Early calcium and phosphorus supplementation in VLBW infants to reduce metabolic bone disease of prematurity: a quality improvement initiative.

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  • Additional Information
    • Source:
      Publisher: BMJ Publishing Group Country of Publication: England NLM ID: 101710381 Publication Model: Print Cited Medium: Internet ISSN: 2399-6641 (Electronic) Linking ISSN: 23996641 NLM ISO Abbreviation: BMJ Open Qual Subsets: MEDLINE
    • Publication Information:
      Original Publication: London : BMJ Publishing Group
    • Subject Terms:
      Bone Diseases, Metabolic*/etiology ; Bone Diseases, Metabolic*/prevention & control ; Calcium*/therapeutic use; Dietary Supplements ; Female ; Humans ; Infant ; Infant, Newborn ; Infant, Very Low Birth Weight ; Phosphorus/therapeutic use ; Quality Improvement
    • Abstract:
      Objective: To reduce the incidence of metabolic bone disease (MBD) among very low birthweight (VLBW) infants admitted to neonatal intensive care unit from baseline of 35% by 50% over 2 years by implementing a quality improvement (QI) initiative.
      Methods: A multidisciplinary QI team used evidence-based interventions and the healthcare improvement model to reduce MBD rate in VLBW infants. The specific interventions included routine enteral supplementation of calcium and phosphorus using Human Milk Fortifier (HMF) to expressed breast milk by day 14 of life (Plan/Do/Study/Act (PDSA) cycle 1), parenteral and early enteral supplementation of calcium and phosphorus (PDSA cycles 2 and 3). We included VLBW infants admitted within the study period at birth and excluded babies with congenital malformations, skeletal disorders and those who died before 2 weeks of age. Compliance with adding HMF by day 14, compliance with adding calcium and phosphorus in total parenteral nutrition (TPN) from day 1 of life and compliance with starting HMF when the baby reached 100 mL/kg/day of feeds were used as process indicators. The incidence of MBD was used as an outcome indicator during the study. The incidence of MBD was tracked using the Statistical Process Control methodology.
      Results: The baseline MBD rate in 2015 was 35%. After the first PDSA cycle, 20% developed MBD (p=0.02). The same was sustained for a period of 1 year with the rate of 22%. After the second and third PDSA cycles, there was a drop in the MBD rate to 17%, and sustained for 3 months with 21%.
      Conclusion: Implementation of QI initiatives decreased the MBD rate from 35% to <20%. Early parenteral calcium and phosphorus supplementation in TPN and optimising enteral supplementation with multicomponent fortifiers appear to have significant reduction in the incidence of MBD.
      Competing Interests: Competing interests: None declared.
      (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
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    • Contributed Indexing:
      Keywords: Evidence-Based Practice; Healthcare quality improvement; Paediatrics; Quality improvement methodologies; Statistical process control
    • Accession Number:
      27YLU75U4W (Phosphorus)
      SY7Q814VUP (Calcium)
    • Publication Date:
      Date Created: 20220822 Date Completed: 20220824 Latest Revision: 20220910
    • Publication Date:
      20231215
    • Accession Number:
      PMC9403146
    • Accession Number:
      10.1136/bmjoq-2022-001841
    • Accession Number:
      35995540