High-Calorie Formula Preferred for Infants With Neonatal Abstinence Syndrome

By Marilynn Larkin

September 15, 2020

NEW YORK (Reuters Health) - High-calorie formula (HCF) was associated with a shorter hospital stay for neonatal abstinence syndrome (NAS) compared with other formula types, a quality improvement initiative has found.

The 47 study sites in Ohio, caring for a total of 546 infants with NAS, self-selected into four groups: low lactose/HCF (11 centers; 94 patients); standard lactose/HCF (five centers; 74 patients); low lactose/standard calorie (20 centers; 333 patients); and standard lactose/standard calorie (11 centers; 54 patients).

Response plots revealed the benefits of HCF on weight loss, treatment failure, and LOS, researchers reported in Pediatrics. As a result, the Ohio Perinatal Quality Collaborative (OPQC) updated its nonpharmacologic treatment bundle to recommend HCF for these infants when breastfeeding was not possible. During implementation, HCF use increased, and LOS decreased from 17.1 to 16.4 days across the OPQC.

The finding was revealed by a quality improvement method known as orchestrated testing (OT), which allows simultaneous examination of multiple practices (bundle elements) to determine which intervention or combination of interventions affects the outcome.

"Change packages or bundles are used frequently in quality improvement, (and) OT can be particularly useful for learning about which (specific) components of a change package are most impactful," Dr. Heather Kaplan of Cincinnati Children's Hospital and Medical Center told Reuters Health by email. "While we believe OT could be used more widely as a quality improvement method, there is an associated learning curve. Others who are considering OT should ensure that their group has a culture of collaboration, transparency, and sharing."

Dr. Jeffrey Loughead, medical director of the NICU and pediatrics at Northwestern Medicine Central DuPage Hospital in Winfield, Illinois, commented on the findings by email. Although breastfeeding is still the preferred nutrition source, he said, for women who need to use formula, HCF enables "'more bang for the buck,' with an increase of 10%-20% more calories over standard formula."

Dr. Loughead, who trained at Cincinnati Children's and is familiar with the OPQC, told Reuters Health that his hospital uses both HCF and occasionally lower-lactose formulas when formula is needed. The latter, he said, "is typically a formula designed for preterm infants that is 22 kcal/oz."

"The only concern is that formula use may in some subtle ways be discouraging to the mothers and may limit some in their enthusiasm for breastfeeding," he noted. "This can be largely countered through support for the mother by lactation consultants, nursing and physicians. Otherwise, there is no downside to use of higher calorie or lower lactose formula, as they are well tolerated by these infants."

"Treatment of neonatal opioid withdrawal is best done in the context of a standardized bundle of behavioral and medical practices," he added. "The behavioral, or nonpharmacological, practices involving the parents and caregivers are actually more important than most of the medical practices," he concluded.

SOURCE: https://bit.ly/3hvpPDV Pediatrics, online September 10, 2020.