning to standard

formula/BM• More confident in managing the nutritional

needs of preterm infants• Determining the need for enhanced products • Parenting education• Good, can explain detail to patient• Good follow up and knowledge

• Be aware for giving foods to preterm babies.• It is very informative and will allow the

patient to become very educated on the matter.

• Patient will be treated correctly and avoid some disease

• The parents of a pre‐term infants will be able to have knowledge to know what are the nutritional needs of the baby and the appropriate sources of the nutrients needed.

N=986


13

62% of learners will change their practice. Many participants will use tools such as growth charts as well as considering using a wider array of nutritional options to help infants meet their growth targets. An important takeaway from this activity is that much of the nutritional care planning has to be done on a case‐by‐case basis. Additionally, 30% report they will change the management and/or treatment of their patients!

How Will You Change Your Practice?

38%

12%

30%

19%

This activity validated current practice, no changes

Other

Change the management and/or treatment of my patients

Create/revise protocols, policies, and/or procedures by using toolssuch as growth charts and considering the use of multiple formula

types/fortification to optimize growth

Select all that apply:

See next slide for open‐ended comments about intended changesN=986

Intended Changes

Patient education

It will support my treatment and recommendations

Smarter advice

It is improving my prospection and knowledge to better treat patients

Improve nutritional counseling

More knowledge/info

By health education

Improve patient outcome

It has given me firsthand knowledge to transition preterm babies

Better understanding

Revises policies

Proper diet for preterm

I will change my clinical practice ways

Improve patient care

Know the importance of breastfeeding on pre‐term infant.

This was new information for me, so it helps drastically.

Further question parents about feedings and nutritional concerns

Better understanding of preterm nutrition

Better understanding of maternal milk usage and the dread of online maternal milk

Formulating diets for all babies with milk allergies

I will be more knowledgeable on how much a preterm infant needs

I will educate parents better about nutrition of their preterm infants

Assess all factors

Learned new information that I can pass onto patient

To take greater care of patients

Help us know when to change formula and what formula to use

Opportunity to educate

Help in improving patient care

Increased knowledge

This activity will surely change my practice by guiding proper and good information require for treatment

Will increase my referrals to appropriate individuals

New information

Understand and advise preterm infant's parents for proper nutrition

How will you change your practice as a result of participating in this activity:

14

Intended Changes (cont)

Help me teach better

Make more time to educate parents

I do not see preterm infants but I do counsel new mothers all the time. This information will help me council them when they have feeding issues

More confident advising moms about nutrition

Update nursing staff

Knowledge of nutrition needs

For transitioning formulas and when to do it

Increase knowledge

Provided a baseline knowledge for patients I deliver preterm. I am a CNM and don't directly care for babies

In this session, if we recognized the correct management will be able to address the proper treatment and the after health of the patient

Will be more able to take care of pre‐term infants in NICU and NBSU

Better knowledge of treating infants

I am a PA student without a practice currently, but I will have the information to better inform patients and future providers regarding proper formula regimens for preterm infants

Confidence using preterm formulas and transitioning to regular formulas

Patient home care instructions

More comprehensive knowledge of milk to formula transition

Have more information to give to parents

Will have criteria on when to switch formula/stop fortifying

How will you change your practice as a result of participating in this activity:

Impact of Activity

44%

37%

11%

4% 4%

Number of preterm or early preterm infants seen each month:

0

1 to 5

6 to 10

11 to 15

>15

N=986

Changes could impact up to 3,060 preterm infants each month. This assumes data in chart above is representative of the 1,178 clinicians who participated in this

activity, who also indicated they would change their practice as a result of this activity (62%).

15

Confidence: Ability to Design a Healthy Care Plan

7%

39%

47%

8%


Not very confident

Very confident

Extremely confident

How confident are you in creating nutrition care plans which impact a healthy lifestyle?

This question was posed to participants while they were viewing the webcast (ie, intra‐activity polling question). Forty percent of participants at the beginning of the activity rated

themselves as not very confident in the development of nutritional care plans. The following slide shows how their competence to adjust and tailor the care plan improved as a result of

participation in this activity. N = 250

Confidence: Ability to Differentiate Between HMF and Preterm Formula

Before/following participation in this activity, how confident are you with regard to prescribing preterm formula or fortified breastmilk for very low or low birth weight infants?

