Food for thought: a mixed methods analysis of nutrition decision making during bedside rounds in the neonatal intensive care unit.

BACKGROUND: Variation in nutrition delivery contributes to poor growth in preterm infants in the neonatal intensive care unit (NICU); however, few studies have examined how clinicians develop nutrition plans. The aim of this research is to describe the nutrition decision-making process during rounds for preterm infants in the NICU. METHODS: We conducted a convergent parallel mixed methods study of bedside rounds on preterm infants at two NICUs. Qualitative data were collected by observing rounds which were recorded, transcribed, and analyzed thematically. Quantitative data were abstracted from the medical record. Data were merged to analyze characteristics of discussion of infant nutrition. RESULTS: Four nutrition-specific themes characterized discussion during rounds for preterm infants: 1) nutrition is important but fluid is prioritized, and discussion of nutrition occurs in the language of fluid; 2) discussions reflect uncertainty and lack specificity; 3) fluid allowance, feeding tolerance, growth and metabolism are primary drivers of nutrition plans; and 4) distinguishing whether measured weights indicate growth versus fluid retention or measurement error is challenging. CONCLUSION: Multiple direct and indirect drivers influence nutrition decisions. Clinicians answer questions about nutrition by discussing fluid. This may lead to suboptimal solutions during the transition phase of nutrition and periods of fluid restriction. IMPACT: In the neonatal intensive care unit, nutrition-specific concerns of fluid allowance, feeding intolerance, growth and metabolism are drivers of the nutrition decision-making process for infants and involve several tradeoffs. Rather than discussing "how much nutrition the baby received," clinicians commonly used a heuristic to more easily approximate energy or protein intake by discussing "how much fluid the baby received." Distinguishing actual growth from measurement error and fluid retention is challenging. Clinicians lack easily accessible data to accurately assess what nutrition the infant received and how the infant grew in response.