167 - A Quality Improvement Initiative to Optimize Weight-for-Length in NICU Graduates on an Inpatient Complex Care Service

Publication Number: 3161.167

Pamela Mazzeo, Children's Hospital of Philadelphia and University of Pennsylvania, Collingswood, NJ, United States; Susan Boyden, The Children's Hospital of Philadelphia, Warminster, PA, United States; Winona D. Chua, University of Pennsylvania Children's Hospital of Philadelphia, Gladwyne, PA, United States; Rebecca Tenney-Soeiro, CHOP/PENN, Philadelphia, PA, United States; Alexis Karkoska, The Children's Hospital of Philadelphia, Collingswood, NJ, United States; Mary Clare Fanning, Childrens Hospital of Philadelphia, Merchantville, NJ, United States; Ao (Sophia) Tan, Childrens Hospital of Philadelphia, Lansdale, PA, United States; Chris Feudtner, Children's Hospital of Philadelphia, Philadelpia, PA, United States

Background: Infants born preterm are at risk for bronchopulmonary dysplasia (BPD) and poor growth. While inadequate nutrition in the neonatal period may increase an infant's risk of severe BPD, excessive growth in early infancy can be associated with adverse pulmonary outcomes in childhood. Of 206 NICU transfers to our complex care service (CCS) between January 2020 and July 2023, 45% had weight-for-length (WFL) above 97th percentile for age.

Objective: At baseline, most babies who entered CCS with WFL >97th percentile had achieved lower WFL by the time of discharge, with only 32% of discharged patients having WFL >97th percentile. We aimed to further reduce the proportion of babies discharged from CCS at WFL >97th percentile from 32% to 25%, within 8 months and without negatively impacting linear growth.

Design/Methods: Complex care service attending physicians, nursing leaders, and a registered dietician (RD) experienced with this patient population identified drivers of appropriate weight-for-length in hospitalized post-NICU premature babies, from which change ideas were generated.

The group created an algorithm (Figure 1) which guided the RD to assess the WFL of CCS patients on a weekly basis and recommended target weight gain goals based on WFL. These individual goals for each baby were noted in the RD's weekly progress notes and communicated to the physician team, who used that information to adjust tube feedings accordingly (all babies in this population were primarily tube fed).

As a balancing metric, we assessed whether length z-scores indicated worsening linear growth trajectory for these patients; paired coordinate plots were created to allow visualization of changes in length z-scores.

Results: Between 4/1/24 and 1/1/25, there were 64 NICU transfers to CCS. During this period, the proportion of patients with WFL >97th percentile at transfer to CCS decreased from 45% to 31%. The proportion of babies discharged from CCS with weight for length >97th percentile declined from 32% to 17%, below our target of 25% (Figure 2). Length z-scores, as represented on paired coordinate plots (Figure 3), did not decline in association with lower WFL in these babies.

Conclusion(s): This quality improvement initiative demonstrated that, through the use of an algorithm to allow the designation of patient-specific weight gain goals, we were able to improve the discharge WFL of a population at risk for adverse health outcomes. We were able to do this without negatively impacting patients' length z-scores. Future work will involve potential spread of algorithm use to additional hospital services.

Nutrition management algorithm for CCS babies transferred from NICU


Distribution of WFL percentiles at transfer to and discharge from CCS


Scatter plot indicating changes in length z-scores between transfer to and discharge from CCS
With the exception of one unusually tall outlier, length z-scores did not decline in this population