5%

32%

45%

18%

18%

45%

24%

13%

0% 25% 50%


Not very confident

Very confident

Extremely confident

Pre (N=1,119) Post (N=1,015)

Post‐activity, 63% of participants felt either very or extremely confident, when recommending either fortified human milk or preterm formula for an infant. This is in contrast to the 37% of participants who fell into

these categories during the pretest. There were multiple talking points within this activity about how the two formula types differed nutritionally as well as the types of infants who would stand to benefit the

most from each or a ratio of both formula types.

16

Perceived Clinical Barriers

Please indicate any barriers you perceive in implementing these changes.

13%

9%

14%

16%

5%

7%

4%

2%

27%

4%

Cost

Lack of availability

Lack of opportunity (patients)

Parent compliance issues

Lack of administrative support

Lack of time to assess/counsel patients

Reimbursement/insurance issues

Lack of consensus or professional guidelines

No barriers

Other, please specify

Of the learners that intend to address barriers to practice, identified strategies include: educating parents and caregivers, reinforcing information with colleagues, nutritional counselling of parents and close/more frequent follow‐up with

preterm babies.

N=986

41% of learners indicated, via the evaluation, that they will attempt to address these barriers to implement

changes.

Attempt to Address Barriers

Education of parents and other caregivers

Reinforcement at future meetings

Perform improving patient education and follow up programs

Nutritional counseling of parents

Adjusting scheduling to permit counseling time

Proper parent or family education with the help of social worker and dietitians

Health education

More support to parent possibly written plan

Set up plan of action for other provider to follow (saves time)

Promote and implement the learnings. raised during the meetings

Close follow‐up of the families with preterm babies

Better IEC and IPC will help in taking care of this.

Better knowledge of treating infants

Communication with parents about proper nutrition

Permit more time and counseling for parents caring for their infant.

Parental education of diet of child

Regular follow ups

Try to spend more time w/ pts when appropriate

The availability of mother's milk and milk fortifiers will be a challenge in my community and will need an input from the business sector

Take more time to educate parents on specific nutritional needs

Please describe how you will attempt to address the identified barriers:

17

Objectivity & Bias

5%

95%

0%

20%

40%

60%

80%

100%

Yes No

Did you Perceive Any Bias?

N=986

This activity was perceived as objective, balanced, and non‐biased.

49%

51%

35%

33%

14%

14%

1%

1%

1%

1%

Excellent Good Satisfactory Fair Poor

Faculty Evaluation

Ability to effectively convey the subject matter

Expertise on the subject matter

Sharon Groh‐Wargo, PhD, RD, LDProfessor, Nutrition and Pediatrics

Case Western University School of MedicineSenior Nutritionist, PediatricsMetro Health Medical Center

Cleveland, Ohio

N=986

Learners highly rates Dr. Groh‐Wargo’s expertise and ability to convey the subject matter.

18

51%

49%

49%

36%

36%

36%

12%

13%

14%

1%

1%

1%

Excellent Good Satisfactory Fair Poor

Activity Satisfaction

Please evaluate by marking the appropriate response:

Quality of educational content

Level of instruction

Facilities, technical arrangements, efficiently supported this activity

N=986

Quality of educational content and level of instruction were highly rated.

Topics of Interest

2%

19%

33%

46%

Other

Parenteral/NICUnutrition for premature

infants

Infant brain growth and development

What topic areas would you like to see in future activities?

Best practices for breastfeeding

N=986

Best practices for breastfeeding, followed by infant brain growth/development and parenteral/NICU nutrition for premature infants were reported as future educational topics of

interest.

19

For questions, please contact:

Brittany Puster

Director, Education Development

Academy for Continued Healthcare Learning (ACHL)

E: [email protected]

P: 773‐714‐0705 ext. 134

nutritional needs of preterm infants: outcomes assessment … › upload › userfiles › pdfs ›...

Documents