NICU Nurse Amy Paradis discusses best practices for effectively and accurately measuring growth of premature infants in the NICU
Amy Mailand Paradis, NNP, nurse practitioner and clinical nurse specialist (Modesto, Calif.), is an advanced practice neonatal nurse with 29 years of experience in a level III NICU with 15 as a neonatal nurse practitioner. She is a frequent lecturer and a researcher on topics related to neonatal care.
The full potential of human milk has yet to be realized. Speaking of Human Milk provides healthcare professionals with information on the latest science and clinical research. Each episode features an interview with a thought leader passionate about uncovering the unknown potential of human milk or better understanding the science of neonatal nutrition.
In addition to hosting Speaking of Human Milk, Keli Hawthorne is the director for clinical research for the Department of Pediatrics at the University of Texas Austin, Dell Medical School. In her current role, she trains faculty and staff on effectively executing high-quality protocols for research. She has authored more than 40 peer-reviewed publications on neonatal nutrition.
Keli Hawthorne: Hi y’all, welcome to Speaking of Human Milk, where we give you bitesize episodes on the latest science and innovation surrounding human milk. This podcast is brought to you by Prolacta Bioscience, a company dedicated to Advancing the Science of Human Milk. I’m your host Registered Dietitian Keli Hawthorne. Today, we will be discussing the topic of growth in the neonatal population with Amy Paradis, a neonatal nurse practitioner and clinical nurse specialist. Amy has nearly 30 years of Level III NICU experience. She has been working in central California for the past 15 years as an NNP clinician in a community Level III NICU. And I’ve gotten to know her the past couple of years through her involvement as a member of NPAC, Prolacta’s Nursing Practice Advisory Council. Thank you for joining us today, Amy!
Amy Paradis: It’s a pleasure to be speaking with you!
Keli Hawthorne: I’m really excited to talk to you about growth today. So, my first question is what are the biggest challenges that clinicians have in understanding growth in very low birthweight babies in the NICU?
Amy Paradis: There are several modalities to monitor growth, including various growth charts and measurement techniques. Also, there are obvious challenges to accurately measuring the very sick and unstable premature baby in the NICU. Having a reliable bed scale is essential, however I’m always concerned about the calibration frequency of the scales and reliable day to day measurements related to the addition and removal of necessary equipment such as CPAP devices, vascular access securement, and other tubes and lines. Daily weight measurements can be very stressful for the ELBW infant and takes excellent attention to nursing care to be sure to minimize these stressful effects but still obtain valid measurements.
Keli Hawthorne: That’s so true. I think we underestimate the stress ELBW infants have when we measure them and how that may impact the calories they’re burning for that rather than using for growth. But yet, it’s still critical information we need to make decisions about their care. So, what are some tactics to improve the consistency and quality of growth parameters in the NICU when it comes to measuring weight, length, and head circumference?
Amy Paradis: I think the most important tactic is for the bedside to nurse to evaluate the previous measurements prior to weighing the baby. Second, this should ALWAYS be at least a two-person intervention. This ensures that the correct zeroing occurs (all those tubes and lines are managed appropriately and the baby’s needs can be addressed speedily). The most frustrating problem I encounter far too frequently is what I call the “accordion” effect when it comes to head and length measurement.
As we know, babies grow in a linear fashion, they don’t shrink. So, especially with length measurements knowing what the previous measure was makes the ability to assess whether this new length is appropriate and much more reliable. Lastly, accurate measurement of head is essential. Taking at least two measurements to insure accuracy and reporting to the 10th of millimeter (not rounding to the nearest ½ cm) should be done. Also, noting the prior measurement is crucial. Since babies may have elaborate respiratory securement devices around there head, it would be very stressful the remove the device and reapply after measuring only to find out the head had gone down in size, which is high unlikely, only to have to go back and measure again. Having to remove the device again, is obviously very stressful for baby.
Keli Hawthorne: I think length is so important for evaluating a baby’s nutritional status and if they are really growing or not, but it’s often overlooked in NICUs. We’ve all seen that kid who shrinks, or as you called it, the accordion effect. We know babies don’t actually shrink in length. So, talk to us about why length boards are so important and how to use them properly.
Amy Paradis: We recently acquired new length boards in our NICU. We have seen a dramatic improvement in length trajectory and consistency in measurements. The technique should always be done with two people. One nurse stabilizes the head against the “head board” in the midline position. The second person with the diaper preferably off, extends the hips and flexes the feet allowing the “foot board” which is moveable to be slide up to the flexed foot. The WHO and the AAP actually recommend a length board for measurement of all infants.
Keli Hawthorne: What are some tools that clinicians in the NICU can utilize to track growth?
Amy Paradis: My favorite tool is the PediTools app. Easily found on the internet at www.peditools.org and can be saved on your smartphone or desktop. Easy links to the Fenton, WHO and even Zemel (for Down’s syndrome) with precise assessment of percentiles and Z-scores. The other is an app available in the app store called NICUNutrition. The value app allows you calculate nutrient intake in volume, calories and breaks down the macro- and micronutrients, that may be very challenging math in a baby being fed enterally as well as parenterally. It includes Prolacta under the nutrition tab.
Keli Hawthorne: I’ve heard you’ve developed a growth algorithm at your facility. Can you tell us more about that? Amy Paradis: Due to the complexity of monitoring growth, we developed an algorithm to help our NICU team evaluate growth consistently. Basically, the first goal is monitoring return to birth weight for babies of all sizes and gestations. Second, if less than 2000 g at birth and premature (less than 37 weeks at birth) we use the Fenton 2013 growth chart for weight, head and length. Babies born greater than 37 weeks we plot on the WHO growth chart, all using the PediTools.org. Next is determining growth velocity in g/kg/day over the previous week until the baby reaches 2000 g. After that we use the Fenton weekly weight goals which are determined by current weight and adjusted age. Just scroll down the page on Peditools and you will see next to the weight the weekly goal. Lastly, the recent publication of the Grow Baby Grow Toolkit from the California Collaborative has many more resources that help guide your NICU team.
Keli Hawthorne: It’s been great speaking with you Amy, and I appreciate you talking with us about growth, and especially about length measurements. To our listeners, links to resources discussed in this episode are in the description, and thank you for listening to this week’s episode of Speaking of Human Milk, powered by Prolacta Bioscience, a company dedicated to Advancing the Science of Human Milk. For more information on the company visit www.prolacta.com.